Cervical Cancer Screening

HL Deb 03 March 1999 vol 597 cc1778-90

10.30 p.m.

Lord Clement-Jones rose to ask Her Majesty's Government what progress the Department of Health's cervical cancer screening programme is making in implementing the proposals in its 1998 review, in response to the criticisms contained in the December 1998 report of the House of Commons' Public Accounts Committee, and in response to the recent legal cases brought against the NHS.

The noble Lord said: My Lords, after a gruelling week for the health team, I am sorry that this Unstarred Question comes on at this time of night. I know that health teams on all Benches have been working extremely hard over the past week. Perhaps it is getting to be a habit to debate into the early hours of the morning.

Many of us, even a relatively new Member such as myself, remember the late Lord Dean of Beswick with considerable admiration. While battling with cancer he fought as a doughty advocate for cancer treatment in this country, particularly for institutions such as The Christie Hospital. I am particularly grateful to him because a Starred Question in December about cervical cancer aroused my interest in this subject and in the state of the cancer screening programme. I should like to emphasise that this Unstarred Question is put down in a spirit of inquiry, not adversarial criticism.

Cervical cancer is the most common cause of cancer in women under 35 in the western world, and overall the second biggest killer of women in the developing world. We have one of the most effective screening programmes in Western Europe. However, over the years a number of cases have demonstrated grave problems in that programme. I need only recite the names of hospitals without mentioning the number of smear tests which have had to be rechecked as a result—The Inverclyde Royal Hospital, 1993; Gateshead, 1993; Blackpool, 1994, Gorleston, Norfolk, 1996; Merthyr Tydfil, 1994 and Hospital of St. Cross, Rugby, 1998—to produce a roll call of some of the cytology laboratories where problems have been encountered.

The worst case of all has been the Kent and Canterbury hospitals NHS Trust where an independent review reported last year that problems in the trust's former screening services may have contributed to eight deaths, with 30 women needing hysterectomies and over 300 found to be in need of urgent treatment. Around 91,000 smear tests needed to be rechecked. As your Lordships will be fully aware, just a fortnight ago three women—Lesley Cannon, Sandra Penney and Helen Palmer, each of whom developed adenocarcinoma and had to have hysterectomies as a result—won a test case. That case will be followed by others. The damages in that case are yet to be assessed.

To its credit, the Department of Health has taken energetic action since the report of that independent inquiry. In December 1997 the department launched an action programme with an action team to monitor it and to consider such matters as staff resource. The programme included mandatory accreditation requirements by cytology labs, refresher training for staff who were not up to standard, a review of smaller laboratories and regional reviews of screening services.

The action team reported in August last year. It recommended much improved public information, especially about what screening is and its level of accuracy. In April last year, Sir John Bourn, the Comptroller and Auditor General, conducted his own review of the programme. He confirmed that progress had been made on the programme since his last report of 1992—in particular, achievement of the overall coverage target of 80 per cent. adopted in 1993. However, he described a situation where implementation of laboratory guidance and achievements of regional targets was patchy; certain groups were not being reached by the screening programme, in particular ethnic minorities, and, although falling, the number of unscheduled smear tests of 450,000 in 1996–1997 was unjustified. In addition. many women were waiting too long for their smear test results and follow-up with colposcopy clinics, and there was inadequate understanding of what was involved.

Sir John made a number of recommendations designed to remedy those deficiencies. They included: screening at three year intervals, not five; better smear taking, mainly taken by practice nurses in GP surgeries, and, above all, improved quality assurance in the screening labs and colposcopy clinics. When reviewing the NAO Report, the Public Accounts Committee which reported last December—I know this was controversial in many circles—said, The NHS Cervical Screening Programme affects the lives of millions of women each year and despite recent improvements there are still worrying failures at every stage of the screening process". The Public Accounts Committee went on to say, The NHS Executive need to set firm national and local timescales for fully achieving quality standards and take robust action where standards slip". Subsequently, the screening programme's report was published in the autumn of 1998. It was clearly designed to maintain or restore public confidence and it is a user-friendly, upbeat document, perhaps a little too upbeat in the current circumstances. Having said that, it is hardly surprising that most recent public opinion poll evidence—an NOP survey was published recently—is that public confidence in the screening programme has fallen significantly. Half of those polled are less confident in the service than they had been previously. It has given rise to some rather upsetting and disagreeable headlines such as, This cancer screening is a lottery and women are paying with their lives". That is a deeply worrying and inaccurate headline which appeared only two weeks ago in the Sun. In addition, there have been other articles which have appeared in the broadsheets which, in their own way, have been as undermining of the screening programme.

In the face of all that we must not forget that the generality of laboratories do an excellent job, nor the success that the national screening programme, which was introduced in 1998—the first in the European Union—has had in reducing the incidence of cervical cancer; from 14 per 1,000 in the 1950s to below six nowadays. Over 4.5 million smear tests are carried out each year and in fact they reach 85 per cent. of eligible women, which makes it one of the most comprehensive in the world. It is estimated that it prevents up to 3,900 cases each year.

In fact, the same NOP survey said that seven out of 10 of those who knew of recent failures were still happy with the quality of the service. Only one-in-eight are less likely to have a smear test than they were two years ago, while one-in-four claim to be more likely to do so. Nevertheless, it must clearly now be a major government priority to get the programme right in the way it is executed. That is doubly so now that controversy is extending into the area of colposcopy— the examination of cervical tissue following abnormal smear test results.

Many questions remain about the national screening programme before we can be sure that there is a programme on which all women can rely. What further action, for instance, is the department taking to improve detection of cervical cancer? What action is being taken in the light of the recently decided Kent and Canterbury court cases? They were regarded as borderline by the hospital and they disputed negligence, yet the judge disagreed. However, it seems as though the standard Bolam test has been changed as a result of that case. What is the position on the programme in relation to the accreditation of laboratories? Are the low-volume laboratories to be closed? How will the department ensure that the 13 health authorities which failed to come up to coverage targets meet the 80 per cent. target in the coming year? Have the regional directors of public health now firmly grasped the reins of accountability? Is it the case that there is a major recruitment crisis? Noble Lords will have seen some of the articles on that score in the press.

Despite all the management improvements—I know that the Minister will be telling us about some of those—both in train and those suggested by the Public Accounts Committee, the cervical cancer screening programme cannot guarantee detection. One thousand three hundred women a year still die from cervical cancer. We still have one of the highest recorded incidences of cervical cancer in the European Community at 12.1 per 100,000; 50 per cent. of invasive cancers occur in women who have been adequately screened, which means that there are inefficiencies in the test. According to Government sources, the current screening success rate is 80 to 90 per cent., but many people dispute that. There are issues of inadequate smears and false positives and 20 to 30 per cent. of diagnoses are falsely declared negatives, which can lead, as we know, to tragedy.

Cervical cancer is recognised by all major global medical authorities to be the first identified virally induced cancer in women. There are more than 70 types of HPV (papillomavirus), of which 13 high risk types have been identified as determinants in causing 95 per cent. of cervical cancers. Is there not a very good case for introducing the new HPV/DNA test as a supplement to the current pap test? That has many advantages. It can detect all the high-risk types of HPV. In combination with a smear test it can raise detection rates to 97 per cent. It is automated; it reduces the number of inadequate smears and the need for repeat smears. As a result, the recommended recall period is actually five years and not three years. That could lead to savings of something like £30 million by the National Health Service, as a recent BMJ article illustrated. It can also detect difficult adenocarcinoma cases, which constitute 20 per cent. of all cancers and which the three women in the Kent and Canterbury case had.

The FDA in the United States has already undertaken extensive trials. The test is in use in the United States for borderline cases. There are trials in a number of other EU countries. Here in the United Kingdom, the ICRF has a trial involving 12,000 women due to be completed next year. It is already in use here in Marie Stopes clinics, yet the official trials seem to be destined to take for ever. The Health Technology Assessment Programme is undertaking a fast-track systematic review of the role of DNA testing within the NHS cervical screening programme. That will not be completed for some considerable time. The so-called TOMBOLA trial is expected to last eight or nine years and has not even started.

Yet this is a diagnostic tool to supplement an existing test, not a major new treatment. Why cannot we rely on the ICRF trials when they are complete? That does not seem to be displaying the same sense of urgency as the Dutch Government, for instance, who are pressing for interim results.

I mentioned various aspects of the BMJ article and the test with regard to saving resources. The test itself could cost as little as £20. That should be set against all the litigation costs for the NHS which may be incurred by a test which is now known not to be completely accurate. Recently a Californian doctor said: Paps comprise 2% of laboratory activity but 98% of lab losses in terms of litigation". In a recent Parliamentary Answer, John Hutton, the Minister of State, in answer to a question about DNA testing said: The Advisory Committee on Cervical Screening are currently considering the potential role of new technologies in the cervical screening programme". Is not this an important task? Is not the solicitor for the plaintiffs against the Kent and Canterbury Hospital Trust, Sara Harman, correct when she says: We have been using this method to screen cervical cancer for years and we are still getting these mistakes. We have to develop new techniques for reading smear results". The Secretary of State has personally promoted the research on the so-called Campaign Test unveiled in December last year which is being developed in CRC research in Cambridge, which is an improved, computerised way of improving the pap test. But that looks as though it is still some way off being introduced in the programme.

Beyond the issue of management and testing, the issue of communication also needs to be addressed. There have been worrying studies about what women understand about the possibility of having to attend a colposcopy clinic in the event of an abnormal smear. There are a number of issues regarding information which I do not have time to go into today. I hope that we can hear from the department tonight what it is doing to allay current public fears and anxieties about the screening process.

Personally, I am very optimistic about the screening programme in the future. There are many exciting developments in medicine, including both vaccines and cures for HPV. Has the department taken a view on the news of the potential new chemotherapy treatment for cervical cancer shortly due to be published in the New England Journal of Medicine? It is a fast-moving area.

Whatever the criticisms, those who claim a screening programme of this nature is unnecessary are still in a small minority. The development of a totally reliable screening programme, however, is of crucial importance. If we do not get it right there will be a major effect on the quality of life and worry for hundreds, if not thousands, of women.

Finally, I quote from Dr. McGoogan, who is a clinical director of pathology at the Edinburgh Royal Infirmary. In the programme review published in December, she said: We've never been in a better position to be confident and enthusiastic about the future because so many things are coming together now". I ask the Minister to help underpin that optimism and assure us that the issues I have raised tonight will be dealt with urgently.

10.45 p.m.

Lord McColl of Dulwich

My Lords, I should like to thank the noble Lord, Lord Clement-Jones, very much for bringing this subject to our attention this evening. There have clearly been some spectacular failures in the cervical cancer screening programme. However, as the noble Lord said, it is important to put this in the overall context that the service is having a most desirable clinical effect. It is one of the biggest cervical screening programmes in the world and it is saving lives. Following its introduction, there has, over the past five years, been a 7 per cent. reduction per year in cervical cancer deaths. That is really very good news.

The Chief Medical Officer set up a review of the screening programme and, following its recommendations published in August of last year, practically all laboratories undertaking screening have now applied for accreditation. Those which have not applied are likely to be merged with larger laboratories. It is unlikely that the actual accreditation will be completed before the end of the year, because this does take some time. Those laboratories which undertake fewer than 15,000 specimens per year are being merged with other laboratories. On the quality assurance side, I can tell noble Lords that a number of programmes have now been developed and there are regionally appointed quality assurance directors for cytology now in place with appropriate budgets, which is good news. A national committee for quality standards in colposcopy has also been established.

The Royal College of Obstetricians and Gynaecologists has been actively involved in training. It has developed a joint accreditation of colposcopy training programmes with the British Society of Colposcopy and Cervical Pathology. This began just over 12 months ago. The college is just about to circulate its working party report entitled, Recommendations for Service Provision and Standards in Colposcopy. So it is quite clear that much has been achieved.

The Cervical Screening Programme Review 1998, which has some beautiful flowers on its front cover and is known as "The Flower Report", has a foreword written by another flower—the Parliamentary Under-Secretary of State for the Department of Health in the House of Lords. This has been a very useful report because it has given the public the true picture about cervical screening programmes, emphasising that they do not give an "All Clear" to the patient but provide what has been described as a safety belt. I think that the report should be compulsory reading for all people involved in medical litigation in this sphere.

Reference has been made to the Kent and Canterbury Hospital case. I can tell the House that the reason why this case was defended was that it was quite different to the large number of other cases which were settled out of court. The three patients concerned had a cancer involving glandular cells called an adeno-carcinoma, whereas the cervical screening programme is for the detection of a different kind of cancer called a squamous cell cancer. Detecting border-line abnormalities in glandular cells would be fortuitous in such an exercise. All three patients had smears which could easily have been overlooked in any laboratory, even if they had been checked by other experts. In fact, in one of the three cases, the smears were passed as normal in a teaching hospital laboratory in the Midlands.

The two expert witnesses for the plaintiffs maintain that they should not have been overlooked, while the three expert witnesses for the defence said they could. It is clear that the defence expert witnesses see far more cervical smears every year than the other witnesses and certainly undergo the annual cervical cytology performance test, which is a kind of annual driving test.

As I am sure noble Lords are aware, in medical research we try to reduce bias which could readily distort our findings. There are two kinds of bias to which I should like to draw attention. There is outcome bias, which will occur when one looks at a smear knowing that the patient subsequently developed a cancer. It would be a thoroughly biased eye that would scrutinise every cell at great length, which is quite a different technique to that of screening. The other bias is context bias, and that obtains where one looks at a smear knowing that it is not a routine smear but is involved in litigation, especially when the slide has written on it some comment such as, "Query abnormality. Query glandular".

If the court wishes to obtain unbiased opinions, I suggest that rigorous scientific methods should be used. Each expert witness should be required on his own to examine a doubtful smear, together with 10 negative smears. It is imperative that all the smears should look alike and that their only distinguishing feature should be the number inscribed. Each witness should be required to record his opinion without discussing it with anyone. That gets rid of the problem of a "retrospectoscope" which people find so useful. If that were done, it would simulate to some extent the circumstances under which those in the cervical screening scheme actually work. Had that been done in the Kent and Canterbury case, I suspect there would have been many surprises.

This case has serious implications for the cervical screening service. The conflicting evidence of the five expert witnesses demonstrates just how difficult it can be to interpret whether a cell is abnormal. The court seemed to take the view that anything short of absolute confidence that the smears were in the normal range required the screener to pass the slide on, which would have meant that a more senior member of the staff would have checked it. The court was also of the opinion that the sensitivity of the test is of supreme importance and much more important than the distress of women who have repeat smears or referrals for borderline abnormalities. The rationale for screening depends on population based data and not necessarily on outcomes for individuals within the population. Screening tests are not perfect: 100 per cent. sensitivity and 100 per cent. specificity, which of course would be the ideal, cannot be achieved. A good cervical smear may contain more than 200,000 cells. Human observation is notoriously fallible and if the abnormal cells in the smear are scanty they may not be reliably detected by a human screener. Misreporting of such smears could surely be defended, in Boland terms, as not amounting to negligence.

The implication of the judgment could be that one cannot have false negatives and therefore 100 per cent. accuracy is required. This is simply not achievable with the present technology. The result of all this is that there will be an increased reporting of smears as borderline and this will lead to excessive demands on the service which simply cannot be met. The other likely long-term effect, of course, is that it will become even more difficult to recruit those who do the screening. The Secretary of State recently expressed concern that some regions in England had not attained the 80 per cent. screening coverage of eligible women because of the present difficulty in recruiting staff. It will become increasingly difficult to recruit as the pressure on those in the service reaches breaking point. They put up with inadequate pay because they know that they are doing a worthwhile job of a very high standard. But altruism has its limits. If the unrealistic public expectations develop into hostility and litigation continues to increase at its present rate, and if they continue to be paid inadequately, they will simply leave. I believe that the screening programme is in jeopardy. I hope that the Minister will be able to give some reassurance, especially to those who have done such excellent work in this difficult sphere.

10.56 p.m.

Lord Hunt of Kings Heath

My Lords, I thank the noble Lord, Lord Clement-Jones, for his kind remarks concerning the late Lord Dean of Beswick. As his Whip, I particularly appreciated his comments and I know that his wise counsel will be much missed by many noble Lords.

As the noble Lord, Lord Clement-Jones, said, we have enjoyed—and I think that is the word—many happy hours of debate on NHS subjects in the past few days. Although we discussed NICE and CHIMP, much of the debate was focused on funding, management and structures. It is very important that the noble Lord, Lord Clement-Jones, has brought us to focus on the prevention of illness, an area which so clearly needs attention. I thank the noble Lord for enabling us to debate this important matter and for the constructive approach which he and the noble Lord, Lord McColl, have brought to the debate. They have made many comments with which I agree and which I much appreciate. The lack of speakers in the debate is certainly no reflection on the importance of the issue.

I will try to respond to as many as I can of the issues raised—there are quite a number—but I would like to start by making a few points. There is no doubt that the identified failures in the programme in the past few years have caused considerable concern. I believe that the Government have taken the right action to try to deal with the problems identified through systematic reviews, identification of weaknesses and the introduction of accreditation for laboratories, by taking a keen interest in new technologies, and in an endeavour to educate women in both the benefits and limitations of screening.

I acknowledge that there can never be room for complacency in this area. Clearly we have to be ever watchful in monitoring the quality of the programme. The Government are determined to do that. The NHS cervical screening programme is a very important part of the Government's drive to reduce the number of deaths from cancer, and it has proved to be a success. More than 5 million women per year are screened in the UK and experts estimate that the programme prevents up to 3,900 cases of cervical cancer each year. As the noble Lord, Lord McColl pointed out, the number of deaths from cervical cancer in England and Wales has been falling by around 7 per cent. a year. This success—and it is success—owes much to the hard work and dedication of all the staff involved in the programme. I believe that they should be proud of what has been achieved. The noble Lord, Lord McColl, made some very important points about those achievements.

As we knew, despite those successes there have been some problems which have attracted a great deal of adverse media coverage. The failings in Kent and Canterbury caused many women and their families a great deal of distress. I would like on behalf of the Government to offer them my continued sympathy. The health authority and the trust concerned have been making every effort to settle the claims for compensation as quickly and as fairly as possible in order to minimise further distress to the women affected.

As has been pointed out by the noble Lords, Lord Clement-Jones and Lord McColl, in three test cases the High Court has recently ruled in favour of the women making the claim. I am not in a position to comment further on this matter. The NHS Executive is currently considering the judgment and the implications for the NHS cervical screening programme as a whole. But I shall ensure that the points made by both noble Lords are drawn to the attention of the relevant officials.

Following the failures in Kent and Canterbury and elsewhere, the Government took swift action to address shortcomings in the cervical screening programme. Over the past year the programme has undergone the biggest shake-up in its 10-year history. We have implemented a wide-ranging programme of action—I acknowledge the kind comments of the noble Lord, Lord Clement-Jones, on this matter—to improve the quality of the programme, and the changes we have introduced will be closely monitored to ensure that they happen.

Regional directors of public health were required to carry out detailed regional reviews of the cervical screening programmes and draw up action plans to deal with areas of weakness. From this year they will be making formal annual reports to the NHS Executive on the performance of the programme in their region. Improvements have been made to the way the programme is managed. Responsibility for commissioning quality assurance for the cervical screening programme is being transferred to the regional office and all regions have now appointed a quality assurance director.

Both noble Lords commented on laboratories and on the fact that those which read smear tests have been required to apply for accreditation by June 1998. All bar one, which is shortly to merge with another laboratory, have now done so. Laboratories which read fewer than 15,000 smear tests and which were not meeting national standards have been reviewed and the majority have now stopped reading smears or have merged with other laboratories. In all cases their performance will be closely monitored.

Where needed, refresher training is being provided for staff in laboratories and in September a Resource Pack for the Training of Smear Takers was published, which has proved to be so popular that a reprint has had to be ordered.

We acknowledge that improvements still need to be made to the programme and we are working hard to ensure that the momentum is not lost. For example, the Department of Health is working with regional offices to improve colposcopy services, building on the action plans drawn up by regional directors of public health last year.

In order for the screening programme to be successful, it is important to screen as many women as possible. A national working group has been established to identify and disseminate cost-effective measures to improve screening coverage in inner city areas. I hope that that answers the point made by the noble Lord, Lord Clement-Jones, about the position of women from minority ethnic groups. Most health authorities are making steady progress in increasing coverage by ensuring that the screening programme they offer is acceptable to women and that their invitation systems are accurate. We recognise the efforts they are making but we know that more needs to he done.

The Secretary of State has set a new requirement that all health authorities should achieve 80 per cent. coverage by March 2002. The 13 health authorities that are not currently doing so provided action plans at the end of February setting out the measures they will take to achieve this. My right honourable friend the Secretary of State for Health will shortly be meeting the chairs of the health authorities concerned to emphasise the priority they must give to running a fully effective screening service. He expects all health authorities to give their closest attention to this matter and the chief executives will be held accountable for their health authorities' performance.

The noble Lord, Lord Clement-Jones, mentioned the development of new technologies. New methods of taking smears and new methods for reading them in laboratories are being developed which could improve the efficiency and effectiveness of the cervical screening programme. We are keeping this matter under close review. But before any new methods are introduced, we must be sure that they are both safe and effective.

The noble Lord, Lord Clement-Jones, also mentioned the question of HPV testing. We are taking a keen interest in developments in HPV testing. While there is a substantial body of evidence on the influence of HPV on the development of cervical cancer, the exact mechanisms are not known and it is not yet possible to tell which women with the HP virus will go on to develop cervical abnormalities and which will not.

Less evidence is available on the significance of HPV testing, and the NHS cervical screening programme has therefore advised that the role of HPV testing has not been established and it should not be used in routine practice within the NHS. However, research is under way to clarify the potential and limitations of HPV testing.

As the noble Lord, Lord Clement-Jones, pointed out, the Medical Research Council is funding a large study (known as the TOMBOLA study) of the management of women with borderline or mildly abnormal smears. HPV testing is an integral part of that study. It is true that the results will not be known until 2005. A number of other research projects are under way in Amsterdam and elsewhere and we await the results of those studies with interest.

In January last year the NHS Technology Assessment Programme was commissioned to undertake a systematic review of research into the role of HPV testing. The report is due to be published later this year.

I turn to the benefits and limitations of screening. We want women, and the general public, to have confidence in the screening programme. But we acknowledge that we must be more open about both the benefits and the limitations of cervical screening. We understand that women would like a guarantee that the results they receive are correct. But even with perfect management and 100 per cent. coverage, no screening programme could be 100 per cent. accurate, as the noble Lord, Lord McColl, pointed out.

A common misconception is that cervical screening is a test for cancer. It is not. It is a test for abnormalities which, if left undetected and untreated, might lead to cancer. Cervical cancer is generally a very slowly developing disease. By having smear tests every three to five years women can reduce their risk of developing cancer by 80 to 90 per cent. That is why it is so important for women to have regular tests. But women should still report any abnormal bleeding to their doctors.

The noble Lord, Lord Clement-Jones, mentioned the report of the Public Accounts Committee which was published on 6th December. It followed the publication of the NAO report in April 1998. The PAC report was largely retrospective, but a formal government response will be made in due course. In responding, we can indicate that considerable progress has been made.

The noble Lord, Lord Clement-Jones, mentioned the issue of whether the screening interval should be three years or five. As I have said, cervical cancer is a very slowly developing condition. In terms of saving as many lives as possible it is far more important to screen as many eligible women as possible than to offer more frequent screening. So the priorities are to ensure that as many women as possible have access to and attend for screening and to improve the quality of the service. But once the coverage target has been met, it is then for health authorities to decide whether they want to recall women more frequently than every five years.

The noble Lords, Lord Clement-Jones and Lord McColl, raised the very important issue of the shortage of cytology screeners. I acknowledge that in some areas there are difficulties with the recruitment and retention of screeners. That has been attributed partly to low morale and partly to pay issues. I very much appreciate the hard work of all staff in the programme, particularly over the past 18 months, when morale has clearly not been helped by adverse publicity. I very much take the point made by the noble Lord, Lord McColl. I have never believed that morale is simply down to an issue of pay. But clearly that is a consideration.

The Government recently announced detailed proposals for modernising the NHS pay system. We shall begin consultation with NHS health professionals and NHS staff soon. We clearly want a system that pays staff fairly for what they do, rewarding them for developing new skills and taking on responsibilities. It is equally clear that we cannot make all the changes overnight. In the short term, cytology screeners' pay will be considered in the current pay round. I am afraid, though, that I cannot anticipate the outcome of those negotiations.

The noble Lord, Lord Clement-Jones, also asked a question concerning public information. Perhaps I may say to him that plans for a national publicity campaign are being drawn up. We are also looking at the provision—and I think this is very important—of better information for health professionals.

In the few seconds left to me, I again acknowledge the contribution made by both noble Lords. I hope they will agree that the Government have taken important steps to deal with the problems identified and to ensure a very high quality service in the future. I end by giving an assurance that the changes we have introduced will be closely monitored to ensure that they happen. We shall continue to work to improve the programmes further. This shows our commitment to achieving what the noble Lord wishes to see.

Lord Clement-Jones

My Lords, before the noble Lord sits down, I appreciate much of what he has said today, but could he elucidate for me the relationship between the MRC's TOMBOLA research and the HTA research? He was almost implying that if the HTA review was favourable, taken together with other aspects such as the Dutch research, it might be possible not to have to wait until that full 2005 project of the TOMBOLA research was complete, which was one of the points I was trying to make.

Lord Hunt of Kings Heath

My Lords, it would be difficult for me to go further on that matter. I was simply trying to say that various research projects and assessments are taking place and that we shall look at each one on its merits. I should prefer to write to the noble Lord in more detail to explain the different approaches in relation to research and how we shall tackle them.

House adjourned at eleven minutes past eleven o'clock.