The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
Dechreuodd y cyfarfod am 09:01.
The meeting began at 09:01.
|
Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datganiadau o Fuddiant
Introduction, Apologies, Substitutions and Declarations of
Interest
|
[1]
Mike Hedges: Can I
welcome everyone to the meeting?
|
[2]
Croeso i’r cyfarfod.
|
Welcome to the meeting.
|
[3]
Participants are welcome to speak in Welsh or English. Headsets are
available for translation of Welsh to English. There is no need to
turn off mobile phones or other electronic devices, but please
ensure that any devices are on silent mode, if only because of the
massive embarrassment that you have when you start fiddling around
searching for it when it starts going off. Apologies: no apologies
have been received—and that’s still no apologies
received.
|
09:02
|
Deisebau Newydd
New Petitions
|
[4]
Mike Hedges: We’ve had some new petitions. I’ll
just mention that the number of new petitions, because we met a
fortnight ago, have now reduced quite dramatically from the number
we dealt with last time. The first one is to encourage planning
committees to ensure that planning decisions take due regard of the
impact on or closure of local community groups and voluntary
organisations. A letter was sent to the Cabinet Secretary for
Environment and Rural Affairs on 4 August. A response has been
received and is in the papers. A research briefing on the petition
and the related issues has been prepared for Members’
information. The petitioner was informed that the petition would be
considered by the committee, but had not responded when papers to
the committee were finalised. Any comments? Are we happy with the
response that we’ve had from the Minister? It says,
really—?
|
[5]
Neil McEvoy: Where is the response, Mike?
|
[6]
Mike Hedges: The response from the Cabinet Secretary said
that the impact on local community groups and local communities
should always be taken account as a material consideration by
planning authorities.
|
[7]
Neil McEvoy: Right. Because, really, I suppose, you’ve
got to look at the merits of taking into account because it
doesn’t make any difference, does it, really? That’s
the problem.
|
[8]
Mike Hedges: As you’ve probably had even more problems
with planning committees than I have over time, there are
difficulties with dealing with planning and planning
officers’ interpretation of views.
|
[9]
Neil McEvoy: It’s just that in Cardiff we’ve had
the local development plan opposed by thousands of people in local
referenda, and it hasn’t made a jot of difference. I think
that’s the frustration from the public, really. I don’t
see much movement.
|
[10]
Mike Hedges: Would it be helpful if we wrote back to the
Cabinet Secretary asking, where it says that impact on community
groups and local communities should already be taken into account
as a material consideration, for clarification on that?
|
[11]
Neil McEvoy: Yes, I think it would be. And the weight it
carries, because our experience in Cardiff is that it carries no
weight whatsoever.
|
[12]
Mike Hedges: So, I think clarification on what it actually
means, and the weight it carries when discussing a planning
application.
|
[13]
Neil McEvoy: Yes. Thanks.
|
[14]
Mike Hedges: Is everybody happy with that? Yes. The next one
is a ban on the manufacture, sale and use of snares in Wales.
We’ve had the petition and we’ve had a letter from
people opposed to the petition. [Interruption.] Oh,
Suzy.
|
[15]
Suzy Davies: Hello. I’m substituting for Janet.
|
[16]
Mike Hedges: Croeso. [Interruption.] You can now be
‘person with no name’. [Laughter.] Okay. Right,
no problem. We’re on the second one on the manufacture, sale
and use of snares in Wales. I just said we’ve had a
1,405-signature petition. We’ve had a lot of correspondence
from other bodies as well. We’ve written to the Cabinet
Secretary, we’ve received a response from the Cabinet
Secretary, we’ve had a research paper, we’ve had lots
of correspondence from Countryside Alliance, and we’ve had
further correspondence from the petitioner. I think that the word
‘contentious’ probably does sum up this petition.
|
[17]
Gareth Bennett: The countryside people were kicking up a
fuss over what they alleged were factual inaccuracies in the
petition, but I don’t know how we’re supposed to deal
with that as a Petitions Committee.
|
[18]
Mike Hedges: There’s nothing we can do about it
because I think the factual inaccuracies are a matter of opinion,
or the interpretation of numbers. We’re not meant to act as
jury on people’s petitions. They’ve got a right to
submit if they meet the criteria, and the Presiding Officer’s
staff have not said we can’t do it.
|
[19]
Suzy Davies: Can I just make an observation? It’s
occurred to me, all the parties put out manifestos very recently,
and those were prepared after lobbying on this issue. I don’t
make a statement on views either way on this, but, having never
served on this committee before, how do you treat petitions that
are on areas of public interest that have already been dealt with
fairly recently?
|
[20]
Mike Hedges: We treat all petitions exactly the same. We get
the petition in, we write to the Cabinet Secretary/Minister asking
for their observations on it, and if they say, ‘This is now
being dealt with’, we come to the conclusion whether we want
to reopen it or whether we wish to just acknowledge that it’s
been done. With this petition, the Cabinet Secretary has already
indicated that a meeting between officials and interested parties
should take place imminently to coincide with the first anniversary
of the code of practice.
|
[21]
Suzy Davies: That’s right, because there’s a
relatively new code on this, isn’t there?
|
[22]
Mike Hedges: The Government is also giving careful
consideration to the Law Commission’s recommendations that
the operation and inspection of snares may benefit from additional
regulations. As such, the committee could forward the
correspondence received to date to the Cabinet Secretary and
request to be kept informed about the outcomes of these discussions
before deciding whether to take further action at a later date,
which is what I would recommend. If people can come to an amicable
agreement, then we don’t really want to interfere with that.
So, can we do that? Yes. Two nods. Yes. Three nods. Okay.
|
[23]
That takes us on to a success now, ‘The Ghost Train’,
which confused me as well when I first read it. It’s from the
residents of the Ardudwy coast. A separate online petition has also
collected over 300 signatures. I think we’ve got a note from
Arriva Trains, which I saw earlier, which says:
|
[24]
‘In response to requests from the public, local stakeholders,
from Monday 12 September 2016, the Arriva Trains Wales 19:00
Machynlleth to Pwllheli service will now stop all stations upon
request.’
|
[25]
So, I think we can mark that down as a success.
|
[26]
Suzy Davies: Yes.
|
[27]
Mike Hedges: Shall we write to the petitioner to
congratulate them on the successful outcome of their petition?
|
[28]
Suzy Davies: Well, yes, it’s encouraging for other
petitioners, then.
|
[29]
Mike Hedges: Yes. ‘Welsh Assembly to Build a
International Mother languages Monuments at Cardiff
Bay’—this was submitted some time ago by Mohammed Sarul
Islam and has 16 signatures. What do you want to do with it? I
would have thought it was a matter for—I look to Neil who
knows more about this than I do—but I would’ve thought
this was a matter for Cardiff council rather than the National
Assembly.
|
[30]
Neil McEvoy: He’s not responded, has he?
|
[31]
Mike Hedges: No.
|
[32]
Neil McEvoy: So, you know—
|
[33]
Mike Hedges: Shall we just note it?
|
[34]
Neil McEvoy: We should maybe just wait to see if he responds
and then maybe close it next time.
|
[35]
Mike Hedges: Give him another fortnight to respond?
|
[36]
Neil McEvoy: Yes.
|
[37]
Mike Hedges: Yes, give him another fortnight to respond.
|
09:10
|
Y Wybodaeth Ddiweddaraf am
Ddeisebau Blaenorol
Updates to Previous Petitions
|
[38]
Mike Hedges: We’ve got updates to previous petitions.
We’ve got two petitions that are virtually identical, one on
slaughterhouse practices and one on CCTV in slaughterhouses, which
we looked at last time and which were so similar that we decided to
treat them together. It was considered on 20 October 2015. The
Welsh Government business unit provided an update that states that,
back in November 2015, an industry group was to investigate issues
surrounding the welfare of animals at the time of slaughter,
including the role of CCTV. This group was to report their findings
to the Cabinet Secretary for Environment and Rural Affairs this
summer, which is summer 2016. The report has been delayed while
they await publication of the Food Standards Agency’s latest
slaughterhouse survey results. So, we’re expecting it to go
to the Cabinet Secretary in the next few weeks. Should we wait
until we find the results of the Cabinet
Secretary’s—?
|
[39]
Suzy Davies: I think you have to, don’t you?
|
[40]
Mike Hedges: Yes.
|
[41]
‘Unconventional Oil and Gas
Planning Applications’—this goes back to 2013. It was
last considered on 2 February 2016 and an update from the Cabinet
Secretary for rural affairs was received on 13 September and is in
the papers for this meeting. The petitioner was informed that the
petition would be considered by the committee, but had not
responded when the papers for the committee were being finalised.
Give them another fortnight to respond?
|
[42]
Neil McEvoy: Yes.
|
[43]
Mike Hedges: Yes, okay. Give them another fortnight to
respond.
|
[44]
‘Cilmeri Community Council Appeal
for The Prince Llywelyn Monument’—this goes back to May
2014. It was last considered on 12 July when we considered
correspondence from the then Minister for Economy, Science and
Transport and agreed to write to the Cabinet Secretary for Economy
and infrastructure to ask for an update. The correspondence from
the Cabinet Secretary for Economy and Infrastructure received on 28
August is in the papers for the meeting and the petitioner was
informed that the petition would be considered by the committee and
a further response is included in the papers. Shall we forward the
petitioner’s comments to the Cabinet Secretary and ask him to
provide the committee with a further update when a decision has
been reached?
|
[45]
Neil McEvoy: Yes.
|
[46]
Mike Hedges: Yes. On to another one of our successes, ‘Food
in Welsh Hospitals’. This was submitted in January 2016. The
Public Accounts Committee is looking at food in hospitals and, as a
member of the Public Accounts Committee, I can say that the auditor
general is looking at it again and the variation between not just
different hospitals, but different wards in hospitals and different
practices between different wards, including adjacent wards in the
same hospital. The auditor general is looking at this and the
Public Accounts Committee have considered it in private, so
I’d better not say any more, but the Public Accounts
Committee have had the petitioner’s views, which have also
been given to the auditor general. So, shall we wait for the Public
Accounts Committee and the auditor general to report back? But I
think the petitioner should be pleased to know that this is a
matter that is being taken very seriously by both the Public
Accounts Committee and the auditor general and by some community
health councils—I say ‘some’, it might be all the
community health councils, but I know that some of them are taking
it very seriously and are doing work on it. So, if the
answer’s ‘all community health councils’,
apologies, but I only know of two and they both are.
|
[47]
Suzy Davies: Well, I’d rather hope that all CHCs will take
this up now.
|
[48]
Mike Hedges: Is it worth us just letting CHCs know about it? Is that a problem?
|
09:15
|
[49]
Mr Francis: About the—?
|
[50]
Mike Hedges: The concern about—. Shall we write to them and
let them all know of our concerns?
|
[51]
Suzy Davies: Do you want to wait for the PAC response, or—?
I think the auditor general’s letter is good enough for us
all, to be honest.
|
[52]
Mike Hedges: Yes, fine. We’ll leave that until we’ve
seen the response from the auditor general. Rather than bring it up
at every meeting, can we agree that any comments on hospital food
that come in, the clerk forwards them on to the Public Accounts
Committee and the auditor general, rather than reporting to us,
because they are the ones doing the work?
|
[53]
Can we have a break until 09:45? Can I
thank you—have I missed something?
|
[54]
Mr Francis: Yes, the Minister’s coming in at
09:45.
|
[55]
Mike Hedges: The Minister’s coming in at 09:45 to follow on
from last week’s report. I’ll see everybody in half an
hour.
|
Gohiriwyd y cyfarfod rhwng 09:16 a
09:47. The meeting adjourned between 09:16 and
09:47.
|
Sesiwn
Dystiolaeth Evidence Session
|
[56]
Mike Hedges: Can I welcome you to the meeting, and would you
like, Cabinet Secretary, to introduce your two colleagues?
We’re waiting for Suzy Davies, who’s due very
shortly.
|
[57]
The Minister for Social Services and Public Health (Rebecca
Evans): Right, okay. I’ll ask my officials to introduce
themselves.
|
[58]
Mr Rees: Irfon Rees, deputy director for public health in
Welsh Government.
|
[59]
Dr Fox: I’m Dr Rosemary Fox. I’m the director of
screening division in Public Health Wales. I was a member of the
United Kingdom National Screening Committee from 2010 to 2015 and
I’m now an observer on that committee.
|
[60]
Mike Hedges: Thank you. Do you want to introduce yourself
for the record?
|
[61]
Rebecca Evans: Yes, Rebecca Evans, Minister for Social
Services and Public Health.
|
[62]
Mike Hedges: Thank you very much. Just a quick introduction,
which I think you should know, is that we had Margaret Hutcheson in
last week. She produced a petition that was first considered in
2016 and she had 104 signatures. She gave oral evidence last week,
and we’re now seeking evidence from the Minister for Social
Services and Public Health and, obviously, your technical advisers.
We’ve written to you in advance telling you what was raised
by the speaker last time and an opportunity for you to answer some
of those comments.
|
[63]
Rebecca Evans: Okay. I took the opportunity to review the
evidence that you received at the last meeting and it was very much
about the affordability of the screening programme. I think we have
to start by taking a step back from that, because whether or not we
introduce a screening programme in the first place is very much
dependent on the best evidence available as to the efficacy and
affordability of such a screening programme.
|
[64]
Screening programmes should only be offered when there is robust,
high-quality evidence that screening will actually do more good
than harm and also be cost-effective within the Welsh NHS budget.
We take our advice from the UK National Screening Committee and
they provide independent expert advice on population-based
screening to all UK Ministers. It’s a world leader in its
field and the screening programmes in the UK, I think, are amongst
the most respected internationally. The screening committee does
not currently recommend population screening for ovarian cancer.
Rosemary sits as an observer on that committee and she might be
able to tell us a little bit more about the kinds of conditions and
criteria that are set in order to determine whether a
population-screening initiative should be introduced.
|
[65]
Dr Fox: Thank you. The first premise of screening programmes
is that they must be shown to do more good than harm. That’s
really important because you invite populations for screening. So,
most of the people that you’re inviting for any screening
test or to enter any screening programme haven’t got the
condition that’s concerned. So, if you do even a small amount
of harm to a number of those people who haven’t got the
condition concerned, that can easily outweigh any good that’s
done to the people who do have the condition.
|
[66]
I think it’s important to state at the outset that I
don’t think anybody would argue that ovarian cancer
isn’t a very significant disease and a terrible disease to
have. But, we need to have the evidence that actually detecting
ovarian cancer early by means of a screening programme will improve
the outcome—and by ‘outcome’, we’re talking
about people dying from ovarian cancer—in the group of people
that have been screened. At the moment, the United Kingdom
collaborative trial of ovarian cancer screening, which reported
last year, hasn’t provided that evidence.
|
[67]
And, I must say, on a personal basis, as somebody who’s
worked in screening for the last 10 years, that was quite a
surprise. I think everybody had been expecting that the trial would
show that there was a benefit from screening. The fact that it
hasn’t shown that means that we need to be very careful not
to allow enthusiasm to do good to overcome looking at the actual
evidence to see whether we will do more good than harm.
|
[68]
Rebecca Evans: Could I add to that, in terms of what the study
Rosemary referred to found? It found that, for every ovarian cancer
case detected by the screening, two additional women in the
multimodal group and 10 in the ultrasound group had unnecessary
surgery, where the ovaries had benign legions or were normal, and
around 3 per cent of the women who had the unnecessary surgery had
a major complication with that as well. So, this is very much what
must be considered when we’re balancing doing more good than
harm.
|
[69]
Mike Hedges: I think Suzy indicated first.
|
[70]
Neil McEvoy: Just a quick question. Do we have the report? Have
you provided it to committee members?
|
[71]
Mr Rees: The link has been provided in previous correspondence
in relation to this, but can be provided again.
|
[72]
Neil McEvoy: What the Minister’s reading from, because
I’ve not seen the report.
|
[73]
Mr Rees: There was a The Lancet article summarising the
results from that study that we can
share—absolutely.
|
[74]
Rebecca Evans: The committee has had the report
previously.
|
[75]
Neil McEvoy: As a new committee member, it would have been helpful
to have seen it before today, really.
|
[76]
Mike Hedges: Suzy, you wanted—.
|
[77]
Suzy Davies: Yes, I just want you to talk a little bit more about
the screening that shows up conditions that aren’t actually
ovarian cancer, because the CA 125 test doesn’t detect
cancer, it detects growth irregularities on the ovaries. Of course,
ovarian cancer isn’t the only condition that affects
women’s ovaries. It is a particularly effective tool for
identifying endometrial cysts, for example, which may not actually
in themselves be dangerous, but can cause women a great deal of
unnecessary aggravation and pain. Don’t you think the
widespread screening should take into account the value for
non-ovarian-cancer conditions that are discovered as a result of
the initial CA 125 coming up with a positive test? It doesn’t
necessarily lead to surgery, but it does lead to the identification
of other conditions.
|
[78]
Dr Fox: The use of the CA 125 as a screening test for ovarian
cancer has really just looked at mortality from ovarian cancer. I
think women who’ve got ovarian cysts that are not causing
them any symptoms are probably just as well not knowing about them,
and if they are causing them symptoms, then obviously they need to
know and that should be recognised and treatment should be offered
appropriately. So, screening for things that aren’t actually
going to cause any harm, just to find out if they’re there or
to know if they’re there, is actually sometimes what we refer
to as a ‘harm’ of a screening programme, because
you’re turning people who otherwise would be well into
patients.
|
[79]
That’s been quite well rehearsed
recently in the case of breast cancer screening, where some women
are being diagnosed with conditions, non-invasive breast cancers,
that probably wouldn’t have gone on to become breast cancers
in their lifetime, but we can’t tell which ones will and
which ones won’t. So, there’s been quite a lot of
criticism of breast screening for that at the moment. I think
it’s really important that we don’t, with the best of
intentions, go down a route that ends up with a lot of women being
told they’ve got conditions that they never otherwise would
have known about if they hadn’t gone for
screening.
|
[80]
Suzy Davies: But you are talking about asymptomatic—sorry,
this is the last bit of this question—
|
[81]
Mike Hedges: Keep going.
|
[82]
Suzy Davies: You are talking about asymptomatic conditions. There
will be women who think there’s something wrong, but it
doesn’t occur to them that it’s to do with their
ovaries. Quite a lot of endometriosis, for example, presents in
other ways. It feels as if it’s happening to you in a
different part of your body, so you wouldn’t necessarily
think, ‘Oh, I must go and get screened for ovarian
cancer’. Wouldn’t the general screening pick up
that?
|
[83]
Dr Fox: I don’t think it would. I’m not familiar
with the fine detail, but, I think, when we’re screening for
ovarian cancer, we tend to be screening women who are
post-menopausal, or over 50. Whereas women with endometriosis are
pre-menopausal, and endometriosis ceases to be such a problem after
the menopause. So, I think it would be an age thing, in that
particular incidence of endometriosis.
|
[84]
Suzy Davies: Okay, thank you.
|
[85]
Mike Hedges: Neil.
|
[86]
Neil McEvoy: Just listening to your opening remarks, so do you
therefore dispute the figures presented by Cancer Research UK that
the survival rate is 46 per cent, but if diagnosed at the earlier
stage, up to 90 per cent of women with ovarian cancer would survive
five years or more? Is there a dispute on those figures?
|
[87]
Dr Fox: I don’t think there’s any dispute on
Cancer Research UK’s figures. I think the dispute is about to
what extent screening prevents mortality. And, at the moment,
Cancer Research UK doesn’t support screening for ovarian
cancer; it doesn’t believe that the evidence is strong
enough.
|
[88]
Neil McEvoy: Okay. Can I carry on, Mike, because I’ve got a
few, or shall I let the others come in?
|
[89]
Mike Hedges: Can you come in after this, because I’ve got a
question that immediately follows this?
|
[90]
Neil McEvoy: Of course, yes.
|
[91]
Mike Hedges: We know, or we’ve been told, that survival
rates are higher elsewhere in Europe. Why do you think that is
then—that other parts of Europe are having better survival
rates?
|
[92]
Rebecca Evans: I think there’s certainly more that we can
learn in terms of international practice for survival rates. I
think part of this is in terms of how we collect and analyse our
data, and perhaps Irfon might be able to say a little bit more
about that. We do participate in some key international
partnerships studies, such as the International Cancer Benchmarking
Partnership, which is enabling us to scrutinise what we do. The
studies do point us in the direction of some of the answers to the
question that you asked, and, so far, they’ve indicated that
we’ve got some issues with data completeness, but also that
some women are less likely here to recognise their symptoms and to
seek help, and that GPs may be less willing here than in other
countries to refer patients for testing, or certainly that has been
the case in the past.
|
[93]
Mike Hedges: Isn’t that an argument for
screening?
|
[94]
Rebecca Evans: Well, screening can only be introduced if it’s
demonstrated to be effective and efficient in terms of better
outcomes for people. It’s an argument, certainly, for greater
awareness raising amongst women and it’s an argument for
greater awareness raising and training amongst GPs, but I
don’t think that that in itself is an argument for a
universal, or a population screening programme.
|
[95]
Mike Hedges: Do other countries in Europe screen?
|
[96]
Dr Fox: No. And the UK has been a leader in the research into
screening, so the UK trial that I referred to, that’s what
everybody’s been waiting for, to see the result of that,
before deciding whether or not the screening programme should be
established.
|
[97]
Mike Hedges: Sorry, Neil, I interrupted you.
|
[98]
Neil McEvoy: No, that was the question I was going to ask,
actually.
|
[99]
Mike Hedges: Sorry.
|
[100]
Neil McEvoy: No—thanks. I was just wondering what the
difference was between what happens in Wales and what happens in
the rest of Europe. But we seem to be saying that, actually,
it’s not worse in Wales, it’s just the way we collect
our data. Is that correct?
|
[101]
Mr Rees: There are data issues, but, as the Minister said,
there are a number of factors where we are wanting to do better.
Some of those factors, as the Minister said, are patient behaviour
and some of those are doctor behaviours and doctors’ capacity
to identify, perhaps, what is a very rare condition when we think
of the day-to-day activities of a GP and the numbers of ovarian
cancer cases in Wales. Therefore, it’s those areas that we
are focusing on improving, both through awareness campaigns, but
significant work with primary care, to improve earlier diagnosis.
To give an example of that, this has been identified as a priority
area in the GP contract, and GPs are now asked to review, as part
of that, every case of ovarian cancer in 2015, to understand
whether there are any lessons that could be learned in terms of
practice around diagnosis and referral.
|
[102]
Rebecca Evans: And that also applies to lung cancer and
gastrointestinal cancer as well.
|
[103]
Neil McEvoy: Okay. On page 64, it says that false positive tests
are common. I just wondered what percentage were not
reliable.
|
[104]
Dr Fox: I’m sorry, I don’t have the answer to
that.
|
[105]
Rebecca Evans: Perhaps we can write to you—
|
[106]
Mike Hedges: You say that false positive tests are occurring. What
Neil was asking is, why, and what can be done to stop
them.
|
10:00
|
[107] Dr Fox:
False positive tests are inevitable in a screening programme. A
screening programme is only ever going to sift out the people who
are likely to have the condition and those who are not likely. So,
both false positive and, very importantly, false negative tests are
inevitable in a screening programme. You will always have some
people who do have the condition and are missed by the screening
programme. So, the blood test itself is a fairly blunt instrument,
if you like. And, as we’ve heard, it can pick up other
conditions, such as cysts or endometriosis. Then you go on to have
a vaginal ultrasound to have a look at the ovaries. Ultimately, the
final diagnostic test is to have a biopsy taken of the ovaries, and
that’s done under general anaesthetic as a surgical
procedure. So, I’m sorry, I don’t know the figures for
false positive tests in the trial, but we could find that out, I
suspect.
|
[108] Mike
Hedges: That would be very helpful. Suzy, you
wanted—.
|
[109] Suzy
Davies: Yes. How much does a CA 125 test cost?
|
[110] Rebecca Evans: Well, we wouldn’t be
in a position to provide you with the cost. As I referred to in my
letter to the Chair of earlier this week, an economic evaluation
would only be undertaken if there was evidence that the population
screening would be beneficial to patients.
|
[111] Suzy
Davies: I’m just curious because, obviously, the tests
are being done now after a clinical decision to take them is
conducted. You must have an idea how much they cost. Not on a
population level, but for a health board.
|
[112] Mr Rees:
Well, if I could just rehearse what would be involved in having a
test and having the follow-up necessary for a test. I’m
afraid that I can’t give you a figure for actually
administrating the blood test, but it’s far more than
actually just taking blood from a patient. The costs would then
involve the costs of a specialist being able to read and interpret
that test. It would then go on to—. If there were issues for
further diagnosis, as Dr Fox has referred to, there would be the
costs for further diagnostic tests, ultrasounds and so on, before
we get into the treatment costs. There would then be, if we were to
be—
|
[113] Suzy
Davies: Sorry. Can I interrupt? I appreciate what you’re
saying about the sort of, ‘Oh, there’s a problem here;
we need to do something about it’, but that actual phlebotomy
moment, where the blood is taken out of you, and the test
that’s run to show whether it’s a high reading or a low
reading, to that point, is that a particularly expensive process? I
genuinely don’t know.
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[114] Mr Rees:
The cost for an individual to have a single test is not hugely
expensive.
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[115] Suzy
Davies: Okay.
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[116] Neil
McEvoy: We were told at the last meeting that it was £25
or £20.
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[117] Suzy
Davies: Oh, right. Okay. Apologies; I wasn’t here
then.
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[118] Mike
Hedges: That was what people were charging for it, not
necessarily the marginal cost of doing it.
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[119] Neil
McEvoy: Yes. So, there’s a profit in that.
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[120] Mike Hedges: Yes.
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[121] Neil
McEvoy: So, it’s less than £20.
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[122] Suzy
Davies: Okay. It was just to give me an idea, really.
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[123] Rebecca
Evans: It’s worth recognising as well that the major
charities involved in this area of work have recommended against
seeking private tests and so on, because they recognise the issues
that we’ve outlined earlier on.
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[124] Neil
McEvoy: Are they UK charities or Welsh charities? Because I
think there’s a differentiation between both. Funding is tied
up, isn’t it, with Welsh charities from the Welsh Government,
so, there’s an issue there.
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[125] Mr Rees:
They’re UK charities with a Welsh—
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[126] Neil
McEvoy: So, UK, yes?
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[127] Mr Rees:
Yes. So, they’re UK charities. Cancer Research UK is an
example that has gone on the record, but others have too. But, yes,
we have relationships with those charities at a Welsh level and,
for instance, are working with Macmillan on some of the
improvements in primary care that I referred to, and they will be
in the same position.
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[128] Neil
McEvoy: Yes. So, just to go back to the overall figure then, if
there’s a profit in £20, could we have a figure—as
Suzy said—about the blunt cost of a test? Not now, but after
this committee at some point. I think that that would be—
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[129] Rebecca
Evans: I’m not sure that—. We can provide the cost,
I suppose, of a blood test, but I’m not sure that that would
be helpful to the committee in terms of your deliberations as to
whether or not, actually, population screening is effective and
desirable. This needs to be an evidence-based decision, not a
cost-based decision. We look at cost after we’ve got the
evidence as to whether it’s desirable or not, and whether or
not the good outweighs the harm that is potentially done.
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[130] Neil
McEvoy: It’s a question now, so, it would be good to have
the figure.
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[131] Mike
Hedges: Don’t you have the figures from the trial?
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[132] Rebecca
Evans: It’s not a Welsh Government trial, but information
should be provided. We did provide the committee with a link to the
trials. So, I’m sure the information would be available in
there. I assume it might be.
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[133] Mike
Hedges: Any more questions? Can I just end with one final
question and then I will thank you for
coming along? But I’ve got a
final question and Neil’s got a final question. Neil will go
first and then I’ll come in.
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[134]
Neil McEvoy: In terms of awareness raising, you’ve outlined
one or two things. Is there a budget from the Welsh Government to
raise awareness amongst the general population about ovarian
cancer?
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[135]
Rebecca Evans: There was an awareness-raising campaign that took
place in March of this year and that was delivered through
Velindre. So, an awareness—
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[136]
Neil McEvoy: Is there a Welsh Government budget for that, though,
or was that done by Velindre? Is there a specific budget from your
department for it?
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[137]
Mr Rees: There isn’t a specific budget assigned to an
individual campaign necessarily within Welsh Government, partly
because some of the awareness raising forms part of day-to-day
interaction between practitioners and the population. There will be
a figure for how much that awareness-raising campaign, run by
Velindre, costs, but I’m afraid I don’t have it with
me, but we can provide it.
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[138]
Neil McEvoy: I just wonder whether it would be helpful or useful
in future to maybe set aside a budget for this, because some of the
things that we were made aware of in the last meeting, I was really
shocked by and totally unaware of. I think it would be helpful for
people to be more aware of this issue, really, and the illness. Do
you not agree?
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[139]
Rebecca Evans: Absolutely. Awareness raising for this and all other
types of cancer is very important because of the reasons that the
committee has discussed about the desirability of an early
diagnosis, which can lead to better outcomes. This
cancer—perhaps you’d prefer a medical view on this, but
certainly the symptoms for ovarian cancer do tend to be at quite a
low level and can be confused for other things as well, which is
one of the issues and one of the challenges in diagnosing
this.
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[140]
Neil McEvoy: Just finally, Chair, I want to touch on Avastin,
which it says here is available in England, but not to women living
in Wales. I just wonder whether that is the case and whether or not
you think that women in Wales are disadvantaged in that sense,
geographically, by being cared for by the Welsh NHS.
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[141]
Rebecca Evans: All new medicines—medicines such as Avastin and
so on—which are deemed clinically cost-effective by NICE and
the AWMSG in Wales are available to patients here in the NHS, but
Avastin has not been deemed to be cost-effective and efficient.
What would be the most appropriate way to describe it?
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[142]
Mr Rees: The manufacturer was unable to demonstrate the
benefits to patients when balanced against the costs, and therefore
it was deemed by NICE to be not cost-effective
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[143]
Neil McEvoy: In Wales, or—? So, it’s not available in
England.
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[144]
Rebecca Evans: It was available in England through the cancer drugs
fund, but that came to a close on 31 March. So, patients in England
who started their treatment before 31 March will be able to
continue it, but my understanding is that that fund is now closed,
so patients wouldn’t be able to access it through
that.
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[145]
Neil McEvoy: So, it’s more of a cost decision, really, than
how somebody would benefit, then, we could say.
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[146]
Mr Rees: NICE take into account a range of factors and, on the
balance of that range of factors, were unable to recommend its use
in England and Wales.
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[147]
Neil McEvoy: Mainly on the basis of—?
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[148]
Mr Rees: A range of factors, including cost.
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[149]
Neil McEvoy: Such as—? I’m just trying to get a handle
on the range of factors.
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[150]
Mr Rees: Clinical effectiveness, cost effectiveness,
availability to bring it to market—there’ll be a range
of issues.
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[151]
Neil McEvoy: So, to reiterate, Avastin, then, is not a very
effective drug in that sense of prolonging life or benefitting
patients. Is that what we’re saying?
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[152]
Mr Rees: Avastin, on the balance of measures, including
affordability within the system, was not recommended for
use.
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[153]
Neil McEvoy: We seem to be hung up on the issue of cost. So,
it’s more about cost than effectiveness. So, it could help,
but we can’t really afford it. Is that the
situation?
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[154]
Rebecca Evans: Perhaps it would be an idea for the committee to
write to NICE or explore this with the AWMSG in order to understand
the criteria by which they recommend drugs to be available in the
NHS.
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[155]
Neil McEvoy: For example, with the compact with Plaid Cymru and
the Labour Party, or the Labour Government, we were looking at the
drugs fund. Do you think that this would be available as part of
that compact in future?
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[156]
Rebecca Evans: This is something that I would suggest that you
explored with the Cabinet Secretary, but I know that the Cabinet
Secretary is currently considering the options for implementing the
fund, so I think it would be far too early for me to make any kind
of comment on that.
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[157]
Mike Hedges: Suzy, you wanted to come in.
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[158] Suzy Davies: Yes. You may not be able to answer this question, in
all fairness, but why do you think survival rates are lower in
Wales than elsewhere in the UK and Europe, and what can we
do to balance that out?
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[159] Rebecca
Evans: Survival rates are improving, which is positive, but,
obviously, there’s certainly more that we can do. Again,
it’s about early diagnosis, and I hope the work that
we’re doing in terms of asking GPs to really focus in on
specific cancers as part of their contract will help do that.
We’ve got our referral-to-treatment times, which apply to
this cancer as well. So I would hope, again, that that would help
people access treatment in the most timely way possible.
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[160] Suzy
Davies: So, timing has a lot—. I appreciate in diagnosis
it obviously does, but timing of treatment has been an issue in the
past as well, then.
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[161] Rebecca
Evans: The latest figures do show that things are improving.
For example, 70 per cent of women living in Wales who are diagnosed
with ovarian cancer survive at least one year, and almost 38 per
cent survive five years. And those figures have actually improved
by 4.3 per cent and 0.2 per cent respectively since 2004. So, there
is an improvement, albeit slow, and obviously we want to seek to
continue to move in this direction.
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[162] Suzy
Davies: Is it easier to pinpoint where that improvement’s
come from? Is it better awareness amongst women, better awareness
amongst GPs, or better diagnostic tools?
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[163] Mr Rees:
I think you’ve hit a number of the factors. I think
it’s a range of those factors. It won’t be a single
one. I think, as we mentioned earlier, there are a range of factors
behind the reasons we want earlier diagnosis, and that’s
better awareness amongst the population, better referral, GPs
better equipped to recognise, and better links between primary care
and secondary care. And, finally, better access and speedier access
to further diagnostics and treatment.
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[164] Suzy
Davies: Again, I don’t want to take you back round in a
circle here, but obviously, stage 1 is when this disease is pretty
asymptomatic—how on earth is a GP going to know you’ve
got it; how are you going to know you’ve got it? I’ll
just leave that there, because I think this is quite a difficult
question to answer.
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[165] Rebecca
Evans: It is. NICE has introduced new referral guidelines for
suspected cancer. That lowers the threshold of suspicion, and
hopefully that will encourage more referrals to come forward in a
more timely fashion as well.
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[166] Suzy
Davies: Because, to be honest, these sorts of symptoms that
could be caused by a host of other reasons—actually, that, to
me, is a reason to go and have the test, even if it does show that
there’s nothing wrong. Thank you.
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[167] Mike
Hedges: The last question I’ve got is: we’re all
agreed now that early diagnosis is the most important thing. You do
not believe—you’ve got evidence to say that screening
is not going to be the solution. What is the solution to try and
get greater early diagnosis, and what’s going to be done to
improve the survival rates in Wales to a level comparable with the
rest of Europe?
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[168] Rebecca
Evans: It is about, as you say, increasing awareness, both
amongst the women concerned, and also amongst the GPs, and allowing
some of the new methods of working to work through, such as the new
reduced threshold for referrals from NICE and so on. No-one’s
suggesting this is an easy topic at all; it’s extremely
difficult. The symptoms are very hard to distinguish from other
conditions. We need to consider what’s worked well, though,
in other awareness-raising campaigns. We do see when we have
awareness-raising campaigns that, actually, there is a small
increase of people seeking diagnosis when an awareness-raising
campaign is ongoing. But, then, we do see that falling off over
time as people become less engaged with those—or looking for
those symptoms.
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[169] But, one example
where it has worked well, I think, is the work that’s been
done on breast cancer, and awareness-raising in that sphere. So, we
should be looking, really, and taking guidance and advice from the
experts as to how we can use learning from that kind of campaign to
inform awareness-raising on this agenda. But, obviously, Chair,
we’ll keep a close eye on the evidence, and, if and when the
evidence changes, and the screening committee is convinced of the
benefit, or the good outweighing the harm of the screening
programme, then, obviously, we will take advice from the screening
committee in future. I think we understand that the end of this
particular research project is probably three or four years off at
the moment.
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[170]
Dr Fox: Yes, it is. So, the work isn’t finished.
The UK national screening committee has asked that the evaluation
of that trial continues over the next three to five years. So,
those women—if there’s a survival benefit, you might
expect it to increase as time goes by. So, that work will be coming
back to the UK national screening committee for further
review.
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[171]
Rebecca
Evans: It’s kept constantly under
review, as other screening issues are as well.
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[172]
Mike
Hedges: Can I
thank the Minister and her officials, Irfon Rees and Dr Rosemary
Fox, for attending the committee today? Can I thank my colleagues?
We’ve actually finished exactly on time. So, thank you very
much.
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[173]
Rebecca
Evans: Thank
you.
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10:15
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Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Eithrio’r
Cyhoedd o’r Cyfarfod ar gyfer y Busnes a Ganlyn: Eitem
6
Motion under Standing Order 17.42 to Resolve to Exclude the Public
from the Meeting for the Following Business: Item 6
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