Cervical Screening (Hansard, 18 March 1985)

§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)
My Lords, with the leave of the House. I shall now repeat, in the form of a Statement, the Answer which is being given to a Private Notice Question in another place on cervical screening. The Answer is as follows:
"Last year we gave all health authorities updated, comprehensive guidelines on an effective screening programme based on the advice of an independent expert advisory group. This followed the circular which we issued in December 1981 telling authorities to establish local recall arrangements for cervical screening by April 1983. All authorities should therefore now be offering a full screening service to all women with a recall service to those at highest risk.
"Responsibility for operating the cervical screening programme rests with individual health authorities. It is obviously important for each authority to have effective arrangements for following up positive tests which should always be notified to the clinician who initiated the test, who should then ensure that follow-up action is taken.
"We are looking into the circumstances of the Oxfordshire cases to see whether there are any general lessons to be learnt. We were already preparing a questionnaire to all authorities to update our information on screening services and we shall be issuing that shortly".
My Lords, that concludes the Answer.

§ Lord Ennals
My Lords, may I thank the Minister for repeating the Answer given in another place which inevitably leads to a large number of questions. I am sure he will agree that a disturbing and sad situation has been revealed in Oxfordshire that looks like the tip of a frightening and large iceberg. Does the noble Lord the Minister accept that cervical cancer is the one form of cancer which not only is easy to detect with a simple smear but can be cured if treated in good time? Does 339 he accept that far too many women with cervical cancer are somehow falling through the net? He must agree with this as he referred to an up-dating.
Will he confirm that, although 3 million tests are carried out annually, about 2,000 women die from cervical cancer in England and Wales each year? Is he aware that Mr. Frank Dobson, the shadow Health Minister in another place, has carried out a thorough review which shows, among many other things, that while in general the provision of testing is "hopelessly inadequate", Oxfordshire is not exceptional but it was one of the 20 authorities which did not respond to his request for information? His report shows that pathology laboratories are overloaded with work and are often understaffed. In one case, in Worcestershire, there was a backlog of more than 1,000 tests.
Is the Minister further aware that, according to a recent article in the British Medical Journal, of 1,000 women in the Nottinghamshire area who had a first abnormal result fewer than two-thirds had been followed up? As in the Oxfordshire case, some 4 per cent. of positive tests were not acted upon by the general practitioners. Is it not true that all health authorities should now install a computer call and recall system? May I ask the noble Lord what reply was sent to the Women's National Commission proposal to his department in January this year that women should be called for cervical testing at five-yearly intervals, starting at the age of 21? Is it really true that, in the light of this deplorable situation in which every year many women's lives are placed at risk, the DHSS has said, as was reported in the press last night, that no new initiatives were proposed to introduce guidelines or in any way to alter the present system of availability of testing and following up positive tests?
Finally, does this not show a deeply disturbing situation? Will the noble Lord ensure not just that there is a careful examination of the three cases in Oxfordshire of which we know, but that there is a thorough survey followed by some immediate action affecting women throughout the country?

Lord Winstanley
My Lords, on behalf of my noble friends on these Benches I should like to join the noble Lord, Lord Ennals, in thanking the noble Lord, Lord Glenarthur, for repeating this important Answer in reply to a Private Notice Question in another place. We share the view expressed by the noble Lord, Lord Ennals, that in recent years the women least at risk of developing a carcinoma of the cervix are women who have been having cervical smears with almost clockwork-like regularity, whereas those most at risk have often not been having smears at all, and the recall or warning process for those women most at risk of developing a carcinoma of the cervix has been virtually non-existent. In so far as this Statement and it related action will remedy that situation, obviously on these Benches we warmly welcome that.
In relation to other aspects of the matter which were referred to by the noble Lord, Lord Ennals, perhaps I could ask the noble Lord, Lord Glenarthur, to look a little further. The cervical cytology campaign has now been going on for nearly 20 years. I was closely associated with it when it first started, as indeed was the noble Lord, Lord Ennals. It has undoubtedly 340 achieved many results, but I think the noble Lord, Lord Glenarthur, will agree with me that we have not yet had authoritative figures over those nearly 20 years which can demonstrate conclusively whether the mortality and morbidity rates of carcinoma of the cervix have declined as a result of the campaign. I do not for a moment say that they have not, but it is high time that cost-effective studies were carried out on routine procedures of this kind which are highly consumptive of scarce resources and manpower.
One of the problems of cervical smears is that an increasing number of the smears are proving in the end to have ambiguous results which leave the doctor and the patient in something of a dilemma. Should they ignore a suspicious smear and wait to see what happens or should they take action—which can sometimes have long-term consequences for women who have not had children, and so on—just in case the smear proves to be a bad one? These are the difficulties.
The noble Lord, Lord Ennals, is right in saying that cervical carcinoma is relatively easily diagnosed and that it can be treated. We should like to know whether all this effort that has gone into the cervical cytology campaign throughout the country has had the effect of reducing the mortality and morbidity rates from these diseases as a result. Perhaps when the noble Lord and his ministerial colleagues in the department are looking into this matter they would consider the general assessment of the whole campaign. It is important to all of us to know what the results have been.

§ Lord Glenarthur
My Lords, I am grateful to both noble Lords for their reception of the Answer which I have just repeated. I agree with both noble Lords that it is a disturbing and sad situation when things such as this come to light. Whether or not it is the tip of an iceberg is a worry which I understand the noble Lord to have. But in this case, as he will be aware, three women in Oxfordshire have developed cervical cancer after doctors apparently did not tell them that their tests were positive. One of the women has died and the other two are seriously ill. There may be more to it than has been possible to ascertain over the last couple of days for obvious reasons. It would not be proper for me to go into any more detail than I have given because not all the answers are known. But I assure both noble Lords that my right honourable friends the Secretary of State and the Minister of State for Health are looking carefully at this matter.
I entirely agree with both noble Lords that this particular form of cancer as such is easy to detect and is easy to treat. It is possible that people could fall through the net, but the difficulty in many cases is one of attitudes. The national recall scheme was stopped because it simply was not working. Only 20 per cent. of those being recalled were going back to be tested. It was for that reason that my right honourable friend the Secretary of State and others decided that the best scheme to adopt was a local system which could be refined within the prevailing circumstances at district level. That is what we have been pursuing, and that is what the issue of the circular last July to health authorities was in aid of.
341 The noble Lord asked me a number of questions which I shall endeavour to cover, but I hope I shall be forgiven if I do not in the end cover them all. I shall write to the noble Lord if I do not. He asked me particularly about the Women's National Commission. I can say that a reply has not actually been sent yet. There is as yet no proof that a call system, as opposed to a recall system, would be effective. The noble Lord, Lord Ennals, asked me about the necessity for having computers for the recall system. We do not believe on face value that a recall system by computer is necessary to achieve that recall. There are other methods which have been in existence without computers, in many cases for a long time, and those that set up a really competent arrangement should be capable of setting up a recall system without them.
We have advocated already screening for all sexually active women at five-yearly intervals—particularly bearing in mind that, whereas it is aimed primarily at the people in the most-risk group, those aged about 35 and over and those with more than three pregnancies, there are others who are younger who may also be active and need to come forward. However, I think he will agree that the prime thrust ought to be at those who are in the greatest-risk group. He quoted figures for deaths, as did the noble Lord, Lord Winstanley. The figure in 1983 was 1,959; but if that total is broken down, 1,415 of those deaths were in the 35 to 74 age group which I think makes the point quite well.
To turn to new initiatives, we are looking carefully at the system. We are monitoring the way in which it is working and we shall be pursuing the individual health authorities to make sure that the systems that they have are adequate. The question of delays in laboratory processing is one on which the department has had some reports. We have had reports of difficulties in processing cervical smear tests up and down the country from time to time. In visits that I have made to laboratories, I have seen that there have been some backlogs—but I think not quite as serious as some people make out. However, it is very much a matter for individual health authorities to determine their own priorities for the deployment of their resources to meet this need and lots of other serious needs as well. The fact is that in this particular case it is going to take some time before we get to the very bottom of it. I can assure both noble Lords that it is being looked at with some vigour. We hope that in the meantime all those who can take these tests will come forward and follow the practice which the department has advocated.

§ Baroness Seear
My Lords, was the noble Lord really talking about an age group of between 35 and 74 years of age? That would not be a group, that would be a regiment.

§ Lord Glenarthur
My Lords, I did say that. Perhaps I can give the breakdown to the noble Baroness. The deaths in 1983 were three in the age group 22 to 24; 43 in the age group 25 to 29; 78 in the age group 30 to 34; and then 1,415 (the vast majority) between the ages of 35 and 74; and 420 in the over 75-group. That is 342 statistical information however the noble Baroness would like to categorise it.

§ Lord Dean of Beswick
My Lords, I too am grateful for the Statement which has been made by the noble Lord the Minister on this very serious and dangerous illness. Can he tell us whether the figure he has quoted for deaths is an increase or a decrease on previous years? When the Minister in his answer referred to "health authorities", was he referring to regional authorities or to district authorities? I listened to his reply to the noble Baroness who has just put a supplementary question. The noble Lord said that it is up to each particular authority to decide its own priorities regarding this and other services for which it is responsible related to its own allocation of resources. Is it not the case that if it is left to the district or area authorities, and not the regional authorities, we could not only have a national imbalance but a regional imbalance for the treatment of this very dangerous and serious disease? And if there is shown to be an imbalance of any kind, is it not the fact that it ought to be corrected urgently on a national basis?

§ Lord Glenarthur
My Lords, I am sorry, I forgot to give the figure. The figure of deaths has declined by 13 per cent. over 10 years. I can tell the noble Lord opposite that cervical screening is the responsibility of the district health authority. I do not see anything that is particularly unusual about that. That is the way most of the system works.

§ Lord Dean of Beswick
My Lords, perhaps I may put this to the Minister. If he said that the level of activity on this particular illness or disease would be at the prerogative of the district authority and dependent on the resources that they have allocated for this and for other uses and responsibilities that they have to carry out, would this not indicate that, depending upon geographical location, there could be a different level of service all over the country? Does he really think this is desirable?

§ Lord Glenarthur
My Lords, it happens in every case within the health service. It is up to the local health authorities to decide their priorities. It would be wrong for Ministers in the DHSS to lay down from the centre what should apply right across the board. It is the system that prevailed also when the noble Lord's party was in power so that I do not know quite what the noble Lord was so concerned about. It is a system which has prevailed for many years. It is the only way to run it. We could not run from here precisely a particular recall system in district health authority "X" somewhere in the North-West of England. It would be quite improper that we should. It is right that we should give them the resources and they should determine what their priorities are within the range of resources that are given to them.
The fact is that this system has been going on, as we have heard, for the past 15 or so years. The figure of deaths over the past 10 years has declined by 13 per cent. We agree that it ought to be greater; we agree that it is an easily treated problem and that is why we issued the circular in July which set out the re-affirmation of our existing policies and went into the detail of how monitoring of screening programmes should take 343 place. We shall certainly follow up all that has been learned from the instances in Oxford. I can assure all noble Lords that that is what we shall do.

§ Baroness Phillips
My Lords, I wonder whether I may underline what the noble Lord, Lord Winstanley, has said. I too was in at the beginning of the original campaign a long time ago. I should like to suggest to the Minister that perhaps the time is ripe to go back to the women's organisations who are admirable campaigners when their help and support is enlisted. This case will have highlighted the necessity for them to get the message through to every woman; and I would seriously suggest that the Minister, through his department, looks again at the marvellous campaign which was got off the ground originally through the women's organisations.

§ Lord Glenarthur
My Lords, I think that the noble Baroness is making a very valuable point because of the 2,000 or so deaths to which I have referred, about 60 per cent. were of people who had not had tests. The problem is one of getting the older women to go for recall. It is one of attitudes, really. As I have said, 94 per cent. of deaths are in the older age group so I think that what the noble Baroness says may well be right. We are funding the Women's National Cancer Control Campaign to publicise the need for screenings and I hope that that will have some effect.

The Earl of Halsbury
My Lords, may I observe that an age-group block is frequently referred to by medical statisticians as a cohort, and I think the reference to it by the noble Baroness as a regiment is not perhaps altogether inapposite.

§ Lord Ennals
My Lords, I wonder whether I may follow up on the point made by the noble Baroness about the breakdown of the total figures. Quite obviously the largest figures were in the age group between 35 and 74. Could there not be a tighter breakdown in this higher age group? I should be fascinated to know the figures for the 35 to 40 age group. As the Minister said, it is perhaps at the age of 35 where the greatest danger lies. I should have thought that the figure for the 35 to 40 group is a crucial one. Can he say whether the DHSS issued a statement, as I quoted, saying that there were going to be no new initiatives as a result of this sad situation?

§ Lord Glenarthur
My Lords, I shall certainly try to find out the breakdown of statistics of deaths between 35 and 40 or 35 and 45 or whatever the noble Lord would like. I hope that that might also meet the concern of the noble Baroness, Lady Seear. I am afraid that I do not have the figures before me. For reasons which I do not understand, they have not been worked out in that way. Why precisely that should be so, I do not know.
However, I have some information which may be useful to both the noble Lord and the noble Baroness and which gives the breakdown for the age group 35 to 39, which might help. I think I had better show the information to them afterwards, because it will take me more than a minute or two to work out what it means; but I will certainly do that.
344 So far as not following up advice is concerned, we are in fact about to put out a questionnaire, as I indicated just now. I am not quite sure what information the noble Lord has received which is contrary to that, but I can assure him that we do monitor the matter carefully, and the fact that we are about to put out a questionnaire indicates how seriously we take it.

§ Baroness Seear
My Lords, I do not wish to be frivolous about what is a very serious subject, but I should like to follow up what my noble friend Lord Winstanley said. The statistical information on this is, quite frankly, totally inadequate. We want far better figures so that we can find out what in fact is the result of this long campaign. When the noble Lord tells us that most deaths occur in the older age group, your Lordships' House is very good evidence that this happens in many groups, even those that are not subject to cervical smears.

§ Lord Glenarthur
My Lords, I did not mean to treat it in a frivolous way at all myself. I merely gave the figures, which happened to be broken down in the way that I indicated; that was the way they were presented to me. However, I have here a table which shows deaths from malignant neoplasm of cervix uteri between the years 1973 and 1983 in all ages. A breakdown of ages is given, and I can tell the noble Baroness that in the age group 35 to 39 the number of deaths in 1983 was 92; for the age group 40 to 44 it was 104; for the age group 45 to 49, 127; for the age group 50 to 54, 155; for the age group 55 to 59, 184: and for the age group 60 to 74 the figure was 717. I will certainly let the noble Baroness and the noble Lord, Lord Ennals, have a photocopy of that immediately after this Statement has been completed.

§ Lord Mulley
My Lords, since this is a matter of general and not specific interest to the two noble Lords, would it not be better for a written Question to be put down, and then the Answer would be available not only to us but to people outside?

§ Lord Glenarthur
My Lords, certainly that is one possibility, but I think that the best way to deal with it, in view of the arrangements that now exist, is for me to write to both the noble Lords, and a copy of my reply will be placed in the Library.

§ The Countess of Mar
My Lords, could the noble Lord say whether he has information on the breakdown of social classes from which the women who died came?—because I very strongly suspect that it is women from the lower social classes who are the ones who are dying from cervical cancer. I was recently in hospital in a bed next to a woman who died from cancer of the cervix, and it was extremely unpleasant. We were told by her relations that she just did not know what symptoms to expect, or indeed anything else, until it was too late. Would it not be a good idea if we tried to aim publicity at those people and not at the people who already have enough intelligence to go to their doctor when anything is wrong?

§ Lord Glenarthur
My Lords, I think the noble Countess may be right, and perhaps that is a role which could be played by the women's organisations, 345 as the noble Baroness, Lady Phillips, described. I have no information on the social classes at present, but if it is available I will certainly let the noble Countess know.

Lady Saltoun
My Lords, would it not be possible to enlist the help of women's magazines in telling women what symptoms to look out for?

§ Lord Glenarthur
My Lords, I am sure that is a good idea. Whether or not they actually undertake it I personally do not know, but I hope they would take note of what the noble Lady has said.