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7 May 2002 : Column 22WH

Cancer Services (South-East)

11 am

Sandra Gidley (Romsey): I welcome the chance to introduce the debate. It was prompted by the realisation that I had dealt with a number of constituents who had had less than happy experiences in cases in which a cancer had been diagnosed. A glance at Hansard shows that other hon. Members have had similar experiences, and I hoped to be able to share those today. However, not many of those concerned seem to be here.

Almost invariably, my constituents have nothing but praise for the staff who treat them. It is important to mention that, because when we say things that might have a negative feel, staff may believe that we are getting at them. We are not getting at staff; indeed, in many cases, they are just as frustrated by the problems as are the patients. Most health professionals went into the profession because they wanted to make things better for people, and it is frustrating if they cannot solve problems quickly. In many cases, staff have verified my constituents' stories and have expressed a great deal of dismay at the difficulties that they have faced from time to time.

I want to touch on a number of matters: first, the problems surrounding diagnosis; secondly, waiting times for radiotherapy, without which the debate would not be complete; thirdly, access to drug treatments; fourthly, funding; and finally, a brief recognition of local cancer support services. Much of what I have to say has a national context, but as much as possible I shall restrict my remarks to those relating to the south-east of England.

I shall start by considering diagnosis. The Government have set a two-week standard for patients who have been urgently referred by their general practitioners. That means that they have to see the relevant specialists within that time. The latest available figures show a somewhat patchy compliance. Patients in the Surrey Hampshire Borders NHS trust, for example, come off best in that 99 per cent. of them are seen within the target time. Not so lucky are the people of Hastings and Rother; in that area, only 58.6 per cent. of patients see the relevant specialist within two weeks. I do not know the reasons for the differences—perhaps the Minister can enlighten us—but it will be interesting to know what performance level would ring alarm bells and, once those bells had sounded, what action would be taken, and by whom, to improve the service for patients in a particular area.

It is all very well if one has a lump or worrying symptoms and one's GP makes a referral. However, some say that GPs have a tendency to over-refer—I might not agree with that—because they know that it will put a patient's mind at rest. Others are more mindful of pressure on resources and may take certain decisions before referring, but that can lead to problems, as a constituent of mine in her early 20s discovered. She was a nursing mother, but was convinced that something was not quite right and found a lump in her breast. Her GP dismissed her as being over-concerned and suggested that her lumpy breast was caused by breastfeeding. He was wrong. By the time that the young woman was believed and the cancer properly diagnosed, it had spread, as it was of a particularly virulent type.

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Also locally last year, the press highlighted the case of a teenage girl who had died of breast cancer. The press reported that she was the youngest person in the United Kingdom to die in that way. Unfortunately, the probability of those two young women having breast cancer was extremely low, as any GP would know. That may work against young women being taken seriously and referred when they visit the GP. I have tried, but have been unable to find figures to show whether the rate of breast cancer in young women is rising, but GPs should be aware that breast cancer can affect women of all ages. Are there any plans to ensure that age is not a factor in determining whether a woman's symptoms are taken seriously?

While I am on the subject of diagnosis, I want to put in a word on behalf of the medical and scientific laboratory officers. They are all graduates and many of them have a secondary qualification. They are essential to the long-term success of the cancer plan, but their wages are very low. My local organisation asked to speak to me about the subject because so many people were leaving the profession. The previous hon. Member for Isle of Wight made the front pages of the local papers with his revelation that highly qualified people earned less than chicken pluckers. The wages are a particular problem in the south-east of England, as property prices are high and there is a high cost of living. There will be implications for the future if the issue of salary levels is not addressed, as the profession will simply not attract the bright young people that it needs to attract.

As I am about to show, accessing some treatments may take time, and there is a debate to be had about whether the two-week target is appropriate or whether it should be longer. Would patients be better served by concentrating efforts following diagnosis to ensure that people are treated more quickly? I suspect that my hon. Friend the Member for Oxford, West and Abingdon (Dr. Harris) will want to elaborate on that point.

I shall now discuss waiting times for radiotherapy treatment. I was first alerted to the problem by a constituent who had developed a form of skin cancer. His specialist decided that he needed urgent radiotherapy and spent two hours on the telephone trying to book treatment for him. He telephoned places all around the south of England and no treatment was available for three months. My constituent had some savings, which he was reluctant to use, but he eventually decided that his life was worth it and his oncologist managed to book him into one of the London hospitals as a private patient. As my constituent did not know how he would be feeling, he had to travel from London by taxi, again at some expense. Although he accepted that it was his decision to access private medicine, he thought it reasonable to try to reclaim some of his travel costs—unfortunately, to no avail, as he had not agreed that before embarking on treatment. I suspect that he had other concerns at the time, focusing on the diagnosis of cancer, which does tend to concentrate the mind. The decision not to pay some of his travel costs, although they were a small portion of the cost that would have been incurred had he undergone radiotherapy under the national health service, seems perverse when we are shipping people to the continent for hip operations.

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Currently, many people in the Southampton area are waiting 13 weeks or more to begin radiotherapy. Recent figures show that that appears to be a problem throughout the south-east. On 30 September 2001, 35 per cent. of in-patients were waiting for more than 12 months for radiology—I cannot believe that figure, but most have to wait more than three months. The latest figures for out-patients show that only 77.6 per cent. are seen within 13 weeks of referral. Is there spare capacity in other parts of the country? Would it be possible to treat patients from the south-east elsewhere?

The plot thickens. Two days ago, The Sunday Times pointed out:

That article specifies surgery, but do the same criteria apply before a patient is put on a waiting list for radiotherapy?

Worryingly, The Sunday Times also claimed that there were long waiting lists for magnetic resonance imaging and computerised tomography scans. Worse still, waiting times for MRI scans are not compiled, as revealed by the Minister in a written answer to me on 15 April. In the light of the importance of that procedure in diagnosis of cancers, does she have plans to collect the figures so that we can know whether our constituents receive a service that is good, bad or as we would expect? Constituents of mine have raised concerns about waiting for up to six months for such diagnostic procedures.

I developed a close interest in drug treatments when a constituent wrote to me in desperation. She had been told that Herceptin was her only chance, but at the time the National Institute for Clinical Excellence had not approved it. Her doctors were reluctant to provide it. She obtained the treatment eventually but, sadly, it was too late for her. In some ways, she was luckier than most, in that she was tested to see whether the drug would benefit her. A Europe-wide survey showed that only 18 per cent. of women with newly diagnosed breast cancer in Britain were tested for HER2. A positive test for that means that the drug will be useful. That compares with 67 per cent. of women in Germany and 87 per cent. in Spain.

Happily, NICE has approved the drug, but some interesting questions have been raised. If doctors still do not test for HER2, they will not be in a position to know whether the drug will be valuable. What steps is the Minister taking to ensure that all women, not only those in the south-east, have access to the test to suggest whether they should receive a NICE-approved treatment?

I have been lobbied by many drug companies since the subject of our debate has been known. I shall deal with a couple of their points briefly because they affect the south-east, although not exclusively so. Is the Minister happy with the delays in obtaining NICE guidance? What estimate has been made of patients who have been denied treatment because of the delay? When a drug is approved, what monitoring of uptake is there? How does the NHS monitor the number of patients and the cost that it bears, and make comparisons with the pre-approval phase of the drug? Without such

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comparisons, it is difficult to say with conviction that NICE guidance is being acted on. An undertaking to provide such information would be most welcome and add to the transparency of the process.

I want to touch briefly on aspects of funding. No one would deny that the extra money for cancer services was welcome. What is less clear is how it is allocated once it reaches a trust. Recently, the Select Committee on Science and Technology considered cancer research, and in one sitting with the Minister specific concerns were expressed about whether funding reached what it was designated for. Macmillan Cancer Relief had received reports that much of the money was diverted elsewhere to pay off debts. At the time, the Minister did not have a categoric answer because the accounts simply were not available. Is there any update on that position, and what action will the Minister take so that her Department—particularly in the south-east region because that is my concern—ensures that hypothecated resources get to the services on the ground?

I want to say a brief word about a couple of local cancer services. We are very lucky to have the Wessex Cancer Trust, which does sterling work. I have mixed feelings about whether such trusts should be funding hospital equipment, rather than the NHS, but it seems to be the way of the world these days. I want to mention briefly Jane Scarth house, which is part of something called Cancer Concern. It is a walk-in centre close to the local Waitrose, in the high street in Romsey—an excellent idea. It provides information, support and counselling. You name it, it does it—from helping women to look good when they have to wear a wig, and really do not want to, to providing counselling support for families, and more or less everything in between. It has suffered financial problems recently, due to the winding up of the parent charity. It has been so worth while and of such benefit to many local people that I wondered whether there was any way of extending that sort of scheme to other areas of the country. People do not always want to go into a medical environment to obtain the help and support that they need. It seems to me that such high street centres are well placed to cater for that.

I am disappointed that there are not more people present today because I have had a considerable mailbag on various aspects of the problem. I had thought that more concern would be shown here today. Of particular concern is the radiotherapy waiting list. I understand that there are plans afoot to put in new equipment, but that will take some time. In the interim, it would be useful to know what we are doing for those patients.

11.17 am

Mr. Julian Brazier (Canterbury): I congratulate the hon. Member for Romsey (Sandra Gidley) on obtaining the debate, and on her thoughtful speech. She was looking, quite rightly, at the full spectrum of cancer services, from primary care through the full range of hospital services and related support.

I want to focus on the narrower but absolutely critical issue of cancer centre services in east Kent. I am glad to see the Minister in her place again because I have had the opportunity to pursue the cancer issue with her in a small way. The debate will give me a little more time to

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focus on the cancer problems that arise out of the proposed reorganisation of hospitals in east Kent, particularly in the light of last week's revelations about cancer.

The cancer centre in Kent is unique in the country in being jointly delivered on two sites: Maidstone, which serves west Kent, and Canterbury, which serves east Kent. They have the ability to treat common cancers and provide specialist services for diagnosing and treating rarer tumours, radiotherapy, specialist nurses, diagnostic services, CAT scanners, MRI, endoscopy, pathology, in-patient medical care for complex treatments, a high-dependency unit for seriously ill patients and dedicated out-patient facilities. In other words, all the various strands that comprise a cancer centre are provided on both sites. That is partly because the logistics of Kent are so bad. To be readily accessible to people at both ends of the county, two sites were needed. There is also a capacity issue, to which I shall return.

Behind that dry list of services there exists an extraordinarily good cancer centre at Canterbury. Several very dear friends of mine have been treated there, in most cases extremely successfully. A former agent, Jo Chapman, who, tragically, did not survive, was none the less treated very professionally right up until the day she died. I saw her just before she died and she was full of praise for the treatment that she had received in the Mountbatten centre, the residential facility in Canterbury, whose construction was largely funded by outside money raised on appeal.

Several problems for the cancer centre arise from the proposed reorganisation of the three acute hospitals in east Kent. I have letters from two of the three consultants who operate in the joint cancer centre. One, from Dr. Stewart Coltart, lists the problems, saying:


He mentions

as well as from Canterbury. Thanet has the largest concentration of deprived people, we are told, in south-east England outside London; Deal and Dover have large amounts of deprivation and I have some extremely deprived wards in Canterbury.

Dr. Coltart raises the question of

He mentions the enormous cost of transferring the facilities from Canterbury to Maidstone, which does not seem to have been included in the private finance initiative proposals at all because of the anomaly that, thanks to the East Kent health authority's last reorganisation, cancer services belong to the Maidstone and Tunbridge Wells trust and not to the East Kent hospitals trust, which designed the document. Listing a final problem, he says:

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Dr. Howard Smedley, another consultant, backed up his colleague's comments, saying:

he alleges. He continues:

Let us look for a moment at the process that has taken place. Cancer was excluded from it. The trust responsible for delivering the joint cancer centre in Canterbury is not a signatory of the document. Professor James, who heads the joint cancer centre, attended the meetings and claimed that he was closely involved with the writing of the appendix that appears in the back of the document on cancer. He said that his main thrust would be to restore confidence for the purpose of attracting new cancer consultants. He also claimed, at the Canterbury meeting, that all three of the Canterbury-based consultants were solidly behind the proposals in the document. He even listed them by name. Yet the two letters to which I have just referred, attacking the proposal, had been widely circulated some weeks before.

I asked Professor James at a subsequent meeting at Whitstable whether he supported the sentence on page 42 of the document that appears to be a direct attack on confidence in the centre. It says:

He was, of course, unable to answer, as his previous spiel had been all about building confidence in the viability of those services.

Asked whether he had seen the letters from two of his three Canterbury consultants vehemently opposing the proposals on the grounds that they would be clinically unsafe, Professor James again refused to answer. Just for the record, I understand that the third consultant was so angry about his claim, which mentioned her name and views, that she subsequently denounced him at a consultants' staff meeting.

I shall look for a moment or two longer at the detail of some of those problems. Page 43 of the cancer appendix—I should stress that it is only an appendix that sets out some ball park points rather than a firm proposal—to the document claims that

That is stated as a bald fact. It was backed up—if that is the right phrase—by Professor James's claims at the Canterbury meeting that four fifths of the people who are currently treated in the cancer centre at Canterbury will continue to be treated there. We have heard the four-fifths figure in a quite different context before. It was claimed for the accident and emergency unit in its downgraded form as a minor injuries unit. That figure

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has now been abandoned and replaced with one of between 50 and 60 per cent. None the less, I mention that as the figure that Professor James was claiming. He made a bald claim that the ambulatory out-patient model would be good for at least 10 years at the lower level of 80 per cent. of current treatments.

After the cancer tsar visited Canterbury, however, he sent a letter headed "Provision of cancer services in Kent" to Dr. Stewart Coltart. It states that if Canterbury ultimately becomes a community ambulatory care centre, it would not be safe to provide in-patient oncology services there. More important, it states that day case treatment, including radiotherapy, "might be possible." All that the cancer tsar can say is that it "might" be possible.

Since then, Professor James has prepared another paper that he has actually signed—there is no signature on the mysterious appendix that appeared in the back of the proposal document. Indeed, as I remarked earlier, his trust was not a signatory to that document. This paper was produced in secret, prepared for his employers in Maidstone and, I imagine, sent to the new Kent health authority. It also happens to have fallen into my hands. As one would expect, it is worded in highly technical language. I shall therefore only quote its aims and final conclusion, both of which are extremely short. It examines the implications for Kent of

and looks at

I shall also quote the paper's first three conclusions. The first conclusion is:

Maidstone already has a 14-week waiting list as opposed to Canterbury's seven-week waiting list.

My hon. Friend the Member for Faversham and Mid-Kent (Hugh Robertson) tells me that he has written three times to the chairman of the Maidstone and Tunbridge Wells trust asking it to give an official response to the cancer appendix to the document. He has not yet received an answer of any kind. He asked me to state that, because he is attending another meeting booked some time ago that prevents him from joining us.

The second conclusion is:

The idea that gynaecological services will be taken away from Thanet, where they are now, has been neither canvassed nor discussed anywhere. Professor James uses the word "centralisation", reminding us that the centre for west Kent is now in Maidstone. The only other place where gynaecological services are delivered at present is Thanet. Is east Kent to lose gynaecological services too? It would be interesting to have an answer to that question.

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The third quotation is the real killer:

Indeed, a large part of the paper, which I shall spare the Chamber, discusses the back-up services for haematological cancers—leukaemia and the other blood-related cancers. In other words, since Professor James's various verbal contributions to the consultation process—they were only verbal—he has already conceded that in the case of blood-related procedures the services are worthless: they will all have to go to Maidstone.

A few minutes ago I was on the telephone to Dr. Stewart Coltart to discuss this issue. He makes the point that the distinction that Professor James draws between blood cancers, in the case of which he has finally conceded that it will not be practical to follow his model in Canterbury, and the solid cancers does not exist: almost exactly the same problems apply to the solid cancer centre services as to the blood cancers. In other words, we face the loss of all the true cancer centre services from east Kent. It is true that on all three sites in east Kent it will be possible to continue to deliver the cancer out-patient unit services. However, to summarise in plain English what I have been saying for the last few minutes, if the proposals to reorganise the three acute hospitals in east Kent go ahead, the first cancer centre closure since the Government took office will take place: the cancer centre, as a centre, in Canterbury will close. I look forward to hearing the Minister's comments on that.

11.31 am

Dr. Evan Harris (Oxford, West and Abingdon): I pay tribute to my hon. Friend the Member for Romsey (Sandra Gidley) for securing the debate and setting out what she wished to say in such a clear and organised way. She draws our attention to key questions about diagnosis, the waiting time for diagnosis and, in a couple of examples, the quality of diagnosis, the waiting time for treatment, access to drug treatments, funding and the role of local cancer support services in the NHS and, particularly, the voluntary sector. I share her regret that more hon. Members from all parties are not present to hear her points of view, but what we lack in quantity the two previous contributions have made up for in quality.

Even in the south-east, cancer services are a large subject. I am sure that the Minister has come prepared to deal with a number of questions from Back Benchers and Front Benchers on all aspects. I concur with my hon. Friend that many of these issues are not only local and regional but national. I have a number of questions to which I hope that the Minister will be able to respond. To ensure that she has time to prepare her answers, I shall set them out at the start of my speech, before I mention each one individually. I should be grateful if she would respond to six questions.

Will the Minister first—she may have guessed that this was coming—set out the evidence base on which the two-week wait policy is predicated, to show that it will improve survival, compared with a policy of a maximum waiting time between presentation and treatment or

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diagnosis and treatment? She will accept that, at best, there is some controversy about the rational evidence base for improving survival for that target.

My second question, which my hon. Friend raised in passing, relates to the shortage of radiotherapists and the fact that the private sector has radiotherapists who may be available to the NHS. A separate question relates to the fact that the bulk of those radiotherapists will have been trained by the NHS, at its expense and that of the public sector, through our university system. Does the Minister think that it is reasonable for the private sector not to carry any overhead for the training of radiotherapists when it tenders for NHS contracts or any other business? Does she agree that there may be some rationale for asking the private sector to pay some form of levy for the time that it uses of NHS-trained radiotherapists and other professions allied to medicine, such as nurses and doctors? Otherwise, there will not be a level playing field in tenders for NHS contracts, which she wishes to open up to the private sector.

My third question relates to a point made by my hon. Friend. By focusing on specific aspects of waiting, the Government fail, by an act of omission, to pick up the overall waiting time between presentation and treatment everywhere in the country, although one can consider it on a regional basis. Can the Minister explain why the Government did not set up a mechanism to measure the time between presentation and treatment and, even more important, between diagnosis and treatment rather than between presentation and diagnosis of referrals, most of whom, fortunately, will not have cancer? The failure to collect such data and the failure to record other waiting times, such as those for MRI and other services, lead to the allegation that the Government seek to disguise long waiting times.

My fourth question is about NICE approval for drugs. Can the Minister tell us which drugs are not funded in order to find the money to pay for drugs and treatments that have been approved by NICE, which must now be used, following the regulation that NICE guidance must be implemented? If she cannot answer that, can she say what system she has set up to monitor the effect on drug treatments that have not been approved by NICE and, therefore, are not protected by the diktat that health authorities and primary care trusts—whoever has the funding—must fund them?

I should be grateful if the Minister would discuss the role of the lottery in local cancer support services. Perhaps the Government have changed their policy, but my understanding was that the lottery would not be used to pay for core services in the health service. We know that the proceeds of people's gambling on the lottery are used to pay for radiotherapy machines and linear accelerators to treat cancer. Is that because the Government's policy has changed or is it their view that such machines are not part of the core service that the NHS should provide? Everyone wants to see more machinery, but is that consistent with the Government's announced policy?

My final question is about the funding of hospice care, which is, I suppose, the end of the process. The Government made a series of announcements about additional funding for hospices, which have not really been part of the NHS. In my constituency and in the constituencies of other hon. Members, that important part of patient care has generally been left, at best, to a

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combination of voluntary organisations that have been fortunate and hard-working enough to raise funding, and small NHS or social services contributions. If hospice care and terminal care are part of core NHS treatment—I believe that they should be—they should be funded by the Government. I am not asking the Minister to repeat her previous announcement about the amounts of money, but I am asking her to clarify when hospices will receive the funds.

My local hospice certainly has not seen any additional funding. I refer to the children's hospice, Helen house, and its partner organisation, Douglas house, which is about to be established. I fear that, despite huge efforts, such hospices will be unable to continue to fund-raise sufficiently to maintain resources. Since there is not an adequate NHS for children and young adults, which is the area covered by the hospices, I should be grateful if the Minister would give a categorical assurance that the funding that she announced—it differed from a Library briefing that I was given—will reach front-line services.

My hon. Friend raised several important points about the two-week wait. Through her work, she showed that the implementation of that has been patchy, which is a source of concern even if it is a rational target. None of us wants our constituents to wait too long for a diagnosis of symptoms. There is a debate over whether people necessarily want a same-day or one-stop service, which has been previously advocated, or whether they want time for investigations, to see specialists, and to return in the near future for a discussion of the diagnosis. However, the trend towards conveniently accessed one-visit diagnoses and further investigations is important.

If there is no evidence of improved patient survival after a two-week, rather than a two-month, wait to see a specialist, one must balance the undoubted gain of speedy referral for some patients with the consequences of such a policy. The consequences do not appear to be improved survival for the patients referred; they appear to be a later referral time for those who are not fortunate enough to be referred under the two-week wait. That may apply to the people in the cases raised by my hon. Friend, who are not thought to have cancer symptoms and are referred by GPs in the normal process if they are referred at all. They must wait longer because resources have been taken from general out-patient services to meet the two-week wait.

Even when funding is available, if there is a fundamental shortage of staff one is simply rearranging queues. The Government have decided to prioritise people referred under the two-week wait, but they must recognise the consequences of that. Professor Michael Baum told me that he was concerned that in the breast cancer field patients who were not referred under the two-week wait would suffer. Many GPs recognise that, and refer as many people as possible for the two-week wait, which somewhat defeats the purpose. Can the Minister say whether any thought has gone into the implications of that policy?

I should like to reinforce the message of my hon. Friend on the state of recruitment among scientific officers, and on their remuneration. The problem is apparent not only in laboratory staff and medical laboratory scientific officers, but in cytology screeners,

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who are a crucial link in the diagnosis of cancer. They are among the worst paid graduates working in a technological area. The south-east has a general skill shortage and will find it more and more difficult to recruit newly qualified graduates. It may also become more difficult to recruit people into training for those subjects. As the former Member for Isle of Wight, Dr. Peter Brand, remarked, for scientific officers on the Isle of Wight to be paid less than chicken pluckers is an indictment of the way in which, over many years, the NHS has treated people with those qualifications.

There is a growing concern, although the problem has always existed, about the wait for radiotherapy treatment. In that case, outcome will be impacted by the time spent waiting for treatment. Many of the points made in the article in The Sunday Times need a response from the Government. In my constituency and other areas throughout the south-east, patients have great difficulty in gaining access to drug treatment. My hon. Friend drew attention to the difficulties for patients waiting for drug treatment when NICE has started its appraisal process because of what is commonly called "NICE blight" in which the take-up and prescription of a drug falls simply because the drug is going through the NICE process. My hon. Friend's questions about the speed at which NICE reaches its conclusions are pertinent and I look forward to the Minister's response.

A number of hon. Members in this debate and elsewhere have asked where the funding for cancer services has gone. My hon. Friend the Member for Twickenham (Dr. Cable) said at Prime Minister's questions that if funds are ring-fenced for cancer services, it is reasonable for people to ask what steps the Government are taking to ensure that that funding reaches its destination. There have been a number of claims that funding has been used to pay off debt or has gone to other areas. One can question whether it is reasonable, legitimate, ethical or distorting specifically to allocate some of the growth to centrally decided priorities, but if the Government do that they owe it to the audit process, if not to patients and staff whose expectations have been raised, to ensure that the funding reaches those priorities. The Science and Technology Committee report on research mentioned the matter and raised serious questions for hospitals not only in the south-east but throughout the country.

I again pay tribute to the hon. Member for Canterbury (Mr. Brazier), who perhaps has more detailed knowledge than anyone of the proposals for east Kent hospitals. He has been very active in the matter and I know from speaking to people in his area that he has worked hard on their behalf, no matter what their political views or whether they have any. The reorganisation of hospital services in east Kent, particularly cancer services, poses difficult problems for a Government with whom the buck eventually stops. His contribution reflected the widespread public concern about the future of cancer services as well as the drastic situation concerning acute services in those hospitals.

In conclusion, I join my hon. Friend in paying tribute to those who work in this area. They have to deal with a difficult condition. Cancer can strike at any age and is, by nature of its pathology, often relentless in its course. They must deal with a condition that receives a lot of political and media attention. Professional staff tell me

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that they know the risks of working with this condition and that they may be labelled negligent if one cancer is missed because the expectation is that screening will pick up every cancer and that early detection automatically and always means an increased likelihood of cure. The picture is more complex. Screening is high risk detection and is not foolproof. It is incumbent on the media and politicians to recognise that when cancer is missed. It was ever the case. We must improve diagnosis and our level of suspicion. We must also improve treatment in the health service, but it is dangerous to raise expectations to too high a level because it will simply put off hard-working staff who do their best.

Tribute should also be paid to the voluntary organisations that do so much to raise resources for cancer research and treatment. My hon. Friend referred to the tension between welcoming fund-raising of all kinds for cancer and the question whether that is a replacement for or an addition to Government funding for the health services. It is clear that without volunteers to offer counselling and raise funds for treatment and research, we would not have the cancer services that we do, and I join my hon. Friend in paying tribute to those people.

11.49 am

Tim Loughton (East Worthing and Shoreham): Like other hon. Members, I congratulate the hon. Member for Romsey (Sandra Gidley) on raising an important subject, although it is a great pity that its importance is not reflected in today's turnout. That said, the reason for the poor turnout may be that we hold debates almost every other week on some aspect of this issue, be it breast cancer, cancers in men or, as today, cancer services in the south-east. However, the low turnout gives the Minister an opportunity to provide a full and detailed response to the points that have been raised. Usually, Ministers must squash their replies into the final 10 minutes or so and are peremptorily cut off just as they get to the essential question that we want answered.

I echo the six questions raised by the hon. Member for Oxford, West and Abingdon (Dr. Harris), which I, too, have raised at various times in the past, not least in this Hall. I want to take up two of the hon. Gentleman's points. First, the two-week policy has been a cornerstone of the Government's approach to cancer treatment, but I have seen evidence that it distorts treatment times following the front-end loading of consultation times, which have been speeded up only through the massive concentration of a finite quantity of resources.

Secondly, I echo the hon. Gentleman's final question, which related to hospice care and to which I hope the Minister will reply. Hospices are finding the going tough, and that will be particularly true following the national insurance increases in the Chancellor's recent Budget. They will receive none of the additional funding that is intended to make up for the £250 million national insurance bill that will fall to the NHS. The vast majority of hospice funding will have to come from additional voluntary contributions and charitable fundraising which we see throughout the country. That is true not least of St. Barnabas hospice in my constituency, of which I am honoured to be a patron. St. Barnabas is conducting its massive chestnut tree

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appeal to build a hospice for children in my area, and it needs to raise £5 million in capital alone. The running costs involved in staffing the new hospice will be that much higher than elsewhere given that it is in the most expensive corner of the country and that it is particularly difficult to recruit medical staff. The Government must consider the issue more favourably than they have done. The Conservative party promised a big increase in funding for hospices, particularly for children, and I would like guarantees along those lines from the Government.

The initial point raised by the hon. Member for Romsey was that our comments about cancer services in this debate and elsewhere are not a criticism of the dedicated and long-suffering staff in this highly stressed area of the NHS. From all the examples that I have seen, I know that, without exception, they do their jobs with enormous dedication and professionalism, even if the results do not reflect their input in many cases.

Cancer treatment remains one of the cornerstones of new Labour's promises to modernise the NHS, but we still hear far too many horror stories and excuses as to why services are taking so long to improve and will need much more investment. The national cancer plan stated:

The Government therefore have an awful lot more to do.

Over recent months, we have heard stories that suggest that things are not going as well as they should, not least the stories in the recent Science and Technology Committee report about the siphoning off of cancer funds, revealing that money promised to improve cancer care appears to have been siphoned off by NHS trusts to pay for other priorities.

In their cancer plan, the Government pledged to increase spending on cancer care by £570 million a year by 2003–04, but cancer specialists told the Select Committee that part of the first round of funding—about £280 million for 2000–01—may have been diverted by NHS into paying off debts or meeting administration costs. The report stated:

The Committee thought it "dissembling" of the Government to allocate funds to cancer care with great publicity, without taking even the "simplest precautions" to ensure that the money reached the intended areas. I am sure that all hon. Members will echo the sentiments expressed in that frank, detailed and welcome report.

As other hon. Members have said, there are continuing problems over spending on chemotherapy drugs. Spending in this country is still way out of proportion to what is spent in other countries. Spending per head of population is £6.24 in Germany, £3.31 in Italy and a derisory 95p in the United Kingdom. That puts it in context.

Conservative Members welcome the Government's cancer plan—it will allow preventive work to reduce the risk, earlier detection and improved community support for sufferers—but the proof of the pudding will be in the

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output, not in the amount of literature produced to identify the problem and to try to convince us that something is being done.

As we have heard, waiting times are still far too high. In a recent Adjournment debate, my hon. Friend the Member for Bexhill and Battle (Mr. Barker) spoke of the alarming problems caused by the time that breast cancer patients have to wait for treatment in his constituency in East Sussex. In an article entitled "Not the waiting list" in The Sunday Times this weekend, we read of further examples of treatment not happening in the south-east. For instance, Joy Barthorpe of Battle was diagnosed with breast cancer last October and had her operation on 28 December. She has now been told that her radiotherapy will not start until 24 June.

Another patient from Sussex was attending the Kent oncology centre in Maidstone. She was diagnosed last autumn as having breast cancer, and she underwent surgery on 21 November. Following the operation, she was told that it would be a requisite part of the treatment that she should start radiotherapy between four and six weeks later. She was told that she would receive written confirmation that radiotherapy would begin in early January, but she heard nothing for seven weeks. On telephoning Maidstone and Tunbridge Wells NHS trust in early January, she was told that her treatment could not begin until 25 March. In practical terms it means that treatment that was recommended to begin four to six weeks after the operation will not now take place until at least 16 weeks later.

Perhaps the most unfortunate aspect of the case is that the hospital made no attempt to get in touch with the patient and tell her that she would have to wait another two and a half months to begin radiotherapy. By its own admission, current waiting times at the Maidstone and Tunbridge Wells NHS trust are not unusual; they are an accurate reflection of the situation across the NHS. The comments of my hon. Friend the Member for Canterbury (Mr. Brazier) show how the centralisation of those services may push waiting times out even further.

Mr. Brazier : I am most grateful to my hon. Friend for giving way, but he has just made exactly the point that I was about to make. We already have completely unacceptable waiting times at Maidstone. Waiting times at Canterbury are currently shorter; however, if Canterbury is run down and everyone is expected to be treated at Maidstone, what can we possibly expect to happen to waiting times?

Tim Loughton : My hon. Friend makes his point well. As we know, Kent has a particular problem. Speed is of the essence in treating these cancers. Six weeks is approximately the time that it takes for many tumours to double in size, and introducing an additional delay of four or more weeks between planning and starting radiotherapy must prejudice outcomes.

It is not all the bed of roses in the south-east that many Ministers seem to think. It is the largest region in the country, with 8,100,000 people, which is 13.5 per cent. of the population of the United Kingdom. It is the most densely populated part of the country and the one with

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the greatest number of older people, as I know from my experience of Worthing. That brings with it problems for the NHS, such as additional costs of treatment for the elderly, bed blocking and long waiting times for hip and knee replacements. What measures have been taken to utilise spare capacity elsewhere in the United Kingdom? Those in the south-east face disproportionately long waits.

The pressures on finance are especially acute in the south-east. One recalls the leaked memo from Ruth Carnell, the chief executive of the NHS in the south-east region, which came to light just before Christmas. The memo showed that NHS trusts in the region would overspend in the financial year 2001–02 by £60 million. The Worthing and Southlands Hospitals NHS trust, in my constituency, is some £2.7 million in deficit.

Jo Yardley, the general manager of Kent oncology centre in Maidstone, in my hon. Friend's area, said:

Hilary Thomas, professor of oncology at Royal Surrey County hospital, said:

someone who does not appear on the waiting list—

Those quotes are from this weekend's edition of The Sunday Times.

In the south-east, the additional pressures of staff shortages at all levels are causing problems. There is a particular shortage of radiographers, as has been mentioned by hon. Members. The figures for radiographer shortages in the south-east are alarming: the number of whole-time equivalent radiographers per 100,000 for the whole of England is 21. In the south-east, that figure is just 17 and in West Sussex, in my area, it is just 12, which compares with a figure of 25 in the north-west and 65 in Manchester. Those are big differences.

The vacancy rates also reflect the differences between regions. Against a national average of 8 per cent. of vacancies for therapeutic radiographers, in the south-east the average is 13.1 per cent. and in East Sussex and Brighton and Hove, next to my constituency, it is 19.2 per cent. Those are enormous differences. When I tabled questions about radiographer vacancies, we were told that information regarding the number of radiographers joining and leaving the NHS was not collected centrally. One might suggest that it should be collected centrally, because urgent central attention is required.

The Government may tell us that the number of qualified radiographers has increased by 8 per cent. since 1997—that is a head-count figure, not a whole-time equivalent. However, the Government have placed extra burdens on radiographers, with the enormous numbers of people who now, rightly, have breast screening. That extra capacity has been used up in dealing with the extra breast screening alone.

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The breast screening centre in Worthing hospital has one consultant radiographer, Dr. Linda Rockall. Goodness knows what problems we would have in that hospital if she fell under a bus. The hospital desperately needs more recruits. People at the hospital say that they would be delighted to offer breast screening to older women, but that they cannot do so because they are struggling to cope with the work load as it is, without taking on a new raft of clients. Breast screening for older people would be a fair promise to make, but it is a worthless promise unless the resources and qualified radiographers exist. Especially in our corner of the world, there is an enormous shortage of those people.

I want to mention breast care services in Brighton and Hove. The central Sussex partnership has proposed the establishment of a single breast care service at the Princess Royal hospital at Haywards Heath, which will mean the closure of the breast care unit at the Royal Sussex County hospital in Brighton. That is a big issue locally. Just last week, a couple of Brighton and Hove councillors, Brian Oxley and Ann Norman, came to see me to try to focus yet more attention on what is a serious issue. A petition on the subject attracted some 30,000 signatures in just 11 days and a unanimous vote by every councillor of every political persuasion on Brighton and Hove council.

The city of Brighton and Hove has a population of just over 250,000, plus another 50,000 people living in the surrounding areas and 750,000 in West Sussex and my constituency, from where many people go to Brighton hospital for treatment. Many hundreds of women who live locally put their lives at risk each year by failing to keep hospital appointments, mainly due to fear of diagnosis. Certainly, as the hon. Member for Romsey said, we need to encourage women to walk into centres and get treatment at an early stage. It is felt that the number who fail to keep appointments will rise if patients have to undertake a difficult journey, often alone by public transport—in this case, to Haywards Heath.

The journey by public transport from Brighton to Haywards Heath and back to Brighton would take approximately four hours to complete, as the Princess Royal hospital is situated on the outskirts of Haywards Heath. The journey will be even more difficult for people who are elderly, disabled or infirm. The hon. Member for Romsey mentioned paying the travel costs of people who have operations on the continent, but it is a real problem at home. By contrast, buses travelling from all parts of Brighton and Hove stop at four-minute intervals outside the Royal Sussex County hospital in Brighton.

Even if the breast care service should be relocated to Haywards Heath, the accredited pathology service and treatment for patients needing chemotherapy or radiotherapy would be available only at the Royal Sussex County hospital in Brighton, and it is felt that separating services could lead to a lack of continuity in care. Two thirds of patients who attend breast care facilities at the Royal Sussex County hospital come from the Brighton and Hove area, where, on average, 2,700 patients a year attend 7,700 appointments.

My point is that the centralisation of cancer facilities—in this case, breast cancer facilities—is not doing anyone any good. Virtually the whole of the population of Sussex will have to use one centre or go

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across the border to Maidstone, and my hon. Friend the Member for Canterbury has mentioned the problems there. Such services should be far more widely available, and far greater cognisance should be taken of the transport difficulties that people, especially those who come from deprived areas, encounter in trying to reach those facilities. That is not happening in Brighton and Hove.

Mr. Brazier : I want to add one point to the powerful case that my hon. Friend is putting on the issue of staffing. Part of the capacity problem results from staff shortages, yet people who are told that they must move to jobs in other specialties do not always go. I have seen a considerable number of resignations result from people being told that they must move from working on cancer.

Tim Loughton : My hon. Friend is absolutely right. It is a question not just of getting patients to the new facility but of getting professionals there to treat them. As the Minister knows, Sussex is a notoriously bad county to travel around, especially going from east to west. We need to take such considerations into account, instead of adopting the approach that big is good and centralising is inevitable. That is crucial in relation to breast cancer services, so I ask the Minister to reconsider. I am not saying that all services should be kept at Brighton or go to Mid Sussex, but we need much greater provision, which is more accessible to everyone in that area, although I do not believe that the example is atypical. I shall not refer to my second example because I want to leave the Minister adequate time to address the serious and important questions that have been raised. I hope that she will use the remaining 22 minutes to do so.

12.8 pm

The Parliamentary Under-Secretary of State for Health (Yvette Cooper) : I congratulate the hon. Member for Romsey (Sandra Gidley) on securing this morning's debate and choosing such an important issue to discuss. The issue of cancer services clearly has immense resonance and importance to people throughout the country, including the many people who have in their family someone suffering from cancer and those whose relatives have died of cancer. Of course, people are anxious that, should they suffer from cancer, they will get the treatment and support that they need.

In introducing the debate, the hon. Lady spoke about the south-east, although she recognised that these were national issues. Other hon. Members also raised national issues, so I will talk about local issues, but I shall need to address many of the national questions that have been raised and put them in the national context.

The Government drew up a national cancer strategy, the NHS cancer plan, in September 2000. It is a 10-year strategy, part of the NHS 10-year plan. It is the first time that there has been a national strategy that covers cancer all the way from prevention, through diagnosis and treatment, to palliative care and research. Although hon. Members have concentrated primarily on cancer treatment, I shall make a couple of points later about prevention and research. It is important to look at the

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overall picture, not to segment the approach to cancer, as happened too often in the past and led to many of the problems that we face.

We should be clear that, throughout the country, NHS patients receive excellent cancer care. Hon. Members have mentioned the gratitude felt by individuals towards those who treat them; many people feel that they receive excellent care. However, it is also true that many patients wait too long for their treatment, and that there are too many variations in care across the country. Before the National Institute for Clinical Excellence and the cancer plan, we had too little in the way of national standards.

Considerable progress has been made, particularly in the areas that have piloted some of the most innovative reforms, but we still have a long way to go. The Government have made substantial extra investment available for cancer—with tangible results in terms of both cancer consultants and extra equipment. We had 560 more cancer consultants in September 2001 than we did in September 1997, including 360 more since the national cancer plan was set out, and we have 29 new MRI scanners, 81 new computerised tomography scanners, 41 new linear accelerators and hundreds of extra pieces of breast cancer equipment.

In the south-east, staff recruitment and retention pose additional problems, although considerable work is under way and good progress is being made with the cancer plan initiatives to recruit and train more cancer staff. We must consider not simply recruiting further members of staff—given the time that it takes to train many health professionals, that could still leave us with an interim concern—but changing the mix of skills and the work that different health professionals do, in order to expand capacity. For example, we have made £2.5 million available to train additional staff in endoscopy and I shall say more about radiotherapy.

Capacity is not the only issue; there is also a matter of reforming the way in which care is provided in order to speed up treatment. In that respect, I pay tribute to the excellent work being done by the cancer collaboratives, including those in the south-east, some of which have demonstrated the most innovative reform in the NHS. For example, the cancer collaborative in north Hampshire has cut the length of time for which a patient has to wait between an out-patient appointment and a CT scan from an average of 20 days to an average of two days, and the one in west London has cut the diagnosis time for prostate cancer from 20 weeks to 14 days simply by changing the way in which it provides the service. On average, since the cancer collaboratives were introduced, waiting times for treatment have dropped by two and a half weeks.The NHS has also made substantial progress in meeting the two-week target for waiting to see a specialist. Between October and December 2001, over 95 per cent. of patients nationally referred urgently with all suspected cancers were seen within two weeks. That figure rose to 97.1 per cent. in the case of breast cancer in the south-east.

The hon. Lady mentioned variations in meeting those targets and referred to Hastings and Rother meeting the two-week target in only 58 per cent. of cases. The latest figure there is 97 per cent. I am advised that in order to meet that target, the health authority developed a one-

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stop breast clinic. It was a question of reforming the way in which it provided the services in order to speed up the time that patients had to wait to see consultants.

Hon. Members raised concerns about other factors not being measured and said that the whole cancer pathway from referral to treatment or from referral to diagnosis should be considered. That is right and that is exactly what we are doing. We have set out a series of targets that will come into force during the next few years. Already, from last December, a maximum one-month wait between urgent referral and treatment has been established for children with cancer, patients with acute leukaemia and those with testicular cancer. A similar one-month target has been established for the length of time between diagnosis and treatment for women with breast cancer. By 2005, there will a maximum one-month wait from diagnosis to treatment for all cancers and a maximum two-month wait from urgent referral to treatment for all cancers.

The two-week wait is just the first step. It is an important step and an important part of the patient pathway, but we must also take action to bring down the waiting times for diagnosis and for treatment. To do that, we need to measure waiting times differently and follow the patient in a different way. The cancer collaboratives are already doing that and we need to do it across the NHS to ensure that cancer patients are getting the best possible care. Work is already in hand to introduce those targets and ensure that they are met across the country.

Hon. Members raised issues surrounding radiotherapy. We have been very open about the problems in that area. The number of therapy radiographers needs to increase and we need to improve facilities. The problems are exacerbated by the fact that the number of patients being referred for radiotherapy has increased considerably during the past few years, following the establishment of specialist cancer teams. The increase in referrals is a positive development because there was unmet need before, but that increase means that considerable work needs to be done. Progress has already been made. The number of therapy radiographers increased by 9 per cent. between 1997 and 2001 and training places for therapy radiographers at university have increased by 62 per cent. since 1997. By 2003–04, the projected increase is 120 per cent.

The numbers are increasing, but we need to go further. We need to consider a different skill mix. Different skill-mix programmes are already being piloted, including the creation of a new grade of assistant practitioner. Pilots are continuing in 10 centres and early indications are positive. Huge additional investment is being made in radiotherapy facilities, but there is much to do and we need to go further.

Hon. Members asked questions about funding. We have made substantial extra sums available to support the implementation of the cancer plan. We are monitoring the extra investment and will continue to do so to ensure that improvements are being made. In the end, the key issue will be the output from improvements in care.

Hon. Members also raised the question of palliative care. We have made available an extra £50 million to support investment in such care by 2004. It will be a matter for local cancer networks to decide how that

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extra money needs to be spent. They will consider hospices, investment in the community and the issues surrounding palliative care in hospitals. It is important that that is done as part of a strategic approach. For the first time this year, local areas have had to draw together palliative care strategies, which are now being assessed. In some areas, it is the first time that hospices have got round the table properly with the NHS to consider strategically the community's palliative care needs. In other areas, good working relationships have been built on and in others there is considerably more to be done.

It is important for the NHS to pay sensible contribution costs. We need to inform that process through guidance produced by the National Institute for Clinical Excellence on palliative care, which is due to be published this summer. However, it should be recognised that extra investment is reaching hospices. The Help the Hospices survey showed an increase in funding to hospices during the past two years of 14 per cent., although I say that from memory and not from my briefing. Extra resources are reaching the hospices, but they must be part of a broader, more strategic approach to palliative care across the country.

Dr. Evan Harris : The Minister is making quick progress through the points that we raised, but I want to return her to my first two questions. The first related to her attitude to the private sector employing NHS-trained radiotherapists, whether there is any compensation for the NHS and, more important, whether one can ask it to reflect the cost of that training in its tenders. The second related to the evidence base for improved survival resulting from concentrating first on a two-week wait to see a specialist rather than giving priority to the waiting time for treatment for patients already diagnosed with cancer.

Yvette Cooper : When it comes to the relationship between the NHS and the private sector, the Government have clearly said that we must ensure that the NHS obtains value for money. There are many different ways to achieve that. The relationship will evolve over time to ensure that that value for money is sustained. However, we must use whatever extra capacity there is and must not disadvantage patients by avoiding doing so, as long as extra capacity can provide value for money without undermining the long-term sustainability of the health service.

The two-week wait must be seen as one part of the patient's journey. There is considerable evidence of the anxiety felt by patients at that important time when they first raise concerns and are referred by a GP, but have not been seen by a specialist: they have not even entered the first stage of the process of being seen by the specialist and sent off for the appropriate tests or possibly being reassured by the specialist. Therefore, we must speed up every stage of the patient's journey. The point is not to separate out the different stages and consider the comparative evidence base, but to start at the beginning and see how quickly patients can get through the whole process once they are referred by their GP. The cancer plan approach is to consider the whole journey, and that is what the collaboratives have done. Their success has come from following the patient from beginning to end instead of looking at the way in which isolated cancer services perform and do their job.

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That is the right approach, but the improvements take time to put in place, because they involve different ways of working as well as changes taking place across the NHS and additional capacity, and the information must be monitored. It is right to make a start with the two-week wait, but we must also speed up the process across the board, particularly by rolling out the cancer collaboratives.

The hon. Member for Canterbury (Mr. Brazier) referred to the cancer services and issues in his area and in relation to the Canterbury hospital. As hon. Members will know, after a public consultation on proposals issued last year the East Kent health authority has made its conclusions known. The new health authority considered those proposals recently, and two community health councils have now registered their objections to some of them. Ministers will have to decide what action to take, and a decision will be needed from the Secretary of State. The hon. Gentleman has raised those issues before and will understand that I can add no more to my earlier comments. It is not a decision that Ministers will take lightly; they will have to consider all the issues. The Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), will visit the East Kent health authority area in advance of any decision to see the situation for herself. I simply underline the fact that decisions on reconfiguration in East Kent must be taken in the best interests of all the residents, who must have access to the best quality treatment. The cancer services and their configuration in the area must reflect those principles.

Mr. Brazier : I am most grateful to the Minister for giving way. Would she accept that the problem is that cancer was not included in that consultation? The trust responsible for delivering cancer care in Maidstone and Canterbury, the Maidstone and Tunbridge Wells NHS trust, was not a signatory to the consultation document.

Yvette Cooper : I know that the hon. Gentleman has made those points. My hon. Friend the Under-Secretary is very much alive to them, and will certainly take them into consideration. Although I cannot comment, the hon. Gentleman made various detailed remarks about the views of different consultants, and I will ensure that my hon. Friend is aware of the points made during today's debate.

On the issue of cancer services in Brighton, I understand that the recommendation for the central Sussex partnership programme has yet to be considered in full by the new health authority. Because that is the case, and because of the possibility that Ministers will have to take a decision on that issue in future, I am sure that hon. Members will understand that it would be inappropriate for me to comment at this stage.

Several hon. Members have raised the issue of cancer drugs and the role of NICE. It is important to remember why we set up NICE. We did so specifically to end the lottery of postcode prescribing. For the first time, we have national guidelines on treatment and drugs, particularly for cancer. It is important that the national guidance is right and that the process that NICE goes through involves opportunities for interested parties to submit evidence and comment on draft conclusions. Directions have been issued obliging health authorities and primary care trusts to provide appropriate funding for the treatments recommended by NICE.

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The hon. Member for Oxford, West and Abingdon (Dr. Harris) asked what the implications were for other drugs. We have made the extra investment available for cancer services. It is clear that that was to cover recommendations made by NICE. We have also made overall investment available for the NHS, which is increasing by more than 7 per cent. and includes a substantial increase in the drugs bill. Local areas clearly have to take their own decisions about prescribing, but the allocations available for them and the investment in drug treatments is increasing substantially right across the board.

There are other areas of progress worth pointing out, including the increase in the number of women receiving breast cancer screening as a result of the extension of the age range up to 70. A total of 87,000 more women were screened last year, and that figure will eventually reach 400,000. There has also been an increase in the numbers of people receiving support to give up smoking. We should not forget that we shall save far more lives from cancer by preventing people from getting it in the first place than purely by improving the care that people receive.

There have been some common themes in the debate, interestingly including, from both the Opposition spokespersons, a concern about more investment and more money for cancer care. They want more money for drugs, treatment, palliative care, staff pay, and consultants. I agree that we do need more investment in cancer treatment, and that cancer services need more funding. They are already getting an increase in funding, but they need to continue to receive that increase during the next few years. That is why the Government set out an overall increase in funding of over 7 per cent. a year in real terms—double the historical increase that the NHS had during the last 30 or 40 years—and we have said that that money will come from national insurance contributions.

The Conservative Opposition, with respect, have opposed the increase in national insurance contributions, but have also said that there should be more money for palliative care and other areas of cancer. I have no inkling of where on earth they think that that money will come from. Frankly, the idea that people should pay extra for cancer care to provide, for example, their own cancer drugs is not something that we would expect to see realised in the NHS, and no one, whatever their background, is likely to be able to afford it easily, given the cost of some of the new treatments that are coming on line. It is right and fair that cancer care should be provided for everyone on the NHS, not simply for those who can afford to pay. We need greater investment but also greater reform.

Opposition Members need to recognise our extra investment, and if they want further investment they need to set out where it should come from. We have set out where it should come from and where it should go—

Mr. Win Griffiths (in the Chair): Order.

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