§ The Secretary of State for Health (Mr. Frank Dobson)
With permission, Madam Speaker, I wish to make a statement on cancer screening.
In June this year, it was revealed that 12 women in Devon who had not been referred for treatment after being screened for breast cancer had subsequently developed cancer, and two of them had died.
On 9 June, in response to a private notice question from the right hon. Member for East Devon (Sir P. Emery), who is not here because he is in hospital, I reported what I had then been able to find out about this awful situation. I announced that I had asked the chief medical officer, Sir Kenneth Calman, to establish the facts about the breast cancer service in Exeter and to review the breast cancer screening programme nationwide in the light of what was revealed in Exeter.
The chief medical officer was assisted by a small team of people with specialised knowledge of various aspects of breast cancer. Their initial inquiries revealed wide-ranging shortcomings in Exeter and in regional and national aspects of the breast cancer screening programme. With my agreement, Sir Kenneth Calman asked the retiring chief medical officer for Wales, Dame Deirdre Hine, to lead a small team to review the national and regional arrangements for delivering quality assurance for breast screening.
Professor A. R. M. Wilson, the director of the national breast screening training centre in Nottingham, was asked to conduct an independent expert audit of 1,920 mammograms of all women who had been called back for further investigation after screening in Exeter and of all women who had developed cancers in the period between screenings in the past two years.
Completion of the chief medical officer's report was held up by the need to complete the audit of mammograms and, most recently, by a legal challenge from one of the doctors concerned. The report was completed last Friday afternoon. I am publishing it today.
The report covers three aspects: the independent assessment of the technical competence of breast screening in Exeter, based on the audit of mammograms; the examination of the organisational, managerial and quality control arrangements in the Exeter breast cancer unit; the review of national and regional arrangements for quality assurance of the breast cancer screening service. The report concludes that there were serious faults in all three.
The audit of mammograms concluded that there was evidence of failure on the part of the two radiologists involved to provide care to the standard expected of consultants involved in mammographic screening. That had not been picked up or tackled by the management of the Royal Devon and Exeter NHS trust over a number of years. It had been aware of questions of professional behaviour and other concerns about the operation of the breast unit, but no action had been taken. Management structures were confused. Lines of accountability were unclear. There was concern among staff and a lack of multi-disciplinary working. Some patients had complained about the attitude shown to them. Staff felt that their views had been ignored by management. They were right.
20 Responsibility for making sure that all breast screening units operated to a high national standard and that any shortcomings were spotted and dealt with promptly and effectively used to rest with national health service regions, but when regional health authorities were abolished, responsibilities for quality assurance for breast cancer screening were split. In the south-west, the Cornwall and the Isles of Scilly health authority took on the role of lead purchaser for breast screening quality assurance. The changes left the regional staff with some quality assurance duties, but neither the resources nor the authority to do the job. That situation applies throughout the country. Lead purchasing has failed the breast cancer screening service. The quality assurance system does not work.
As a result of all this, disciplinary proceedings have been instituted by the Royal Devon and Exeter trust against Dr. Brennan, the doctor in charge of the breast unit, who has been suspended. The other radiologist, Dr. Graham Urquhart, is employed by the South Devon trust, which has commissioned an audit of all his radiological work. Neither doctor is now involved in breast imaging.
Of the 1,920 women whose mammograms were reviewed in the audit, 229 were judged to need further assessment. All the women affected have been contacted, and the last one is due to be seen by clinicians on 10 November.
I know that all women in the Exeter area will be worried about whether they can rely on their screening result. The professional advice that I have received is that no other women in the area need be recalled or rescreened. The main problem was not in spotting possible cancers but in dealing with them appropriately, once identified. I am advised that all the women who needed to be recalled have been recalled. All women should, of course, continue to attend for routine screening appointments.
The report contains many detailed recommendations that will need to be carefully considered. I can announce today, however, the following action that is already being taken to implement the main recommendations: the Royal Devon and Exeter trust is taking action to make sure that the breast unit is properly managed in future and that arrangements are in place for staff to be able to report when things are going wrong; I am placing an explicit requirement on health authorities and trusts to commission and deliver breast cancer screening to national standards; all NHS trusts with breast cancer screening units are being told to review their arrangements to make sure that they deliver a high-quality service, and they must report the outcome of their reviews by the end of January 1998; all health authorities, trusts and regional offices will be expected to agree action plans by the end of February 1998 to ensure that all screening programmes meet national standards.
By 1 April 1998, responsibility and resources for breast screening quality assurance will be removed from lead purchasers and restored to NHS regional officers, who will be given all the necessary authority to secure quality assurance. In the last resort, they will be able to close down screening units that fail to meet national standards.
The shortcomings that the inquiry has revealed and the recommendations that it makes very much parallel the recent report and recommendations made by Sir William 21 Wells following his inquiry into the failures of the cervical cancer screening service provided by the Kent and Canterbury NHS trust. He singled out the failure of lead purchasing, the ineffectiveness of local management, the failure of arrangements for staff to report what was going on, and the absence of effective quality assurance.
Many of the problems at Exeter and Canterbury sprang from the shortcomings of the internal market, which included the absence of arrangements to secure high and uniform standards, even for cancer screening systems that were supposed to be national; legal obstacles to intervening in the affairs of trusts that are falling down on the job; staff not being able to speak their minds. All that must be changed, and the new Government will make the necessary changes. Our forthcoming White Paper on the future of the national health service will spell out proposals to improve the quality of treatment and care by setting high standards and putting in place machinery to ensure that the agreed standards are met. We have already announced the end of gagging clauses in staff contracts.
Cancer screening has two purposes: to identify patients who need treatment and to reassure patients who do not. The breast cancer screening service in Exeter and the cervical cancer screening service in Canterbury failed on both counts. They failed to ensure prompt treatment for women with cancer. For other women with cancer they gave false reassurance. They left thousands of other women not knowing one way or the other. They were a disgrace.
The failure to have in place a system that could identify promptly things that were going wrong and then put them right was also a disgrace. The final disgrace would be if those deplorable failures were to undermine the faith of women in this country in the value of cancer screening. Therefore, I urge all women to continue to attend for screening for both breast and cervical cancer, because, despite what has gone wrong, screening remains the best way of identifying breast and cervical cancers and pre-cancers in time to make possible early and, therefore, more effective treatment.
Finally, I offer my deepest sympathy to all the women who have suffered as a result of these failures and to their families. We owe it to them all to put things right, and we will.
§ Mr. John Maples (Stratford-on-Avon)
I thank the Secretary of State for his statement. I know that this is a subject in which he has taken a very serious interest for a long time. In particular, he has campaigned for better cervical smear testing and breast cancer screening. I join him in expressing my sympathy for the women concerned. This is a simply dreadful disease, and the uncertainty must have been really terrible.
The breast cancer arrangements in Exeter and East Devon failed to ensure proper treatment for breast cancer, and they gave false reassurance. I very much hope—I join the Secretary of State in this—that the inquiry will finally put matters right. I remind the House that it was the last Conservative Government—the first EU country and one of the first in the world—who introduced a nationwide breast screening programme based on computerised call and recall and who introduced the Calman-Hine recommendations, which were praised by the Macmillan Fund cancer relief briefing, which said that the Government had an excellent record on them.
22 This matter was first raised by my right hon. Friend the Member for East Devon (Sir P. Emery) in a private notice question in June, and by my hon. Friend the Member for Tiverton and Honiton (Mrs. Browning) in an Adjournment debate in the same month. They are not here today, unfortunately, as my right hon. Friend is in hospital and my hon. Friend, I am afraid, is stuck in a traffic jam.
The Secretary of State sought in part to blame what happened on the internal market, but was it not a failure of two individual consultants? The report blames them quite clearly. If the Secretary of State is saying that there is a far more widespread failure across the country, perhaps he will tell us. Is everything being done for the approximately 1,900 women who are directly affected?
The right hon. Gentleman told us about the women who have been recalled, but have those who have not been recalled been given a reassurance that they do not need to be? He told us what is being done at the Royal Devon and Exeter hospital, but are there wider lessons that he feels have been learnt across the country which are not just the failure of individual consultants? Does he have reason to believe that similar errors are being made elsewhere? In particular, can he confirm that absolutely nothing that has arisen out of the inquiry is being withheld or not being published?
Should there be a revised national protocol on screening to promote best practice? Is the Secretary of State satisfied that the existing protocol contained in the NHS executive letter of 23 January 1995 is working satisfactorily? That executive letter expires on 28 January next year. Do the results of the inquiry require any change to those protocols? Referrals in the Royal Devon and Exeter hospital seemed to be solely to radiologists. Even doubtful cases were not referred to surgeons for a second opinion. Is that right, or should such practices change?
I apologise to the Secretary of State if those questions are answered in the report, but I received a copy of his statement only at a quarter past 3, and, although I managed to read that, I did not manage to read the whole report.
Will the Secretary of State confirm that the commitments on cancer treatment made by his party before the election still stand, and will he tell us the time scale for their implementation? I shall remind him what they were. In April this year, the Minister for Public Health said:The waiting time to see a specialist and receive a diagnosis should end. If a woman has discovered a breast problem and is concerned, she should be able to see her GP, and be seen without delay by a specialist team at a breast cancer clinic, who can carry out the essential tests on one day.What progress has been made, and when does the Secretary of State expect to be able to fulfil that pledge?
In September 1996, the Labour party announced that the first £30 million of the first £100 million saved by cutting down on red tape would be used to reduce waiting times for cancer surgery. What progress has been made with that money, and when does the Secretary of State expect it to be fully committed?
In a statement in June this year, the Secretary of State said that, as a result of the decision to postpone the eighth wave of fundholding, £20 million would be saved, of which the first £10 million would be available to breast cancer specialist centres throughout the country. Will he tell the House whether that has happened? 23 Is the Secretary of State aware that the Health Service Journal reported that many health authorities had already spent hundreds of thousands of pounds equipping potential GPs? Quite a lot of GPs are becoming fundholders next year, so it would appear that the eighth wave has not been totally postponed.
I notice that the Secretary is not taking a single note of any of these questions, which perhaps shows the regard he has for the importance of reporting to the House on his duties. These are serious questions, and people outside the House have an interest in having them answered. He apparently does not share that view.
Has the postponement of the eighth wave of fundholding saved £20 million? That seems unlikely. If £10 million has been spent on breast cancer services, from where has that money come? What other national health service budget has been reduced to fund the service? Is an extra £30 million actually being spent on cancer services? Since June, when the Secretary of State made the promise, has £10 million been spent on improving breast cancer services?
The Secretary of State mentioned his forthcoming White Paper. We were led to expect it in September, and then in October, so he is obviously having some difficulty with it. Will he tell us when it will be published?
§ Mr. Dobson
I shall deal briefly with the points raised by the shadow Secretary of State that are irrelevant to breast cancer screening. To the best of my knowledge, we never said that we would produce a White Paper in September: we expect that it will be produced this month.
The hon. Gentleman asked about extra spending on breast cancer services. We announced the postponement of the eighth wave of fundholding, which released £20 million, £10 million of which has already been spent in cancer centres all over the country to improve the service provided for women with cancer, although it is not to do with screening. I emphasise that that money has not merely been released: it is being spent now in various parts of the country.
An NHS executive letter is going out today spelling out the changes that we require. No doubt further executive letters will go out when we have had time to consider the more detailed recommendations in the report, which was completed only on Friday. It is foolish for the hon. Gentleman to suggest that this matter springs only from the shortcomings of two radiologists in Exeter. Headlines in the report say:Lead purchasing has failed the breast screening programmeand:
Lack of expertise and resource in lead purchaser Health Authoritiesand:
The result: a quality assurance service that is unable to take effective action".
The basis of my statement is that there is no point in trying just to blame two radiologists: there will always be things that go wrong with the reading of mammographs and the reading of cervical cancer slides. The object is to have a system that identifies things when they go wrong, and puts people in positions of authority to do something about it. The system that we inherited from the last 24 Government, which probably was not too strong in the first place, was seriously weakened by the changes that occurred when regional health authorities were abolished, and that has meant that the quality assurance system throughout the country is weak. It needs to be strengthened, and we will strengthen it.
§ Mr. Ben Bradshaw (Exeter)
I thank my right hon. Friend for his statement, and thank Sir Kenneth Calman and his team for their excellent report. I also congratulate my right hon. Friend on the swift and firm action that he has taken today, which is in contrast to the activities of Conservative Governments over the past 18 years. Will he confirm, however, that the report has not been watered down or toned down in any way as a result of the threat of legal action by one of the consultants concerned?
§ Mr. Dobson
I am not sure whether I am supposed to say this, but I will, because I think that the House is entitled to know.
We were challenged in the High Court by Dr. John Brennan on Friday, and both the chief medical officer and I agreed to three minor changes in the text of the report. As far as I could see, those changes did not really change the meaning of even the sentences in which they were included, let alone the general drift of the report; but that apparently satisfied Dr. Brennan, his lawyers and the judges, and I thought it better to agree to those three minor changes than not to present the report to the House.
§ Mr. Simon Hughes (Southwark, North and Bermondsey)
I thank the Secretary of State for his statement. I approve of both his concern for action to be taken, and the action that has been announced. It is important that we have in the national health service a standard of care that is enforced so that it is applicable across the country, and does not become a lottery that depends on where people live.
In that context, will the Secretary of State reassure us that the regional officers system of monitoring is the best? Would it not be worth considering the idea of a national inspectorate for services such as those that we are discussing, which could do its job wherever and whenever it was required to do so? Are we sure that we have enough radiographers and radiologists around the country, both in practice and in training? Are we sure that we have the resources not just to deal with routine screening, but to ensure that particularly vulnerable people are not missed in the efforts to deal with the volume of people who pass through the very desirable screening process?
§ Mr. Dobson
There are possible shortages of radiologists and radiographers, which will take a long time to address. We cannot just snatch radiographers out of the air. We will, however, do what we can to make available any resources that are necessary.
The small group of extremely expert people who were under the guidance of Dame Deirdre Hine considered whether local, regional or national quality assurance would be the best option, and came down firmly in favour of the regional option as being the most practical, and bringing the surveillance and monitoring as near as sensibly possible to the people actually doing the work. I am sure that everyone will want to consider that, but, 25 given the circumstances and the need to get on with things, I have told the national health service that it must adopt that option.
§ Mrs. Alice Mahon (Halifax)
I congratulate my right hon. Friend on the speedy way in which he has reacted to a tragic and serious situation. The women who suffer from this killer disease—the real foot soldiers—realise that the situation exposes the stupidity of introducing an internal market in the national health service.
Can my right hon. Friend update the House on the progress of the pilot studies being conducted on bringing older women into the recall system? As my right hon. Friend knows, Age Concern and many other agencies representing older people are pressing for that and think that it would be worth while.
§ Mr. Dobson
I am sorry to disappoint my hon. Friend, who has done a great deal of sterling work in this sphere. The studies into the practicability and health gain from screening women over 65 are continuing, as are parallel studies about the merits or otherwise of screening younger women. I am not in a position to report on the state of progress on either of them.
§ Mrs. Virginia Bottomley (South-West Surrey)
I thank the Secretary of State for his statement. As I was the Secretary of State who commissioned and began the implementation of the Calman report, I obviously take a special interest. The right hon. Gentleman is right to say that, increasingly, the general public will be more demanding and discerning about quality assurance, and one of his challenges will be how he can deliver and meet that growing expectation. I urge him to visit the Jarvis centre in Guildford, a breast screening service of great excellence, and one of the early centres.
I detect an encouraging sign. With the delay in the publication of the right hon. Gentleman's White Paper, I note a softening of his approach towards NHS managers, whom he initially appeared to be regarding only with contempt. It seems that he is beginning to see that they have some merit.
§ Mr. Dobson
In answer to the right hon. Lady's final point, I have always been in favour of good managers in the national health service, who manage to the level that one might expect from the salaries that they receive. I applaud the good managers, but I do not applaud the mismanagement that went on or the Ministers who introduced a system that made it more and more difficult to manage quality assurance in breast cancer screening, as has been made obvious not by me but by Dame Deirdre Hine, the former chief medical officer for Wales.
The right hon. Lady asked about expectations, but we are not speaking about rising expectations. Women have been entitled to expect top-quality services in every part of the country and a system that spotted things that were going wrong and did something about them. We are talking about the failure of management, clinicians and politicians to deliver the standards that people could reasonably have expected in the past, let alone higher expectations in future. I have visited a number of breast screening centres, including the one in Cardiff which has been so brilliantly successful under the encouragement of Dame Deirdre Hine.
§ Mr. Gerry Sutcliffe (Bradford, South)
I congratulate my right hon. Friend not only on the speedy and 26 comprehensive way in which he has dealt with the specific cases in the south-west, but on the way in which money has been transferred to breast cancer care. He hits the core of the problem when he speaks about the internal market. Will he continue his deliberations on scrapping the internal market as quickly as possible? Will he say to hospital trusts that have the opportunity to merge and develop to stop sticking their feet out and put patient care first?
§ Mr. Dobson
We are progressing as quickly as we can with removing the internal market. In view of the failures of the lead purchaser system in relation to both cervical and breast cancer, we are reviewing the whole concept of lead purchasers in any part of the country, because, on the evidence that is available to us so far, it is not working.
§ Mr. Gary Streeter (South-West Devon)
Given the level of anxiety about this matter in Devon, I thank the Secretary of State for the speed and, dare I say, decisiveness with which he has acted in this case. I hope that the suffering of women in the west country will not be used as an opportunity to score political points. Can the Secretary of State reassure me that should extra resources be needed to make the breast cancer unit at the Royal Devon and Exeter hospital a viable, efficient and successful unit, he will treat it as a priority and make sure that that excellent hospital receives extra resources?
§ Mr. Dobson
I am sure that any extra resources that are needed to make the hospital work properly can and will be found, but the general point is that to do things clinically badly and to manage things badly is frequently more expensive and more demanding on resources than doing them properly. If it can be done properly in other areas, it should be done properly in Exeter. I pay tribute to the relatively new chief executive in Exeter, who, as soon as this was drawn to her attention, started sorting it out, in marked contrast to her predecessors, some of whom have gone on to promotion in other parts of the NHS.
§ Caroline Flint (Don Valley)
I thank my right hon. Friend for presenting the report, especially just after the end of a month in which breast cancer awareness has been at the top of the agenda—last week, I was happy to publicise that with women Members on both sides of the House. Does he agree that, in their lifetime, one in 12 women may be affected by breast cancer? Only recently, he opened the Jasmine centre at Doncaster royal infirmary, which shows the way ahead in dealing with the problem. It offers one-day, one-stop testing and diagnosis. That is how we should treat and deal with the problem for the 21st century. The centre has got off the ground only with money from this Government after the general election.
§ Mr. Dobson
I was very pleased to open the Jasmine centre, whose combined characteristics women would expect in these circumstances. It has state-of-the-art equipment, but it is also furnished, upholstered and generally laid out in a comfortable and homely way; much waiting and hanging about are involved in screening. It is, therefore, a place where people get the best of high-tech combined with tender loving care. That is what people want from the health service, not just for screening, but for everything else.
§ Mr. John Burnett (Torridge and West Devon)
We are grateful for the speed with which the report has been 27 produced. Did the inquiry or report address any possible conflict between consultants' duties and responsibilities to the NHS and their duties elsewhere, in the private sector?
§ Mr. Dobson
The report does not deal with that, so I cannot comment. All I can say is that what went on when the consultants were there was the problem, not what did not go on when they were not there.
§ Mr. Paul Flynn (Newport, West)
Does my right hon. Friend agree that the previous Government had three measures of success in the health service—the novelty of management techniques, the total amount of money that was spent and the total number of procedures that were carried out-to the almost complete neglect of the quality of service? We often find that, when more money is spent and more procedures are carried out, there is a proportional decrease in the quality of the service.
We are all grateful for what my right hon. Friend has said and for what he has done throughout his period as Secretary of State: he is putting the emphasis on quality and on the outcome of procedures. He must root out from the health service all the incompetence that is around. Of course, it is not universal—he rightly paid tribute to what is happening in Cardiff and elsewhere—but where there is poor-quality work and incompetence at the top and lower level in the health service, it becomes literally a matter of life or death.
§ Mr. Dobson
I agree with most of what my hon. Friend has said. Our White Paper aims to have an NHS that is geared to having quality standards and a system that delivers those standards. I am confident that we will be able to carry the clinical professions with us because they are showing much enthusiasm for the proposals that we are discussing with them before they go in the White Paper. It would appear that the only people who are not up to speed on what NHS patients and staff want are the official Opposition, whoever they may be.
§ Mr. Nicholas Winterton (Macclesfield)
I congratulate the Secretary of State on his very positive statement this afternoon. The hon. Member for Newport, West (Mr. Flynn) said that breast cancer screening was a matter of life and death. Indeed it is.
The assurances that the right hon. Gentleman has given, following the failures in Exeter and Canterbury, will provide great reassurance to the women of this country, who rightly expect the national health service to provide them with the quality service that we all want, wherever we sit in the House.
The right hon. Gentleman announced a change in the system. Will he assure me that the new system, which I support, will be continually monitored to ensure that no further failures occur?
§ Mr. Dobson
We cannot ensure that no further failures occur in the clinics. Failures will occur from time to time, because it is not a precise science. We need a system that 28 does not fail to pick up things that are going wrong. I am confident that the measures that we are putting in place at local, regional and national levels should deliver what the hon. Gentleman and I want.
Once again, I pay tribute to the hon. Gentleman for all his efforts over the years to sustain the national health service and work for top-quality services.
§ Mr. Peter Viggers (Gosport)
In examining a tragic local problem, the Secretary of State has also identified much more comprehensive difficulties. It is clear from what he said that he intends to devote considerably more resources to, and place greater emphasis on, breast cancer screening. I welcome the extra resources for that area, where the staff involved are highly skilled. It is a stressful area, as I know because my wife works in it as a doctor. What extra costs will fall on the NHS, and from which budget will they come?
§ Mr. Dobson
At this moment, I am not promising any extra resources. I said that I want to change the system so that the present resources are deployed to greater effect and so that we produce top quality. If, in the end, people make a convincing case that they cannot do that without additional resources, I will be prepared to listen and see what I can do—but they will have to make a convincing case. As I said earlier, badly run places frequently cost more than well-run ones.
§ Mr. Andrew Lansley (South Cambridgeshire)
The terms of the Secretary of State's statement will give rise to obvious concerns about the quality and standards of breast cancer screening throughout the country.
The right hon. Gentleman referred to headlines in the report. Will he outline the proportionate difficulty experienced around the country by referring to the evidence in the report, rather than to the headlines derived from the evidence? In that way, those listening to his statement—as hon. Members will have done carefully—will be able to see the matter in its proper proportions.
The right hon. Gentleman referred to the abolition of the internal market and the centralisation of quality assurance services. Does he agree that, for the time being, it remains the responsibility of purchasers to obtain those services on behalf of patients? Does it make sense for quality assurance to be separated from the purchasing function, as, to my mind, quality assurance and purchasing form part of the same function?
§ Mr. Dobson
On the hon. Gentleman's final point, there is a basic philosophical and management division of opinion. Unless I am misreading the Calman-Hine report, it suggests that it is probably best to separate the quality assurance function from the purchasing function. However, I am prepared to look carefully at that matter to determine whether the opposite case is more convincing.
In fact, quality assurance was not centralised; it was first balkanised and then virtually abandoned, so that there was no one in the system—nationally, regionally or locally—who had the responsibility, resources and authority to do anything about quality assurance. The split for breast cancer screening was introduced with the abolition of the regional health authorities.