We now move on to item 9, which is a debate on petition P-05-849, 'All men in Wales should have access through the NHS to the best possible diagnostic tests for prostate cancer'. I call on the Chair of the committee to move the motion—David Rowlands. 

Motion NDM6982 David J. Rowlands

To propose that the National Assembly for Wales:

Notes the petition ‘P-05-849 All men in Wales should have access through the NHS to the best possible diagnostic tests for prostate cancer’ which received 6,345 signatures.

Motion moved.

Diolch, Dirprwy Lywydd. This evening’s debate will focus on a petition submitted by Stuart Davies, who lives in the constituency of Clwyd South. It calls for all men in Wales to have access through the NHS to the best possible diagnostic tests for prostate cancer. The petition received 6,345 signatures and the Petitions Committee is grateful for the opportunity to bring this petition to the Assembly today, under the process whereby the committee considers the merits of holding a debate on a petition that receives more than 5,000 signatures.

It is worth noting here that prostate cancer is the most common cancer for men in Wales, with more than 2,500 men diagnosed in Wales every year. Mr. Davies’s petition calls for the latest prostate screening technology to be available to all men where there is a suspicion of prostate cancer. Specifically, the technology is the multiparametric MRI scan, or mpMRI. This combines up to three different types of scan in order to provide a clearer picture of the prostate gland. It is different to standard MRI scans, which are rarely clear enough to facilitate a confident diagnosis of prostate cancer at an early stage.

Up to now, men have typically needed to undergo a biopsy to diagnose prostate cancer. These are invasive and painful, and the potential side effects can include bleeding and infection. They may also miss up to one in five cancers of the prostate, because the precise location of the cancer is unknown when the biopsy is carried out. Alongside biopsy, the most commonly used tests for diagnosing prostate cancer include a blood test and physical examination of the prostate.

A study published in February 2017, known as PROMIS, found that using an mpMRI scan could reduce the number of unnecessary biopsies and improve the detection of clinically significant cancer. The petition is seeking access to mpMRI scans for all men in Wales as a priority, in order to improve diagnosis and reduce the number of men having to undergo biopsies. Prostate Cancer UK is also campaigning for increased access to mpMRI across the United Kingdom.

The National Institute for Health and Care Excellence, NICE, is currently in process of revising their guidance in relation to the diagnosis and management of prostate cancer. This review includes an assessment of the latest evidence, including the PROMIS study. In December, NICE published new draft guidance for consultation. It includes a recommendation for mpMRI scans to be used as a first line investigation for people with suspected prostate cancer, as called for in the petition.

The guideline proposes that patients should still undergo a blood test initially, with an mpMRI used to better detect suspected clinically significant prostate cancer. NICE states that the scan can help clinicians understand the location of the cancer and target the biopsy directly, reducing the time taken to accurately identify the cancer and the need for multiple biopsies. Therefore, it is expected that increased use of mpMRI will prove cost effective by reducing the number of biopsies performed and the need for further treatment, because cancers are more likely to be detected and identified earlier. The final guideline is expected to be published at the end of April.

The petitioner and Prostate Cancer UK both argue that the current situation is inequitable. A number of areas already offer access to mpMRI scans. In Wales, Cwm Taf and Aneurin Bevan health boards routinely provide mpMRI scans for suspected prostate cancer. Another, Cardiff and Vale health board, offers pre-biopsy MRI scans, though not the full specification targeted by the campaign. This leaves patients in west, north and parts of south Wales currently unable to access the tests, whilst patients in Powys are generally referred elsewhere. In areas where the scans are not available, the petitioner states that he and other men with suspected prostate cancer have faced paying £900 to have one done privately. He has pointed out that a trial was previously carried out in Wrexham Maelor Hospital, but the scans are not currently available on the NHS in north Wales.

Across the UK, Prostate Cancer UK has found that only half of men with suspected prostate cancer are offered the highest standards of mpMRI scans before a biopsy. The new NICE guideline, if confirmed, should change this. However, the Petitions Committee has learned that there are likely to be a number of challenges to implementing this quickly in Wales. The most obvious challenge is access to the scanners themselves.  High-quality mpMRI scans rely on MRI scanners being configured in a specific way and, generally, being less than 10 years old. Existing demand on the scanners is another potential challenge due to high demand for their use existing across a wide range of conditions. A further potential barrier is the number of radiologists, especially those with the required training to accurately report the results of scans and to use them to conclusively rule out the presence of cancer in some patients.

These are challenges that health boards and the Welsh Government are likely to need to face when the final NICE guideline is published. The Minister has stated that he expects all health boards to consider new guidance and amend their pathways of care accordingly. He has also informed the committee that he expects there to be greater consistency in service provision after the NICE guideline has been updated.

We understand that several workshops have already taken place, led by the Wales urology board, to assess the changes that will be required and to help health boards to plan for them. The Minister has also stressed that health boards do not need to wait for the final guidance to determine what local changes are needed.

The petitioner stresses that time is of the essence and that any delay in this process could cause issues in diagnosing individual patients. He is calling on the Welsh Government to ensure that the new standards are implemented rapidly and for mpMRI scans to be available across Wales as early as possible. In the meantime the petitioner has argued that the Welsh Government should fund interim arrangements, under which the NHS would pay for patients to access private scans in order to ensure that all patients who would benefit from mpMRI technology can do so.

Dirprwy Lywydd, I am sure that other Members and the Minister will wish to comment on these issues further through the remainder of the debate this afternoon. Diolch yn fawr.

Wrexham Maelor Hospital's urology unit is one of 11 units across England and Wales that took part in the prostate MRI imaging study PROMIS trial to discover improved ways of diagnosing prostate cancer. The results showed that 27 per cent of men who had a negative mpMRI did not need a biopsy at all, but, crucially, 93 per cent of aggressive cancers were detected by using the mpMRI scan to guide the biopsy, compared with just 48 per cent where only a transrectal ultrasound-guided prostate—TRUS—biopsy was carried out. When I raised this in the Chamber last March, I quoted the North Wales community health council welcoming the health Minister's commitment to expect health boards to revise their diagnostic pathways to incorporate these scans, if recommended by the National Institute for Health and Care Excellence, or NICE, in revised guidelines after April 2019, but also expressing concern that this would be too late and that patients in north Wales would continue to be left behind and that their discussions with urologists in north Wales suggested that we need to be developing the service then in preparation for NICE accreditation.

Noting that NICE guidance already stated that mpMRI scans should be considered for men with a negative transrectal ultrasound 10 to 12-core biopsy to determine whether another biopsy is needed, I referred to constituents in north Wales who met this criteria, but who then had to pay around £900 to fund these scans because they were not provided or funded by the health board in north Wales. Three of my constituents then wrote to the Minister confirming that they had had to pay and stating that they had watched this and seen him, quote, 'smirk and laugh at them'. After raising this again with the health Minister last April, they told me that his statement to the Senedd that service provision in the Welsh NHS is in line with NICE guidelines is patently not true, as you evidenced in your question.

Another patient told me that last March's announcement by NHS England that it was launching a one-stop service using MRI techniques to revolutionise prostate cancer treatment and slash the time taken for a diagnosis there was a game changer and patients across Wales should not be left behind. Last December, NICE issued new draft guidance recommending pre-biopsy mpMRI for suspected prostate cancer, with final guidance expected next month. In January, the health Minister wrote to Members stating that he had asked all health boards to work with the Welsh urology board to ensure that they have full implementation plans within one month of this. In the same letter, he stated that health boards had confirmed that, at present, they deliver care in line with current NICE guidance. North Wales patients subsequently reiterated that care was not delivered in line with current NICE guidance in their cases.

The north Wales community health council stated that the health board have consistently declined to produce proof that they did any scans for men with rising prostate specific antigen following a negative biopsy, and that they are co-ordinating refunds to all of their clients who did not receive scans in line with the 2014 guidance. They also state that their correspondence with the health Minister gives them no comfort that he will intervene if they make the same decision on the pre-biopsy mpMRI guidance.

This petition’s sponsor, Stuart Davies, states that interim arrangements should be put in place now so that men do not put their lives at risk; that although patients pay approximately £900, the cost to the NHS at Wrexham’s Spire hospital is only £365; and that men contacting the campaign say that they are either waiting for it to become free or are taking out loans to pay for their scan. Last December, I attended a meeting with Mr Davies, the health board and community health council, at which the health board apologised and offered to refund the money the men had paid for scans. However, only this week, a constituent received a letter from the health board stating that,

'although current clinical advice suggests that the use of full diagnostic mpMRI may be beneficial…this has not yet been supported by NICE'.

Noting, however, that NICE has now backed mpMRI scans as a cost-effective first-line investigation, Tenovus Cancer Care have called on the Welsh Government to ensure that mpMRI is available across Wales, stating that it is not available at Betsi Cadwaladr, Hywel Dda or Swansea bay, and not available at PROMIS standards in Cardiff and Vale. As Prostate Cancer UK states, mpMRI revolutionises prostate cancer diagnosis, so let's listen to the experts with lived experience. These men have been telling the truth from the very beginning.

When it comes to cancer, we do know that one of the most important elements to improve the chances of survival is ensuring an early diagnosis. Sometimes it’s easier said than done, but with prostate cancer specifically, there is a testing method that does simplify and therefore accelerates the process of providing a diagnosis, and that is the mpMRI scan. You can’t have a diagnosis of prostate cancer through a non-invasive test. The PSA test is available, but that only recognises whether you need further tests. The further tests include biopsies and they include a surgical method, which is undesirable for patients and should be avoided if possible. Other tests are not entirely reliable either. They can miss cancers—give the impression that patients are clear. That, of course, can lead to a patient ignoring symptoms and being untreated as a result. They can also suggest that the cancer is in the body when there is no cancer there, leading to treatment that can lead to lifelong complications.

The mpMRI scan does offer a much more promising pathway for accurate diagnosis. Very simply, it gives a clearer picture of what’s happening in the prostate. And the evidence that’s emerging—and I thank Tenovus specifically for one brief that I have—shows that mpMRI scans can be much more sensitive than other biopsies in recognising significant clinical cancers. So, it is much less likely to produce negative, fake results. However, it doesn’t remove the possibility of a false positive, so when the test does recognise the cancer, the patient does have to go through a biopsy. So, no, it’s not perfect, but NICE has supported the use of mpMRI as a significant improvement on the old system and has published guidance to that end.

The question, therefore, that we have before us is not about a petition calling for something where the evidence is not there yet to support it—we’re asking: why is there not regular or consistent access to tests that have been proven to be valuable under the appropriate circumstances?

The petition itself notes the limitations on who and where in Wales and in which health boards the testing can be accessed, where the tests are being fully utilised, and it's that lack of consistency that the petitioner found to be particularly unacceptable. And I would like to take this opportunity to thank Stuart Davies and those behind this petition on the work that they've done in bringing the issue to the Senedd. I know that, as a result of their campaign, they've been inundated with correspondence from other men who failed to find access to mpMRI scans on the NHS: men whose doctors weren't yet aware, perhaps, of the real benefits of this diagnostic tool; men who have paid to have the test privately as a result; and men who have been resigned to borrowing money in order to fund the scan, as it wasn't readily available to them on the NHS. And I'm grateful to Mr Davies for updating me on some of the contact that he's had from other men in all parts of Wales.

Now, some patients in the Betsi Cadwaladr university health board area have actually now been reimbursed for the private fees they paid for scans. They were paying it because they knew it was effective. They had the evidence that it worked. The evidence was pretty clear that this was an effective tool, which leads me to ask here now: why is it that the Welsh NHS, again, here, has been slow to adopt new technologies and treatments where the evidence was pretty clear, and, then, when the go-ahead had been given by NICE? The reason the Welsh Government introduced the new treatments fund was precisely because the Welsh NHS couldn't meet its legal obligations to ensure new treatments were made available within three months of NICE approval. So, that point has been conceded already, and we're currently in a situation where NICE has approved the technology for use in diagnosis but it's still not being done right across Wales, so 'why?' is the question.

So, to conclude, we know that access to diagnostic testing as a whole has been a problem for several years here in Wales. Welsh Government, in my mind, has been complacent on not pushing on that front. That's why we in Plaid Cymru have supported introducing tougher targets for diagnostic testing, which has been voted down, time and time again. So, this petition shouldn't be needed. We need a proactive NHS that's able to adopt best practice following a NICE ruling, and identify those new techniques and treatments that really work for patients in Wales, like mpMRI.

I would like to thank the Petitions Committee for bringing forward this debate and give particular thanks to the petitioner, Stuart Davies, for bringing the petition to the Assembly. Only yesterday, my husband had to attend Neath Port Talbot Hospital for an extremely painful biopsy on his prostate. So, this is a topic that is dear to my heart. The fact that my husband and hundreds of men like him could have a faster, less painful and less risky route to diagnosis but are being denied is unacceptable.

Multiparametric MRI has the potential to transform the prostate cancer pathway, but it is not available to all. Men are being forced to pay over £1,000 for an mpMRI scan because it is not available on the NHS in their part of Wales. My local health board doesn't offer this service. Had we lived 15 miles to the north-east, my husband would have had an mpMRI scan with dynamic contrast enhancement, which would have given his oncology team the best possible and most comprehensive detail about the health of the prostate. This would possibly have negated the need for the painful and invasive biopsy he underwent yesterday. It could have meant that he didn't have to undergo days, maybe a couple of weeks, of painful recovery. He might have avoided the need to live with the side effects of the powerful antibiotics he has been taking, and will continue to take, to stave off the threat of sepsis.

Over the border in England, the NHS has mandated the adoption of multiparametric MRI by 2020. We are making some progress in Wales, but it is slow due to a lack of trained radiologists. I welcome the moneys that the Welsh Government have put into improving MRI provision across Wales, as well as the establishment of the Welsh Imaging Academy. But this is not helping today. Welsh Government need to ensure that maximum utilisation of our MRI capacity is made. Where a health board cannot offer mpMRI with dynamic contrast enhancement, they should refer to other health boards or the private sector. Men should not be forced to find £1,000 to fund private MRI scans because they happen to live in a part of Wales that doesn't offer this revolutionary prostate cancer pathway. We are supposed to have a national health service, not seven regional health services. We have to end this postcode lottery today. We have to offer the best, the quickest and the most effective treatment pathway available today. I fully support this petition and the motion before us today, and I urge my colleagues to do likewise. Diolch yn fawr.

Can I say how much I value the petitioning process? In this Assembly, we've had a particularly strong Petitions Committee and really interesting petitions coming forward. I congratulate the way David outlined the case in very forceful terms. It is right that we discuss these issues that our constituents feel are particularly important and ask ourselves have they seen something in the current practice or pattern of service that really needs to be addressed.

What strikes me is that there can be something of a disconnect if we're not using the most up-to-date and readily available diagnostic techniques, and getting over, as Rhun said, the tricky barriers of false negatives, false positives, and the very uncomfortable, possibly painful, biopsy procedure. So, I think it's really important that we try to move and be consistent, especially when, in fairness to the Government, there's so much public campaigning out there to be aware of your body, to be aware of some of the changes that may be taking place, and then to access tests.

So, I think, in terms of our own public engagement, of saying why we are allowing certain approaches but not others, and especially when it's patchy, so that if you live in a certain part of Wales, you do get the latest MRI technology, but not in others, that we need to be very clear about that.

I do think that it's probably time for us to have some sort of assessment and statement on screening in general, because the public do get quite mixed messages, sometimes, about its efficacy and the role NICE has played. You're being urged to take care of yourself and be attentive to any change, but then there's not always the clarity, really, of what then should follow. It reminded me of the policy we have on bowel screening. Currently, test packs get sent to anyone between 50 and 74 that wants it, but once you hit 75, it just stops. A constituent asked me why, and I tried to find out, and it didn't seem very clear to me that there was an overwhelming reason why that is the case.

So, I do think that a more comprehensive view of screening—. And it's for other cancer conditions as well that the efficacy of screening is sometimes raised. With medical science advancing, the tools available to us are ever increasing. So, I do hope the Minister will be attentive to the concerns that have been raised, and will put the patient first: clear information, then quick diagnostic services that are as good and comfortable as possible. I think it's really, really important because, as we've heard, the earlier that these cancers are detected, the prognosis improves massively. So, again, I just think we should be very grateful to the gentleman that brought this petition in, and to the good work that the Petitions Committee is doing in insisting that we debate these issues in the Chamber. Thank you.

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

Thank you, Deputy Presiding Officer. Can I start by thanking the petitioner and the Petitions Committee for bringing this matter forward for debate this afternoon? At the outset, I want to acknowledge the impact of prostate cancer, both physically and emotionally, on men and their families. I also recognise that some of the diagnostic tests, as we've heard, such as biopsies, can be unpleasant and add to the worry and stress that men are already going through. I have received considerable correspondence from Members, patients, families and clinicians about the availability or otherwise of the test known as pre-biopsy mpMRI. Now, you've heard on a number of occasions during the debate today what that is, so I won't repeat the specifics about what multiparametric magnetic resonance imaging is, but it is, of course—this point has been made regularly—a less invasive diagnostic opportunity than the currently available and recommended standard diagnostic test. Now, given that the prospect of a less invasive and more accurate test is literally on the horizon—days away, and we expect NICE to confirm that—it's completely understandable that people want to see that procedure made available as quickly as possible across Wales.

I also understand completely why there is a concern about the current availability of the test between different health boards. The initial trials that have taken place, including here in Wales, including some within north and west Wales, have been positive, showing the effectiveness of mpMRI, and the public and clinicians are encouraged, and they want to see it rolled out, too. As we've heard, on the basis of the emerging evidence and the draft guidance issued by NICE in December last year, some health boards in Wales are starting to provide the test already. It is of course not unusual to trial new treatments in different parts of the health service, but I do understand why that gives rise to concerns from those parts of Wales where the test is not yet regularly available. But there is this point about, when we consider each potential advance in healthcare, what we do as a whole system, and in decision making, to consider the evidence for the best intervention and then to try to take a consistent national approach to delivering it once that evidence base is sound and accepted. So, NICE are committed to publishing their revised guidelines in April. Ahead of that, as we've heard—and I'm pleased that this has been acknowledged—I've directed NHS Wales, through the urology board, to work through and agree that clinical consensus. And you've seen, from the correspondence I've provided to the Petitions Committee and others, that's in preparation to implement the guidelines. We're not waiting; we're not doing nothing and waiting until some point in April when we expect finalised guidelines to be made available.

And it's crucial this urology board is not made up of civil servants, it's not made up of people that I am directing as to what they could or should do; the urology board is made up of clinical representatives from across health boards in Wales, and there is agreement as to how NHS Wales—not if, as to how NHS Wales—will transition from the current methods of diagnosis to one that includes the mpMRI test. But introducing a new element to the care pathway is never as simple a matter as it is sometimes presented. There will always be a number of areas to be addressed. Factors like the imaging capacity, like the workforce and training all need to be looked at, addressed and delivered. I have always been clear and stated on the record a number of times that if, as we all expect, NICE recommends pre-biopsy mpMRI, then I expect all health boards to amend their pathways accordingly.

The work being done by the Wales urology board is supporting our health service to be in a position to provide these tests consistently and equitably in line with the evidence. That will help us to deliver the improved experience and outcomes in care that we all want to see in every part of Wales. I am happy to underline the commitments I have already given to update Members in due course on progress and on the targets we have and timescales to make sure that service and that test that we expect to be recommended is available across the country. 

Thank you. Can I now call on David Rowlands to reply to the debate?

Diolch, Diprwy Lywydd. First of all, can I thank all the Members who have made a contribution to this debate? And if I can just go through a few points that some of them have made, Mark Isherwood pointed out the superior outcomes with mpMRI scans over normal MRI scans, and he said that there was a lack of data being provided by health boards, particularly in north Wales. 

Rhun ap Iorwerth pointed out the necessity of recognising cancer—as we all understand—as early as possible and many of the alternative tests to mpMRI are very inferior to the mpMRI scan itself. And he posed the question: why are the tests not routinely available? 

Caroline Jones gave personal evidence of the impact of the other invasive forms of testing for prostate cancer and the effects that it could have on a family. And she pointed out the differences and inconsistencies between areas in Wales, where one type of test is available and another is not. 

David Melding again questioned why we are not using state-of-the-art diagnosis wherever and whenever in Wales. And he asked about the methods and also questioned the disparity within regions. 

If I can come to the Minister and his acknowledgement of what's been going on, first of all, he did acknowledge the impact of prostate cancer, which we all understand. For men of my own age, it's one of those terrors that we face, I suppose, on a daily basis—that it could happen to just about any one of us. He also agreed that mpMRI is less invasive and, I think he acknowledged as well, is a superior way to biopsy. He talked of testing and creating a database that would confirm the effectiveness of new procedures, and we can all understand that that is the case, however I do believe that there is enough evidence out there to show that mpMRI is a far superior way of making a decision as to whether someone has prostate cancer, and I would urge the Minister to make sure that all our local health authorities do, as soon as possible, use mpMRI in their procedures. I do recognise that there is a problem with teaching up people to be able to properly use the diagnosis that the mpMRI may give, and that is a problem, and there may well be a delay in getting those people trained up and in place.

So, can I thank again Members for their contributions to the debate and to the petitioner, again, for bringing the petition forward? It remains for me to thank Stuart Davies and those who signed this petition for bringing this issue to the Assembly through the petitions process, and the Petitions Committee will consider the petition again in the light of contributions made during this afternoon's debate and, of course, the Minister's response to it. Diolch.

Thank you. The proposal is to note the committee's report. Does any Member object? No. Therefore, the motion is agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.