§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. McNulty.]
7.22 pm§ Mr. David Taylor (North-West Leicestershire)I am grateful for the opportunity to draw to the attention of the Minister and other hon. Members the role of primary care in the treatment of cancer. I shall discuss present practice, current shortfalls and some potential improvements.
Cancer places a heavy burden of disease on the community. One in three people in the United Kingdom will contract cancer in his or her lifetime and one in four will die from it—compared with 5 per cent. of all deaths at the beginning of the last century. The factors driving the increase in cancer-related deaths include both better control of infectious illnesses and ageing of the population, because two thirds of all cancers occur in the over-60s.
The good news is that, as medical techniques and health services continue to improve, age-specific cancer mortality rates will fall. Even now, about a million British people diagnosed in previous years with cancer have effectively been cured of the condition or are living with it. Those numbers will rise, and that brings into sharp focus the role of primary care in the treatment of cancer, which I shall argue needs to be given a higher profile and greater resources.
As noted by Dr. Nick Summerton in his recent book on primary cancer care, the general practitioner's most fundamental role for many patients is being able to act appropriately when they attend with a symptom that concerns them. In a recent review of complaints about general practitioners received by the Medical Defence Union, failure or delay in diagnosis accounted for 28 per cent. of the notifications in 1998. The most frequent clinical condition associated with diagnostic failure or delay was missed malignancy.
Primary care clinicians are often in a very difficult position in relation to diagnosis of cancer, which frequently presents with common symptoms such as non-specific abdominal pain or a persistent cough. Of course, only a tiny number of people displaying such symptoms who are seen by a GP will prove to have cancer.
Dr. Summerton noted an acute dilemma for general practitioners. While on the one hand they are always aware of the importance of avoiding over-referral or over-investigation of their patients, on the other they continually strive not to miss important conditions in patients. That invidious position is complicated by the human trait of patients of delaying initial consultation with their doctor about potentially significant symptoms. Thus, GPs have to be trained and skilled in identifying, within a largely unselected population, which symptomatic patients are more likely to have malignant disease. A different approach to diagnosis may be needed in dealing with community-based patients, who are often less familiar with medical terminology than those who attend clinics.
The Government's initiative of a maximum two-week wait for cancer patients is a most welcome move to relieve patients' anxieties. It is both an opportunity and a challenge for general practitioners. It is an opportunity, in 1210 that family doctors can assume important new and overdue responsibilities for developing higher quality oncology services. Oncological research and development is driven by agencies, organisations and interests that are not always fully aware of the primary care and community dimension.
The capped waiting time is a challenge as the average GP sees just two patients a day with symptoms of cancer—fortunately, most do not have it—and might only diagnose lung cancer, the most common form of the disease, just once a year.
I said that a central task for GPs has traditionally been to avoid overreaction to low-risk situations, but we must treat GPs fairly. If, in future, we expect them to refer more low-risk patients to specialists in the hope of detecting a limited number of additional early cancers, the taxpayer must foot the bill. If, conversely, GPs are urged not to overload limited or expensive hospital facilities, we must not blame them too readily for the missed cancers that could be a consequence of more restricted diagnostic strategies.
To prevent hospitals being over-burdened with referrals and to reduce patient anxiety, two areas must be addressed. First, research is needed to find the evidence about which symptom clusters and findings put the patient at higher risk of having cancer and to define those cancer patients who can be safely and conveniently followed up in primary care, thereby relieving the burden on secondary care.
§ Mr. Andrew Reed (Loughborough)Does my hon. Friend agree that it is not only GPs who are important in that primary care group, but the whole spectrum of those who are involved in such care, particularly nurses in the community, and it is necessary to take a holistic approach and ensure that they are included in the strategies that he has mentioned?
§ Mr. TaylorI thank my hon. Friend for that point, and I am coming to the importance of the whole team being involved in the support of cancer patients.
The second area that needs to be addressed is effective, evidence-based education for GPs and nurses, which is a prerequisite to allow them to implement existing knowledge in all practices. Dr. Arthur Hibble, who leads for the Royal College of General Practitioners on cancer, describes the role of primary care in the patient's cancer journey as aiming to highlight risk prevention, including issues such as diet, tobacco and occupation, and to diagnose cancer early, either in screening programmes or by recognition of disease. There must be prompt appropriate referral to recognised centres. Primary care must include continuing care of the person and their families and carers in all areas of their health. There must be recognition of recurrence, and finally palliative and terminal care at home.
Dr. Hibble flags up the issues for primary care cancer services. They must incorporate effective interpersonal communication skills, in order to diagnose and explain better to patient and carers; professional knowledge and information about cancer; high-quality interprofessional communications in every aspect of referral to specialist service and patient management; multi-professional team working; and, most important of all, a service provision of consistently high quality.
1211 I shall take a more detailed look at that last issue because there is an immense variability of service provision in our country. As a Back Bencher, I am proud of the various cancer initiatives that the Government health team have introduced. Indeed, just weeks ago, I congratulated the Under-Secretary, my hon. Friend the Member for Pontefract and Castleford (Yvette Cooper), on the launch of the cancer services collaboratives with their nine pilot national networks, including one part based in north-west Leicestershire, which involves the local primary care group, the Measham medical unit and Glenfield hospital near Leicester.
I know, from talking to Dr. Orest Mulka and Dr. Pawan Randev at the Measham practice and from listening to patient and carer stories, that the way in which cancer sufferers throughout the country are cared for in the community is very variable, with excellent care in one area accompanying the unacceptable in another. The proportion of cancer patients being looked after at home nationwide varies from 13 per cent. to over 50 per cent.
Now, the diagnosis of cancer is, in most cases, suspected or confirmed in primary care. Most of a patient's cancer journey is spent in primary care. Yet, with recent changes in out-of-hours provision by general practitioners, most patients are looked after by doctors other than their own for most of the 24-hour period. That can lead to variable quality care, but need not if the issue of communication is adequately addressed. I shall return to this point shortly.
The primary health care team offers continuity for the patient. The average patient encounters around 25 doctors during hospital care, but usually has one GP and a named nurse in the practice. The all-important patient-doctor relationship is usually well established prior to a diagnosis of cancer.
The family is a vital part of the care team for most patients. The family can care for most patients at home, but doing so needs a high level of appropriate support from GPs, nurses and other members of the primary health care team who are only too willing to do so if they are properly resourced.
Primary care is responsible for the round-the-clock, everyday response to cancer patients' physical and psychological problems. Out-of-hours arrangements are implemented almost universally, but, with appropriate measures, they can be seamless for cancer patients dying at home. Quality improvement in primary care cancer is needed. Service improvements in primary care can, I believe, be achieved via a system of accreditation. Such a system for hospitals is a major outcome of the Calman-Hine report, and it has improved quality of care in the hospital sector.
Primary care has a greater quality variability than the hospitals had, but there has still been no significant move towards a national system of accreditation for primary care. Without such a quality system, patients can feel vulnerable and powerless. They feel that they are not being heard by professionals, and have inadequate information to make decisions on their treatment. They are worried about continuity of care—especially at nights and at weekends, when access to their notes is often difficult. Patients do not always have information about 1212 specific treatments and complications, and in the terminal stages of some cancers, their wish to die at home is not granted.
The whole medical profession supports the principles of the Calman-Hine report, whereby diagnosis and treatment of cancer takes place in specialised centres. However, there is at present no specific role for primary care in the clinical management of cancer patients. One should be developed, having at its heart cancer: accredited general practices whose approach is centred on patients, listening to their experiences and respecting their wishes for care at home. It should involve the whole primary health care team—as my hon. Friend the Member for Loughborough (Mr. Reed) pointed out—including nursing staff and others, use patient-held records to improve communication and collaboration, and incorporate a practice-based cancer registry of patient information with appropriate data collection systems. Finally, the approach should have access to appropriate equipment, reference material and support groups for patients and carers.
Two practices in Leicestershire—I have already referred to one—have been performing a pilot year of accreditation for cancer management in primary care. The practices were supported by the health authority up to this year, when the obligation fell to the primary care groups. The PCGs have, however, been unable to support the practices financially. Fourteen out of the 15 practices in the North-West Leicestershire PCG wish to be involved, but the project marks time while it awaits secure funding. Protecting resources for primary care development is thus necessary.
North-West Leicestershire PCG had earmarked a small sum—£120,000—out of a budget of £90 million for all primary care development, but that was deleted as a result of the unexpectedly steep rise in the cost of generic drugs. A slightly larger sum is earmarked for next year, but it is vulnerable to any crisis in the secondary care sector, such as bed pressures or flu outbreaks. A ring-fenced budget for primary care development would address the problem, which is unique neither to cancer care nor to Leicestershire.
Primary care is evolving from a history of isolated small practices. Each primary health care team should not have to reinvent the wheel of high-quality cancer management in the community. There is a need for a national framework that teams can pick off the shelf, with the appropriate financial back-up available. The framework would encompass a system of cancer accreditation, which I have outlined, audit modules to allow quality to be improved and educational modules for all members of the team.
Such a framework would clearly also use the expertise and experience of the Royal College of General Practitioners, the Royal College of Nursing, cancer charities and the national health service. It would respond to groups campaigning on these matters such as BACUP—the British Association of Cancer United Patients—CERT and the NHS confederation. It would look to Macmillan, which has much relevant training experience.
1213 Patients want better-quality cancer treatment, as near to home as possible when that can be provided safely. This fits with current policy on the importance of primary care and it can be delivered, but it needs protected investment in primary care, as well as the current investments in secondary care.
I pose four questions to my hon. Friend the Minister and to the profession. How can patient wishes about place of care be best fulfilled? What proportion of cancer development funding should be earmarked for primary care? How can primary care development budgets be protected from unexpected overspends in other parts of a PCG's budget? Finally, are the Government prepared to offer a firm commitment to pump-prime key aspects of primary care oncological research and development, and to support and resource general primary care oncology? I would appreciate an early response to those key questions.
High-quality, generalisable primary care oncological diagnostic research is difficult. The types of large, prospective and methodologically rigorous cohort studies needed will require significant amounts of time, funding, collaboration and organisation, which are not in any plan of which I am aware. Furthermore, such research needs to be built on a robust foundation involving broad-ranging, systematic reviews combined with qualitative and quantitative re-examinations of patients' paths to diagnosis. Unfortunately, it is proving to be a Herculean effort to convince the major cancer charities and the Department of Health of the enormous practical value of such work and the need to alter their funding strategies to accommodate it.
I am delighted that, two weeks ago, the Department announced £23 million of funding for the Living with Cancer programme, which will enable more cancer patients to be treated at home, and will provide more support for those who are caring for them. Many thousands of cancer patients and their families will benefit from the programme. I hope that it will be extended into other areas, both geographical and professional.
The missing element in high-quality cancer care is a case manager, who would ensure proper co-ordination of care, appropriate support services, including counselling, and the existence of an advocate for the patient in the event of problems. I contend that the primary health care team is well placed to undertake that role under existing commissioning arrangements, but with the new accreditation system that I have outlined.
For too long, the role of primary care in the treatment of cancer patients has been undervalued and under-resourced. Active and aggressive treatments have obtained great investment and have been successful in many ways, but primary care, given certainty of research funds, a flexible education programme and imaginative development, can do much more, especially when allied to the magnificent services offered by Macmillan.
I hope that the Minister will agree that early diagnosis and quality continuing patient care deserve a higher priority in the exciting national cancer care programme on which our Labour Government have embarked. I urge her to persuade our right hon. Friends the Secretary of State and the Chancellor to invest in developing the role of primary care in the treatment of cancer.
§ The Parliamentary Under-Secretary of State for Health (Yvette Cooper)I congratulate my hon. Friend the Member for North-West Leicestershire (Mr. Taylor) on choosing to debate the role of primary care in the treatment of cancer. It is a timely choice of topic, as the Government are developing cancer services across the spectrum. I know that Leicestershire is a national site for the cancer services collaborative programme, which my hon. Friend mentioned, and that the development of primary care services for patients with cancer and of palliative care services have been key issues for the Leicestershire cancer centre.
As my hon. Friend knows, at the heart of our health modernisation programme is a determination to reduce the impact of cancer on people's lives and to create the best cancer service in the world. We have set a challenging target to reduce the death rate from cancer by 20 per cent. by 2010, preventing 100,000 deaths. To succeed, we will need to deliver a tough programme of action spanning prevention, screening, early diagnosis and high-quality treatment and care. Primary care has a role to play at every stage in the treatment of cancer.
I shall cover some of the general issues raised by my hon. Friend, and then deal with some of the detailed questions that he raised. The advent of primary care groups last year, and the first primary care trusts this April, means that local clinicians are firmly in the driving seat in delivering the new NHS. Local general practitioners and primary care teams ensure continuity of care, informed advice, treatment and, when required, referral to secondary care. As my hon. Friend the Member for Loughborough (Mr. Reed) said, that means the entire primary care team, not simply the general practitioners who work in primary care. The primary care teams care for patients on their discharge and, in the case of terminally ill patients, until their death.
My hon. Friend the Member for North-West Leicestershire is right to say that we need to be confident that appropriate models of cancer care are in place to meet the significant changes expected in our society over the next few years—changes in the population's age structure, in inequalities, in the availability of informal care and in expectations.
Primary care has an important role to play in terms of prevention, particularly in regard to cancer. With an ageing population, the incidence of cancer is likely to rise, but preventive measures, including action on smoking, diet, alcohol, exercise, exposure to the sun, will affect the risk of developing cancer. There is good evidence of the effectiveness of brief interventions by primary care teams in reducing alcohol intake and in encouraging people who want to give up smoking.
Primary care also works with local authorities, in settings such as schools, workplaces and the community, to promote healthy life styles. Nor should we overlook the role of community pharmacists, dentists and optometrists, each of whom provides health services to a substantial proportion of the population each year, and often offers advice on prevention or identifies symptoms of disease.
1215 We continually look for innovative ways to improve health promotion and prevent ill health and cancer, putting additional resources into services for ethnic minorities and for people in low income areas, and, in particular, working with the public health development fund on matters such as smoking cessation.
The role of primary care is important in tackling health inequalities, particularly with regard to cancer. There is some evidence that patients from low-income areas are diagnosed with more advanced tumours than those from higher-income backgrounds. That may be one reason why people from low-income areas have worse survival rates. Health authorities and primary care groups have a key role in addressing such health inequalities. Their role is vital, especially through local health improvement programmes.
Primary care groups have an important role to play in tackling health inequalities through health action zones. The 26 zones are trailblazers, leading the way in tackling health inequalities, acting as test beds for innovation and recognising that the health service cannot do everything in terms of improving people's health.
Primary care also has a role to play in terms of screening for cervical and breast cancer by providing information and education, directly undertaking cervical smears, and by assisting with call and recall programmes for breast screening. We also know that uptake of screening programmes varies across the country from one group to another. Primary care, working with other agencies, can play a vital role in increasing uptake and encouraging health awareness.
My hon. Friend talked in particular about diagnosis and treatment referral. He is right to say that people need to have confidence in their health service, so that, if they have symptoms that could be caused by cancer, they can discuss them with their GP and be referred quickly and appropriately if necessary.
Although cancer is a common problem, with 220,000 new cases diagnosed each year in England and Wales, an individual GP is unlikely to see more than eight or nine cases a year. The task for GPs is to differentiate between patients whose symptoms may be cancer and the much larger group of patients with similar symptoms arising from other causes. My hon. Friend is right to say that that creates important challenges for primary care teams.
That is why we are working with primary and secondary care groups, the voluntary sector and patient groups to develop cancer guidelines for primary health care teams to help them identify those patients most likely to have cancer and to require urgent specialist investigation. Equally, the guidelines will help GPs identify those patients who are unlikely to have cancer or who may require alternative treatment or diagnosis. The guidelines have been issued for consultation. We received many comments on them and we are revising them in the light of those comments.
General practitioners are naturally concerned to ensure that we continue to undertake research to determine the symptoms or signs that indicate someone who has a higher risk of developing cancer and the patients who can be safely followed up through primary care.
1216 Cancer and primary care constituted two of five topic working groups in the recent strategic review of the NHS research and development levy. That reflects their high priority in the Department's research and development activities. The sub-groups on cancer and primary care acted together closely and thus provided an integrated approach. That is important. They recommended a series of priorities for NHS research and development, which reflected gaps in the current evidence base for services and planned service developments. The Department is considering the best way of taking those recommendations forward.
We have also set up a cancer research funders forum to help improve the strategic co-ordination of research and to examine all categories of research including life style, prevention, screening, diagnosis and treatment.
My hon. Friend mentioned the two-week wait. He is right to say that, for patients who have suspected cancer, seeing a specialist quickly is extremely important. That is why, since April 1999, all patients with suspected breast cancer who are referred urgently by their GPs have been offered an appointment within two weeks. During the next year, we will roll out that high standard of care for all cases of suspected cancer that require an urgent specialist investigation.
My hon. Friend also mentioned the way in which primary care provides physical, psychological and emotional support, acts as link and advocate with the secondary and tertiary sectors, and deals with parallel non-cancer illnesses. It also gives the crucial continuity of care and support that nothing else can provide.
Primary care is vital to providing palliative care, which is a core responsibility for GPs and community nursing. The primary care team has, and will continue to have, a central role in providing and accessing palliative and terminal care for patients.
By introducing pooled budget arrangements with social care agencies, the funding for primary care allows primary care groups and primary care teams to develop innovative and flexible services to tackle their local communities' needs, thus making the best use of the resources that we can make available to them.
My hon. Friend raised several specific anxieties about resources. As he knows, we have already put significant additional investment into cancer services. In addition to the £23 million that he mentioned to support the living with cancer programme, another £93 million from the new opportunities fund is being used to buy new equipment for cancer screening, early diagnosis and treatment.
From April this year, £80 million over the next two years will support improved access to cancer care, and we are encouraging health authorities to engage with primary care to support educational arrangements to help implement national cancer referral guidelines and ensure that patients are speedily referred.
However, as my hon. Friend said, we also need to consider how we can minimise variation in cancer care delivery within primary care. Professor Mike Richards, the national cancer director, is already leading work to 1217 develop a national quality improvement framework. That will concentrate initially on developing standards of care for secondary and tertiary cancer care.
I know of the excellent work in Leicester, and that the development of a GP practice cancer accreditation programme has recently been awarded primary care NHS beacon status. I have asked Professor Richards to explore with leading GPs and other interested groups whether we should consider rolling out the quality improvement framework to encompass primary care, and to develop a framework for ensuring consistency across the country through investment in cancer education and audit in primary care so that we can deliver a consistent, high-quality service.
1218 We believe that there is considerable scope for developing the work of primary care in prevention, diagnosis, treatment, support and palliative care as well as in line with many of the points that my Friend made. I look forward to following developments in his area. I shall make sure that the experience in Leicestershire is fed into our developing national work.
The Government are determined to improve cancer services. The role of primary care in the prevention, early detection, treatment and care of cancer is vital to delivering the modern, seamless, comprehensive and high-quality service that we all want.
§ Question put and agreed to.
§ Adjourned accordingly at ten minutes to Eight o'clock.