The following amendment has been selected: amendment 1 in the name of Julie James.

Item 9 on the agenda this afternoon is the Plaid Cymru debate on head and neck cancers, and I call on Rhun ap Iorwerth to move that motion.

Motion NDM6751 Rhun ap Iorwerth

To propose that the National Assembly for Wales:

1.  Notes the increase in incidence of head and neck cancers among men.

2. Notes the evidence of the effectiveness of HPV vaccination in protecting against these cancers.

3. Calls on the Welsh Government to extend its HPV vaccination programme to all adolescent boys.

Motion moved.

Thank you very much, Deputy Presiding Officer, and I'm pleased to open this debate today on expanding the use of the human papilloma virus vaccine, which was the first to be developed to be used against cancer. In anyone's book, that is a major development. To a certain extent, of course, we are taking advantage of that major development because it is offered to young women at the moment and to men who have sex with men. But we're not yet providing this vaccination to adolescent boys, despite the clear evidence of the effectiveness of this vaccine in preventing serious cancers, including head and neck cancers. Using this vaccine more broadly would also enhance the protection for women against cervical cancer.

I'll turn immediately to the Government amendment, which more or less says that they will reject the findings of Cancer Research UK and every oncologist in the country, as far as I can see, and will wait for the Joint Committee on Vaccination and Immunisation recommendations instead. But I have no doubt, if truth be told, what that recommendation will be, which poses the question: why wait? But I do think that it is not only fair but also important to return to the earlier JCVI recommendation not to roll out this vaccination more broadly, and why they made that recommendation, because it does raise some fundamental questions, I think. Are the methods that we currently have of analysing cost-effectiveness—nobody doubts the clinical effectiveness—are those methods truly appropriate for this age?

The previous rationale of the JCVI for not expanding this programme was that they believed that the benefits of vaccination would be expanded to boys in any case, as vaccinating many young women would provide herd immunity for boys too. But we believe that this conclusion is deficient for many reasons, and I will go through them. It is based on the assumption that a very high level of girls would receive the vaccination—something that unfortunately isn't the case because of the huge variations between various groups, and it is something that could be put at risk by one scare story about a vaccination, as we do see appearing in the press from time to time. It assumes that the responsibility for providing herd immunity and the prevention of sexually-transmitted diseases should be placed on the shoulders of girls and women. Why not argue, for example, that a boys-only vaccination programme would be sufficient in providing this defence to girls and women? Thirdly, there are far too many women and girls, as I was saying, that haven't been vaccinated and can transfer the virus to boys and men who would have been protected if they had been vaccinated themselves. Fourthly, the view of the JCVI was based, it appears, on heteronormative presumptions, namely that every man is heterosexual. I think this is recognised partially by the decision taken in due time to extend vaccination to MSM. That was a decision taken separately. It is concerning and it could also be dangerous only to provide vaccinations to men who are willing to reveal their sexuality, and by assuming that this isn't a problem the JCVI shows the need for greater equality training in the health sector.

Vaccinating boys, as I say, would provide higher levels of herd immunity among women and girls, so there would be benefits to women and girls from the vaccination of boys. The evidence of efficiency in preventing other cancers has also been strengthened since the original analysis, and it's important to note that, and it's likely to become even stronger over time. If the vaccine wasn't already in use, then I think the conclusions of the JCVI on introducing a mass programme across the board for girls and boys would be different. If it were to be introduced anew now, then I'm sure that it would be provided universally.

Finally, in considering the outcome of the cost-efficiency evaluation, I believe that there is a grave underestimation of the cost-efficiency of introducing a vaccination for boys. The reason for that is that I believe that the benefit doesn't come until much, much further down the line. The cost is paid now, of course, in providing the vaccination, but it's possible that the cancer won't be prevented for 50 years. Now, I fear that the processes of measuring cost-efficiency are failing to deal with that kind of delay in outcomes, and I think the JCVI itself notes these outcomes and the fact that, in a way, their hands are tied, because in their interim analysis they say this:

'The Committee recognises arguments made by stakeholders on the issue of equality of access and that there are additional clinical benefits that could be achieved in males with a gender neutral programme. The Committee therefore wishes to refer the issue of equality of access to the Department of Health for consideration.'

In other words, Cabinet Secretary, they want you to make the decision. I think the idea that this could be too expensive just doesn't stand up to scrutiny. The estimated cost of extending the programme to boys is around £0.5 million a year. We would only need to prevent seven or eight cases of cancer each year, which the introduction of this vaccine most certainly would, to recoup this cost. In fact, the only reason the cost-effectiveness argument has been used is based on the idea that we can get the benefits of the vaccine on the cheap through assuming this herd immunity based on a girls-only programme. As I hope I've outlined, this is flawed, and I think the Government should change its mind now.

Thank you. I have selected the amendment to the motion. Can I ask the Cabinet Secretary for Health and Social Services to move formally amendment 1, tabled in the name of Julie James?

Amendment 1—Julie James

Delete point 3 and replace with:

3. Notes that the Welsh Government is awaiting advice from the Joint Committee on Vaccination and Immunisation on whether to extend the HPV vaccination programme to adolescent boys.

Amendment 1 moved.

Formally.

Thank you. Angela Burns.

Thank you, Deputy Presiding Officer. I'd like to thank Members of Plaid Cymru for bringing forward this debate, which we will be supporting more than wholeheartedly, because in today's NHS we are constantly talking about the need to prevent rather than cure and isn't prevention so much easier, and, if we can go out and capture people who might have the misfortune to develop a cancer of this type, then let's try and stop it, and let's try and stop it now.

It doesn't cost, as Rhun ap Iorwerth said, too much money when you start looking at what the effects of this would be further on down the line. Let's not just think about the individual and what they may go through, but actually the cost in terms of employment, the cost in terms of all the state support, and the cost in terms of the impact on their lives and the lives of their families. So, I think that we must adhere to this prevention agenda, and it does tie in so very clearly with the way the Government says they wish the direction of travel to go. We're asking people to take responsibility, to step up to the plate, and we're saying, 'Get thinner, stop smoking, do more exercise', and here's something that we could quite easily do that would help eradicate just some of those opportunities that are out there for somebody to develop what is the most unpleasant of conditions.

We're not asking the Welsh Government to do something that's never been done before. Let's be really clear: teenage males get this in a number of countries around the world, New Zealand since 2008—they really were trailblazers—Austria, Croatia, large swathes of Canada—about four of the big provinces of Canada—and the lessons that they've learnt is that the prices of this injection will drop with the economies of scale. So, again, it's very hard to look at that and refute the whole desire to do it. 

But, above all, we keep saying how much we rely on our clinicians, how much, we say, that we need our clinicians to make the best decisions for us, and our clinicians have been very, very clear, and I'd like to reference one of them, in fact, Dr Evans. She is a consultant clinical oncologist at Velindre hospital in Cardiff, and she has said—I'm not even going to say what the mass name is for all of these cancers, I'm not sure that I could pronounce it, but, essentially, head, neck, tonsils, tongue and throat cancers have trebled in Wales over the past 15 years, and she says there is a direct link between these cancers and HPV. So, here's a clinician, very well respected, world renowned, and she led a campaign—quite a strong campaign, because we supported her, the Welsh Conservatives—in August of last year when she was really coming to the table and saying, 'We ought to look at this'. So, again, Cabinet Secretary, the parliamentary review, the vision for health, clinician led, clinician decisions—clinicians are saying we really ought to look at this, and I think that you should. 

I'm not entirely clear how Rhun ap Iorwerth got the funding numbers, because I have to tell you in all honesty that my numbers are significantly higher than yours, but I'm quite prepared to say that my numbers could well be out—but I did also find a solution. It'll be wildly unpopular, I know, so try not to hiss too much, but analysis of NHS Wales data estimates that, if paracetamol, aspirin, ibuprofen and co-codamol were removed from the Welsh NHS list of free medicines to those who are not destitute or vulnerable or have chronic conditions, there would be a saving of some £16 million annually. When I can go into very large supermarkets—I'd better not name them—and buy a packet of ibuprofen for 32p, and then other people can have a life-saving treatment—. Because there isn't money growing on trees, so I do have some sympathy, because I think it's going to cost more than £0.5 million. If we looked at subsidising the vaccination of Wales's 36,000 12 to 13-year-old boys, then that would cost—at a high street cost of some £300, which is what a very famous, large chemist is currently charging, that would, at the most, cost the NHS an estimated £11 million.

So, I would say to you, Cabinet Secretary, prevention is better than cure. We're trying to have a public health message, we're trying to prevent people from getting sick, so that the long-term cost to both the NHS itself, to the state in general, to employment, and the awful, awful pressure it brings about on the individual and on families—if we can start eradicating all of that, then there's every reason in the world why we should just go ahead, listen to the clinicians, and do this. And you can afford it by actually asking someone like me, who earns the money I do, to pay 32p for my ibuprofen, whilst you're still protecting the vulnerable and the poor.

I'd like to thank Plaid Cymru for proposing the motion before us today.

Human papillomavirus, or the easier to pronounce name HPV, is the most widespread sexually transmitted virus on the planet. It is believed four out of every five people will contract one of the 100 or so types of the virus at some point in their lives. In the vast majority of cases, the men and women infected show no outward symptoms and never know that they've contracted the virus in the first place. However, HPV infection is known to be responsible for nearly 2 per cent of all cancers in the UK. It is because of this close association with certain types of cancer—cervical cancer in particular, where it is believed that 99.7 per cent of cervical cancer is caused by HPV infection—that the decision was taken to vaccinate all girls between the ages of 12 and 18. At the time, it was considered too costly to vaccinate boys in order to combat cervical cancer. However, evidence has emerged linking type 16 and type 18 HPV to anal, penile, and some head and neck cancers.

This evidence is reaffirmed by the joint committee on vaccination and immunisation’s interim statement on extending HPV vaccination to adolescent boys. The JCVI allude to the strengthening evidence on the association between HPV and non-cervical cancers. However, the JCVI are minded to rule against the routine immunisation of young men because the modelling they used shows that it is not cost-effective. But how can it be cost-effective to not immunise teenage boys? We are looking at a few hundred pounds per teenage boy vaccinated, against the cost of those boys or the girls they come into sexual contact with developing cancer in the future.

Even if we were to ignore the benefits to the boys of immunising against certain head and neck cancers and certain anal and penile cancers, we can’t ignore the benefits in increasing protection against cervical cancer. The models used in developing the HPV vaccination programme for girls assumed uptake rates of over 80 per cent. Evidence obtained by Cancer Research UK shows that, in some local authority areas, uptake is as low as 44 per cent. This will not offer herd protection, and therefore we need to immunise adolescent boys, as well as girls, if we are able to have any chance of combating cervical cancer.

This is also an equality issue: why is it okay to expose young men to a virus that could lead to them developing head or neck cancer when there is a proven and effective vaccine, just because it’s not as cost-effective as it is in young women?

I urge Members to support Plaid Cymru’s motion today and to reject the Welsh Government’s amendment. The JCVI made it clear a year ago that they wouldn’t support extending the vaccine to adolescent males on cost grounds. Unless they have listened and updated their modelling, they are unlikely to change that view. We need to act now, not wait another few years for the policies to catch up with the evidence. Thank you. Diolch yn fawr. 

I'm pleased to take part in this debate. About immunisation in the first place, vaccination, there is a remarkable success story here of medical research, because for decades now we've thought immunisation is only really any good in preventing infection. Now, in the last few years, we've found a vaccination that stops cancer. It's an amazing step change, and when I first heard that news about 15 years ago or more—it really has a tremendous effect on how, as a doctor, you think of the world. We think of immunisation just stopping infection; you're stopping that annual slaughter of diphtheria and tetanus and stuff that filled our old cemeteries and old chapels in Wales, and now, all of a sudden, you immunise and you can stop cancer. It's amazing. It really is a step change, and sometimes we forget that we ought to marvel at certain things that we've discovered. 

Obviously, human papillomavirus is the virus in question here. It's sexually transmitted and, obviously, this vaccine stops, obviously, the infection, but it stops the cancers developing. It is really, really amazing, particularly in terms of we're on about the cost-benefit analysis, and, in boys, in men, it's about preventing head and neck cancers. These are significant cancers with huge cost implications in terms of fairly horrific, disfiguring surgery, because it usually presents late: you have a lump on the side of your throat, behind your tongue, in all sorts of crevices that we can't see until there's a late presentation. There's a horrendous, huge cost to each individual presentation of a head and neck cancer that has to be brought into this formula of how we judge whether something is cost-effective or not: if they've had their HPV vaccine, they will not be developing that head and neck cancer. Because the overwhelming rise in—. The figures I've got here, there's been a 63 per cent increase in the last decade in oral and oropharyngeal cancers in men in Wales. Those are the figures, and that rise is associated with the rise in HPV infection. So, we can do something about that by vaccinating the boys tomorrow. 

This is the prevention agenda supreme, as Angela Burns pointed out. The girls are already getting vaccinated. The boys could be as well. Cervical cancer faces eradication. It's amazing, isn't it? You're talking about cervical cancer in women facing eradication by this vaccination programme, and we should be offering the same to young men. As they grow older, we could sort out head and neck cancer, which is a horrific, destructive cancer, with huge cost implications that have obviously not been factored into all the cost analysis. So, here's a vaccine that prevents cancer in women, here's a vaccine that international experience shows prevents cancer in men as well. So, girls have it; boys should have it too. Diolch yn fawr.

Thank you. Can I now call on the Cabinet Secretary for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. I'd like to thank Members for their views on this important issue that we've discussed before and I hope we can discuss again in the future once a decision is made. The United Kingdom's independent expert panel on immunisation matters that we've heard about today—the Joint Committee on Vaccination and Immunisation—gave further consideration to extending HPV vaccination to boys at its latest meeting on 6 June. Reports on the discussion at that meeting have appeared in some parts of the media, but the JCVI has yet to publish a statement giving its final conclusions and advice. I expect that to be available very shortly, and certainly before the end of July. So, the advice is imminent.

Now, I can't, despite the urging of Members today, pre-empt what that statement will say, but I do want to respond to some of today's discussion. As has been said, on the advice of the JCVI HPV vaccination has been routinely offered to adolescent girls since 2008, and a recent study by Public Health England showed that, since its introduction, the number of young women infected with HPV has fallen dramatically by up to 86 per cent between 2010 and 2016. Protection is expected to be long term, and eventually saving hundreds of lives a year. As a number of Members have said today, this is about saving lives. The good news is that the HPV vaccination in girls does provide some indirect protection for boys, and I know that Rhun ap Iorwerth's commented on this, and in particular he commented on vaccination rates. Actually, vaccination rates in Wales are relatively high. The last figures were 83 per cent and improving, with 89 per cent in Cwm Taf and 79 per cent in Powys. So, there is always more to do. But, in April 2017, again in response to the JCVI's advice, we introduced a targeted programme for men who have sex with men, and that was done in a prompt manner, acting on the updated advice from the JCVI.

Notwithstanding those positive developments, I note from today's debate and previous correspondence from others, including a range of clinicians in a number of different spheres, that concerns remain about the issues of equality of access to HPV immunisation and the reliance of herd immunity rather than offering direct protection to men and boys. I am aware that these concerns were raised with the JCVI by a number of sources as part of the consultation following the publication of its interim statement last year. Now, their review since then has taken longer than anyone of us would have wanted, but it is now reaching a conclusion, as I referred to in my earlier remarks. That review looked at a number of complex issues that the JCVI itself is best placed to assess, not least in respect of cost-effectiveness, albeit there will be a decision for me to make at the end of it. I don't think we should shy away from cost-effectiveness being important because we need to fairly, consistency and robustly evaluate the potential benefits of national programmes. We need to deliver value for money and the greatest health benefit possible to the population.

I do disagree with Angela Burns's point about how easy it could be to remove four or five named items from the prescription list. I don't think you could avoid reintroducing an expensive means test to do so, and I don't think it either is easy, as was suggested, or, indeed, that you would deliver the cost savings that she refers to, and, of course, there are differences of principles about our continued free prescriptions policy.

But I just want to make this clear because I know a number of people referred to evidence and the views of other campaign groups and interest groups in this area who all want to see positive change, but I just don't think you can put aside the JCVI as the authoritative body that the whole of the NHS UK family relies upon to help make evidence-led choices on immunisation and vaccination. Once their statement is available in the very near future, I will, of course, listen to the advice carefully before deciding how best to proceed in Wales. However, I do want to assure Members that I will prioritise consideration of that advice and I will then make a decision for which I will be accountable, but I will do so in a timely manner, certainly without any lengthy delay.

Thank you. Can I call on Rhun ap Iorwerth to reply to the debate?

Very, very briefly, thanks to everybody, including the Cabinet Secretary, for your support for pressing ahead with this at some point. What I can't understand, quite, is why not crack on with it now?

To answer your question, Angela Burns, about the cost, we put in some freedom of information requests on costings. The £0.5 million was based on 5 per cent of the cost of the immunisation programme for girls in England. We come to the £0.5 million, and we have no reason to believe it would cost differently for boys, and that figure has been corroborated through other means as well. So, if—[Interruption.] Yes—please.

Just to clarify, as we're swapping numbers, we looked at the NHS census data— the numbers of young men, or boys, in Wales today—and if we were to go out and start from ground zero and give them all that very essential injection, or two injections, and then move forward from there.

Thank you. What's important here is that we agree that this is bound to be cost-effective because of the serious illnesses, the cancers that we could be avoiding by the introduction of this. As I say, the first immunisation, the first vaccine for cancer. 

This is the third issue today, Cabinet Secretary, that I've brought up here in the Assembly on something that could be introduced, that could be rolled out further, that is clinically proven, that we believe is cost-effective, that is somehow being held back. I raised the issue of the eight-year fight for the introduction of radiofrequency ablation treatment for Barrett’s oesophagus, and I appreciated, again, your positive response and hopefully we'll get some movement on that.

I raised once again the question of mpMRI scans that allows the diagnosis of prostate cancers without biopsy—something that we're awaiting NICE approval for, even though England and Scotland are also awaiting NICE approval, but they're just doing it. So, in all these cases, I believe clinical evidence is clear. Here we have something that will save the lives, no, not of people today, but 50 years down the line—[Interruption.] I would love to, but I can't. So, please support this and show that we want people in Wales, be they male or female, to get the best possible chances in life, and HPV has given that opportunity. It's just a matter of rolling it out.

Thank you very much. The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Therefore, we will vote on this item at voting time.

Voting deferred until voting time.