1.  INTRODUCTION

  1.1  The Prostate Cancer Charter for Action is made up of 21 organisations from the voluntary and professional sector with a commitment to tackling prostate cancer.

  1.2  There are a number of health inequalities which affect prostate cancer, including:

—  Men of African descent are three times as likely to be diagnosed with prostate cancer than men from other backgrounds

—  Awareness of the prostate and its function remains low amongst many groups

—  Men continue to experience challenges in accessing primary care, with services often not being designed around their needs

—  Too many patients are only diagnosed with prostate cancer once their cancer has spread, limiting treatment options and significantly compromising their chances of cure

—  Men with prostate cancer continue to report a significantly worse experience of their treatment and care than patients with other common cancers

  1.3  We therefore welcome the Health Select Committee's decision to hold an inquiry into health inequalities.

2.  THE EXTENT TO WHICH THE NHS CAN CONTRIBUTE TO REDUCING HEALTH INEQUALITIES

  2.1  Despite some progress in improving prostate cancer services over the past few years, much more needs to be done, particularly if inequalities in experience and outcome are to be addressed. We welcome the recent publication of the Cancer Reform Strategy, which includes a number of commitments which could help tackle inequalities. These initiatives need to be implemented as a matter of urgency.

  2.2  The NHS does have an important role to play in reducing health inequalities. Whilst it is true that many of the causes of inequalities relate to other policy areas such as a patient's employment status, housing conditions or educational background, the NHS should function in a way so that these factors do not stand in the way of a person accessing timely and appropriate healthcare.

  2.3  Of particular relevance to prostate cancer, the NHS has a role to play in reducing health inequalities by providing timely and relevant information about health issues, including disease symptoms and treatment choices. A man diagnosed with prostate cancer has to make many complicated decisions about his treatment and care, each with differing benefits and drawbacks. It is therefore vital that a man has access to standardised information and support as he makes choices about his treatment, letting him weigh up issues such as efficacy and quality of life. It is the role of the NHS to make sure that this information is available to prevent low levels of health literacy from widening health inequalities.

  2.4  The provision of specialist nurses can also play an important role in reducing health inequalities by supporting men with prostate cancer in making difficult choices about their treatment and care. Access to a named specialist nurse is particularly important for prostate cancer patients who perhaps may require support in coming to terms with living with cancer, or managing side effects of treatment such as incontinence or impotence. A recent report by the Prostate Cancer Charter for Action, Because Men Matter—the case for clinical nurse specialists in prostate cancer, found that significant geographical variation exists in the provision of urological cancer clinical nurse specialists and provision of such specialists lags behind that for patients with other forms of cancer. Clinical nurse specialists for men with prostate cancer have, on average, double the workload of newly diagnosed patients compared with breast cancer nurses.

  2.5  Suggested recommendation—The NHS should invest immediately in improving the provision of urological cancer clinical nurse specialists. This would mean that men with prostate cancer have access to information and advice on their treatment options, as well as greater support from experienced professionals in their battle against prostate cancer. As a first step, the NHS should aim to bring provision for urological cancer up to the same rate of newly diagnosed cases per Clinical Nurse Specialist as currently exists for breast cancer. This would require an additional 260 Whole Time Equivalent Clinical Nurse Specialists for urological cancers, more than doubling the current workforce.

3.  THE DISTRIBUTION AND QUALITY OF GP SERVICES AND THEIR INFLUENCE ON HEALTH INEQUALITIES

  3.1  Both the accessibility and quality of GP services can have a significant impact on inequalities in prostate cancer.

3.2  Accessibility

  Men and women have very different healthcare needs and therefore require different kinds of health services. Women are more likely to visit traditional primary care services such as the GP surgery because of issues such as reproductive health or childcare. Indeed statistics about GP usage confirm that men are far less likely to visit their doctor—on average, males visit an NHS GP four times a year while women visit six times a year.

  3.3  This difference in access produces an opportunity cost—there are fewer opportunities for healthcare professionals to identify a variety of health problems, including prostate cancer, in men at an earlier stage where a greater range of treatment options is available.

  3.4  We welcome the positive reference in the Cancer Reform Strategy to community based prostate health clinics as a potential model for enhancing the primary care support available to men with prostate health problems. As part of this model, decision advisers would help men at the following points in the pathway:

—  Men without symptoms considering having a PSA test or equivalent

—  Men with urinary or other potential symptoms of prostate cancer

—  Men considering having a biopsy for prostate cancer following a PSA test

—  Men diagnosed with benign prostate disease

  3.5  Decision advisers could be clinical nurse specialists (CNSs) on a dedicated or outreach basis, GPs with a special interest in prostate cancer, community based specialist urologists or other appropriately trained practitioners. Access to prostate health clinics would be via GP referral or direct access for men concerned about their prostate health.

  3.6  Improved support for men in making decisions about further investigation or treatment would not be a form of rationing, but rather a way of ensuring that men have the best possible information and support when making difficult decisions. Improved support for men will ensure that more appropriate referrals for biopsy or further care will be made, reducing unnecessary interventions and complications, saving significant levels of NHS resources.

  3.7  Suggested recommendation—The community-based prostate health clinic model should be piloted and evaluated. Clear guidelines will need to be developed for community based prostate heath clinics so that they address, for example, the difficulties men currently have in accessing traditional primary care services and so do not worsen health inequalities in this area. Experts in prostate cancer and wider men's health issues, including charities and patient groups, must be consulted as part of this process.

  3.8  Further use should also be made of the workplace as a potential venue for health information and advice. Research by the Men's Health Forum amongst others indicates that men welcome the provision of health information and services in this setting. Such an approach can also avoid some of the access issues which can result from many primary care services only being open during normal working hours.

4.  QUALITY

  4.1  Feedback suggests that there are also variations in the quality of advice and support given in primary care on issues relating to prostate cancer, notably those relating to PSA testing and diagnosis. Introducing models such as community-based prostate health clinics could help address this, but it will also be important to update and improve the support available to GPs.

  4.2  The Prostate Cancer Risk Management Programme (PCRMP) is intended to support men without symptoms of prostate cancer in making an informed choice about whether to have a PSA test. We support the principle of informed choice but believe that the PCRMP is in urgent need of updating to reflect developments in the evidence base and experience gained from its use in practice. Furthermore, a Department of Health-funded evaluation has found that there are significant variations in the way in which GPs use the PCRMP, so potentially leading to inequalities in the advice given to men who are concerned about prostate cancer.

  4.3  The Department of Health has committed itself to updating the PCRMP on several occasions over the past few years, but there have been extensive delays in this process.

  4.4  Suggested recommendation—The PCRMP should be updated urgently and launched no later than April 2008. Patients and men who have not been affected by prostate cancer should be involved in this process. Particular attention should be given to encouraging GPs to make use of the revised PCRMP and assessing its impact on reducing variations in the advice given to men.

5.  THE EFFECTIVENESS OF PUBLIC HEALTH INTERVENTIONS

  5.1  Public awareness can play an important role in tackling health inequalities, ensuring that everyone is informed about signs, symptoms and risk factors of ill-health. This is true of prostate cancer, where men need to be aware of their prostate, its function, what can go wrong with it and where they can seek help and advice.

  5.2  Unfortunately the evidence base on what works in raising awareness remains relatively thin, particularly amongst men. With this in mind, signatories to the Charter co-funded with the Department of Health a pilot awareness programme on the prostate and its function which took place in Coventry. The pilot demonstrated both the importance of carefully targeting health messages to reflect cultural sensitivities and that community-based approaches to awareness raising can be effective. It also showed that further research work is necessary to test and evaluate different approaches to raising awareness. These findings helped to inform the Department of Health's decision to launch a National Awareness and Early Detection Initiative (NAEDI) is part of the Cancer Reform Strategy. We wholeheartedly welcome this initiative and call on the Department of Health to ensure that prostate cancer is an early focus for it.

  5.3  Suggested recommendation—The NAEDI should be supported by significant levels of funding to test and evaluate different approaches to raising awareness and encouraging early detection of cancer. Further prostate cancer pilots should be initiated within this. The findings of this work should be disseminated to all those with an interest in raising awareness.

January 2008