§ 2.47 p.m.
§ LORD LEATHERLAND rose to ask Her Majesty's Government what progress is being made in providing facilities for cervical cancer tests, and to what extent the difficulties in securing and training staffs are being overcome. The noble Lord said: My Lords, I beg leave to ask the Question of which I have given notice and which appears on the Order Paper. In a modest and perhaps amateurish kind of way I am a Party politician, and possibly a prejudiced one at that. I think there may be a good many of your Lordships who wear that same kind of halo. But this afternoon I want to forget all that and to pilot my words into some smooth backwater where Party polemics will not be able to raise their heads. I want to think for a few moments about a menace that digs down deep into the roots of human happiness, irrespective of Party, irrespective of class and irrespective of race.
This problem of cancer is an enormous one, and it is one that is growing. It is a disease that kills 110,000 of our fellow citizens every year. Fortunately, some ameliorative treatments have been devised, but an essential factor for the success of all those is that there should be early diagnosis. One of the easiest forms of cancer to diagnose, and one of the easiest to treat and virtually to cure, is cancer of the cervix; but, again, the urgent necessity is for early diagnosis. I feel that I must sound this optimistic note of reassurance as a duty, so that women may, as they really should, know that a diagnosis is not necessarily a death sentence. As the World Health Organisation said in its report last year, with all the wealth of wisdom that it has at its command:
Cancer of the cervix is now a preventable disease".
§ There has been quite a lot of research by medical statisticians into the causes of this particular kind of cancer. One thing that has been revealed is that there is a very varying incidence between various classes of the population. The rate is highest among the wives of men who work in dirty, dusty occupations—miners and builders' labourers. On the other hand, the rate is lowest among 738 the wives of men who work in more refined occupations, like clergymen and lawyers. There is a good deal of evidence to show that the marital states of women have much to do with their suffering from this disease. A very recent investigation showed that for every million deaths in this country for reasons of all kinds, those for cervical cancer, so far as single women were concerned, were only 62 per million; for married women without children they were 111; for married women with children they were 142, and for divorced women and widows they were 211.
§ The same report said that among film artistes and actresses generally the rate was much higher than was normal for their particular social class. It said also that among women who married at a very early age, in their teens, there was an increased liability. It said also, very significantly, that among nuns the rate was very low indeed. It seems to me that this reveals a possible causative factor, but I do not want to go into that this afternoon. I do not want to talk about causes, but about the ease with which this disease can be diagnosed and the ease with which it can be treated.
§ It is fortunate that a very simple testing device has been discovered which will reveal the early stages of cervical cancer at a time when it can be treated very successfully indeed. But the test goes very much further than that. It reveals also the presence of a pre-cancerous condition where there are no symptoms, where the woman has no suspicions whatsoever, and where the actual cancer itself may not grow for ten or fifteen years. When once this pre-cancerous condition has been discovered, then a minor operation will cure it. Only about ten days are needed in hospital, and the ability of the woman to bear children in future is not affected in any way at all.
§ I hope, therefore, that there will be a speeding-up of this routine checking and testing of women in the ages of risk, which are generally realised to be between 35 and 65. Your Lordships will know all about the nature of this testing, but I am afraid there are a good many women who do not. It is a simple affair. It merely involves taking an internal smear which can be taken by the family doctor, the local authority clinic or by 739 the gynæcological department of a hospital. It takes a few minutes, causes no pain and gives no trouble at all. Later, the smear has to go to a hospital laboratory for testing, where the services of trained pathologists and technicians are needed and where a certain amount of special apparatus is also necessary. This is where the real difficulty arises, because there has been a shortage of these technicians. The need to train them is very urgent indeed, and I doubt whether the urgency that has been shown in recent years has been sufficient to meet the situation.
§ May I go back into the history of this particular process for a year or two? In 1962, the Central Health Services Council admitted that there were benefits to be derived from this kind of testing, but they would not go further than to suggest that the testing service should be allowed to develop, as they said, gradually and naturally. There, I think, they were being over-cautious. In 1963 they were slightly more progressive, but still their motto was one of "go slow". They were suggesting only that the facilities should be made available to gynæcological hospitals and general practitioners—in other words, for women who, by the very nature of things, were already under some degree of gynæcological suspicion. There was nothing suggested for the ordinary woman who was not aware of any symptoms.
§ One thing they did suggest, in the year 1963, was that more laboratories should be equipped in hospitals. Unfortunately, they did not suggest that there should be any speed-up of the training of pathologists and technicians. They contented themselves with suggesting that there should be some recruiting of those specialists, and said that the number who would be needed was not formidable. I believe that they underestimated the needs of the situation. However, in the same year, 1963, the Ministry themselves showed a little more courage. They said that the value of these tests was fully accepted. They accepted in principle the policy of testing women over the age of 35, but they warned that there would be a considerable period of delay before these tests could become routine. They admitted that there was a shortage of staff, and 740 said that for the time being the tests would have to be confined to the gynæcological departments of hospitals, and, of course, to cater for any women who might be referred to them by their own family practitioners. It must be said that later in the year the Minister decided to set on foot some system of training these technicians.
In 1964, the Ministry themselves were showing much greater urgency. Three training centres were set up, and two more were envisaged; and the possible use of local authority clinics was mentioned, but nothing more than mentioned. By the end of last year, the position was this: there were 200 pathologists trained in this process; there were 150 technicians trained, and women were being tested at the rate of 39,000 a month. But once again these were not the ordinary run of women; they were women who were already under inspection by their doctors or in hospitals for some gynæcological condition. At the end of the year, the Ministry admitted that the position was still lagging. What the Ministry's Annual Report said was this:
The rapid expansion of laboratory facilities has not yet overtaken the even more rapid increase in public demand.
§ I have traced those developments through the last few years with no other object than to show that the medical profession itself is not unalert of the need for these developments, and to indicate that some drive, some impetus, has to be imposed by Parliament as well. A few months ago, I believe, the position had improved. I think that by then about 280 pathologists, and 380 technicians had been trained. I hope that this afternoon Her Majesty's Government will be able to report some further progress, for it is on this question of the training of these technicians that the whole success or failure of this scheme must depend.
§ The Trades Union Congress, which has many hundreds of thousands of women members, and speaks on behalf of millions of women in industry, and has taken very close interest, along with its medical advisers, in this question, estimates that about 750 technicians will be needed. I do not know whether that figure is too high. It may conceivably be so, but we have to bear in mind this 741 other factor, that the greatest efficiency is not necessarily achieved by keeping these technicians employed all day on this particular kind of testing and on nothing else—and the greatest possible degree of accuracy is necessary here. So perhaps the 750, if your Lordships bear in mind that they should not spend their full time on this work, may not be very wide of the mark.
§ I should like to put a few questions to the Minister who will be replying, because I think they will enable us to get a picture of the situation. The first is: How many pathologists and technicians do the Ministry, and the profession, think will be necessary to give routine testing every five years, or, alternatively, every three years? Second, when these technicians finish their central training and go back to their local hospitals, do they then there pass on that training to other people? Third, has any attempt been made to bring back married medical women from retirement into part-time work in this activity? Fourth, has it been considered whether we should import specialists from abroad for periods of six or twelve months till our own shortage has been overcome? Fifth, can we reduce some of the need for these scarce technicians by resorting to biochemical tests or automatic electronic screening? Sixth, are some Regional Hospital Boards more advanced in the facilities they have provided than others, and is there any question of progress being held up by lack of funds? Seven, to what extent is the testing of what we will call symptomless women being carried on by general practitioners at this stage? And, finally, can the Government give us a general idea of what the extent of this available service will be by the end of this year and, additionally, by the end of next year?
§ I want to distinguish between the two separate aspects of this question. The first concerns the facilities which are available for women already undergoing gynæcological treatment, either with their doctors or in hospital. I believe they are fully catered for, but here, of course, we are fighting a defensive rearguard action. The second aspect concerns the facilities which should be available in a general routine way for women who have no suspicions and are aware of no symptoms; and here we are carrying the war right into the enemy's camp. I should like to 742 feel that adequate resources will soon be available for making these testing facilities accessible to all women in the risk group, which is between the ages of 35 and 65. I know some progress is definitely being made in a number of places. My own County Council of Essex has adopted a scheme for providing many of these facilities at some of its health clinics. The East Sussex County Council has adopted quite a comprehensive scheme; in Manchester and Cardiff wonderful work is being done. At Brighton and Leamington the pioneers have started work on a voluntary basis without waiting for official and formal schemes; and in Scotland there are about thirty family planning clinics where these facilities are available. There are some family planning clinics in England and Wales as well which are providing the service.
§ These are only a few of the examples which might be given to show that local authorities are becoming aware of a service which they ought to provide. I believe fifty other local authorities have already obtained permission from the Ministry to set up these services or are in process of negotiating for them, and I am told that by the end of this year there will he 130 hospitals which will he able to carry out the microscopical testing processes. I hope that as these facilities become available in one district after another they will be very well publicised, because it is no use having the facilities if the fullest possible use is not made of them.
§ It may be said that many women are rather apprehensive about undergoing this test. They should not be nervous, because it is a simple test which takes only a few minutes. But there is this fear factor in the minds of women, and in addition to advertising the availability of the service our local health authorities will also have to undertake positive educational propaganda in an attempt to convince women of the desirability of presenting themselves. The women have everything to gain and nothing whatsoever to lose.
§ If we take the United Kingdom as a whole as distinct from England and Wales, for which many of these statistics are published, there are nearly 3,000 women each year who die of cervical cancer. It may not be a very large number when we set it against the 110,000 743 people who die from cancer in all its forms, but if we add to it the further number who die after the cancer of the cervix has invaded the body of the womb we then reach a figure which accounts for a fifth of all the deaths from cancer of women under the age of 50; and, in any event, the figure is nearly half as big as the number of fatalities that we have each year on the roads. The really important fact is not the number of women who die from this disease; the important fact is that practically all these 3,000 could have their lives saved if this service were available, because they are women who have not yet reached old age and who normally have a good expectation of life before them. I am assured that there is no difficulty in treating in the hospitals those cases which are diagnosed as cancer. It is useful to know that, because it would be no use whatsoever discovering the women suffering from this form of cancer if it were not possible to take them into hospital and give them the simple operation which is needed to remedy it.
§ The real difficulty is this question of early diagnosis, but of course apart from the actual death roll we have to take account of another factor. There are undoubtedly millions of women who are very much worried about whether they are going to discover that they are suffering from cancer at some time of their lives. There is really no reason why they should, in many cases. Of every 1,000 cases that go for a test, 997 are given a clean bill of health. Their fears, their phobias, can be removed for ever as a result of this test; and in the other 3 out of 1,000, where there is a positive reaction, a week or ten days in hospital and a simple operation will put them at ease for the rest of their lives.
§ My Lords, I believe that this five-year test must be introduced as quickly as possible, and as widely as possible. Despite this phobia that exists about cancer, most thinking women are already pleading eagerly for the introduction of these general facilities. The Women's Institutes, the Townswomen's Guild, the National Council of Women, the Women's British Legion have all asked for these facilities to be generally provided. The University Women's Guild, The Medical Women's Federation, and The Health Visitors' Association have said the same 744 thing. I believe that the Liberal and Conservative women's organisations have also clamoured for it. The Trades Union Congress, as I said, has been in close contact with the Minister on this matter for some time past, and if we look at the Labour Party agenda for the recent Conference we find four motions demanding these general facilities; and, if I might put that in perspective, I would add that those four motions compare with only one motion calling for the outright abolition of your Lordships' House!
§ I do not want to plunge into the confused controversial sea which concerns contraception. But there have been suggestions that the growing use of the pill might, in many years' time—not in the immediate future—possibly have (and they go no further than that) some results of a cancerous kind. It would be unfair to attack the pill at this time on any such grounds as that, but what I am saying is that its growing use provides us with an additional reason why we should take very seriously this question of routine periodical checks, because we are tampering rather in the dark with a very delicate piece of machinery.
§ In schemes of the kind which are being suggested for general routine testing, an interval of five years is understood to be acceptable at the beginning, but three years is regarded by medical experts as being desirable later on. Such schemes are in existence in Germany and Switzerland, in Canada and the United States, and in Russia; and also, to some degree, in China, though there, of course, the scheme is not general. But I think we are all aware of the huge success that attended the mass X-ray campaign against tuberculosis a few years ago. I have the feeling, and so have many other people, that if a similar mass campaign on behalf of cervical cancer were carried on in the same serious mood we might meet with a similar degree of success. And in that event it could bring peace to millions of women; it could make many happier homes; it could save 3,000 lives a year, and prevent an enormous amount of suffering. The real difficulty, as I have said, is in securing adequate numbers of properly trained technicians. I hope that Her Majesty's Government will approach that particular aspect of the subject with all the responsibility and urgency that it seems to call for, because 745 prevention is still better than cure. And certainly I hope that the Minister will be able to give us to-day a satisfactory report on progress.
§ 3.12 p.m.
§ LORD AUCKLAND
My Lords, the House will have listened with much interest to the noble Lord, Lord Leather-land, who has raised a matter of great importance, and, as he has said, of great concern to many people in this country. I hope, however, that the publicity which is given to this condition will be put in its proper perspective. I have been in very recent contact with the Clerk to the Corporation of the City of London who has given me some facts which I should like to reveal to your Lordships' House, together with some questions emanating from them. As your Lordships know, the working population of the City of London is growing very much year by year, and more and more women are included among those who travel from the suburbs to work in the City.
In 1959 the City Corporation set up a cancer diagnostic clinic which is now very widely used. Currently there is a grant of between £5,000 and £6,000 per year from the City Corporation for diagnosis of cancer, and I believe that a good proportion of this is directed to cervical cancer. This year already 468 women have been diagnosed at this clinic and 15 are seen at each weekly session. But, of course, as your Lordships will appreciate, this is a very small proportion of those who would like to receive these services. The trouble is that, as a result of an article in a women's magazine very recently, there has been a vast increase in the number of women from all over the Home Counties who are trying to flood into this clinic, with the result that the staff, and the staff of St. Bartholomew's Hospital, which also has facilities for diagnosis, cannot cope. I should like to ask the noble Lord, Lord Champion, what facilities will be extended to the larger hospitals, particularly in the South-Eastern Area, and the South-Eastern and South-Western Metropolitan Hospital Boards, because if it were possible to set up centres there and to train technicians and staffs, which I understand is an extremely difficult business, it would offset the problems that face the clinic and St. Bartholomew's Hospital in the City of London.
746 I should also like to ask the noble Lord what is being done further North. A new medical school is to be set up at Nottingham. Nottingham and Leicester, particularly, have very large elements of female population, and it seems to me very important that if a new medical school is to be set up some clinic of this kind or some facilities of this kind, together with the necessary staffs, should be given priority; because, as the noble Lord, Lord Leatherland, has said, this is a very difficult problem and 3,000 mortalities per year is a tragically high number. Quite clearly, if one can set up more clinics and train more staffs this number may well be reduced. The noble Lord also mentioned the question of funds, and I would ask the noble Lord, Lord Champion, whether he will convey to his right honourable friend the point that in forthcoming years more funds should be directed towards Regional Boards for providing the necessary facilities, particularly for this kind of cancer.
As I have said, the problem in the City of London is very acute, and there is a waiting list up till next May for women to be availed of these facilities. This is a staggering and very disturbing situation, and I would ask whether the Government are seized of the urgent priority which this matter should receive. While we recognise that so many types of cancer are incurable (and as one who has lost two valued friends very recently through cancer I have seen this myself), I would urge the Government to make this question of cervical cancer a priority one where it is needed.
§ 3.17 p.m.
§ BARONESS SUMMERSKILL
My Lords, I feel that we should all thank my noble friend Lord Leatherland for giving us an opportunity of focusing the attention of the House on this most important aspect of preventive medicine—because that is how we must regard it to-day. This is not the first time that this matter has been discussed. I have raised it on occasions when we in your Lordships' House have had debates on health; it has been raised in another place, and, as my noble friend Lord Leatherland quite rightly said, conference after conference, usually women's conferences, put this matter on the order paper in some form 747 of motion and ask the Ministry to recognise that the area in which the conference is held has not been given these facilities.
What is the degree of importance of this debate? The degree of importance is that cancer of the uterine cervix is now a preventable disease. This is not the view of a few doctors; there is no group which dissents from it. It is the view of the committee of cancer experts which was convened by the World Health Organisation. Therefore, if we argue from that premise, those who are responsible for dragging their feet by failing to provide these facilities are surely guilty of a most grave omission in the Health Services, for if we are to prevent cancer we must in the first place recognise the pre-cancerous condition. Unfortunately, we cannot come to the House and say in a dogmatic fashion that in many conditions of cancer we now recognise the pre-cancerous condition, but we can in cancer of the cervix, and that is why my noble friend quite rightly comes to my noble friend who is answering for the Minister and asks him to recognise this as a matter of great urgency. I would also remind the House of what this expert committee of the World Health Organisation said on the subject. They said:The training of the medical profession in this subject is perhaps one of the most important current aspects of cancer prevention. It is most urgent that such training as is now practical in certain countries should be made world-wide".The cytological examination of women for cancer must in the first place depend on the routine taking of cervical smears, which my noble friend has mentioned. He does say, of course, that only those women in gynæcoloaical clinics would have the opportunity. But I would remind him that there are women now in ante-natal clinics, post-natal clinics, obstetrical clinics, family planning organisations, and in all such places they should be given this treatment as a routine measure. No woman should be satisfied when she is discharged from one of these clinics unless she can ask herself, "Was a smear taken?" That is the question she must ask, and that is the question she must have the courage to ask the authorities. She must not be afraid. They are there to do a job and, if they fail to do it, she has a right to say "Have you done this? Have you examined me 748 to see if my cervix is in a pre-cancerous condition?" If they have not done this, they have failed her, and indeed they have been negligent. Not only must smears be taken in the clinic, but the general practitioner must also be given an opportunity of sending a smear in to a laboratory.
My noble friend asked a lot of questions, but the one I want to ask is a fairly simple one and is more or less embodied in his. I want to ask the noble Lord who is here to answer for the Ministry: What is the position in the country today? Which areas have failed completely to respond to the invitation to set up laboratories and to instruct their clinics to take these smears? The second examination must consist of the screening of women in a given population at set intervals. What has the Ministry done in this respect? What areas of the country now are being subjected to screening? My noble friend must not answer by saying, "I have not been given a warning" The Ministry has been warned for years, and this debate is now being held because the whole of the women of the country (the noble Lord opposite calls them "the element of female population") are demanding that—
§ LORD AUCKLAND
My Lords, may I just qualify what the noble Baroness has said? I was referring to the fact that two of our largest Midland cities have a large preponderance of women who are naturally especially anxious about this particular matter.
§ BARONESS SUMMERSKILL
My Lords, I was merely joking at the phrase "female element", nothing more. I was not criticising the substance of the noble Lord's speech. To me, it is absolutely delightful to find men interested in this subject, and therefore I welcome his contribution. I was saying that my noble friend must not say that he has not had warning, and if the Ministry give him that answer the time has come to tell them that they are dragging their feet. They have been prodded; they have been talked to nicely by pathologists all over the country; they have been asked by women's organizations—and I hope we are not too high and mighty to ignore these conferences of women—to see that facilities are established in every part of the country.
749 Some countries have already embarked on large-scale surveys. From Canada it was reported that a decrease of 45 per cent. in the incidence of clinical cervical cancer was achieved in eight years in a section of the population in which half the women had been regularly screened. These figures come from the Report of the World Health Organisation. A survey in China of over one million women gave a detection rate of carcinoma in situ of 0.145 per cent. of those examined. The astonishing thing is that, although exfoliative cytology as a practical diagnostic measure was first prescribed by Dudgeon in St. Thomas's, across the water, some forty years ago, we seem to be the last nation of any consequence—in fact we fall behind Communist China—to exploit its potential.
If we are to be told—and this is what I anticipate—that the failure to take more energetic action is due to the shortage of suitable women for training, may I again ask (I have asked this before, and my noble friend behind me has just mentioned it) what efforts are being made to use the part-time services of women doctors? An estimate has been made by the Royal Free Hospital that altogether 5,000 women on the medical register are not practising. I need not remind your Lordships of the difficulty of finding domestic help in these days. Many of these women are married, the majority with a small family; and they find that they cannot secure women who they feel are adequately qualified to care for their homes and their children while they practise as doctors. So, for a comparatively short time, they are out of circulation. But they have part-time to spare.
I have asked Professor Kenneth Hill, the Professor of Pathology at the Royal Free Hospital, for his opinion on the matter and he has been most helpful. I regard Professor Hill as one of the most eminent pathologists in the country, and he has written to me. I should like to put this on the Record so that the Ministry can read it carefully. He says:My colleagues and I believe that married women doctors could he employed in the field of cytology on a part-time basis. We believe that this could be preceded by a course of training at one of the Ministry of Health training centres, for example, the Royal Free Hospital, for a period of six months. This training would, of necessity, be on a part- 750 time basis, meaning that they would attend for five half-days a week—that is to say, 10 a.m. to 3 p.m., but allowing two to three weeks off for school holidays within the period of this six months. After the period of six months it should be clearly realised that these cytologists would not be experts…but could help to develop the Cytology Service in conjunction with pathology departments and pathologists generally".Professor Hill is realistic in his approach, and understands of course that these women doctors will not be forthcoming if the financial considerations involved are ignored. Therefore, he has added this. I ask your Lordships to forgive me if I mention some figures, but I think they should go on the Record because this is the nub of the situation—how we are to get these technologists to do the work. He says:In order to encourage married women to do this, the Government must seriously look at the financial incentives given to the professional woman. Some two years ago, in New Society, it was estimated that for the first £1,000 of a working mother's earnings, the expenditure may well be: tax and insurance, £200; domestic help, £450; transport. £150; extra expenditure, £150; net profit £50.He continues:By any standards, a net profit of £50 is hardly an incentive, when other disadvantages must be weighed against it. The Government should also take into consideration that, besides current tax relief, the employment of married women in a part-time capacity during the early part of their working life should he considered as a continued capital investment over and above the £10,000 already spent on their undergraduate education. If she is kept professionally active, then, when domestic responsibilities have diminished, the woman doctor can proceed at full speed on a full-time job.There is the answer to the complaint that there are not enough women to be used.
This is not, of course, the first time that information has been sought about what facilities are available, and on every occasion (I will be kind to my noble friend who is to reply, because I will give him time to find out the answers to some of these questions) the Government have answered, "We have not got the women". May I suggest something else? In view of the pressure on our available doctors, could we not use B.Sc's. in biology as cyto-technicians after one year's training? Could we not use secondary or grammar school candidates with "A" level, or its equivalent, in biology after two years' training? In order to preserve the salary structure of the medical laboratory technicians who have undergone five 751 years' training, and who, I understand, might object to this new proposition, a special category of salary scale must be made for cyto-technicians. It is no good classifying them as junior technicians, because the salary ceiling would inhibit recruitment.
My noble friend quite rightly said that three training centres were originally established and two more have been established since, so there are now five training centres in England and Wales; but still this is not enough. I am given to understand—and I can assure your Lordships that my information comes from the most reliable sources—that the report of the first year's working shows that relatively few pathologists are attending the centres and that technicians, after a three months' course of training, have gone back to laboratories where pathologists have not shown any particular interest and where little work has been demanded. Perhaps this is the answer to the noble Lord, Lord Auckland, who has told us that there is a queue until next May for this simple smear-taking process. The latest reports on work in the centres are entirely unsatisfactory. My information has been given to me by one of the most eminent pathologists in the whole country.
Why is this the case? I suggest that the fault lies in the method of financing the centres. The Ministry, in order to start the five training centres, made a central allocation to cover two years, which is the projected life of these training centres. But then the responsibility is put on to the shoulders of Regional Hospital Boards to allocate money to the cytology service. As we all know, every Regional Hospital Board has a number of priorities, and members of Boards attach more importance to one priority than to another. We have found that the field of cytology is given very little consideration. Therefore, I would suggest to the Ministry that the time has come when they must recognise what the World Health Organisation said in this matter—that the Government of the country should be directly responsible and that the Ministry should not even delegate its function in this way to the Regional Hospital Boards.
If this service is unsatisfactory, as it clearly is, if there is a queue of women waiting to have this preventive measure, 752 then there is something wrong. If other countries like Canada and China are in the forefront of this preventive medicine, then we have failed the women of this country. All I have to say is that this preventive service in regard to a malignant disease, which takes a toll in terms of human suffering which cannot be assessed, places a heavy burden on the consciences of us all. If the Ministry are thinking in terms of finance, I would remind them that it is cheaper in the long run to prevent this terrible, deadly disease than to allow these women to wait until they are infected. Therefore, on humane and economic grounds, I hope the Ministry of Health will show greater energy and expedition in providing a nation-wide service.
§ 3.35 p.m.
§ LORD SEGAL
My Lords, in common with the noble Lord, Lord Auckland, and the noble Baroness, Lady Summerskill, I, too, would wish to join in paying a tribute to my noble friend Lord Leather-land for having raised this subject for debate this afternoon. Knowing him as we all do, I am sure he will be readily exonerated from any suspicion of a smear campaign against the Government. Rather, one ought to be grateful to him for trying to prevail upon the Government to urge them to conduct a really active campaign to clear up this terrible scourge which is now prevalent in our midst.
That there is still room for further advance is best illustrated in a reply given in another place on March 15 this year, and I quote from the Hansard of that date. The honourable Member for Bournemouth (Christchurch) asked the Minister of Healthwhether he will consider the experimental use of mobile units, similar to those successfully used for mass X-ray in the detection of lung diseases, for diagnostic tests as a means of detecting cervical cancer."—[OFFICIAL REPORT. Commons, Vol. 708, col. 183, March 15, 1965.]If I may point it out to my noble friend who is to reply, the Answer given on that occasion is to my mind a perfect example of a side-tracking answer. This was the Answer the Minister gave:For mass X-ray vans are needed to carry complex equipment. Very little equipment is needed for taking cervical smears and so the same need does not arise. Many types of accommodation are adequate for this purpose." [Ibid.]753 But surely if very little equipment is needed for carrying out these tests, one would have thought that this was all the stronger reason for having these mobile examination vans started by the Government so that the patient is not required to come to the doctor for examination. In the same way as examination for prevention of lung cancer reaches out to all sections of the community, so I feel these vans could very easily be equipped for a similar purpose. It is a strong argument that the Government ought to bear in mind in initiating this campaign.
One is fully aware of the difficulties involved in carrying out these tests. It is not sufficient simply that a smear should be taken. What happens after the slide is subjected to examination? At least forty minutes are required before a clear opinion can be given whether or not a slide shows sips of a positive smear. If it is borne in mind that the eye fatigue of a specialist, experienced in looking through a microscope continuously during the course of a day, enables him to do something like four hours only of continuous scrutiny, one realises that only about six slides, or perhaps eight slides at the most, can be carefully examined even by an expert.
When one thinks of what is at stake in the result of each examination, one realises that what is important is the question not only of proper training, but also following on the training, of having properly experienced specialists, pathologists or technicians, to scrutinise carefully a slide which is sent up to them for examination. We all realise that there is a shortage of pathologists and technicians, and I understand that now the period of training has been reduced to something like three months. But to train a technician in cytology to become really expert, anything from six months to twelve months is required, and I suggest that in order to acquire the experience that follows on the training it would be far better to allow these technicians six months rather than three months before they are permitted to decide on the fate of a patient who comes up for examination.
I have said that something like six to eight slides only can be examined during the course of a day by a single person. If we realise that this is thirty slides a week and that ten weeks of concentrated 754 examination are required before one suspicious case turns up, it means that in the course of a year of fifty weeks something like five doubtful cases may appear for examination in the hands of a skilled microscopist. Although the appalling figure of something like 3,000 to 3,500 deaths from cervical cancer occurs each year, the actual incidence of cervical cancer is very much higher. Whatever the mortality rate may be estimated at—and it is rather difficult to get accurate figures—it surely must mean that something like 12,000 to 15,000 cases of cervical cancer come up for treatment each year, and surely this figure is sufficient for the Ministry to realise that the steps which are now being taken are totally inadequate to meet the present need. The risk of an error in diagnosis is such, to my mind, that it requires a highly trained and skilled examination of all the slides that are sent up.
Not only is there the risk of error in diagnosis of women between the ages of 35 to 65, the commonest period of incidence, but there is also the risk in those exceptional cases of cancer which occur below the age of 35, and surely adequate provision should be made available. Anyone in doubt would then have full facilities provided to enable these tests to be carefully carried out. Whatever the risks may be of cancer phobia, or of neurosis, or even of an obsession of cancer, these appallingly difficult cases which the doctors are sometimes called upon to treat do not justify the Ministry at this stage in being content with these totally inadequate measures.
Reference has already been made to new methods of diagnosis. In addition to the cytological tests, there are chemical tests now undergoing investigation which may yield far more accurate and far more effective results than the cytological tests. It is hoped that these chemical tests will enable a specialist to diagnose not only cancer of the cervix, but also cancer of the ovaries and cancer of the body of the uterus, which are also prevalent to a marked degree and are sometimes hidden from a cursory cytological examination. The remark has been made that men usually suffer from neoplasms in a much more acute form than women do; that if cancer of the prostate were as insidious in its onset as cancer of the cervix, perhaps more radical and more energetic measures 755 might be impressed upon the Ministry. But I come back to my original plea, that the great need to-day is for mass cervical examination tests to be carried out in properly equipped vans, specially adapted for the purpose, on symptom-free women, of whatever age group, who may feel uneasy about themselves.
There should be no real difficulty for the Ministry to initiate a pilot scheme on a relatively small scale, to see how it would operate in a restricted area, and at this stage I think there is no excuse whatever for any delay in that respect on the part of the Ministry. The women who went to these mobile examination centres would be issued with leaflets carefully explaining to them what were the risks of neglecting treatment, and given reassurance that proper early treatment could lead to a complete cure, and I think that nothing but good could result from the Ministry's undertaking a campaign now on a restricted scale to provide these mobile examination centres. The time is overdue when our country should no longer be content to lag behind Canada and America in initiating these mobile centres, and should do the examinations even on symptom-free women of all ages. It is also high time that our own country took a lead in the whole world, in eliminating once and for all this deadly scourge which exists in our midst.
§ 3.48 p.m.
§ LORD AMULREE
My Lords, I must apologise to your Lordships, and to the noble Lord, Lord Leatherland, because I was not able to be present when this debate began, but I think I have heard enough of what has been said to realise that there is little more for me to add at this time as the field has been very widely covered. I should like to say how pleased I was to find that the noble Lord, Lord Leather-land, was going to draw attention to the urgent need for more of this kind of work to be done. I say that, because it has been known for quite a long time that if cancer of the cervix is treated early it can be one of the most successful forms of treatment for cancer that we know. But the trouble at the present time is that so few women go to see their doctor in time for the treatment to be as successful at it could be.
756 The work which can be done by the examination of cervical smears is very important. Not only can such an examination detect cancer in what one might call a pre-cancerous stage, when it has not fully developed, but I think I am right in saying that it can also detect cancer when it is very early in its growth and, therefore, particularly prone or liable to successful treatment. So we are pleased to find that the number of centres where instruction is given has gone up to five. That seems quite a good beginning, but there is obviously a very long way to go before the country is completely covered.
The point I should like to say one or two words about is this: What is the most satisfactory way of getting these smears to the experienced technician or pathologist? Because, although you may have very good technicians, so far as I can make out a fairly large number of these smears must be examined by a trained pathologist as well as a technician, so the work will not be done entirely by a technician. But here, I should have thought, a great deal could be done by the local health authority; by the medical officer of health and his staff working from his clinics. There is a certain attraction about a van travelling around the country, like the mass radiography unit did; but it seems to me that it would be much simpler if use could be made of the existing clinics, except perhaps in the country areas where these do not exist. There, I think it should be possible for general practitioners, if they so want, to take the smears themselves and to post them to the centre.
Another advantage of the local authority doing it is that they have the means of advertising; they have the means of telling people what it is all about and of encouraging people to come to the centres for examination and tests. I do not think the amount of money involved is going to be very large when one compares it with the amount of suffering which can be prevented and with the expense which is involved in treating a cancer which is fully developed. Even if it is not done by major surgery but by radiotherapy, by radium, by deep X-rays or by various forms of ray therapy, the expense is very considerable; and, as has been said by other noble Lords who have spoken, it would be a great economic advantage if we could prevent this 757 disease, which seems to me to be one of the really preventable ones, before it comes along.
There will, of course, be certain administrative difficulties, but they are merely there to be overcome. What is the proper time or the proper frequency at which women should be examined? Should they begin at 30 or 35? Should the examinations take place every five years, every three years, every one year? What are you going to do with the person who gets some sort of phobia or feeling about it all? Ought she to be examined every fortnight? There are certain things like that which have obviously got to be thought about and dealt with, but these are minor matters compared with the importance of getting such a scheme going as quickly as we can. I should therefore like to support every word that has been said by the noble Lord, Lord Leatherland, and I trust that the noble Lord, Lord Champion, will be able to give us a satisfactory reply.
§ 3.53 p.m.
My Lords, before the noble Lord, Lord Champion, answers, may I very shortly say that I have a particular and personal reason to be grateful to the noble Lord, Lord Leatherland, for raising this subject because, in what he has said, he has thrown a good deal of light on the only case of cervical cancer with which I have been personally concerned. This was the case of a woman who died before the age of 50, a widow with four children, whose husband had been killed more than twenty years before. She was not at all ignorant of medical things and, unlike me, was rather interested and not at all frightened. I was particularly interested because this was my sister, and at the time I felt a certain shame for my not knowing more about it—and I feel more so now.
I was also interested in what the noble Lord said about the particular councils which are taking this up, and later on I should like to ask him privately one or two questions about this. But, as the only person here who is ignorant of medical things, I should like to emphasise that I believe it is very important that a satisfactory answer should be give to what I think are the very clear questions that have been asked.
§ 3.55 p.m.
§ THE MINISTER WITHOUT PORTFOLIO (LORD CHAMPION)
My Lords, I am sure that the whole House is extremely grateful to the noble Lord, Lord Leatherland, for asking his Question, and for the manner of its asking. I believe that his opening remarks, particularly, were a message of assurance and hope for women—those women who are at risk from this cervical cancer. This applies also to the remarks of the other noble Lords, and particularly those who have had medical experience: what they have said is a message of hope. What we, as the Government, have to do is to try to carry out as rapidly as possible the things that will make this screening possible and the treatment available to everybody. That is our job.
I must say that at this moment I very much regret the decision of my noble friend Lord Taylor, for personal reasons, to resign from the job that he held—and I do so for three reasons. First of all, his valuable knowledge in the health field has been lost to the Government, and to some extent to the House. Secondly, his competence at this Box was such that I, sitting behind him, was completely happy with his performances here. Thirdly—a much less worthy reason—I have been deputed to undertake in his stead, with no specialised background of knowledge, the task of answering for the Ministry of Health in this House. But, my Lords, I will do my best. I think that in this matter the Government have a good story to tell—not due only to this Government, of course. As has been said, this work was started some time ago. What is being done at this time is an extension, and I hope a fairly rapid extension, of what was started during the period of the last Administration.
As I say, there has been good progress, which continues to be made, in providing the facilities for these cervical cancer tests. The noble Lord, Lord Leatherland, asked a similar Question about progress on March 3, and the reply then was that women were being tested at the rate of 39,000 per month. I am glad to be able to tell the House that the returns from hospital authorities for June showed that the rate had risen then to 51,000 per month. The pace of progress naturally varies in different parts of the country. 759 In some areas routine screening for cervical cancer is in full swing; in others it is starting; while in a number of areas the service is for the present still limited to a diagnostic service for patients with symptoms. Here, I agree with the noble Baroness, Lady Summerskill, that this just is not good enough; and it must be our job, from the centre, to stimulate activity in those areas where they are still failing to provide the full service which we hope to be able to provide throughout the whole of the country when the technicians and pathologists are in fact available.
The pattern of local arrangements varies from place to place. In all areas smears are examined in the hospital pathology laboratories, but smears may be taken in the family doctors' surgeries or in hospital, in local health authority clinics or in voluntary clinics. Everywhere this service is a co-operative venture between the three branches of the Health Service; and while most of the smears are still taken in hospital clinics, the proportion of them taken elsewhere rose from about one-quarter at the end of last year to one-third in June. This reflects the increasing participation in the service of family doctors, local health authorities and voluntary clinics.
The smears taken by family doctors, for example, have almost doubled in number and those from the local health authorities' clinics have trebled. The contribution of the local health authorities is especially to be commended. Whereas the number of councils that had taken power to participate in screening was only 3 at the end of last year, it is now 51; and the number will be substantially higher by the end of this year. I must, however, point out that 51 is only just approaching one-third of those who could take this power. We hope for a substantially higher number by the end of the year and expect this hope to be realised. These figures reflect the keen interest displayed by local authorities in the screening service. The noble Lord, Lord Leatherland, mentioned some of those authorities which have been particularly good and advanced in this field, and we welcome this.
The noble Lord, Lord Leatherland, is, I think, particularly anxious to know what progress will be made by the end 760 of next year. It is rather difficult to be precise since so many different local factors are involved: the speed of recruitment and training of laboratory staffs; the degree of financial priority that hospital authorities are able to give to the service; the extent of the co-operation of the general practitioners and the local health authorities; and, even, the local differences, which are quite marked, in the proportion of women coming forward for testing. However, by the end of next year we expect screening to be local and readily available to well over half the female population over 35, and we hope it will be possible for any woman anywhere who especially wants a test to obtain it.
Nevertheless, we must go beyond that. I think it is quite clear that the time must come (and this has been mentioned by noble Lords) when we should be not only able to provide the service for the women who know about it and who ask for the test, but educating women of all classes in the necessity for having this test. This is a job of education which must be undertaken. But we cannot, until the services are available everywhere, embark upon mass education and propaganda only to disappoint the women concerned because the screening is not available everywhere. But this, of course, does not and would not prevent local authorities, where it is possible for these tests to be carried out, themselves to undertake a certain and necessary measure of education. Education is most needed in that class of the population which is clearly shown to be at the greatest risk. This point was made by the noble Lord, Lord Leatherland. In some measure the classes one would expect to be better informed, who come forward voluntarily, and who understand what all this means are the classes who are not at great risk. It is the other classes that we must somehow get at. This I hope and expect the Minister to do something about; but we must not lead people to believe that all the facilities are available in their localities, only to disappoint them. This would be the wrong thing to do.
My Lords, I should now like to turn to the question of laboratory staff. As noble Lords know, the main problem in developing the screening service has been the shortage of laboratory staff trained in cytology. At the end of last year hospital 761 laboratories in England and Wales already had in post some 200 pathologists and 150 technicians trained in cytology. I am glad to be able to tell the House that at the end of June these numbers had risen to 283 pathologists and 383 technicians, and that a further 29 pathologists and 131 technicians are undergoing training either at the five special centres or under local training arrangements in the hospital regions. The demand for places in the five special centres continues at a satisfactory rate and we foresee that there will be the need for the training facilities they provide for the next twelve months. The training programme will be carried forward with vigour. This represents an encouraging increase in the number of laboratory staff trained in this special field. The training of these staffs provides a solid basis for the expansion of population screening, and while there will continue to be local variations in the programme the general picture is one of steady and continuing expansion.
My Lords, I have been asked a number of specific questions. I am grateful to the noble Lord, Lord Leatherland, for giving me notice of the questions he was going to ask. The first of his questions was: How many pathologists and technicians do the Ministry and the profession think are needed to give a full testing service every five years and, alternatively, every three years? The answer is that the number of pathologists is already sufficient to provide the essential check of positive smears obtained in population screening. On the latest calculations, about 500 whole-time technicians would be required to screen adult women in England and Wales once every five years and, perhaps, 800 to 850 if the screening is to take place every three years. Since cytology is part of hospital pathology, many of the trained staff necessarily work part-time on other duties. I must admit that I think it is important that we should recognise, when we are talking about the training of laboratory technicians, that the people trained for this work will have to be trained in accordance with standards which have been laid down following the passing by Parliament of the Professions Supplementary to Medicine Act.
There is also the fact—and I think this was brought out with some force by the noble Lord, Lord Segal—that per 762 haps it would not be wise to train and expect people to have their eye to the microscope for hours on end. It is well that it should be possible for them to be used in other fields because a change is as good as a rest; that is what it amounts to. Too high a degree of specialisation or too short a course would be wrong in this field. And this, I believe, would be the opinion of those engaged in pathological work who understand what is involved. But, clearly, the remarks that have been made about this will be studied by the Minister. The second question that was asked by the noble Lord, Lord Leatherland, was this: Are the people who have been centrally and regionally trained now being used to train others locally on returning to their own hospitals? The answer is that laboratory staff trained in cytology are being employed to assist in training others locally. This applies particularly to those from the five special centres which have been mentioned several times this afternoon.
The third question was, is anything being done to attract married medical women back into the hospitals for part-time testing work? In this connection we had the very pungent remarks of my noble friend Lady Summerskill about how was it possible to attract them back if the financial inducement was not there? I do not propose to enter into a discussion on the figures given by my noble friend, but I can assure her that they are worthy of study, because this problem of getting professional women back into the professions in which they served before marriage, not only in this extremely important sphere but in others, is important, because their skills are being lost to the nation as a result of our inability to attract them back.
The official answer to my noble friend Lord Leatherland is that the employment of married women technicians is a matter for the Regional Hospital Boards. Many of them are seeking recruits from this source and married medical women are more likely to be employed in taking smears unless they have previous experience in pathology. I should have thought this the sort of job that they could do and one which they would be welcomed to do, rather than looking through a microscope. I think this the best way to do it, provided that we can 763 overcome the difficulties mentioned by my noble friend Lady Summerskill.
The fourth question I was asked was: has the possibility been considered of temporarily importing expert technicians from other countries for six or twelve months? The answer is that technicians from other countries already work in our hospital laboratories in order to further their own education. Before such recruits could be employed in routine screening work, it would be necessary for them to be given special training. However, our main aim is to build up a body of trained technicians who will be able to undertake the work in connection with population screening in the years ahead.
The fifth question was: to reduce the number of technicians needed, has any consideration been given to biochemical tests or automatic electronic screening? My Lords, work is in progress at several hospitals on the evaluation of enzyme tests for cytological diagnosis. The Department are also considering, with the Medical Research Council, the possibility of using electronic screening devices. Our present state of knowledge suggests that changes in screening arrangements to take account of these new methods will not be practicable for a considerable time. The noble Lord also asked me whether some Regional Hospital Boards are more advanced than others in providing laboratory facilities, and whether the shortage of funds was causing any delay. This point was referred to by the noble Lord, Lord Auckland, who asked whether sufficient funds are available or whether delay is being caused in the establishment and expansion of this vital and important service.
My Lords, progress in the expansion of laboratory facilities has been generally good, though naturally it varies from region to region. The cost of this service is not very great and should not prove a major difficulty. Special funds have not been allocated for the expansion of laboratory work caused by the screening service, since it is not the practice to earmark sums for particular purposes or services. All Hospital Boards receive a revenue allocation which is reviewed and increased each year in the light of their requirements, 764 including developing the service like cytological testing and it is for the Boards to allocate the sums required. On the other hand, the cost of providing and running the five special training services for laboratory staff has been met from central funds, since these serve a national rather than a regional purpose. This answer makes fairly clear that it is left to the Hospital Boards to decide how fast progress should be.
I feel that at this time the Minister must be considering whether he should stimulate those Boards which are slow in establishing the service, but that is a matter for the Minister. If I happened to be the Minister directly responsible, I should, realising the importance of this service, be calling for returns and exerting such pressure as I could. I would not suspect my right honourable friend of failing to appreciate the extreme importance of this matter. I know my right honourable friend very well, and I am positive that these thoughts are also in his mind.
The seventh question put by the noble Lord, Lord Leatherland, was: to what extent are general practitioners now applying tests to symptomless women? Our returns show the number of women tested, but not the number of general practitioners, hospitals, local authorities or voluntary clinics testing. Out of 51,000 smears examined in June, more than 4,500 came from general practitioners. In the Joint Report of the negotiations between the general practitioners' representatives and the Minister of Health, now before the medical profession, it is proposed to include the taking of cervical smears among the. services for which a special fee may be offered. This may further stimulate the participation of family doctors. I think it a good step, and I hope that it will have the result we seek.
The eighth question put to me was: what will be the general expansion of the service by the end of this year and the end of next year? To a large extent I have answered this point in my opening remarks, but if I may repeat myself, the answer is that at the time of the June return it seemed likely that about one-third of the female population over 35 would have screening available locally before the end of this year, and that a more limited service would be available 765 in most other areas. The return in December will show the position in more detail.
The noble Lord, Lord Auckland, asked at least three questions. The first related to the facilities available in the Metropolitan Region, and he indicated that a large number of people appeared to be swamping a clinic which he knows has been set up. Facilities in the Metropolitan Region are expanding rapidly, and major centres are available in each region—that is, I take it, each Hospital Region within the area. There are now six active local authority clinics in Nottinghamshire, and more are being provided. This should help to clear up the difficulty caused by Nottingham being flooded by people from the surrounding areas. Facilities at St. Bartholomew's Hospital are limited, but other clinics are available in the Central London area.
The noble Lord, Lord Amulree, rightly said that the work cannot be done entirely by technicians. We must have the technicians to back the training and skill of the pathologists. Without them, much of this work would be useless and, as I have shown in the answers I have given and in the first part of my speech, this fact has not been overlooked. We are grateful to the noble Viscount, Lord Barrington, for the point he made out of his deep interest, which arises from his personal experience—a point which I am sure is not lost on the House and on those who are responsible.
My Lords, it may be that I have not answered all the questions put to me 766 this afternoon. I will, however, go carefully through the debate and write to noble Lords, giving them such information as is available to the Ministry on any points that I have failed to answer. I end by thanking all those who have participated in this short debate, and particularly my noble friend Lord Leatherland for having asked this Question, which has enabled me to tell something of a success story, though the Minister will not, and, I would say, dare not, be satisfied until screening is locally and readily available to the whole of the female population regarded as being at risk.