Health and Sport Committee

Meeting date: Tuesday, February 6, 2018

Official Report 602KB pdf

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Preventative Agenda

Good morning, and welcome to the fifth meeting in 2018 of the Health and Sport Committee. I ask everyone to ensure that their mobile phones are switched to silent. I will do it myself, as an exemplar. Devices may be used for social media, but please do not record or film proceedings. We have our own people to do that, and all the recordings are publicly available.

Agenda item 1 is a round-table evidence session on the detect cancer early programme. The session is part of our wider preventative agenda inquiry.

I ask everyone around the table to introduce themselves, please. I am the convener of the committee and a North East Scotland MSP.

Good morning. I am the deputy convener of the committee and the Scottish National Party MSP for Edinburgh Eastern.

I am head of services for Macmillan Cancer Support in Scotland.

I am a Conservative MSP for Lothian and the Conservative spokesman for health and sport.

I am a consultant in public health medicine and director of the Scottish cancer registry.

Hello, everyone. I am the Liberal Democrat MSP for Edinburgh Western.

I am the head of external affairs with Cancer Research UK.

I am the constituency MSP for Mid Fife and Glenrothes.

I am one of the MSPs for the South Scotland region.

I am a Lothian MSP.

I am a co-director of the Scottish cancer prevention network, and I also chair the United Kingdom National Screening Committee.

I am director of the Scottish cancer prevention network and a professor at the University of Dundee.

I am the MSP for Glasgow Provan.

I am a reader in cancer and primary care at the University of Edinburgh.

I am a South Scotland MSP and the Scottish Conservative spokesman on health education, lifestyle and sport.

I am the MSP for Glasgow Kelvin.

I am from the Royal College of General Practitioners in Scotland and was a general practitioner in Govan for 30 years.

I am an MSP for the Highlands and Islands region.

Thank you very much. I warmly welcome all our guests.

I will start the questions by asking about the rationale for the detect cancer early programme, which clearly—at least, in part—relates to late diagnosis and late presentation in Scotland compared with diagnosis and presentation in other countries. What contributes to that late diagnosis?

There are a number of reasons for late diagnosis. It is partly about many people delaying going to see their general practitioners with symptoms, and it is partly about the fact that, in some cancers, symptoms are not good early indicators of disease. That is why we have screening programmes for breast, cervical and colorectal or bowel cancers. There are two main issues.

Why does Scotland show a relatively greater tendency to late presentation and late diagnosis than comparable countries?

There are various issues to do with levels of deprivation. We also have to think about the causes of cancer. Scotland traditionally has had behaviours that are not conducive to cancer suppression: diet, smoking habits and lack of exercise have contributed to the high incidence of cancer.

I can speak to a couple of points that Professor Steele has raised about what we describe as “the patient interval”, which is the time from when a patient first spots symptoms to their presenting at their GP. That interval can be months, or even years.

The convener asked about Scottish differences. International evidence points to UK differences that are grounded in our relationship with the national health service. There is a unique UK view that plays out in a lot of the evidence, which is that we do not want to overburden a system that we all hold in very high regard.

On more Scotland-specific issues, a lot of public-opinion testing has discovered that a strand of fatalism exists in deprived areas in particular. A healthy level of fear of cancer is required in a population; we want people to hold it in some fear so that they present. However, when fear drifts into fatalism, it becomes disabling and we hear concepts such as “the big C”, “cancer means curtains” or even “I’d rather not know.” Those concepts are particularly prevalent in deprived areas in Scotland. The DCE programme has made some efforts to challenge those concepts, but there is a long way to go.

I will add a general practice perspective, having worked in Govan for many years. The issue is not just the absolute deprivation but the gulf that exists and is increasing between the haves, who include people like me, and the have nots, who include a lot of the people whom I was trying to serve. Not only does that induce fatalism, but it leads to a loss of purpose, a loss of hope and people asking, “What’s the point?” which can be extremely frustrating and very difficult to overcome. We struggle to get people who have been diagnosed with cancer to go back for review—it is that big a problem. I suspect that global inequalities underlie a lot of the issues; we see that writ especially large in countries including the UK and the United States.

I would reiterate what my colleagues have said. Literacy and health literacy are related to that. We deal with the wider contexts of people’s lives, too, so when we try to address fear and fatalism through information and awareness campaigns, it is very important that we use appropriate language. DCE efforts have, in different ways, tried to give messages in such a way that people will take them on board.

I have a small follow-up point, as someone who was born in Govan, who lived there and who still has relatives there. I know exactly what Dr Paterson means about fatalism. I wonder whether we should put more effort into explaining that being diagnosed with certain types of cancer does not have to be a death sentence. We have screening, which is great, but with the help of Macmillan Cancer Support and others, people can live with cancer. Do you think that we should put more resources into spreading that message, especially in particular areas?

We have a lot of insight from across the UK and we know that people in Scotland are more financially stressed. We also have some insight from Easterhouse, where we did a health improvement study a few years ago. People said that they did not trust health messages: there is something about health messages being made at national level that does not reflect what people see outside their windows. We need to make that real to the people who live in such areas, and we need to build trust and work with communities.

On the wider point about attitudes to health messages, there is natural embarrassment about seeking help with cancers that affect the bowels and genitals, especially in deprived communities, but it exists in all communities. We try to break that embarrassment through national messaging campaigns, but we still do not seem to be getting it right. There was a report last week about uptake of cervical cancer screening, which was based on the fact that women are embarrassed about being examined in that way. How can we do better in breaking down that embarrassment?

I want to bring the discussion on messaging back to prevention. There is a huge gap in this country in respect of raising awareness about preventative action for cancer, which is not covered by the DCE programme. There is not a person who has been diagnosed with cancer who does not wish that it could have been prevented in the first place. Although Sandra White’s question was about the time after diagnosis, we must think about earlier prevention.

Do you want to come back on the previous question, Gregor?

Yes, convener. I believe that the question was about challenges to people presenting, where invasive tests would be involved. I think that technology might have a lot of solutions to that. As part of the cervical screening programme, for example, home-testing pilots have been established—I know of one in Dumfries and Galloway—so that people do not have to present at clinics. The fact that the people themselves rather than nurses are doing the tests will break down barriers for some.

The next thing on the horizon is the new faecal immunochemical test—or FIT—for bowel cancer screening. That test, which is already on stream, involves taking one sample rather than three, and evidence is showing that that approach is breaking down a lot of barriers, particularly for men—and especially for men in deprived areas. We therefore impress on the Scottish Government the need to give that test a real push and to ensure that the public are well aware of the change and how much easier it is to do that screening.

We have a growing amount of evidence that makes it clear that not all the discussions have to take place in healthcare settings. When Macmillan launched our service in the libraries in Renfrewshire a couple of years ago, people came in and saw the kit. When they started to talk and inquire about it, they realised that they had received it in the post a couple of months previously. We need to make those things more visible and we need to have those kinds of conversations. In our work with libraries across Scotland, we are—as we have been told many times—giving people what feels like a safe space. People might feel barriers to going into healthcare environments, so we need to use community spaces more in that way.

I call Alison Johnstone.

I have to confess that my question is about prevention, convener.

We will come back to you later. Do you want to comment, Dr Campbell?

With regard to the previous discussion, embarrassment is a huge issue. Work is going on across Scotland on it—we in Edinburgh are doing some work, as are colleagues in Glasgow and many other places. Qualitative interviews and focus groups involving men and women in various communities are happening in order that we can understand the local issues.

One key point is about the power of narrative and stories. It can be very useful for people to see someone like them at a health forum, a local event or a supermarket, talking about being screened or using the kit. I know that CRUK is trying, through its local primary care engagement programme, to do a lot of that sort of thing.

I believe that Miles Briggs has a question about deprived communities.

Staying with the point that Janice Preston made, how might we develop the approach that she outlined? Do we need, say, community health hubs to give people a forum at which to discuss the issues and which provides a space that different charities could use?

As for how we take the messages to people, could we make links with bookies, for example, where you might be more likely to have conversations with people? Do panel members know of any examples of work that is going on elsewhere that we could introduce in Scotland?

There is a lot of evidence to suggest that we are improving the cancer journey in Glasgow—through an approach that we are spreading to Dundee, Fife and other places, we hope in partnership with the Government. We are now engaging with 80 per cent of people in the most-deprived areas, so people from those areas are taking up provision. There is something about using community venues and having that shared community space that makes access easier for people. Of those people, 61 per cent come from deprivation category 1, and we have found that if a needs assessment is carried out of all their needs—financial, practical and emotional, as well as clinical—they feel able to self-manage three months on, and the growth in their confidence is enormous. That is the point in time when not only the people in question but their entire families are receptive: we need to build on that teachable moment. I absolutely believe that using community spaces cross-organisationally and collectively is a huge plus.

I will just pick up on Janice Preston’s point. In my Glasgow Kelvin constituency, the Annexe Communities drop-in centre in Partick could be used to capture a lot of men who tend not to go to their doctors. After all, men are used to going to the centre to have a cup of tea, play a game of dominoes or whatever. Should those kinds of facilities be used more for testing? People would not have to go to a health centre; they would be going to a place that they go to once or twice a week anyway.

Absolutely. Men’s sheds, or similar places, are ideal venues. We mostly use volunteers—people in communities, helping other people. The service is managed through the libraries, but it goes wherever people are.

09:45  

Based on my experience as a screening co-ordinator, I say that one of the challenges is the need for better technology. We all know that screening tests in all their forms are embarrassing and uncomfortable. One of the positive things about the new FIT test is that it is easier and quicker. People face real practical challenges in taking three bowel motion samples and doing a screening test—men and people who are less resourceful find it a challenge to get everything together. Similarly, we can all fully understand how embarrassing and sensitive cervical screening can be. There is also a challenge for the medical profession to develop future screening tests that are more pleasant and easier to do. I would welcome an easier way to do screening tests that do not impose so many barriers.

To go back to community approaches, I was one of the research team that designed the weight-loss programme that was carried out through the Scottish Premier League, called football fans in training. Various charities, including Bowel Cancer UK, have been working to try to raise awareness through football clubs. There is a huge opportunity there: a door has been opened for cancer awareness by the football fans in training programme. It seems to be an obvious route to take.

I know that programme well from Aberdeen. It happens in other parts of the country, too.

On the impact of the detect cancer early programme, a striking bit of evidence was that there was an increase in consultation without an increase in diagnosis. Ivan McKee has a question on that.

Thank you all for coming to talk about such an important issue. My question is on the point that was raised by the convener. If you look at the data from the past couple of years, you see that the numbers for diagnosis at stage 1 have increased very slowly. Very limited progress has been made on that. For example, the data shows an increase in colorectal cancer referrals, but the number of detections has remained flat. Are we targeting the wrong people, or is there an issue about how GPs are dealing with referrals?

That is a really challenging issue. The problem with bowel cancer is that the symptoms are common ones that many people get every day—rectal bleeding, abdominal pain or a change in bowel habits, for example. There has been a drive—rightly—to increase awareness of those symptoms. The problem is that then many more patients go to see their GPs, who are faced with an almost impossible situation: they have a patient with symptoms that could be due to bowel cancer and they do not want to ignore them. There is a drive to use the FIT at a more sensitive level to help GPs to make a decision about whether an individual should go on to invasive testing. The problem is that if too many patients go for colonoscopies, all it does is clog up the waiting lists so that people who need that investigation are delayed in getting it. We have to be cleverer about having tests to help GPs to make a decision on how they deal with the patients that come to them with symptoms.

I was part of the National Institute for Health and Care Excellence guideline group that examined the revision of referral for suspected cancer. That did not cover Scotland—it looked at England and Wales—but I was there through the RCGP. In that review it was clear that even symptoms that one would think are really serious have a fairly low predictability for turning out to be a cancer. For example, diarrhoea on its own has a positive predictive value of 0.94—it is a tiny number. Even big things, such as bleeding, are not that common the first time round.

Martin Marshall describes GPs as “boundary specialists”—they are trying to sit across the boundaries and work out exactly what to do in incredibly complex situations. The complexity comes not just from how complicated the presenting symptoms are, but from the index of suspicion that arises when a patient is somebody who never comes to see the GP. The fact that they have come makes the antenna start to wave.

That can be followed by serial longitudinal encounters and continuity, which in turn—apart from providing the narrative that was talked about earlier, which is so important—engenders a degree of trust, it is hoped, and starts to break down embarrassment. It is probably easier for an old man whom I know to have his bottom examined by me than by someone whom he has never met before. That is the reality.

To have that, though, we need an adequately resourced and staffed general practice workload. I mean to say general practitioners, because when we were at university, we were trained to make diagnoses and plan treatment—the rest of it is a bit of a bolt-on. That is the real deal with doctors.

I think that expecting other people to take on that diagnostic role, without the continuity or the relationship, will present significant challenges and might adversely impact on the detect cancer early programme.

I understand that it is complex to determine from the symptoms whether there is cancer, but a lot of that relationship can be modelled. Is there enough data to understand where we need to look and where the highest chance is of finding cancer based on what is being looked at?

It was striking that a lot of the responses said that not much in the way of cost benefit analysis is going on. Do we need to be better at understanding where to put resources to get the maximum effect?

Who would like to respond to that?

On the point about putting things together and the idea that symptoms A, B, C, D and E could come together, the work by the NICE guideline group suggested that there should be an urgent referral for suspected cancer if the overall positive predictive value was above 2. That would mean that 98 of the people who were referred would turn out not to have cancer. The hit rate is pretty small. That, again, is the reality.

The additional danger is that, if we target resources to ensure that those people are seen timeously, which is incredibly important, it means that the people who have a PPV of 2.5 wait for an inordinate length of time before they are seen. The group that is not quite bad enough but is also not okay can get a really raw deal if we are not careful.

That is right. A huge amount of work has been done to look at different symptom complexes, but it is not very effective. The most effective tool that we have at the moment, as NICE has picked up, is a sensitive test for blood in stool. If someone does not have blood in stool, the chances of having serious disease are very small. That test is something else in the mix.

Are you arguing that the use of simple blood tests—which are used to test for prostate cancer, for example—should be extended or more targeted?

The test that we are talking about is the same as the test that is used for bowel screenings, which looks for blood in stool, except that it is set at a much more sensitive level, to be able to pick up very small traces. There is no peripheral blood test that would be helpful in that context.

You said in response to Ivan McKee’s first question that we need to get smarter at identifying who we should target. How can that be done, in the context of what Euan Paterson has described?

It can be done with a combination of looking at symptom complexes and testing, and at the moment the best test that we have is a test for blood in stool. That combination is probably the way forward.

It is about assisting GPs, not telling them what to do. As we have heard, GPs are professional people. They are doctors and they make sensible decisions.

We can also look at how we can gain efficiencies once we have referred patients on. It always helps me to understand the context that the GPs are in when I think that they see only eight to 10 cancer cases a year, on average, out of 6,000 to 8,000 appointments. That is what they are trying to sift through in terms of cancer diagnosis.

It may be possible to make efficiencies when it comes to referring to secondary care. More direct referral pathways could be offered to GPs, for example, which would allow them to refer directly to some diagnostic tests. The current model is that the patient goes to someone in secondary care, and that person makes an assessment, then perhaps has a conversation with the GP and a conversation with the patient. We hear anecdotally—and there is data behind it—about patients who are bounced around the system. There is probably value to be had by building capacity in the system, which would also improve patient experience in that regard.

Cost benefit analysis was mentioned. My understanding is that it is quite broad: you have a set of costs and different kinds of benefits and you can put costs against them. That helps to open up the debate about where our resources might best be put for primary prevention, which is to stop people from getting cancer; for, as Gregor McNie said, making the systems more efficient to get people through to an early diagnosis and treat them effectively; and for what we can do to make the experience of cancer less onerous and less difficult.

That cost benefit analysis is a big question. There is a tighter question about cost effectiveness: if we have one effect, which is how to detect cancers as early as possible, what is the cheapest way of doing it? That is what we have been rehearsing so far. That question and the use of the term “cost benefit analysis” is useful, because it starts to raise the question about where, in all the experiences of cancer, we can put our different resources. We need a distribution of resources, because we cannot do everything at every point. We cannot prevent or cure every cancer and we can do something to palliate cancers that we cannot cure.

What we need to think about is not a very long-term agenda, but it should certainly not be a quick fix. It is important to remember that awareness campaigns, for example, must be sustained, because the people who will get cancer at some point—us—need to have those messages in mind. Therefore, there is a need for sustained awareness. People take time to absorb the messages and change their behaviour. We trust that, in time, that will feed into the broader cost to benefit ratio.

On health systems, it is important to remember that there is research going on in the UK and internationally on how, while keeping a primary care gatekeeper or boundary role, triage and redesign or tweaking of the health systems can allow for faster referral of the appropriate people. There are pilots going on in England on fast-track systems. There is also a redesign of the Danish primary care for cancer symptoms that considers high suspicion, medium suspicion and low suspicion. A lot of evaluation of that redesign is being done to determine what the optimal pathway is for patients. Scotland is also part of the international cancer benchmarking partnership, which is comparing patient pathways in a number of different jurisdictions to learn what we can about optimal design.

Thank you very much for that contribution. I am interested in cancer survival rates throughout Europe. You touched nicely on international studies. You will know that, last month, The Lancet published the Concord 3 study, which compared the cancer survival rates in countries throughout the world. The figures in that were for the UK, not Scotland, and, from memory, we came out extremely well—around fourth place—for all childhood cancers, but not so well for colon cancer, on which we were 17th out of 28. There are obviously big comparisons. Why are the survival rates so different in different European countries?

I am sure that David Morrison will want to comment on this, but it is really important to realise that such studies do not always compare apples with apples. We have such good cancer registration in this country that we have an accurate knowledge of survival rates, whereas some of the other countries with which we are compared have poor cancer registration, so only a small proportion of the population is being examined. I do not know whether the new Concord study has dealt with that, but it always strikes me as a significant problem. We do ourselves down because of it.

That is a useful point. A quick glance at the study shows that 71 countries were being considered. However, the figure that I quoted was within the 28 European Union countries. We were fourth out of those 28 for childhood cancers, but a lot lower for colon cancer. Why do we have different scores for different types of cancer even within the EU, which has fairly advanced health systems relative to some of the other countries in the 71?

10:00  

Even within the EU—in Germany, for example—cancer registration is only about 7 per cent of everyone with cancer, so these comparisons are dangerous.

There are certainly differences between the UK and the Scandinavian countries, for example, where we are pretty sure that the comparisons are similar. It is probably related to fairly simple things such as levels of deprivation and smoking rates, but I am sure that others will have their opinions.

I agree with what Professor Steele is saying. The Eurocare 5 study is the other big international European comparison of cancer survival rates and it has repeatedly shown that UK survival rates for nearly every cancer, apart from skin cancers, are relatively poor. The biggest gap is in lung cancer, where no country’s average survival is particularly good, but the gap between the other countries and the UK is particularly large.

I will rehearse what the discussions are. As Bob Steele says, one of the issues is that, at an international level, we do not have the fine detail to show that this is exactly the same kind of patient at exactly the same stage with the general other illnesses or comorbidities that contribute to their ill health. We have to look at a fairly high level and ask whether the result could be an artefact or whether it is just that countries are being selective. That is true of some countries, but the Scandinavian countries return 100 per cent of all their data so it is not the only explanation.

I have done some work with colleagues in Germany and tried to understand who their lung cancer patients are: why, out of all of the people who have lung cancer, those people come to their specialist centres. It is the same story when you look at information from the United States. People tend to report a selective best-case scenario.

We are then left asking questions such as whether we are getting worse kinds of cancers or whether they are more aggressive in some way. The general health of the population answers some of that but we use a thing called relative survival, which compares the population with what we would expect within that population. General health contributes to people’s survival and their capacity to take some of the more aggressive types of cancer treatment. Being in good health is a good way to tackle cancer on top of everything else.

Thank you. That was useful.

I have one more question to throw in. I am not making a judgment by making this comment. Professor Michel Coleman, the author of the study, suggested that the reason for the differences is that some European countries spend a higher proportion of their gross domestic product on health, and that the UK has not spent as much as other European countries. I know that there has been a big debate about that, and the Sunday Times had an article about how the inflation rate on health is a lot higher than the normal consumer price index, because of technological changes. The author of the study has one view; do our witnesses agree or disagree with it?

That is a highly political question and I would be cautious of coming down on one side and saying whether it would explain everything.

However, as we have already said, when looking at the efficiency of a system, we have to accept that, in order to capture patients who might not obviously have cancer—it is one thing to say that someone has symptoms of cancer, but a lot of people are diagnosed by surprise as an incidental finding—we have to allow a certain throughput or number of investigations. Trying to be highly efficient and trying to diagnose people at the earliest stages is a difficult balance. I am not necessarily going to side with Michel Coleman’s view on whether that means that we need a change in our total budget, but there is certainly a cost that comes with investigating more people and accepting that a lot of those investigations will have negative results.

One thing that I like about the detect cancer early programme is how ambitious it is. The last thing that we should do is drop the level of ambition to be the best and concentrate on why we seem to be one of the worst. We have a unique opportunity to shift that.

When it comes to the cost benefit, in particular, if we were to change the statistic that says that 29 per cent of those in more deprived areas are diagnosed late and their lives are then very short, the benefit to the community and Scotland as a whole would be huge.

As members know, Macmillan Cancer Support focuses on people with cancer. That is where we invest and where we focus our time, and we will continue to do so. However, our community engagement is unparalleled by that of any other national agency. People have enormous trust in Macmillan, and there is a real opportunity to get to the heart of those communities and shift the story. It is not about investing in Macmillan or Macmillan investing; it is about the wider collective joining Macmillan and adding to the work that we are doing. We could shift the story with prevention messages, detecting cancer early and screening.

I will jump back slightly to the question of whether we are worse than other countries—and why we are worse, if indeed we are—or whether it is just about poor registry and poor comparison. Maybe I am taking a slight leap here, but there is good, solid evidence that the greater the divide between the haves and the have nots, the worse the levels of some fairly impressive health and social metrics, such as life expectancy, maths and literacy, infant mortality, homicides, imprisonment, teenage births, trust, obesity, mental illness—including drug and alcohol addiction—and social mobility. It would not take much to extend that to why we are not doing so well with things such as cancer, because those factors will play out in every single health and social situation that every person in this country suffers from. It bothers me that we still seem so unwilling to acknowledge something that seems so staggeringly obvious. If that issue was addressed in part, the benefits outside of detecting cancer early and preventing it would be enormous.

You have led me very nicely into the area that I wanted to address. I have a couple of questions. Will the witnesses speak about poor access to GPs and the influence of 10-minute GP appointments on detection levels?

That question is coming my way.

It looks like it.

The simple answer is that the 10 minutes that we have nowadays is a woefully short time. When I started in general practice in 1985, we had 10 minutes, and that was more or less adequate. Over my time in practice, the complicatedness of health and care, and of treatment and decision making, seemed to grow exponentially to me. We also introduced a whole raft of complexity. In many ways, we introduced very good things, such as involving in a far more natural way the individual whom we were with, rather than having the doctor-knows-best approach. Even as a young GP, that approach did not quite feel right for me, but it was still quite prevalent 35 years ago. However, GPs’ time with people has not changed at all, and 10 minutes must be inadequate now.

We are creating a very elderly, very frail and multimorbid population through social care and health interventions, for example, and many people in that population will suffer with dementia. Within the next decade, dementia will become the commonest cause of death. I suspect that the majority of people in this room will peter out in a care home.

That is depressing.

As I am one of the older men, I will be one of the first. That is a reassuring fact.

Cost benefit has been talked about. The costs of providing care to the population that we are creating will be astronomical, because those people will require observed care. They will not manage to be looked after in the family home. It is very difficult to look after somebody with end-stage dementia in the family home, so those people are heading for a bed somewhere. Where? That is the committee’s next agenda item this morning—that is just a marker.

I have gone on a bit, but 10 minutes for an appointment is not adequate.

That led to where I wanted to go. We are asking our GPs to do more and more.

Professor Anderson mentioned the prevention agenda, and smoking, obesity, alcohol and a lack of physical activity have huge parts to play. I want to look at the social prescribing that we ask our GPs to do.

If there is no time to do that social prescribing, the issue becomes one of access to opportunities to be active—especially for people in deprived areas—to get advice and to be included in society. To my mind, if people were more active they would be less likely to smoke and more likely to be in control of their weight and have a better relationship with food and drink. That would provide some redress with regard to the sense of fatalism or lack of hope and achievement, and people would feel included and have better mental health. Where are we with that with regard to cancer prevention? Social prescribing has a big role to play in tackling the high levels of cancer that can be found in deprived areas.

What point would you like me to respond to? [Laughter.] As a topic, cancer prevention is the elephant in the room: people do not like to talk about it, because it makes them feel guilty, while health professionals say that they are not trained in the area and that they are there to treat. Social prescribing is of great interest, but it is not being as rolled out as widely as it could be.

We lead on the ActWELL study. As part of that, women attending routine breast screening—that is, women who do not have breast cancer but who are at a teachable moment when they are interested in cancer—are asked whether they would like a lifestyle intervention. We deliver that in local leisure centres, but we have found that women do not really like going to leisure centres—they are big, sweaty places that women are not used to. We are offering the opportunity and making the link, but we are also listening to what people are saying.

Physical activity is one element of the lifestyle complex. I do not think that it is the sole route to people thinking about food and drink and obesity, although it is an important part of the jigsaw. Instead, we have to get wiser and smarter about how we introduce prevention. It should be part of the role of all health professionals; moreover, the health-promoting service initiative in secondary care should be flagging it up, but sadly it is not doing so at the moment. Primary care, too, has a role to play, but those people are busy.

We need to look at the totality of opportunities. In the detect cancer early work, we recognise that screening provides opportunities to talk about prevention and, as I said in our submission, we feel that that should be explored. We have evidence that people like such opportunities and take part in them, but they are often missed.

I completely agree. However, that is just one example in which the inverse care law is writ large. I was amazed at the amount of time and effort that I sometimes had to put in to encourage people to make a lifestyle change. I can be very persuasive when I put my mind to it, but it was a struggle. I think that it would be relatively easy to get me to shift my mind, but the fact is that the GP workforce per capita is more or less the same across the country, and more time needs to be available in deprived areas to ensure that very complex behavioural change interventions can be made.

I am sorry, but I forgot to say about ActWELL that the people who do the interventions are Breast Cancer Now volunteers, who have been trained in an intensive programme. Hundreds of people have come forward to be volunteers, allowing us to develop community capacity with regard to prevention. The ActWELL study is being rolled out now, and our preliminary findings show that it is an opportunity that we ought to be taking.

I really appreciate the general focus this morning on health inequality and its impact on everything that we are doing. I have been on the committee since the beginning of the session, and we have done quite a lot of work on prevention. The message is coming across loud that messages are preventative for only some people—the people whom the messages reach. In some ways, that increases health inequality, and so the question is how we reach the people whom the messages do not reach.

We have also heard from Dr Helene Irvine and Dr Margaret McCartney, who expressed the perhaps quite controversial view that screening might not be the best focus for the money. I do not know whether we want to go into that, but Dr Paterson seems to be suggesting that longer appointments could be preventative. Having visited the Govan social and health integration partnership project, I think that if GPs had that bit more time they could reach people for whom an exercise programme might just be too challenging at the moment.

10:15  

Longer appointments are useful with regard to signposting people to things. I think that I enjoyed a fairly high level of trust among most of the people I was attempting to serve and that it was helpful for me to make suggestions to them and push, encourage or coerce them to go to an appointment to be checked for something, to attend their screening appointment or to follow up on a live active referral.

Some good work was done five or more years ago in Scandinavia—in Sweden, I think. The study estimated that it took about 10 or 11 consultations between the same two individuals in primary care for a trusting relationship to develop and for people to feel that they could work together. It takes a lot of time, but perhaps that is the sort of time that is needed if we really want to see some transformation.

I would not in any way underestimate the importance of using social prescribing methods such as the links worker programmes, which are great. The issue is not only in general practice, and I would not like social prescribing to be forgotten about.

Does the combination of both strategies represent the most effective primary prevention strategy for Scotland? Is there anything else to point out?

All the initiatives are good and absolutely need to be supported. However, every submission that you received for today’s meeting pointed out that we rely on that health interaction, and the problem is that a lot of people do not get involved in that until it is too late. Working through communities is important—the link officer programmes have been mentioned in that regard. The Scottish Government is committed to spreading one of the link officer programmes with us. Called improving the cancer journey, that programme uses a social prescribing model and reaches 80 per cent of people. The other link officer programme is based in GP surgeries and relies on people going through the door.

We are missing the whole-community effort. We have good communication, but how do we build those messages on to that, how do we start to change the conversations and communities, how do we reduce the stigma, and how do we use our safe spaces where people can talk to organisations that they trust? We need to build on that, not duplicate effort. I think that we need to do more.

On primary prevention, so far, we have been talking about how to treat or cure people as effectively as possible once cancer has developed. Let us be positive. We have achieved a lot with smoking, which is the biggest preventable cause of cancer. We still lag behind the rest of the UK in that regard, so further effort is needed—it is an old story, but it is still one that we need to keep pushing.

There is also good news in terms of the minimum unit pricing policy that we are about to implement in Scotland, which we hope will bring down alcohol consumption. However, as I said in my written submission, there is no safe level of alcohol—I am afraid that I cannot tell you a comforting story about that; if you want to minimise your cancer risk, no alcohol is the best policy.

On the issue of overweight and obese people—I am just addressing the three most common issues, but there is of course a longer list—we are not doing well. We are not turning the corner on that issue. Two thirds of our population are overweight or obese. A lot of people do not realise that that is such a major risk factor for some of the most common cancers, such as breast cancer and bowel cancer.

On our attempts to try to stop cancers occurring in the first place, we still have a long way to go with regard to the old enemies and some of the new cancers that we have not tackled so far.

I want to talk about prevention. Janice Preston made a good point. We have been talking about people presenting themselves to the doctor and so on, but I see prevention as ensuring that people are healthy enough not to have to present themselves to the doctor. Budget wise, is enough money spent on prevention, through things such as advertising? Dr Morrison mentioned obesity. Someone in a deprived area who has to feed their family might well go to one of the shops—I will not name them—that sell a lot of food that is not healthy.

What are we doing to educate people? We are doing a lot of work on exercise, particularly in Glasgow, with free entrance to gyms and through football and so on. We need to get the message out to the community. Could we link the Child Poverty (Scotland) Bill to the preventative agenda? Are there some innovative methods that we can use to get the message across to people that their diet is important? Methods such as the Mediterranean diet, which we hear about constantly, are not really that innovative. Minimum pricing of alcohol is a fantastic policy, but we should also consider banning some of the things that go into our food and look at how we label the food.

That was more of a rant than a question—I just wanted to open up the discussion. In order to prevent obesity, we need to educate people to eat better and so on.

Sandra White has set the scene. There has been a lot of good discussion about local projects and ways in which we can encourage individuals to think about their lifestyle. Euan Paterson has also talked about what can be done in a GP setting. However, once someone steps outside the practice, they are stepping into a different environment. I remember hearing a Govanhill deep-end GP talk about the fact that their patients had no access to fruit or vegetables within walking distance. That is the context that we are talking about. Academics and wonks talk about the obesogenic environment—they mean places where the unhealthy choice is easier and often perceived to be cheaper.

Cancer UK is tackling that environment to an extent by challenging supermarket high-fat, sugar and salt promotions. The cheapest way to eat is still to eat pasta, rice and whole foods. There is probably some need for education in cooking skills. On the promotion environment, there is plenty of science, such as nudge theory and so on, that shows that people’s behaviours in retail environments change depending on promotions and what is on offer. At the moment, the balance is tipped towards unhealthy foods and we need to tip it towards the healthy ones. That is why environmental interventions such as minimum unit pricing and challenging the promotion of unhealthy foods are vital.

I have a point that is related to our earlier discussion—although it also picks up Gregor McNie’s point—about the broader prevention agenda, long-term thinking and how we get everyone to think about the issues. Education is really important. Schools are not represented around the table today, and we should be thinking about fizzy drinks and what is available to kids in school. When I was at school, we had home economics classes, which were about how to cook and eat well, even on a budget.

My colleagues in Stirling and elsewhere have been doing work with the Teenage Cancer Trust on raising cancer awareness among young people without frightening them. The aim is to present a dual message: the cancer symptoms that they ought to think about and the broader healthy lifestyle thinking.

I come from the university sector and, to pick up the discussion on a health promoting health service, one way forward could be to include prevention as part of the broader curricula for students of nursing, medicine and allied health professions, as well as including it in the sports science agenda.

David Morrison mentioned lung cancer. I am interested in that, as I am the convener of the cross-party group on lung health and we are looking at a respiratory quality improvement plan for Scotland. It looks like we are going to get Dr Tom Fardon to look at that, given that such plans are working in Wales and Northern Ireland. Is that something that can add to tackling lung cancer, even though it is a quality improvement plan that will focus on lung health in general?

I do not know the details of that, so I cannot say. What is good for your general lung health will be good for lung cancer—not smoking and not being exposed to environmental or occupational risk factors for lung diseases will greatly reduce your chance of getting lung cancer. Even if you do smoke, the interaction with other environmental or occupational exposures can make things worse. Any strategy to improve lung health will be useful for lung cancer.

We have been talking about other issues, such as obesity, and it is worth saying that what is good for cancer is usually good for heart disease, stroke, dementia and many other chronic illnesses. Therefore, we are not in a silo when it comes to cancer. A lot of what we are looking for to improve the general health of the population will be good for all of us.

The answers are complex, of course. On obesity, the foresight report was a superb report that involved some broad thinking, but if one message can be taken from it, it is that it is not a case of tackling any one issue. Education is not the only answer, nor are health interventions. It is an immensely complex subject. In a sense, tobacco is one of the easiest issues to tackle, because there is no good in tobacco. However, when it comes to our diets, people have to eat, and we must understand people before we can think of an approach that is fair.

My point is linked to that. In the 30 years for which I worked as a GP, I honestly think that there was only one person whom I encountered who smoked and who had a level of learning disability that meant that they did not understand the issue. In that entire time, I did not see one other person who smoked who did not know that smoking caused cancer and maybe some of the other stuff as well. Providing that information is not enough. The message is out there.

I will go round the table quickly. This is a group of highly privileged individuals. Put your hands up if your body mass index is between 20 and 25. Now do so if your fat index is less than 20 per cent. Now do it if you have five portions of fruit and veg a day. Now do so if you have no alcohol. Oh, my goodness! That is not good news. Now put your hands up if you do not smoke, you do not do drugs and you exercise for at least 30 minutes a day. Can anyone here say that that is the case? I see that Brian Whittle and Anne Anderson have raised their hands—leave now! That is two out of 30-odd highly privileged people, yet we are trying to suggest that this is an education message that we need to get across to the general community. We ought to be cognisant of that.

On obesity, it might just be the case that I am sometimes overinfluenced, but I thought that the series of programmes entitled “The Men Who Made Us Fat”, which was shown about five years ago, was really powerful. Arguably, obesity is a result of the underlying social malaise of aggressive marketing and consumerism. That is what is making people fat.

We have a lot to learn from tobacco control when it comes to other lifestyle factors. It has taken a long time—two or three decades—to get to where we are on pricing and availability of tobacco. We need to look at how that happened. It did not just happen overnight. The legislation that is in place would not have been introduced if it had not been popular enough to get the thumbs-up from the electorate.

Rather than education, I will call the first stage of that process awareness raising. Awareness had to be raised of the link between tobacco use and risk to health. CRUK is doing stellar work in raising awareness of the link between obesity and cancer, but for such a long time in this country we have had bland messages about activity being good for us. Physical activity can help to prevent cancer—we need to get that message out and be clear about it. Physical activity helps with other things, too, but let us get the cancer message out loud and clear.

That is what the tobacco control people did—they raised the bar on awareness and then they got people on board. Where are our role models now? Where are the health professionals saying to people that we need to do something about cancer and physical activity? With tobacco, we used advocacy by really important people in our communities. We needed to work on that before we could get people to agree that we ought to do something about the marketing, the pricing and the availability of tobacco.

The issue is not just about children. Tobacco control has always involved tackling young people smoking. Christine Campbell talked about children and students, but cancer prevention is possible for adults. We know that, even after the age of 50, we can help to reduce the risk of breast cancer among post-menopausal women.

Let us not call it education. We are talking about awareness raising, advocacy, having role models and getting people on board. Let us not focus only on kids. We need to look at the whole population. At any age, lifestyle changes can help to reduce cancer—and, by the way, diabetes and heart disease.

I want to drill down on Sandra White’s point about education. Does the strategy need to be more explicit? Professor Anderson has just made the powerful point that physical activity can help to prevent cancer. I know that the issue is not all about children, but Christine Campbell said that none of us around the table is involved with schools, and I was a teacher in a previous life. You talked about schools banning fizzy drinks. In Fife, The Courier is campaigning to ban energy drinks in schools, which is a good example of how schools can take action to try to inform behaviours. The issue is not just about schoolchildren or younger people but, presumably, if we can have an impact on people’s behaviours at an earlier stage, that can have an impact on their chances of contracting cancer later in life.

10:30  

Do you agree that there needs to be more of a connection between health and education, because the committee keeps hearing that there is a disconnect between the two? In our session with Dr Burns, he talked about that disconnect with regard to adverse childhood experiences. The two systems are not talking to each other or sharing information adequately. Do the health and education systems need to sit down and audit the health and wellbeing curriculum, which is one eighth of the school curriculum? Do we need to sit down and look at the detail?

I confess to being president elect of the UK Society for Behavioural Medicine, so I will use my theoretical basis in answering.

Clearly, working with children and parents is needed. Cancer is a disease that has a life-course impact, so the early years are important. With regard to children, the education on food in particular is now very good in Scotland. There is a difference between what someone hears and the knowledge and education that they have, and what someone does. One of my party pieces when talking to an audience is to ask “Who knows the five-a-day message?” Everyone puts their hand up because they have learned the message. However, when I ask “How many people eat their five a day?”, it is about 3 per cent. Education and health are so important as a basis, but let us not lose the bigger picture, which includes parents and every aspect of a life course.

That is entirely true. I am a huge believer in the teachable moment. That does not involve only the person who has cancer but their family as well. In schools, there is something to be said about not wrapping things up in cotton wool but using the experiences that there will be in schools every day to talk about those things and join up health and school. We absolutely need to ground learning in the reality of a situation—someone told me the other day that their kid was getting resilience training for the second day but that they did not quite understand it.

We have a programme in Lanarkshire called “Give us a break!”, which is geared to 10 to 14-year-olds who are going through a difficult time—it is not bereavement, just change. At that point in time, they are open to uncovering their own strengths, using them and building their resilience. When we teach that in the abstract, they can learn the messages but they do not act on them. We should be bold and use the opportunities in school to talk about cancer.

I will change the topic slightly because I wanted to pick up the idea in Cancer Research UK’s written submission of GPs referring directly for tests. At the moment, if somebody suspects that they might not be well, they go to a GP. If the GP agrees, they are referred to a secondary care specialist, who then orders the tests. If the GP knows what tests to order, they could refer for them straight away, which could save money and free up some out-patient time as well. Is that something that we could look at in Scotland?

That should be looked at. The Scottish Government is looking at one strand of that on direct access to computerised tomography scans for some vague suspicions. Anecdotally, we hear more and more that patients are often bounced around a system only to end up getting the test that the GP would have asked for in the first place. If we are redesigning systems, we must ensure that it is those patients who are referred directly, and not a huge number of patients who do not need tests. There is strong evidence from some pilot areas that direct access is being used quite well and not being overused, and that the normal fears that we might get about secondary care and the system being overwhelmed are not being borne out. There is a lot of opportunity in that area.

General practice has a reasonable amount of access to a reasonable amount of tests, which probably cover a lot of the common tumours. Direct access for CT scanning, which is available in some but not all boards, is probably more for people for whom the likelihood is that the boat has been missed. Those people present with the triad of weight loss, loss of appetite and being tired all the time, but nothing much else. Clearly, there is something serious going on at a biopsychosocial level—it could be almost anything—but a quick CT scan might well get to the bottom of it, rather than that person having to be bounced round the system. However, we will probably not be able to make a huge difference to the life expectancy of those people.

Euan Paterson and Professor Anderson have both touched on this but, as we all know, smoking gives you cancer. Despite the great work that has been done in Scotland to reduce the number of people who smoke, we find when we dig underneath the data that the percentage of people who smoke is only 9 per cent in the 20 per cent least-deprived areas smoke but 34 per cent in the 20 per cent most-deprived areas, where people can probably least afford to do it. Obviously something else is going on; indeed, witnesses have mentioned fatalism. I guess that we know the answer to this question, but are we putting enough resource into this area to carry on the great work that is being done here? How do we tackle that major inequality?

I think that you are right to suggest that health messaging is probably not the best way of challenging tobacco use in some of these constituencies. A lot of the data will probably bear out the impression that those to whom the health messages have penetrated will have given up already, and we face a harder mission in some deprived areas, where different motivators are probably required for people to quit. Those motivators might include nicotine’s control over people’s lives, and, in that respect, one might focus on the financial aspect and the idea of being able to buy more independence and freedom from nicotine dependency.

However, this is also about breaking what in many cases is a social glue. As you have pointed out, smoking is a very normal behaviour in many of these postcodes; in some places, the percentage of those smoking is touching 40 per cent. Cancer Research UK is investing a lot in research into the potential of e-cigarettes, and as long as such devices remain in the hands of smokers, we see a lot of potential in them to move people from tobacco. So far, the data shows that they are being used by smokers instead of being taken up by non-smokers. We need to do all that we can in what is an extremely challenging area, and that is one aspect that we would point to for a potential win.

With regard to health inequalities, I want to move beyond the issue of tobacco and highlight obesity as a very good example. In our submission, we highlight two studies in which we have been involved that bring prevention and screening programmes together. Our BeWEL study involved those who had tested positive for bowel cancer and been invited for a colonoscopy but who did not have cancer, although they were at higher risk of getting it, as they had had a lesion or a polyp that was removed. We offered them the opportunity to go on a weight loss and physical activity programme. That paper, which was published in the BMJ, was very successful. We also recently published a paper that showed that there was no difference in response by social demographic group. As we all know, it is not necessarily the case that the whole population goes through screening—people from poorer areas are less likely to, for example—but we sometimes forget that a lot of people from poorer areas do come through it, and that is an example of those people responding equally well to an opportunity. It is a similar story with the pilot study for the ActWELL programme, which I have already mentioned.

Eighty per cent of women are coming through the breast cancer screening programme; not all of them come from deprived areas, but a lot of them do. It provides an opportunity to offer something, and as we have seen, the uptake has been high. There is no one way of addressing health inequalities, but we should be looking at things that could make a contribution, and we have demonstrated that offering lifestyle programmes to those coming through screening, who are at a teachable moment, seems to work equally well with people from deprived areas.

That is absolutely right. What we need to do is make the most of that point of engagement. This is not about putting in lots of extra resources but about working together and making the most of every engagement.

Perhaps I am being overly pessimistic, but my slight worry is that, given that we are talking about the people who have attended for screening, we are already tipping the balance against people from deprived areas because fewer of them go. Although it is a small difference, that will inevitably widen the gap in health inequalities.

We are talking about great points of intervention. If people go for screening and find that, crumbs, they have had a lucky escape, no wonder they begin to get a wee bit more motivated. The problem is the people who have not had that yet. It is still not easy, but we can encourage people to think about smoking, for instance, after they have had an infarct, and they say, “Yeah, maybe you were right. Let’s stop now.” However, until that point, it is different. We have to do more for the people whom we are not reaching at all.

Sure, but do you ignore the opportunity? They might never come through another health service. Do we say that, because we cannot get them all, we should not do something?

It is a matter of the cost benefit ratio. Absolutely.

Health inequalities cover rural and urban areas. I am a South Scotland MSP; that region is pretty much rural. Are there specific challenges or things that we could do differently? Our local NFU Scotland group has engaged a lady from the national health service to go to the auction marts and do health checks and blood pressure checks on farmers. That is something unique that is happening in my rural area. What can we do in addition to that?

It is really important that deprivation in rural areas is different from deprivation in cities. We examined uptake of bowel screening and breast screening in relation to deprivation. We found in cities a huge difference between deprived communities and non-deprived communities in uptake of bowel screening. However, in rural areas there was no difference at all.

What we measure in rural areas using the Scottish index of multiple deprivation is quite different from what we measure in cities, so we need to take a different approach to deprivation in rural areas. What the approach will look like is something for us to work on—one size does not fit all.

Would that be a variant of the kind of targeting about which other witnesses have talked?

Yes. That is exactly right.

We have a mobile bus, use of which has grown. We target remoter areas with it. There is also an opportunity to attach other messages. We find that uptake in those areas is high in relation to their population, so that is good use of our time.

No matter where people come from, we need to address their needs holistically. If they are worrying about where their next meal will come from, they will not engage with messages about prevention or getting better. In Glasgow—we are doing work in Fife and Dundee, too—we have found that with the 80 per cent whom we engage with, if we sort the other things out, three months later they are receptive to the conversation because they are in a better place. In that respect, it does not matter where people live. We can do that through current resources, not new ones. In Scotland alone, 17,000 people were helped with benefit advice last year, which amounted to £45 million.

To respond to the question about rurality, we still have a bit to learn about the variations in early diagnosis and access to care. One of my current academic pieces of work is to examine access to radiotherapy services throughout the country in order to see whether there is a barrier to getting to such services because they cannot easily be moved and made local. There are mobile vans for breast screening. In NHS Greater Glasgow and Clyde, there is an initiative to make those services more accessible and to use them more helpfully in order to reduce the travel barriers that are faced by people who do not have access to a car.

There is better understanding of the barriers to be gained. Is there a barrier to getting to the GP, a screening service or hospital? We do not yet have that fully laid out; the evidence is a bit thin, so we need to do more work. However, there are also some practical things that we can do and, in some cases, are doing—for example, reorganising the mobile mammography vans.

10:45  

I want to touch on the future of the detect cancer early programme. It has focused on the three main cancers—lung cancer, colorectal cancer and breast cancer—which account for about 40 per cent of all cancer cases. To what extent, does the panel feel, have other cancers been neglected? This week, for example, we found out that prostate cancer is now killing more people than breast cancer. How would the panel like to see the detect cancer early programme developing, particularly in relation to some of the rarer cancers, such as brain cancer?

With regard to different cancers, you have to be careful with what can be done. Prostate cancer is a good example. There has been a lot of interest in screening for prostate cancer, but we know that it does more harm than good. It is a very important principle that we should not introduce a screening programme that will cause more harm than benefit. It is really difficult to get at prostate cancer, because even symptoms are not predictive of it. Therefore, until we know what would be effective intervention, it might not be valuable to put an awful lot of effort into prostate cancer. Further, some of the rarer cancers are extremely resistant to early diagnosis.

The detect cancer early programme has been a fantastic opportunity, and a lot of the work that has been done through it has been amazing. However, it is not focused on prevention. I wonder whether we should be moving towards looking at early detection and prevention together, because we might get a bigger bang for our buck.

When the Scottish Government established the detect cancer early programme, it set a target of a 25 per cent increase in detection or examination at the first stage of the targeted cancers that Miles Briggs mentioned. However, the figures fall far short of that target. Can you explain that?

I think that it is because the target was hugely ambitious—but why not?

Is the conclusion therefore that a less ambitious target should be set?

That is certainly not the conclusion. We should keep pushing.

On what we should do next, I absolutely accept what Bob Steele has said. A rational approach would say that it is difficult to find good symptoms. People do the obvious things; if a person obviously has symptoms of cancer, the GP will refer them.

One of the surprises that has come out of the detect cancer early programme has been the amount by which early detection of lung cancer has increased. We might not have predicted such a large increase in early detection of the disease because lung cancer has obvious symptoms; for example, a chronic cough, because we are talking about people who are smokers anyway and who might have other lung diseases that go with that. I have to say that, from other audit information on cancer services, the evidence is that more people are getting curative surgery, and that, in recent years, survival is starting to increase as a result.

It is possible to be pleasantly surprised. If I had to be pessimistic, I would have said that it would have been really difficult to shift the rates on lung cancer. However, there has been a welcome increase in the rate of early detection, which just shows that we cannot necessarily guess what will succeed.

The success in relation to lung cancer that David Morrison just mentioned is beyond what many people would have imagined. The challenge now is to build on that. More people are surviving because of that success—that is the human story behind the figures.

The DCE programme will be needed more as our population ages. We have talked about the early detection challenge, which very much relates to people with cancer. Efforts around that have to be maintained.

We have talked previously about public awareness and the need for people to be willing to present with symptoms. That needs continued investment. There also needs to be a continued feeding to the public of the message that they should report to a GP if there is a change from what is normal for them.

On the prevention agenda that involves the four in 10 cancers that could be prevented if people led healthier lives, and the benefits with regard to other diseases, I contend that the £40 million that the detecting cancer early programme has behind it would not even touch the sides of a proper prevention effort. We need to look to the total £13 billion health budget and really challenge how much is going into prevention: we need to put some big investment into it.

On what was just said about lung cancer, NICE’s work showed that symptoms are not particularly good as positive predictive values. However, a pretty good test can be offered that is relatively well taken up and not particularly embarrassing to take: the patient can be sent for a chest X-ray. It is not the be-all and end-all, but it is a great place to start.

If a patient has vague symptoms and a normal chest X-ray, the role of the general practitioner is often to undiagnose rather than to diagnose. In that situation, a GP can to a degree be confident that the person is okay. They might need to be watched for a while, but they do not need to clog up the expensive acute care system.

Ditto with introducing—[Interruption.]

Thank you: I could not think of the name. Ditto with introducing the FIT for bowel cancer as a point-of-contact test. We used to do point-of-contact testing for bowel cancer—not with the FIT, to be fair—but the test was withdrawn. Point-of-contact testing would make a huge difference. Those tests have big benefits.

The final question is from Emma Harper.

I believe that Gregor McNie brought up near the start of the meeting the trial of self-testing for human papillomavirus that is happening in Dumfries and Galloway. That could lead to something really amazing because of the time that it will save for people who will be able, instead of attending appointments, to take a wee kit home. That could be beneficial all round—5,000 women in Dumfries and Galloway are defaulting on the smear test right now.

Does Bob Steele want to respond?

It is not particularly important, but I will just say that the previous test, which was withdrawn, was not sufficiently sensitive, but the new test is much more effective and helpful for GPs.

If I were to summarise in a sentence the message that we might take from this evidence session, it might be that we should continue to be ambitious on detection, but do a good deal more on prevention. That none of our witnesses does not support that view allows us to reach a consensual conclusion.

I thank you all very much for your input. We will take a short break.

10:52 Meeting suspended.  

10:58 On resuming—