§ Mr. Dai Havard (Merthyr Tydfil and Rhymney)
The subject of the discussion is treating anaemia in cancer patients. I shall speak first about why the matter is important; secondly, about the current effects; thirdly, about the Department's responses; fourthly, about a survey that I have undertaken to gather further evidence; fifthly, about what should be done; and, sixthly, about what I am doing to contribute.
First, the matter is important to me because there is a high incidence of cancer in my constituency. The debate is about the processes of government and the efficient running of the health service, but it is also about people and the real effects that I see every day—it is not an academic exercise. People living in the valleys have to travel and face disruption, but they might receive better treatment in their own homes if we adopted different policies.
In 2000, a study showed that anaemia-induced fatigue is the most socially debilitating aspect of cancer care, greater than the pain and nausea associated with treatment. In its survey, the charity CancerBACUP showed that 84 per cent. of cancer patients were ignorant about the haemoglobin levels associated with fatigue. That exposed a lack of quality in the consultation between them and their clinicians: while most had discussed the fatigue, fewer than half had been told that it was related to anaemia.
A soon-to-be-published review of the literature by Professor Bosenquet of Imperial college, London, an adviser to the Select Committee on Health, will show that cancer is emerging as a chronic, long-term illness. More people will be living longer with anaemia and cancer. The prevalence has increased because survival rates are increasing. Clinicians and others are winning the fight to keep people alive, but patients are suffering the debilitating side effects of their treatment longer.
Evidence is building that treating anaemia before and during cancer care has beneficial medical as well as social effects. Patients require an overall package that includes support for carers, complementary treatments and counselling. Cancer plans across the home counties were important immediate responses to the need for improved care, but it is now clear that they need to be adjusted because cancer is changing from an acute problem to a chronic illness, and needs to be treated as such. I have evidence of that in my constituency, where the useful charity, Cancer Aid Merthyr, supports cancer patients with both complementary medicines and counselling.
Not only does the package of care need to be reformed by the health service, it needs appropriate funding. Anaemia treatment should be central to the package. Unfortunately, it is not. For example, while Birmingham Heartlands hospital recognises the importance of the principle, it has abandoned treating cancer patients for anaemia either by transfusion or by medical alternatives; patients simply do not receive that aspect of their care.
I support the principle of choice for patients. Such choices are a matter for debate between individual clinicians and patients, so I do not have a problem with 124WH the fact that in certain parts of the country, patients with religious objections to blood transfusions receive alternatives. That is right—but it should not be the only reason for receiving alternative treatment. Professor Bosenquet's forthcoming report shows that while communication between doctors and patients is improving, there are major gaps.
I am not playing a blame game with doctors. Often, patients do not know what is available and clinicians cannot give it to them; or if a patient does know, and asks for something, the clinician is in a cleft stick and cannot provide it. The rhetoric—that is all it is—about choice becomes a sham. We need to work towards a situation in which everybody gets the right treatment, not only the articulate middle classes who can exert pressure, or those with a particular objection to a certain treatment. Will the Minister conduct an evaluation of cancer care networks, to see when and how treatment is given, and how the current policies stand up in practice? I would like a guarantee that patients who, following an educated discussion, request an alternative are able to receive the treatment that they have requested.
I raised this matter more than 12 months ago. Since then, the safety of people receiving blood transfusions could have been improved. We could have helped to protect the supply of blood, an enormous proportion of which—some 30 per cent. or more—is given to cancer patients. We could have gained a series of efficiencies in terms of releasing health service resources. We could have made quicker progress towards European standards. The quality of care of patients could have been improved. We have missed all those opportunities. The current responses are insufficient.
The appropriate use of blood working group has suggested measures that will help. I welcome the fact that precautionary principles have been applied to children under six and to other groups such as haemophiliacs, but why can precautionary principles and the better care principles not be extended to the largest group of people involved? Many clinicians tell me that the alternatives cannot be introduced because of economics, and I have sent information to the Treasury and to the Department of Health on the economics. Catalyst Health Economics carried out a study that showed that the costs of blood have increased from £250 million in 1994–95 to £898 million a year in 2000–01. There has been an enormous increase in costs, and the hospital stay element of that approaches £600 million. Information on spending and on hospital efficiency is available to show that.
§ Dr. Ian Gibson (Norwich, North)
I am so pleased that my hon. Friend is making the strong case for improving the quality of life. Has he in his researches come across evidence of other countries carrying out such care and looking after people to improve their quality of life? That happened in the US. I know that the US has a different system, but there were positive measurements there of the effects of investing money and resources in the care of patients suffering from cancer.
§ Mr. Havard
Yes is the short answer. I do not have time to itemise all the studies that I researched, but I will put a document in the Library so that hon. Members can consult it. My hon. Friend is entirely correct that better standards of care do exist and that there is good 125WH evidence that not only does such treatment help with palliative measures, but it may help with curative aspects of care as well. There are benefits all round.
The other part of Professor Bosenquet's study that interested me was the fact that there are now additional costs that I had not seen before. A 2000 study by Curt et al shows that 75 per cent. of the people surveyed left employment, so there are considerations involving whether people are well enough to remain in employment. From being net contributors to the economy, they stop being taxpayers and become dependent on state benefits. That adds to the overall costs of treatment. I have been asking for some time for the issue to be looked at in the round rather than in compartments.
There is a suggestion that the issue be referred to the National Institute for Clinical Excellence, but that is an inadequate response. In addition, the terms of reference of the referral are not clear—it is not clear how it has been prioritised or even whether it has been prioritised. My fear is that it is far too narrow a referral because it does not talk about all cancer patients, but only about those who are receiving chemotherapy. It is clear that the progress of the referral will be too slow—it will go into the ninth wave of consideration. I ask the Minister to find out whether it can be accelerated and brought into the eighth wave of consideration. Will the Minister also look at a wider referral that will include anaemia in general? I have carried out my own survey of hospitals, and it seems to me that more important than information is political will. I would like a commitment today that thought will be given to broadening the consideration to include all cancer patients and that it will be accelerated to the eighth wave.
As I said, I conducted my own survey of more than 200 trusts. To date, more than a third of them have replied to my questions about the treatment of anaemia in cancer patients and the associated economics and bed blocking. I am grateful to those that have replied. The results consistently show that funding constraints are a major issue, but in some places it is a matter of luck whether one gets treatment at all—I gave an example of that from Birmingham. Abandoning treatment for cost reasons is not acceptable.
I would like to give hon. Members a pr écis of some of the responses. Barking, Havering and Redbridge Hospitals NHS trust said that cervical cancer patients respond better the higher their haemoglobin levels. The response from Newcastle upon Tyne was that using erythropoietin, which is the drug alternative, as a default could save 150,000 bed days a year. The Brighton and Sussex cancer centre does not have enough beds and patients must wait for blood treatments. The response from Wigan was that EPO improves the quality of life better than transfusions. The response from Newham was that it looks to EPO first and only uses blood as a second resort—EPO is its default treatment. That is the policy that should be adopted.
What should be done? Over the past 12 months, I have been calling for both step change and incremental change to satisfy the pressing needs of cancer patients and their families. Unfortunately, there is a limited and confused response from the Department of Health. Given the growing body of knowledge and experience, 126WH the Department's activities border on negligence. Doctors are being put in a position where they might find themselves the subject of legal claims, and I believe that that will happen to the Department as well. Mr. Deputy Speaker, you will know from your past experience of health and safety legislation that the test applied is that if something is in your current knowledge and experience and you do not do something about it, you may well be held accountable for it. That needs to be given serious consideration.
I am interested in achieving change, not in scoring political points. Both step changes and incremental changes need to be made. As I said earlier, I want a guarantee that, when they are requested, alternatives will be given to patients. I want a commitment today to broaden the referral that has already been made to NICE and to accelerate consideration to the eighth wave. The survey clearly shows that we are not matching European standards. There must be a political declaration and a declaration of policy and intent from the Department. We want to match not only European but other international standards. We should help to prevent and pre-empt any form of crisis in blood supply and blood safety. We should develop a patient policy that is driven by quality of care. I also want a blood policy developed for both use and supply that does not constantly respond to what are effectively short-term crises.
Out of all that, what am I doing? I have explained what I have done. I support initiatives in my local trust. Prince Charles hospital in Merthyr now has a cancer care co-ordinator. We have done many things to advance the plans and ideas that my hon. Friend the Minister shares about cancer care policy involving patients, carers and society and understanding it. Cancer Aid Merthyr, the charity that I mentioned, is part of that project. I have sponsored and will continue to help to promote iCan, a special free magazine for cancer patients and their carers, so that they understand what is available to them and how they can help and support themselves. A little agitation is needed, which will take the form of a charity-led campaign to educate people so that they know what their haemoglobin levels are and what to ask for. Hopefully, some pressure will come up from the bottom, to add to the demands for the organisation to change at the top.
I will share the information that I have. As I said earlier, I will place the information in the Library and I am quite happy to contribute in the best way that I can to any discussions that the Department might wish to broker. I will organise a discussion seminar in the House later in the year, to which I will invite all of the relevant parties and all those who express an interest. I hope that the Minister will play a role in that, so that we can work together not only to achieve early step change, but to ensure that we make the right long-term consolidated incremental changes. I will also ensure that we work together to deliver our shared objectives: to improve not only the mechanics of the health service, but patients' quality of care and their lives.
§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I congratulate my hon. Friend the Member for Merthyr Tydfil and Rhymney (Mr. Havard) on securing the debate. I am well aware of 127WH his special interest in the treatment of anaemia in cancer patients. Indeed, I answered his Adjournment debate on this subject in January last year. We have also corresponded on several occasions, and I know that he has also written to several of my colleagues. I apologise for the length of time it has taken to get those replies to him and I will personally ensure that I respond much more quickly in future.
My hon. Friend's interest in this area has been prompted by the high number of cancer patients in his constituency. I have no doubt that this is not simply a passing interest. His background work and research, and the depth to which he has explored these subjects, are testament to his absolute and overriding commitment to try to ensure that patients get the best services they can. His persistence is paying off. The treatment of anaemia and cancer patients, particularly the use of EPO, is well and truly on my radar. His constant pressing of this matter has made a difference to the way that we look at these matters.
I should first like to say a few things about the blood service, because I know that my hon. Friend is concerned about that too. Clearly it is important to maintain adequate supplies of blood. As he well knows, for some time we have been looking at ways of getting alternative uses in place, rather than simply depending on traditional blood transfusions. At present there is no prospect of any blood shortages and I am delighted that donors are continuing to donate. For the past three years not one single operation has been cancelled or postponed because of shortages of blood, but we must not be complacent. We must plan ahead for contingencies that might arise and there is pressure on us to look at alternatives.
We want to encourage the NHS to use less blood, to consider alternatives to donor blood where that is appropriate and to try to make blood as safe as possible. Blood is never without risks, but the safety of blood is paramount to us as a Department. We have been working for some time on better blood transfusion. It is essential that blood be used only when strictly necessary. In 1998 we started our better blood transfusion initiative. The UK's four chief medical officers got together and that was followed up with a major conference in 2001. New guidance was issued to the NHS last year.
We now have a national network of hospital transfusion committees: people from all the different clinical disciplines are coming together to see how we can reduce the use of blood and improve our blood transfusion practice. Their guidance should have a real impact on avoiding unnecessary blood transfusion and encouraging the use of effective alternatives to donor blood, including the use of patients' own blood, which is being explored at the moment.
§ Ms Blears
Yes. I am informed by the group that publication is likely to be shortly or soon. It was originally going to be in spring, but my hon. Friend will know that the seasons in the Department of Health tend to run into one another. I have asked for clarification today and the report will be published in the next couple of months. That is about as firm as I have been able to 128WH get it. He can rest assured that I will press to see that report on my desk within that time. I thought that that was better than saying spring or summer and I hope that my hon. Friend will be reassured by that.
§ Ms Blears
Indeed. There is a great deal of work going on right across the service in that group to try to ensure that we address these issues. The group has four main tasks. The first is minimising exposure to the risks of transfusion, particularly in relation to vCJD. I know that my hon. Friend has not mentioned that today, but it is a big concern. The second is ensuring the most effective use of an increasingly scarce resource, the available blood supply. Thirdly, and this is of particular concern to my hon. Friend, the group will consider alternatives to blood transfusion, all forms of blood substitute therapies, including correcting anaemia with appropriate vitamin and iron supplements, and the feasibility of bloodless surgical units. Such units are now beginning to develop in hospitals up and down the country. In my local hospital in Salford, two surgeons are able to operate in a virtually bloodless environment. That is a great step forward.
As I said, the report should be published in the next couple of months. I am glad to share that with my hon. Friend, who has a great deal of knowledge about this area. One issue that he emphasised today is the use of erythropoietin—it is probably best if we simply refer to EPO—in the treatment of anaemia and cancer patients. Anaemia is a common problem in people with cancer. It can be caused either by the disease itself or by treatment, especially chemotherapy. Mild anaemia is not usually a significant problem, but once it becomes more serious it can leave patients feeling exhausted, breathless, tired and fatigued. It can have a significant impact on their quality of life.
That would be a problem for any of us, but if those symptoms are considered together with the physical and emotional strains that cancer patients undergo, it is easy to see that it can be a serious problem. That is why treating anaemia can do much to benefit cancer patients and improve their quality of life during treatment. It makes them feel better, less tired and more able to cope with the strains they are facing.
I am concerned about my hon. Friend's statement about Birmingham, where he indicated that treatment for anaemia in cancer patients has been abandoned. I undertake to look into that situation, because although there are a variety of methods of treating anaemia in cancer patients, it is a matter for concern if no treatment is available in that area.
My hon. Friend said that the decision was made on grounds of cost. I am sure that he will be aware that the 10-year cancer plan adopted by the Government is backed up with significant extra resources: £407 million extra this year and £570 million extra next year. I am extremely concerned if those cancer networks are saying that anaemia in cancer patients is not a spending priority, because it is clearly a significant issue.
§ Mr. Havard
Can I take it therefore, as per my earlier request, that my hon. Friend will survey the cancer networks to establish how the cancer policies are running? The letter to which I referred states: 129WHThe situation may change as blood becomes less easy to obtain and more expensive".
§ Ms Blears
I am happy to undertake to look into the issue raised by my hon. Friend. I would also like to see, if he is willing to share that information, the results of the survey he conducted. The comments from the commissions would be extremely useful.
Blood transfusions are currently the main means of treating anaemia, but EPO is another option. It works by stimulating the production of blood in the bone marrow. My hon. Friend has looked closely at the use of EPO and he considered it not only in terms of how it could benefit patients but the knock-on effects for future blood supplies and for the NHS more generally in potential savings in bed days. I have looked at the evidence presented by my hon. Friend in terms of the calculated projected savings that the NHS could make by introducing EPO more widely for cancer patients, compared to using blood transfusions.
At present there are significant variations within the calculations. I am told that cancer patients having transfusions does not necessarily have to be the only use of that bed day and that they can have a transfusion at the same time as chemotherapy or CT scans. If we are to make decisions, we need to obtain the best possible evidence and to drill down into some of the calculations about the number of possible bed days that could be saved to the health service.
§ Mr. Havard
I accept that my calculations are crude because I had only limited resources with which to compile them. Nevertheless, they show a basic trend. I am happy that more qualitative work should be carried out on the incremental long-term consolidated change. There is more than a little empirical evidence that certain immediate changes could also be supported.
§ Ms Blears
I am sure that my hon. Friend will continue to press on this matter. I will do my utmost to ensure that we obtain the best evidence about the implications of introducing this service.
My hon. Friend referred to the actions by NICE. As he knows, we set up the institute to obtain the best possible advice about how to get the right treatment to patients, working within available resources. As I mentioned in correspondence, I believe that NICE is the most appropriate forum to consider the use of EPO versus blood transfusions. It has the responsibility and, most importantly, the expertise to appraise the clinical issues, the cost-effectiveness of the treatment and whether it should be more widely available.
It is difficult to circumvent the processes that we have established. NICE now has a well-respected place in the NHS, ensuring that what is done is based on proper, rigorous evidence, which gives us security for the future. As my hon. Friend said, EPO is currently being considered for referral as part of NICE's ninth wave work programme. I understand his wanting to press ahead, and although I cannot promise that it will be in the eighth wave, I shall consider whether it could be included early in the ninth wave.
130WH NICE sometimes has to take difficult decisions. There have been so many developments in cancer treatment in recent years that it must consider drugs that treat and cure cancer as well therapies, and EPO falls into that category. It is hard to differentiate between drugs that can cure and those with therapeutic benefits. Such decisions can be rather like the judgment of Solomon, but doing it properly is important.
Even in the absence of a NICE decision, it is open to the NHS and clinicians to make decisions about the clinical treatment of their patients on the basis of evidence that is already available. Therefore, nothing prevents clinicians from deciding that it would be an appropriate treatment. It is not right for Ministers to tell clinicians, from a distance, what sort of treatment they should be providing for their patients. If it is decided that a treatment is appropriate for those cancer networks, there are no barriers or hurdles to it proceeding.
I know that there are questions about costs, but significant extra investment is now being made in the system. It is for clinicians to decide whether they want to travel along that route; it is not for Ministers to usurp NICE's role or to substitute for the decisions of clinicians.
§ Mr. Havard
There is, of course, a disparity of practice. In certain parts of the country, clinicians may have a budget for drugs but not for blood. They will see that one commodity is free and that the other is available only at a cost, and they may therefore make different decisions than clinicians for whom both have a cost. The disparity of treatment comes from the mechanics and the process.
§ Ms Blears
I want to make two points. First, a number of new cancer drugs have been introduced through NICE, and the 31,000 patients who are now benefiting from those drugs would previously have been in the postcode lottery of care. Provision has clearly been made for the drugs service. Secondly, patients are integrally involved in the cancer service collaborative projects. They and their families are working side by side with clinicians. For the first time, patients have a mechanism to participate in that debate.
That brings me to what my hon. Friend said about choice, and it not being treated as rhetoric. The collaboratives give patients a significant influence on the shape and design of cancer services. Their views are not being sought as a sham, but are needed in order to change the design of those services. For the first time, patients have a real chance to influence the process.
My hon. Friend knows that we are only two years into the 10-year cancer plan, and we clearly want to make progress in several areas, but we have always said that it should be a step-by-step process. However, no one could deny that the cancer plan has already made significant improvements. Some 97 per cent. of patients are now seen within two weeks; we have extended breast screening to women over 65; and we have 800 new pieces of equipment. I know that it is not directly linked to the object of my hon. Friend's concern, but that extra investment has resulted in a significant progress in cancer treatment generally. Most cancer patients say that the service has been transformed in the past few years.
131WH I know that that will not stop my hon. Friend from continuing to press on the matter, because he is passionate about it and committed to it in the very best way that a Member of Parliament can be. I therefore reassure him that he is making constructive suggestions. I am fully engaged in trying to ensure an early review by NICE of the process, to ensure that patients get the best services.
§ Mr. Havard
I agree with my hon. Friend the Minister that there have been massive improvements. As I said earlier and as Professor Bosenquet's study shows, it is because we have been successful in treatment that we now have a problem with associated fatigue.
§ Ms Blears
The interesting point made by my hon. Friend is that cancer is changing from an acute to a chronic, long-term disease because people are surviving for longer. That means that we need to consider our processes afresh and to feed new thought into our services, which I gladly undertake to do.