January 8th 2019 Early Diagnosis and the Cancer Workforce in the NHS Long Term Plan Debate


Full transcript below from Hansard:

Dr Philippa Whitford MP

Thank you very much, Mr Howarth. It is a pleasure to serve under your chairmanship. I, too, congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) on securing the debate. It is a slight pity that it is less than 24 hours after the publication of the long-term plan, but people seem to have done lots of fast reading last night.

Like others, I welcome the plan and particularly the extra funding for the NHS, but it is important to remember that this brings it back to 3.4%, which was the average over many years—indeed, below the average over many years—prior to 2010. As the Secretary of State highlighted yesterday, with a million extra patients, the money per head of the population is actually going down. That is something that should be looked at, because it is a much better comparative measure.

In Scotland, we spend £163 per head more on health than here in England and £113 per head more on elderly social care. We know that if we do not fix social care, then unfortunately any money put into the NHS is haemorrhaging out because of elderly people trapped in hospital, where they do not want to be. We see money focused on the NHS, because that sounds good to the public, but also further reductions in public health, despite all the talk in the plan about prevention. That does not make sense.

I welcome the Making Every Contact Count initiative. In Scotland, we have had Making Every Contact Count for years. As a breast cancer surgeon, I have discussed issues around smoking with all of my patients, because they inevitably ask, “Why did I get breast cancer?” We do not have the answer for breast cancer, but we do have the answer for the majority of lung cancers. I do not make my patients give up smoking immediately, when they are under stress, but I get them to promise me that they will do it in the long term, and quite a number of them do that. I do not have time to support them through that journey. We still need smoking cessation services, to which they can be referred. Those services are being cut, and that is a problem.

In the plan and in the Secretary of State’s letter yesterday, we again have a focus on cancer, which, as a breast cancer surgeon for over 30 years, I welcome. In his letter he talks about early diagnosis, but not about prevention, yet smoking is still the biggest cause of cancer, with obesity chasing it up as a close second. We need to tackle childhood obesity and we need a 9 pm watershed for advertising foods that encourage it.

Half of us will get cancer. As all the speakers have said, early diagnosis is crucial. It is particularly important to avoid diagnosis as part of an emergency admission, as that tends to result in a very poor outlook. For symptomatic cancers, as the Member for Shannon highlighted—[Interruption.] I keep saying that; I mean the hon. Member for Strangford (Jim Shannon). It is because the Shannon is another body of water in Ireland; I always get mixed up. We will just change it—you can be the Member for Shannon. [Laughter.] As the hon. Gentleman said, it is important to know the symptoms, but the public and sometimes GPs are too focused on late symptoms. Weight loss, jaundice and even, for some cancers, bleeding are not early enough. We need to educate people about that.

In Scotland, we have used humour. There was a testicular cancer advert over Christmas talking about men’s baubles. I do not care what kind of humour people need, whether it is toilet humour for bowel cancer or talking about boobs for breast cancer. If it gets people talking about it, that makes it easier for them to come forward. Many years ago we did an audit in Scotland looking at the whole patient pathway. It showed that for particular cancers, including bowel cancer, the longest step was from the first sign or symptom to going to the GP. The plan talks a lot about the pathway after going to the doctor, but there are only a couple of lines about educating the populous about what to look out for. That means we have to get people talking about it.

In Scotland, we have had bowel cancer screening starting at the age of 50 right from the beginning. I am sorry that the hon. Member for Torfaen (Nick Thomas-Symonds), who is no longer in his place, lost his mother in her 50s. In the last year or so we have also had celebrities diagnosed late with bowel cancer, who might well have been picked up if the screening had started at the age of 50. Last August, I welcomed the Government’s commitment to making that change, but there has been no discussion in any announcements or in the plan about when that change will happen.

When I turned 50 and the poo-in-the-post envelope landed on the mat within two days, I found it a bit harsh. As my birthday is Christmas Eve, I got another one last week. I would not mind if they were a bit more sensitive, but it is something that people have to do. In Scotland, we have already changed completely to the faecal immunochemical test, which involves only one sample. We have already seen a 10% increase in uptake. Again, the Government have committed to that and the roll-out has commenced, but when will it be complete?

It is important to be prepared for the impact that that will have on the NHS here. If the starting age for bowel screening is dropped from 60 to 50, there will be an increase of two thirds in the screening population. If there is then the same 10% increase with FIT, together that will mean an increase of three quarters in the colonoscopies required. The NHS will have to be prepared with endoscopists and, as mentioned earlier, pathologists, who will analyse the samples. In Scotland, we have seen an increase in waiting times for colonoscopies, just with the change to FIT, so it is important to be prepared.

There is a similar impact with public education campaigns. Intense campaigns alone are no use. When we did the first Detect Cancer Early campaign, an audit of the breast cancer units across Scotland found that there had been a doubling in referrals, but not a significant change in the number of cancer diagnoses. Women are pretty breast aware, but the adverts need to be trickled throughout the year, or the chances are that there still will not be an advert when someone is sitting and ignoring a symptom.

As well as endoscopists and pathologists, the other workforce is radiologists. Not all radiologists can be identified as cancer radiologists; they will find cancer in all sorts of parts of the body. This diagnostic workforce is critical. If we look at the waiting time performance across the UK, people are struggling, particularly with the 62-day target, which has fallen below 80% in England. Everyone is struggling with it. Looking at the 31 day target—from diagnosis to treatment—most cancers are over 90%, or indeed 95%. Once the NHS knows that someone has cancer, the pathway is relatively swift, but there is long gap to be diagnosed.

In my own speciality of breast cancer, radiologists are critical for the initial test, the investigation and the follow-up. For every three breast cancer radiologists who will retire in the next five years, they will be replaced by only two. The problem is that breast screening came in around 1990, so all the young consultants who were appointed at almost the same time will all, sadly, be retiring at the same time. The clinical radiology workforce census report shows that the UK has a shortfall of 1,000 full-time radiologists at the moment, which will grow to 1,600 by 2022. Some £116 million is being spent on outsourcing and overtime. The issue is not even money, because that amount would fund 1,300 full-time radiologists; the issue is that we do not have the workforce. Yet we see in the plan that health education has had its funding cut over recent years, despite grand statements about all the extra nurses, radiographers, allied health professionals and doctors who will be trained.

The plan talks a lot about IT, but instead of focusing on digital GPs it should be focusing on internal IT. We have had electronic prescribing, referral and response letters for years in Scotland, and one of the things we have that can help with the radiology shortage is the picture archiving and communication system, where imaging is shared right across Scotland. Every hospital uses the same system, which means that if one place is short of radiologists or is very rural, an image can be sent hundreds of miles to be looked at by someone else. The plan talks about generalists, and they are needed, but we also need specialists. The workforce plan is critical.