§ Motion made, and Question proposed, That this House do now adjourn.—[Margaret Moran.]7.30 pm
§ Mr. Gary Streeter (South-West Devon) (Con)
Susan Van Neck was born on 10 January 1967. She married in 1991, and became Mrs. Susan Spratt. She died of cervical cancer in September 1999, at the age of 32. She had three smear tests during her life, which were examined in the laboratories of two different hospitals. As events have proved, two of those tests were inaccurate. They did not detect the first signs of cancer that would have made it possible to treat her fully and save her life.
As we all know, every woman in the United Kingdom between the ages of 25 and 64 is eligible for a free cervical smear test every three to five years. In 1988, Sue's first test gave her the all-clear, but recommended a further test a year later. The outcome of her second smear test in 1989, examined by the cytology laboratory at Derriford hospital in Plymouth was an all-clear, suggesting that no further test was necessary for five years. In 1993, the test result conducted by the cytology laboratory at the Taunton and Somerset hospital was also an all-clear and suggested no retest for five years.
Sadly, in 1995, just two years later, Sue was admitted to the accident and emergency department at Yeovil hospital with evidence of advanced cervical cancer. She received intensive treatment, which seemed to work for a while, but in April 1998 she was found to have a recurrence of the tumour. This time, she failed to respond to chemotherapy and after a brave struggle she died on 28 September 1999.
Since then, the NHS has admitted that it had been negligent and compensation has been paid to Sue's husband. The debate tonight is not about compensation, blame or looking backwards: it is about looking forwards. As part of the contact with the NHS following Sue's death, an eminent medical expert, Professor Dulcie Coleman, was invited to re-examine the original smear tests. She produced a report showing that, among other things, the 1989 smear test that pronounced Sue all clear should have found the early signs of cervical cancer and referred her for further examination by a specialist and treatment. The professor also found that the 1993 test, which again pronounced Sue to be all clear, should have found the traces of cervical cancer that were present and should have sent her for further examination and treatment.
Professor Coleman concludes her report with these words:If Mrs Spratt's smears had been correctly read in 1989 and 1993, her cervical cancer would have been diagnosed 6 years or 18 months earlier when it was still in the pre-invasive stage. She would have been treated conservatively by local ablation and her prognosis would have been excellent. The local treatment would have been unlikely to affect her chances of becoming pregnant and she would not have had a hysterectomy, radiotherapy or chemotherapy.Sadly, that was not to be, and Sue became one of the thousand or so women who die from cervical cancer every year in the United Kingdom.
Before Sue died, Mrs. Van Neck promised her daughter that she would do all she could to improve 1540 cancer screening for Sue's sister and nieces and for all women, so that fewer families would have to suffer the trauma and tragedy of a life so full of vitality and promise being cut short. Since then, Mrs. Van Neck and her husband have been very active, delivering on that promise. They have been in contact with the hospitals in Taunton and Plymouth to chase up improvements in the system. In June 2001, they learned that clinical trials of a new type of cervical cancer screening—liquid-based cytology—were being carried out at a number of hospitals across the country. They made contact with each to set out their tragic family experience and to urge rapid progress.
As the House will know, until recently all smear tests were conducted by the traditional Pap method. Unfortunately, over the years, it has been found that about one in 10 smear tests using that method have to be repeated, because the person checking the test at the laboratory cannot see whether pre-cancerous cells are present. The errors and anxiety that may arise are amply demonstrated by the Van Necks' experience and by several similar cases.
The Van Neck family were delighted when, in October 2003, the National Institute for Clinical Excellence, as a result of the trials, recommended the use of liquid-based cytology throughout the NHS. As the Minister will know well, liquid-based cytology is a new way of collecting and preparing cell samples from a woman's cervix. Samples are collected using a brushlike device, rather than a spatula. The head of the brush is rinsed or broken off into a container of preservation fluid that protects the cervical cells. The evidence of the trials was that liquid-based cytology results in samples that are of better quality and easier to read, thus reducing the number of tests that need to be repeated.
Obviously, the introduction of liquid-based cytology would offer a much improved service for all women and would be a positive step forward, so Mr. and Mrs. Van Neck decided to do all in their power to ensure its early introduction. They first visited me at my constituency surgery in November 2003 to tell me of their tragic experience and of their determination to see a better smear test system introduced in this country. I found their story deeply moving and their determination to redeem the promise that they had given their daughter very impressive. I welcome their presence, with their other daughter Debbie, in the House this evening.
Following that meeting, I tabled a written question on 4 December, which was answered by the Under-Secretary of State for Health, the hon. Member for Welwyn Hatfield (Miss Johnson), on 10 December. She set out the welcome news that the Government had decided that liquid-based cytology would be rolled out nationally across the national health service, for everybody. The reply also stated:We expect the roll out to take up to five years, due to the retraining of all laboratory staff who read cervical screening tests and all sampler takers in primary care."—[Official Report, 10 December 2002; Vol. 415, c. 506W.]I have also written to the South West Peninsula strategic health authority, and its chair, Judy Leverton, replied that the authority hoped to introduce the new 1541 system in the next financial year, depending on a number of factors, especially on whether all the necessary staff could be trained in the use of the new procedures.
§ Mr. Andrew Lansley (South Cambridgeshire)(Con)
My hon. Friend makes a compelling case for the speediest possible introduction of cytology in screening. Does he agree that the HART—HPV in addition to routine testing—study suggested that the human papillomavirus test, in conjunction with cytology, might be the most effective mechanism for primary screening? Three implementation pilots are due to report but have not yet done so, and it would be helpful for the House to know when we might receive more information about that further improved screening method.
§ Mr. Streeter
I am grateful to my hon. Friend for that intervention. He is right: the HPV testing method will give additional support to the cytology process that we hope will be introduced. I hope that the Minister will be able to say a few words about the likely speed of the roll-out when he responds. The Van Neck family, too, will be keen to see the HPV test become part of the procedure.
The purpose of the debate is to urge the Government to ensure that the roll-out of that new screening system happens as quickly as is humanly possible, to give every woman in this country the best chance of detecting cervical cancer at the earliest moment. If at all possible, the new screening procedure should be rolled out within the next 12 months.
It would also be helpful if the Minister could place on the record tonight detail about the age at which it is now intended that women will have their first smear test, and the intended frequency of subsequent testing.
More than 3 million women are screened each year. No doubt this year, 2004, will be little different. Under the old system one in 10 of those tests—300,000 of them—might have to be redone. That is not to say that all 300,000 would produce an inaccurate result. Of course that is not true, and I have no wish to cause any unnecessary alarm. But it is certainly the case that accuracy will be improved under the proposed new system. So every year counts; every month counts.
We understand the need for retraining and the never-ending claims on finite resources, but I urge the Minister to make sure that resources are made available to enable the new liquid-based cytology screening process to be introduced within the next 12 months.
The Van Neck family know full well that nothing can be done to bring back their lost daughter. All of us who are parents can stand with them tonight and acknowledge their loss. We can also admire their fortitude and perseverance in pursuing the improvement of the system of smear testing in this country, a redemption of a promise made to Sue while she was terminally ill. But most of all we can respond to their courage and tenacity by advancing the plans to roll out the liquid-based cytology system as soon as is humanly possible, so that not a single life is lost unnecessarily to this dreadful disease. I call upon the Minister to assure the House that this will indeed be done.
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)
I congratulate the hon. Member for South-West Devon (Mr. Streeter) on obtaining this debate and on representing the views of his constituents so well.
I also congratulate the Van Neck family on their campaigning. It must have been a horrible tragedy for them to have their daughter taken in the way that occurred. It highlights exactly why we need a high-quality cervical screening service, and why we must take every opportunity to improve it. As new techniques become available, and we obtain evidence to support them, we must try to implement them as rapidly as possible.
That said, and acknowledging that tragic mistakes do happen, I have to begin by pointing out that the United Kingdom has one of the most successful cervical screening programmes in the world. That is something that we should be very proud of. Experts estimate that the programme prevents up to 3,900 cases of cervical cancer each year. Experts also agree that that the NHS cervical screening programme is responsible for a reduction of over 40 per cent. in the incidence of cervical cancer in the last decade.
But we are not complacent. We are always striving to improve the programme, and that is why the National Institute for Clinical Excellence was asked to look at the liquid-based cytology technique. As the hon. Gentleman said, LBC is a new way of preparing cervical samples for examination in the laboratory, and it has the potential to improve efficiency and ensure that fewer women have to be recalled because their test could not be read.
Following the evaluation of a Government-funded pilot of LBC, NICE issued its final appraisal document on LBC on 22 October 2003, concluding that it should be rolled out across the NHS. My hon. Friend the Member for Welwyn Hatfield (Miss Johnson), who has ministerial responsibility for public health, announced on that day that LBC would indeed be implemented across the service, as part of a package to modernise the NHS cervical screening programme. That is the first indication for the hon. Gentleman that we do not intend to waste any time.
The independent evaluation of the pilot concluded that LBC resulted in a clear reduction in the number of inadequate tests, from 9 per cent to between 1 and 2 per cent. Inadequate tests are those that cannot be read in laboratories for a variety of reasons. When LBC is fully rolled out, 300,000 women a year will not suffer the anxiety and uncertainty of an inadequate test, and will not need to be re-tested.In addition, the evaluation showed that the productivity of laboratories rose by 9 per cent., and backlogs were reduced, meaning that women will have to wait for a shorter time to get their test results.
There are therefore clear benefits in introducing LBC, and that is why the Government are providing £7.2 million to kick-start the process over the next two years.
However, we do not underestimate the challenge that implementing LBC across the NHS presents.
As LBC is a totally new technique, the time scale of implementation in England will be determined by the need to retrain all laboratory staff involved with cervical 1543 cytology—all the doctors and nurses who take the samples—and to install equipment in laboratories. About 3,000 laboratory staff currently read cervical screening tests in England, and it will take around six months of training before an individual is competent to use LBC techniques satisfactorily. Rigorously developed courses can accommodate only 10 to 12 people at a time. In addition, 40,000 doctors and nurses who take the samples will need to be retrained. For that reason, we anticipate that implementing LBC will take up to five years to complete nationally. Implementation could not progress more quickly even if we provided more funding.
The key to LBC implementation is retraining the staff in LBC techniques, both in primary care and in laboratories. The programme is already successful, and we must be very careful not to jeopardise its quality. LBC is being rolled out nationally. All those in cytology training schools in England will be trained as part of the first phase of implementation. Strategic health authorities have been issued with advice on how best they can roll out LBC for their local populations, laboratories and primary care.
We are also taking the opportunities presented by LBC to modernise the NHS cervical screening programme in other ways. The frequency with which women are invited for screening has been standardised across England for the first time, thus correcting a long-standing inequality. Following the publication of research from Cancer Research UK, the Advisory Committee on Cervical Screening has advised that clinical best practice is that women should receive their first invitation when they are 25 years old and that they should be invited every three years until they are 49, and then every five years until they are 64.
A fundamental tenet of any screening programme is that it should do more good than harm. Cervical cancer is very rare in women under the age of 25. Research presented to the advisory committee, coupled with 15 years' experience of screening, shows that screening women under the age of 25 may do more harm than good. They may undergo unnecessary investigations, after false positive results suggest that they appear to have cervical abnormalities when, in fact, they do not. Screening women from the age of 25 onwards will help to reduce anxiety, as well as the number of unnecessary investigations and treatments in younger women.
We will further modernise the service. In some areas, there are difficulties with the recruitment and retention of cytology screeners, which has been attributed partly to low morale and low pay. We appreciate the hard work of all the staff in the programme, particularly over the past few years, when morale has not been helped by adverse publicity.
We are taking steps to modernise pathology services through the Department of Health's pathology modernisation programme. We recognise that pathology's most valuable resource is its staff and that the need to support and develop those staff is vital. A number of long-term initiatives are in place—which, in time, will provide the NHS with the pathology staff it needs. That will also bring staff into the cytology-screening programme.
We are also committed to developing new and innovative ways of working, such as extended roles, improved skill-mix and more flexible career pathways, 1544 providing new opportunities and better ways to work for staff. One example of that is the new advanced practitioner in cytology grade, which increases the opportunities for staff to extend their skills and improve their pay. Furthermore, my right hon. Friend the Secretary of State for Health recently announced that, as part of the broader NHS recruitment drive, health care scientists who decide to return to the NHS will also now be eligible for a returner's package.
More broadly, as part of the Government's improving working lives initiative, by 2003, all NHS employers must be able to demonstrate that they are delivering flexible working arrangements, that they are offering good quality, affordable and accessible child care, career breaks and flexible retirement and that they are investing in staff training and development, tackling discrimination and harassment and providing healthy and safer workplaces and other measures to support staff and improve retention.
I shall now touch on the issue of human papilloma virus that the hon. Member for South Cambridgeshire (Mr. Lansley) mentioned. As part of the LBC pilot, we also piloted the use of human papilloma virus testing as triage for women with mild or borderline test results. HPV is a group of more than 80 virus types, some of which are associated with an increased risk of cervical cancer. Most women, and indeed men, are infected with the virus at some point, but it is not yet possible to tell which infected women will go on to develop cervical abnormalities, or which of them will naturally expel the virus by the normal functioning of their immune system. Most HPV infections disappear, and even those women who contract high-risk HPVs rarely go on to develop cervical cancer. Carrying out an HPV test at the same time as a smear test may help to decide how to manage a woman if her smear shows minor abnormalities, and could avoid referral to colposcopy, with its associated anxiety.
There is currently insufficient evidence to support the use of HPV testing as a primary screening tool. However, we know how important HPV is in the development of cervical cancer, and that is why we are piloting the use of HPV testing. The independent evaluation report of the HPV arm of the pilot is expected in the summer. In addition, Professor Henry Kitchener, professor of gynaecological oncology at St. Mary's hospital in Manchester, is co-ordinating a study to investigate HPV as a primary screening method. It began in January 2001 and will take six years, including the follow-up of the data, and will involve 28,000 women. The Department of Health is funding equipment for the study at cost of £90,000 per annum. The health technology assessment programme is funding the rest of the study.
However, we must all remember that early detection by screening and follow-up treatment can prevent only 80 to 90 per cent. of cervical cancers from developing. Like any screening test, cervical screening is not perfect. It might not always detect early cell changes that could lead to cancer. There are three main reasons why abnormal cells on a slide might not be recognised. First, sometimes they do not look very different from normal cells. Secondly, there might be very few abnormal cells on the slide. Thirdly, the person reading the slide might miss the abnormality. This happens occasionally, no matter how experienced the reader is. It is always very unfortunate, but these errors do occur.
1545 Women invited to participate in the NHS cervical screening programme need to understand the potential benefits and harm in doing so, in order to be able to make an informed choice about whether they wish to proceed. Information provided to women must be honest, comprehensive and understandable. Following the target set in the NHS cancer plan, all women now receive a national evidence-based information leaflet with their invitation for cervical screening.
Strict quality assurance is operated within the cervical screening programme at a cost of £4 million a year. Laboratories that read cervical screening tests as part of the screening programme are subject to rigorous external quality assurance procedures that aim to spot potential problems before they become serious, and quickly to identify solutions. When a laboratory consistently fails to meet quality standards, the strategic health authority or primary care trust can require it to stop reading screening tests.
In conclusion, we do not yet know if LBC will be more accurate than conventional cervical screening, but we hope that it will prove to be more sensitive. We do know, however, that 300,000 fewer women a year will have to undergo the anxiety of a repeat test, and that laboratories will be able to process samples more quickly. But this will take time. Retraining all the staff who work in the programme is an enormous task, and we must do it properly. The issue of quality, both of the programme and the people who work in it, is paramount. We would do a disservice to the 4 million women a year who participate in the NHS cervical screening programme if we were to rush the training of the staff who provide the service. Nevertheless, the Government and the Department of Health are committed to rolling out the technique as quickly as possible. I am therefore pleased to give the hon. Gentleman and the Van Neck family the assurance that we shall not waste a single day—or, we hope, a single life—in introducing this technique.
§ Lady Hermon (North Down) (UUP)
I am always reluctant to intervene in an Adjournment debate, especially when I have not spoken to the hon. Member who initiated it, but I am increasingly concerned that the NICE guidelines do not extend to Northern Ireland. The Minister, perhaps unwittingly, has mentioned 1546 England several times. Will he confirm that what he has said about liquid-based cytology and the retraining of staff will apply to Northern Ireland as well? Women there who read this debate or watch it on Sky television will be worried that only England has been mentioned this evening.
§ Dr. Ladyman
I am grateful to the hon. Lady for that question, but I am a health Minister for England. Devolution means that my responsibilities are only for England, so it is not for me to speak about what will happen in Northern Ireland. However, I undertake to make sure that the attention of the relevant Northern Ireland Ministers is drawn to this debate. I will also make sure that any evidence that we in the Department have is shared with colleagues in Northern Ireland. I will ask those Ministers them to write to her about their intentions, and I will put a copy of the correspondence in the Library.
§ Lady Hermon
I am grateful for that response, but I remind the Minister that the devolved Northern Ireland Assembly was suspended in October 2002. Many months have passed since then, and it is important that the women of Northern Ireland are not forgotten.
§ Dr. Ladyman
The hon. Lady is right to say that the Assembly is not sitting at present. However, the legislative framework in which Northern Ireland Ministers take decisions is very different from what applies here. My responsibility is for England only, but I accept that women in Northern Ireland will want this technique to be rolled out there. I undertake to ensure that Ministers in Northern Ireland are aware of the concern that she has expressed, and that they respond as positively as they can.
Once again, I give the hon. Member for South-West Devon and the Van Neck family the assurance that they seek. We will not waste any time in rolling out the technique. We know how important it is. We cannot guarantee that it will be any more accurate than the other technique, but we can guarantee that it will be more sensitive. Fewer women will have to undergo the distress of re-tests, and I believe that fewer mistakes will be made in the future.
§ Question put and agreed to.
§ Adjourned accordingly at three minutes to Eight o'clock.