This is, I believe, the first debate on women's health called in Government time for a long while, and I believe that it shows how far we have come on this important topic. In a moment I shall outline some of the major improvements that we have seen in the last year or so, and some aspects on which I want to take matters forward.
Women have been receiving advice on their health and welfare for a long time. Here is the columnist of Home Companion magazine of 12 November 1898, writing in answer to two correspondents:
In your trouble, 'AM', you have my sympathy, and though I can hardly tell you how to become as thin and wan as a willow, I can at least tell you how you can reduce your form to graceful proportions. Take plenty of vigorous exercise and I advise you especially to try bicycling … And here comes 'Dorothy' who wants to know how she can grow stout. Laugh, and grow fat, 'Dorothy'. A good laugh promotes digestion and tends to lengthen life. All good advice!
Modern problems have also been around for a long time. This is "Meg", writing to Woman's Weekly in June 1918—the date is significant:
I should very much like to have your opinion on the modern woman's craze for smoking. One hears so much for and against the habit. A few years ago when I was in Paris, I asked a Frenchman if he admired a woman who smoked. He replied: 'Well, I should not like my wife to smoke, and would not allow her to.
The answer would not satisfy us today:
I don't approve of men taking this kind of tone, as if their wives were small children; but at the same time, I think Meg's words are worth attention from another point of view. Tobacco is getting very short and we are told it will have to be rationed. Think of what that will mean to our soldiers and sailors. Girls, every packet of cigarettes you buy to smoke yourselves leaves a packet less for our fighting men!
But yesterday's agony aunts had a different attitude on other subjects. Here is one letter, coyly signed "Wavelet", on the problems of cycling, in Home Chat magazine of April 1897:
On a recent cycle ride, I was overtaken by another cyclist who told me one of my tyres was soft, and offered to blow it up for me. I accepted his offer. Since then, when we meet, he bows. Yesterday, I had a note asking me to take a ride with him on Sunday week. He appears to be a gentleman, but I don't know what to do with regard to this request.
The answer was very firm:
Give the letter to your parents, who will no doubt so deal with it that this very impertinent young man will not take such a liberty again.
The obvious question to ask is why women's health? Why not health in general? Is it not somewhat artificial to separate out "women's health", along with "women's
issues", "women's rights" and other, as Private Eye would put it, "loony feminist nonsense"? I am no feminist. When I was asked to take on responsibility for women's health in 1986 I wondered whether, apart from maternity, there were indeed any separate issues. There are two answers: we should look at women's health because it is completely different from men's health at almost every stage in our lives, and because many aspects of women's health and women's role in the health of their families have perhaps received far less attention in the past then they merited, not just from men but also from the women.
The differences start from the first day. More boy babies are born, but relatively more girls survive: we do not know why. Women outnumber men in every age group after middle age and the imbalance slowly increases throughout later life, until women form two thirds of the age group above 75. Thus, illnesses that increase with age affect far more women than men, and women account for the majority of in-patients in the National Health Service—that does not apply to acute care only. Women outnumber men in most age groups in diagnoses of mental illness in England; for every three men admitted to NHS mental illness hospitals and units in 1986 there were four women. Even if elderly people—75 and above—are excluded, the ratio is two men to three women. In fact, admission rates for women outnumber those for men in most of the main diagnostic groups in mental illness. The main exceptions are schizophrenia, and drug and alcohol-related mental illness—although for the latter two, women are beginning to catch up.
Women's health is different. Women tend to suffer from different ailments, and not just the obvious ones associated with reproduction. Among the preventable diseases, our main killer in this country is heart disease. It is mostly men, however, who die of heart disease. Women in middle age are on the whole far less affected than men by diseases of the cardiovascular system, unless, of course they are foolish enough to be smoking while on the pill, when their risk of a heart attack rises 10 times. In middle age, women are more likely to be victims of cancer, particularly breast cancer. It follows therefore, that health campaigns for women that may help to improve their chances of reaching a healthy and happy old age are significantly different from those for men.
Let us consider some issues of concern to women. The major killer of women before their time in the United Kingdom is breast cancer. About 250,000 women every year in the United Kingdom get a breast lump—90 per cent. are benign but 24,000 are cancer and 15,000 women die each year from this disease. That is more than seven times as many as from cervical cancer, which is probably the better known disease. The survival rate is improving. Sixty four per cent.—nearly two thirds—survive longer than five years now following first diagnosis of breast cancer, and there should be a real improvement in survival in the next decade. Although much research is under way, there is no clear causal link between breast cancer and environment or lifestyle. Therefore, apart from women with a family history of the disease, who can be warned to be especially vigilant, there is as yet no good advice we can give women on how to avoid it. That is one reason why we have developed the breast cancer screening programme. If we cannot avoid the disease—primary prevention—then the next best is to find it as early as possible and treat it while still curable—secondary prevention.
Many hon. Members will know that the NHS is setting up a national breast cancer screening service over the three years to 1990. The programme traces its origins to a working group that was set up in July 1985 on behalf of United Kingdom Health Ministers. The group was chaired by Professor Sir Patrick Forrest from Edinburgh. In February 1987, the then Secretary of State, my right hon. Friend the Member for Sutton Coldfield (Mr. Fowler), announced the Government's acceptance of the proposals in the Forrest group's report.
The Forrest report concluded that screening women aged 50 to 64 by mammography every three years should eventually reduce the deaths from breast cancer by at least one third. That is several thousand women. The NHS breast cancer screening service will do what he recommended, and provide a computerised call and recall system to screen women in the age group 50 to 64 by mammography with screening for women of 65 and over if requested.
We are often asked, why not younger women? As a younger woman I assure the House that, if there was any evidence that screening would help, that would have been taken in to account, but there is insufficient evidence to show that mass screening for younger women is effective in significantly reducing mortality, and more research is under way. Younger women at special risk—for example if there is a family history of breast cancer—may be offered mammography if referred by their general practitioner. Hon. Members may already know that 88 per cent. of all deaths from this cancer occur in the over-50s and its incidence in young women is far less common.
I am glad to report that the programme is making excellent progress. Each of the 14 English regional health authorities was asked to set up its first screening centre by the end of March 1988. In fact, 17 centres have now been set up—of which four will provide training for staff from the whole programme—and nearly all have now started screening. This afternoon, I shall he visiting the London training centre at King's college hospital and the first inner London screening unit at Camberwell.
By 1990, we expect to have about 100 centres nationwide, each covering a population of about half a million people. Mobile caravans will be used for screening in some areas. We hope to announce all the details about the remaining centres before the recess. The programme must be developed relatively slowly because of the need to train staff and to provide back-up facilities for diagnosis, treatment, counselling and after-care. The initial response has been excellent—in some places over 80 per cent. of the first women responded to their screening invitation. That is very encouraging.
Between 1987–88, the last financial year, and 1989–90, on current plans, nearly £55 million will have been provided to set up and run the screening centres including staff training, development of computer software, health education and counselling and support for patients. A service on the same lines is being developed in Scotland, Wales and Northern Ireland. This will be the first nationwide comprehensive breast cancer screening service in the world. We are well ahead of all our partners in the European Community and there are no comparable programmes in nations such as the United States, which spends far more on health than we do. Our system will save many lives and we should be proud of what we are doing and aware of the massive investment which demonstrates the Government's commitment.
We have taken a similar approach to cervical cancer. It is far less common than breast cancer, with about one seventh the number of deaths per year. In 1986, 2,004 women died of cervical cancer in England and Wales. It has been linked in research to smoking and to the number of sexual partners. The significant factor, however, is that this cancer has a relatively long detectable pre-cancerous stage, during which the condition is 100 per cent. curable. Cervical cancer was one of the first cancers for which that was true. We believe that the cancer screening programme that we are implementing should save most of those 2,004 lives. All district health authorities in England have implemented computerised call and recall systems That has been an enormous task. It has meant providing 750 visual display unit terminals; making an investment of £10 million in information technology and computerising 35 million records. The result of that may mean that we shall have a completely computerised system to assist us in all sorts of preventable screening work in future, which, of course, will also cover men.
As a result of the effort, all DHAs are now able to call women who have never been screened before, as well as recalling women who have previously had smear tests; and within five years the system will have invited all women in the age range 20 to 64 who are registered with a GP—all those we can reach, which is around 13 million women. Programmes for cervical cancer screening on similar lines are being implemented in Scotland, Wales and Northern Ireland.
A mass screening programme of a kind has existed since 1966. Its value is shown in the fact that deaths from cervical cancer have fallen by 14 per cent. in the 10 years to 1986, the year for which we have the latest figures. Without the existing system, we believe that deaths would have been much higher and could have risen. The efforts of the Government will ensure much more systematic screening and this should further increase the effectiveness of the services against cancer. Again, Britain is well ahead of the rest of the European Community on this programme and—apart from Scandinavia—is the first major country in the world to implement such a nationwide programme.
We should not underestimate the huge scale of the effort required to detect cervical cancer. Last year, about 4 million smears were done. Many of these were repeats or were done outside the screening programme. About 150,000 were abnormal, but again many were repeats. Most of the abnormal ones showed up non-cancerous infections of varying degrees of severity. Therefore, we are picking up many gynaecological conditions through this system. About 4,000 new cases of cervical cancer are reported each year, many of which do not come through the screening service at all. As I have said there are about 2,000 deaths each year, mostly among older women. It follows that the incidence of this cancer is tiny—a handful of cases in each district health authority each year.
It is important that health care professionals, especially doctors, are aware of these data so that they can reassure women with abnormal smears that the odds are that the condition is not cancer, and whatever it is, it is likely to be treatable. This programme is intended not to alarm people: but to reassure them.
There is one point to make about all our cancer screening programmes. All this money and effort will be wasted if we women do not use the systems properly. There is no need to approach one's doctor or hospital for a test unless there are symptoms. Everyone will be called in time, and we hope that everyone will respond. If there are symptoms—a breast lump, or a discharge, or anything unusual—the woman should see her doctor at once. She does not need to wait.
Incidentally, it is up to us as patients to ensure that the computer knows where to find us. Now that we have computerised every register in Britain, we are coming up against the problem that some of the registers are inaccurate to an unacceptable degree. If we move house, we should ensure that, along with the post office and the gas board, the doctor knows our new address. In these ways we will have a cost-effective and confident service and save lives.
I should like to deal with one or two matters on the cervical cancer programme about which women have written to me. I have no doubt that the hon. Ladies in the House will raise these points, so perhaps I can take the opportunity now to deal with them. Many women want to know why we do not reduce the recommended time interval between smear tests from five years to three years. The guidance that we issued in January says:
recall should be at least every five years".
Most deaths occur in women who have never had a smear test. We know that a five-year screening programme can reduce deaths among women screened by an estimated 84 per cent.
For this reason, we believe that increasing the proportion of women being screened at all should take precedence over increasing the frequency of screening. In terms of saving lives, we are trying to get from a very low figure to 84 per cent.—and we are not there yet. That accords with advice given to us by Professor Jocelyn Chamberlain and her team at the DHSS cancer screening evaluation unit, which is based at the Royal Marsden hospital in Sutton.
We are not pressing health authorities to recall women more frequently than at five-year intervals, but we will not hinder them from doing so. I know that some district health authorities have decided to recall after three years. Before DHAs move from five-year screening to three-year screening I would expect them to have satisfied themselves on two points. First, they should be getting a high response from the women in the eligible age range, but particularly from older women who have never been screened before. Secondly, they should be able to run the system smoothly without laboratory backlogs or delays in diagnosis and treatment. We monitor laboratory backlogs very closely.
I see that my hon. Friend the Member for Winchester (Mr. Browne) is in the Chamber, and no doubt he will tell us about one or two laboratory backlogs in his area. As I say, we monitor the backlogs very closely and have been pressing districts to take action where there is a persistent problem. Three quarters of district health authorities do not have any backlog to report.
If we did not insist on these rules, there is a risk that we would overload the laboratories. The same, keen women would come in to be tested repeatedly and we would miss many of the women most at risk and might waste everybody's time and money.
There are other cancers which affect women. The most worrying of these is lung cancer which is rapidly rising. Since 1979, the death rate from lung cancer among men in the United Kingdom has dropped by 6 per cent. but among women it has risen by 27 per cent., and that is causing considerable alarm. Lung cancer is the second largest cancer killer of women in this country and accounted for 11,000 dead women last year. It looks set to overtake the major cancer killer—breast cancer. The survival rate over five years of women with lung cancer is very poor—betwen 3 and 13 per cent. according to age.
Cigarettes offer women more than the long-term worries about cancer. They interfere with hormone levels in both men and women, and on average lead to the menopause five years earlier. Nobody believes me about that but that is what the research shows. Smoking is regarded as having a role in the increased incidence of osteoporosis. I have mentioned the well-documented link between cervical cancer and smoking. A recent study in the United States of America has suggested that just a few cigarettes a day doubles our risk of heart problems. Worst of all we know that, among pregnant women who smoke, the risk of perinatal mortality is 28 per cent. higher than for a non-smoker. It is also associated with a significant reduction in birth weight by as much as half a pound. The effect of smoking on the baby can be both rapid and devastating.
I suppose that many women believe that smoking keeps them slim, but there are sensible ways to keep one's weight at a healthy level without taking up a habit that stands a good chance of doing irreparable damage to one's health and the health of one's baby. Some people say they smoke to deal with stress, but there are healthy options to deal with stress and most people, including most doctors, have found other ways.
For all these reasons we are very concerned about patterns of smoking behaviour among girls and young women. Smoking has been falling in older women in recent years, but that had not been happening among women under the age of 25. Among secondary schoolchildren in England and Wales, who fortunately still smoke far less than their parents, girl smokers outnumber boys by nearly two to one. As I said in a debate on 23 October, we commissioned research on this to try to find what influences the behaviour of girls in this way. Preliminary results suggest that girls are influenced in a different way from boys.
I have asked the Health Education Council to look at a sustained programme of health education aimed at young people. We have accepted the Froggatt report which recommended:
It is essential that more smokers are encouraged to stop smoking and that non-smokers are strongly discouraged from starting".
We are now considering how best to take that forward. I am pleased to see that the Royal College of Nursing, the largest trade union in the National Health Service, representing about 250,000 women, recently adopted a no smoking policy, as has the Royal College of Midwives and the Health Visitors' Association, both of which have a preponderance of women members. In the DHSS, where we employ about 100,000 people, the majority of them female, I understand that no smoking policy guidelines will soon be issued to local social security offices with the support of the trade unions. We look to see considerable progress there to help all our excellent staff work in a smoke-free atmosphere.
In ways like these we shall continue to do what we can to promote health education and disease prevention campaigns such as those for women's cancer. We watch with interest developments for screening for other conditions such as ovarian cancer, although we are nowhere near a sound, accurate system that we could use nationwide.
Similarly, we are keen to encourage the development of laboratory tests which are less demanding of scarce staff than the current smear test reading method. However, as my right hon. Friend the Minister of Health said in the Adjournment debate on the organisation Quest for a Test for Cancer on 13 May, any new test we adopt must be cheap, effective, fast, accurate and robust. By robust we mean that it should be capable of being performed in different types of laboratories and by operators with varied levels of skills. I am hopeful that some automated system will come in before too long. I was impressed that a recent meeting of our scientific advisers had 13 such proposals to consider, some of which looked promising.
It might be helpful if I say a word about the growing involvement of the private sector in screening programmes, which we welcome. For a long time preventive medicine was the poor relation in the NHS and we have much catching up to do. The private and non profit-making sectors stepped in to fill the gap and have developed their schemes to the benefit of their millions of members. I understand that more than 150 clinics of various kinds are now in operation. There are two main points I would make to them and their customers.
First, it is not enough to offer simply a testing service. Proper arrangements should be made for laboratory services and to notify the woman's GP that she has been tested and of the results, subject to her consent. That is intended to avoid unnecessary repetition of tests especially as the National Health Service gets it own screening services up and running. Further sensible arrangements should be made for the care, counselling and treatment of women and they should be explained to the customer when she first comes. This also applies to occupational health screening, such as the splendid system that I saw at the Post Office last week, which uses the services, where required, of AMI International and thus relieves the National Health Service of the burden entirely.
Secondly, those setting up such screening systems should be well aware of the good medical reasons why we do not screen younger women for breast cancer. In women under 35, for example, the condition is rare, but benign lumps and cysts are very common. The mammogram used under these circumstances is likely to pick up a high level of false positives, leading to unnecessary anguish until the all-clear is obtained and, worse, possibly to unnecessary treatment. Mr. Ian Fentiman of the Imperial Cancer Research Fund unit at Guy's hospital has expressed his concern about that matter, and I share it. I hope that the reputable companies involved will take note.
We are pleased that the private sector is taking steps to provide a quality assurance scheme supported by a system of registration, inspection and approval. We shall watch that development with interest.
There is no doubt about the growing interest in women's health inside the House and among the population at large. This has led my Department to respond by organising a full-day conference on the subject on 22 June. The many subjects covered will include the cancers that I have mentioned, but the afternoon session will look at conditions which do not kill, but from which millions of women suffer, often silently, such as mental illness—in which women outnumber men—the menopause—problems associated with which were regarded until quite recently as either imaginary or untreatable—and osteoporosis, the thinning of the bones, which is increasingly filling accident and emergency departments and orthopaedic beds. There will be a session on puerperal psychosis, which is an appalling mental illness that affects some women after childbirth and can vanish as quickly as it came, leaving havoc in its wake in the woman's family. The conference is designed to have learned speakers sharing the latest information with lay people, including representatives of more than 50 women's organisations, and press representatives who write on women's issues and health. Many hon. Members and Members of the other place have accepted invitations to attend.
Since some important new issues will be covered on that day, it will be apparent that the Government want to move the discussion on. We have put our efforts against cancer on a sound footing, but now we must turn our attention elsewhere. Osteoporosis, for example, is a condition which probably affects one woman in four, and is clearly linked to falls in hormone levels after the menopause.