We now begin a one-off session on innovation in eradicating diseases. In the spirit of the festive season we want to spread the good news of progress on disease eradication, while recognising the challenges and the distance still to travel. We begin by welcoming Professor David Lalloo and Dr Lisa Stockdale to the Committee. I am going to ask each of you to introduce yourselves briefly; then we have some questions for you.

I am David Lalloo. I am vice-chancellor at the Liverpool School of Tropical Medicine. I am an infectious diseases clinician by background, and have worked in a number of different infectious diseases, mostly in low and middle-income countries, for 30-odd years.

I am Lisa Stockdale. I am currently the senior immunologist at the Jenner Institute, at the University of Oxford, working on the R21 malaria vaccine. My previous experience is immunology, public health and working in low and middle-income countries on a variety of infectious diseases.

Thank you both for joining us today. As we know, tropical diseases—sometimes referred to as neglected tropical diseases because they do not receive the same attention as some other diseases—are a significant burden to a large part of the population globally. Professor Lalloo, how would you describe the global health burden of tropical diseases?

I think it is enormous, and difficult to quantify. One of the troubles that we have had with neglected diseases is that, by definition, we do not always have good epidemiological data; but the number of deaths, and the number of cases around the world, is phenomenal. Although we have seen some decrease in that in the last 20 years, there is still a long way to go.

Which tropical diseases would you say are close to eradication, and why have there been more advances for those than for others?

Guinea worm is a good example where there has been huge progress in getting close to eradication. We have seen quite a lot of progress with filariasis in certain countries; you may know of it as elephantiasis. In certain countries, where there has been concerted UK funding—12 target countries with DFID funding over 15 years—we have seen reductions so that 99% of the populations of those 12 countries are no longer at risk from filariasis. That is a direct result of UK funding. There are areas where we have seen substantial reductions, but that is targeted and we need to expand it to other countries as well.

For those who may not be familiar with these diseases, can you say a word about what they involve, or what their impact is?

Filariasis is a parasitic disease. It is transmitted mainly by exposure to mosquitoes in tropical countries. The consequences of untreated infection are the development, fundamentally, of problems with the lymphatics, which can lead to very large leg swelling and scrotal oedema. Those are two major consequences of filariasis.

Hence the term “elephantiasis”. It is fantastic to hear of progress towards its eradication. What would you say, Dr Stockdale?

From my perspective as a vaccinologist, there has been some progress on a Leishmania vaccine. Leishmaniasis is a parasitic infection transmitted by the sandfly. It has not received very much funding—obviously, it is a neglected tropical disease—and it is very much associated with poverty, but there have been some advances in clinical trials of vaccines.

Great. Lauren, can I bring you in here?

This is about a celebration, really, so, looking at the last 10 to 20 years and the role that British science has played in this space, could you expand any further on any particular highlights? Probably one, given your example, is the malaria vaccine. Would you expand on our role in helping combat this disease?

Absolutely. The Jenner Institute has, over the past decade or 15 years, been developing the R21 malaria vaccine, which got WHO approval at the end of last year, and commenced roll-out this summer. It is 75% effective for cases of malaria in high endemicity countries, and it is a real success story. It is very cheap. It is between $2 and $4 a dose and requires three doses for the primary series, with one dose a year later, and has been recommended for use in children aged between five months and 36 months.

Young children are the main victims of malaria.

Does it give lifetime protection?

It does not give lifetime protection and, in terms of follow-up, we are not there yet; we do not yet know exactly how long it provides protection. While you are right that young children are the main sufferers from malaria, in terms of eradication we cannot forget about adults who have parasites in their blood that are accessible to mosquitoes, to continue the life cycle.

This is ensuring that children can live, basically.

Absolutely, yes.

I am a neglected disease person as well, and the opportunity to study these weird, quite quirky diseases in a lab space has meant that we have got other really interesting things in science. We visited Liverpool recently. Would you be able to expand on the device that can detect filariasis in the arm, and how that platform works?

Sorry, I missed what specific technology it is.

It is a platform that is going to be like a little watch. It can detect filariasis in the lymphatic system; but that technology can then help with diabetes and other diseases that we may well all experience.

There is a trend in medicine generally to wearable devices. People have heart rate monitors on at the moment. Diabetes is a great example of what they can detect, and the fact that we are starting to see them used in filariasis is a really good example. To expand slightly on what Lisa was just saying, it is not just in malaria vaccines that we have made huge progress. The UK has been a world leader in malaria control generally. That is a combination of vaccines; partnerships with technology companies to develop insecticides that are now effective where there is resistance; partnerships with drug companies such as GSK for antimalarial drugs; and partnerships with the countries themselves on how you get nets out to the populations that need them. The UK is leading in a huge amount of standard medicine and technological medicine, and malaria is a good example.

In 17 countries across the globe malaria has been eradicated. Do you think we can eradicate it globally, with all the new tools and techniques?

The critical thing is that we will need multiple tools. A vaccine is great, but we will need lots of other things alongside it. I think we will struggle to eradicate it completely from countries where there is very intense transmission. In some countries a child gets an infected bite every day. If you reduce that by 99% there will still be a chance of infection. I think it will be quite a long time before we get rid of it in every country, but we can certainly eradicate it in many more countries than we have done.

And deaths from malaria.

Absolutely—and deaths have gone down by half since the beginning of the century.

That itself is a fantastic good news story. Two points: is it about one vaccine, or are there a number of vaccines for the different types of malaria? Also, we hear a lot about climate change, which impacts disease progression and prevalence. Are there concerns that climate change will lead to malaria being present in parts of the world where it has not been, such as Europe?

Absolutely; climate change means that the available areas where mosquitoes can live will increase. It was not that long ago when Europe had a lot of malaria and there was widespread DDT spraying, which helped us enormously. Yes, there is a large chance that it could come back. There is an increase in prevalence of the Anopheles stephensi mosquito, which is much more adapted to urban living. That is a real problem, and the WHO is really worried about the spread of that mosquito, which does not only bite at dusk when people are going to bed and might be protected by mosquito nets.

Can I just put it into perspective? I think the climate crisis will affect all neglected tropical diseases. Predictions for pretty much all of them are that we will see a generally increased rate. It is complex, because malaria will go down in some areas and up in others. A really good example is the dengue that we are now starting to see affecting southern Europe. We do not have to have much higher temperatures in the UK before we start to see transmission of dengue fever. It is a neglected disease that will be on our shores within, I suspect, 20 years, unless we do something radical—or unless you do—about the climate crisis. This is going to change the face of neglected tropical diseases. If you ask me what I am most worried about, it is that climate change has the ability to undo all the advances that we have made in the last 25 years.

I suppose it is also saying that the neglect will change as they come closer to countries that have greater resources in this area.

There is a great deal of surveillance, and a critical thing for the diseases you have mentioned is whether we have the right mosquitoes. The spread has been because the mosquitoes that carry those diseases spread upwards as temperatures increase; so there is a lot of surveillance. The key to that is that, as those mosquitoes become present in the UK, we need to control them and get rid of them at the earliest available point. Treatment and management will depend on how much of a problem it is, but I think we will probably be able to control those, from the UK perspective.

I wanted to ask about research into some of the medieval hits that used to impact on us, which are, effectively, eminently eradicable, but which are not eradicated in parts of the world, such as leprosy and cholera. Are the barriers purely practical? Is there research into some that were previously big killers here and in other parts of the world that might make the eradication more efficient in parts of the world where delivery is difficult?

To take leprosy, for example, the figures have gone down fundamentally over the last 20 years. There are still 200,000 cases per year around the world. To a certain extent, we know what we need to do with leprosy, in that we can treat it, albeit not easily. It is about finding new cases. It is fundamentally a problem of the health systems. It is the same to a certain extent with cholera. This is about poverty-driven disease. Unless you change economic conditions, you are still going to struggle to control that. Cholera is essentially really a hygiene issue. There are great new vaccines emerging out of Oxford, but it is a hygiene issue.

You say there are new cholera vaccines.

Yes, there are new vaccines emerging out of Oxford. There are decent vaccines becoming available but, again, you have to deliver those. Fundamentally, it is economic growth that will make a big difference to a lot of those diseases. There is an important connection between reducing disease and economic growth. If you look at estimates of the effect on an economy if you eradicate malaria, it is phenomenal for the economic growth of that country. We are in this mixture: we need to treat disease to improve the economic status of a country, and that will further prevent disease.

I would say they go hand in hand. Although I am a vaccinologist and a proponent of vaccines, I do not think that that is the fix for everything. It is much more of a holistic public health fix that we need. As David was saying, it is not just that they are associated with poverty and if you increase the economic growth potential of a country disease eradication will follow. It is also the stability of the country. Cholera is a hygiene issue in areas where there is not good sanitation, where there are refugees, and in war-torn areas. This is where those diseases really come to the fore. I do not think that a vaccine is going to help in that kind of environment.

I just want to make the point that the UK has been amazingly good at thinking about this from the poverty perspective. We are the global leader in thinking about diseases that affect poor people and about the holistic approach, rather than saying that there will be a drug or a vaccine or something—a technology—that will solve it. On its own, that does not work.

Thank you, David. That is very good to hear. I am going to bring in Emily, and then Steve on HIV.

Picking up on both your points, the UK previously led the way in overseas assistance and research into health, but our health spend in 2023 was £20 million less than it was in 2010, and half our ODA spend percentage. What kind of impact do you think the decrease in both the health ODA spend and the total ODA spend has on our efforts to eradicate disease, on research and on the poverty that drives some of these diseases?

There is no doubt at all that the official development assistance cuts that we saw during covid were a major problem in terms of the progress we had made on a number of diseases. We have seen that play out. It was also a major problem in terms of our UK reputation. Partnerships that had been built up over 25 years were lost within two months. As a consequence, the country needs to get back some of that respect we had. An important thing about the ODA funding is that we used it wisely—particularly the research element—to inform our development assistance generally. If you get the research right, you know how to spend the rest of the budget wisely. That is where we have been very good. It is important to maintain that. To a certain extent, the proportion that went on research has been maintained, despite the total going down. Having said that, if you look at all the estimated reduction, it means we are less able to contribute, particularly to the multilaterals. We have not spoken about that, but contributions to Gavi and the Global Fund, and to the product development partnerships that have brought in new drugs, such as DNDi and MMV, are a really critical part of the way in which we as a country have reduced diseases. Our ODA reduction means that we cannot spend as much on those multilaterals either. We are not giving as much to Gavi as we should. We are not doing as much with the Global Fund as we should. That is why I would be pushing very hard for the percentage to go back to 0.7%, as you might imagine.

You rightly recognise Gavi and the Global Fund, which are UK innovations.

Absolutely; and DNDi. All those PDPs have been absolutely pushed—IVCC on vector control. They come from UK initiatives.

Thank you very much. Steve, you are going to lead for us on HIV and AIDS.

In 20 years’ time we will look back on antiretroviral roll-out in Africa and think it was one of the most amazing things we have done as a medical and human community. It has been phenomenal to go from no people being treated to the large number being treated now. As a clinician, I went round wards in Africa 20 years ago. All you saw were dying patients. Now people who are HIV-infected are getting on with normal lives. It is transformed. There is no doubt at all that we have reduced deaths and the number of new infections, but we are not going to stop transmission by 2030. That is not going to happen. There are still a number of areas where we need to improve. One problem is not just getting people on to treatment but getting them on it quickly enough—so early diagnosis. Self-testing, which was pushed very much by the UK, has been really important in getting early diagnosis. It is about maintaining people in treatment and having health systems that maintain people in treatment. Prevention is a really interesting area. You will have heard about this concept called PrEP, which is giving drugs or injections to prevent HIV to those at highest risk. There have been some fantastic innovations recently. In a trial of one of the latest drugs there were no new infections in people at high risk of HIV, over a year, or a year and a half, of follow-up. There are some very interesting prevention interventions that, if they become affordable and available, will make a huge difference, in addition to targeting in the really important populations—the key populations where HIV is a big problem.

Yes, they can be used for treatment or prevention. The great thing about that, in a health system where you may have to travel for 30 miles to get to a health clinic, is that something that means you do not have to go back and get tablets every three months is a real advance. If you have injectables that you can give less often, it makes things much easier for patients.

Sorry?

The current situation is that NICE wanted more economic data on that before it reached its threshold for cost-benefit, as with all interventions. As I understand it, that was an interim judgment and that assessment is still going on.

It is in trials. There have been two trials, one in women and one in a much broader population that shows enormous benefit with 98% to 100% success. That is likely to come to market very rapidly, as I understand it. Most of the data needed for the dossier is there, or will be very soon. Again, the question will be about cost and accessibility, as it always is with a new drug, both to the UK and LMIC population.

No, they are very definitely drugs. There are also some new antibody technologies that look quite promising for prevention, but those are a little bit further down the line.

Yes. At the moment, most HIV preventive medication means taking a pill every day; these injections can be given every two months, or six months in fact, which means people do not forget it. In particular, in countries where there is a lot of stigma around HIV, it means it is not obvious. If you have an injection twice a year, no one notices; if you are taking a tablet every day, people ask, “Why are you doing that? You must be HIV-positive or at risk of being HIV-positive. Maybe you’re promiscuous.” Those kinds of stigmas are still a big issue for many of the diseases we are talking about.

There are one or two, but it is like malaria. We need everything together. There is no magic bullet. Whatever Bill Gates tells you, technology is not the answer; it has to be an integrated approach.

But the best technology is hopeless if you do not deliver it to the population that needs it. So often we know the answer and have the tools; we just cannot get them to the populations that need them.

Yes. If we take a UK perspective, the reality is that we should be normalising HIV testing like any other test. That is now happening to a great extent. On opt-out testing, many places have been doing it anyway, slightly unofficially, if you like, and I think it is just good clinical practice now. If you have anyone with a symptom or signs that could be vaguely related to HIV, the sooner you make that diagnosis, the greater the chance of rapid treatment.

I think it is getting at the populations that are still not accessing care, and making sure they can access care rapidly enough. If you reduce the time from someone being infected to making their diagnosis, the time at which they can infect others is reduced, obviously. That is one of the major things we need to do at this stage.

I think we are probably doing most things, and we should be doing more of it. That is the whole spectrum. Absolutely supporting Gavi or supporting the Global Fund is particularly important, but also continuing the research that both develops these new approaches and new drugs, and research on how you get them to the populations that need them.

On the last point, how would you characterise the UK role in supporting and developing both the therapeutics and vaccines, and delivering them across the world? What is the UK doing? Are we doing well? Are we making a significant contribution?

Lisa will talk about vaccines, and I will come to the drugs.

In terms of what we are doing and how the UK Government are funding it, I am afraid I am not best placed to answer that.

Taking the second bit first, Gavi is the major instrument by which we are making vaccines available to populations that need them. That is why I think Gavi support is so important. In terms of developing vaccines, undoubtedly the UK is a world leader, and Oxford is a leader within the UK of a wide range of vaccine technologies. As we saw in the pandemic, our ability to turn on vaccines very rapidly was our expertise. Ironically, we protected the UK population by investment that had gone into vaccines for LMICs.

Sorry?

We protected the UK population with our covid vaccine because of investment that had predominantly gone into vaccines for non-UK populations.

Low and middle-income countries.

Low and middle-income countries. We should not forget that connection. Investment in global health and those conditions of people over there is quite an important part of protecting UK public health as well.

That is a point well made.

As for drugs, in the UK, the pharma industry and the engagement of UK academic institutions with big pharma is unparalleled in joint solutions. Filariasis—elephantiasis—got a donation of £940 million- worth of drugs from Merck, so that partnership is really important to our role.

I have a final question for Dr Stockdale. I know that the Jenner Institute was instrumental in the covid vaccine. Presumably, there is a canteen in the Jenner where you all mill around and different research groups get together. Which group are you all talking about that will be the next big thing coming out of the Jenner? It might be you. What is the next big thing that we can expect coming out of this amazing institute?

The malaria vaccine group is still doing amazing things. Malaria is not just one parasite that you need to worry about. There is also vivax, which is a latent form of malaria. We are working towards a vaccine on that. When you talk about the main form of the malaria parasite, with our 75% effective vaccine we are just focusing on the first life cycle stage. If any parasites evade that, they can come out in different life stages of the parasite. Another group at Oxford University has just come out with a paper with very good efficacy on a blood stage vaccine as well. The idea is that not only can you have these individual vaccines against different forms of the parasite and different life cycles; you can form them into, potentially, one vaccine that will help against all of those life cycle stages and different forms of the parasite.

Fantastic.

That is what all the talk is about in the canteen.

My head shot up when you were talking about the amount of funding that is given to different diseases. I was wondering about fungal diseases. To cast my mind back, as a group it is a bigger killer than even malaria. How is the funding going down that route? Are there any major fungal diseases that we need to be thinking about?

I am not sure I would say they are a bigger killer than malaria, but they certainly are significant. There are two elements to that. There are fungal diseases that have been typically associated with HIV-infected populations—patients whose immune system does not work very well are at much greater risk of fungal infections generally. Cryptococcal disease is a good example of that. This is a fungus that causes meningitis in patients, particularly those with advanced HIV. The UK, over a period of 20 years, has done a whole load of trials and has now got to the point where you can give a single dose of treatment. That is revolutionising the treatment of this disease, particularly in low-resource settings. We are doing reasonably well on that, and funding has been available for those. We see challenges with some of the more chronic fungal diseases. These are things like mycetoma, which are fungal diseases that get into the foot via the soil and then cause swelling—a bit like elephantiasis—and severe lesions. Those have only just become recognised as a neglected tropical disease. We are probably way behind the curve in research in those areas, but I think that, for very severe, systemically life-threatening diseases, we have done reasonably well.

Thank you so much, Professor Lalloo and Dr Stockdale. I think you have brought hope in terms of fantastic and innovative research and development. We have talked about the steps taken and the support the UK is offering in the diffusion of new treatments and therapeutics. Given that there are a quarter of a billion people suffering from malaria every year, 40 million living with HIV/AIDS and millions more with other neglected tropical diseases, that is a great testament to the work that you and the UK are doing. The fact that these diseases may be coming closer to our own environments, and that we as a country gain from the work that is being done on neglected tropical diseases, has made an impression on the Committee. So thank you very much. Witnesses: Professor Chandran and Dr Stott.

Good morning, and thank you for joining us for the second part of this one-off Christmas session looking at eradicating diseases. We are now going to move on to dementia and Parkinson’s. I would like to welcome Professor Siddharthan Chandran and Dr Simon Stott. I will ask each of them to introduce themselves briefly before I ask Tom to start the Committee’s questioning.

I am director of the UK Dementia Research Institute. This is a national MRC institute distributed across six leading universities of this country—in Scotland, England and Wales. Our mission is, through research, to transform the outlook for people living with, or at risk of, neurodegenerative disorders and dementias. That will be from Alzheimer’s, Parkinson’s, motor neurone disease and so on.

Good morning, and thank you very much for the opportunity to present evidence today. I am director of research at Cure Parkinson’s. We were founded in 2005 by four gentlemen who wanted to cure the condition rather than have better care. We focus solely on finding disease-modifying therapies for Parkinson’s: treatments that will slow down, stop or reverse the condition.

Thank you for giving us your time and joining us today.

Thank you very much both of you. Professor Chandran, what steps are being taken to tackle dementia? Principally, what progress are we seeing, and how does that vary depending on the types of dementia? I appreciate that is quite a big and broad-ranging question.

It is an important question. It might help for us to frame dementia. What is dementia? Dementia itself is not a disease; it is an umbrella term that describes a group of conditions that cause progressive decline in brain function. That has a range of symptoms with which we are, sadly, familiar: loss of memory; problems with language and understanding; and changes in personality, behaviour, movement and so on. All dementias-related conditions share three things. The first is they are all age-dependent, progressive and incurable. There is a lot of it; we will come back to that. The second is that, as the word “neurodegenerative” would imply, they are defined pathologically by loss of nerve cells— neurodegeneration—but they are also defined by the accumulation of one or more of a handful of toxic proteins. The details do not matter, but the principle does. The type of disease that you have reflects which nerve cells go wrong and which protein is involved. For example, in Alzheimer’s, the most common cause of dementia, nerve cells start to go wrong in that part of the brain that controls memory, but it is due to two key proteins. You will have heard of them: amyloid and tau. In Parkinson’s, the area that goes wrong is brain cells in the mid-part of the brain—dopamine cells. The protein is called synuclein. In motor neurone disease, in motor nerves, there are proteins called TDP, and so on. The reason why that is important is that underlying all of this are common biological features. For example, inflammation of the brain is common. The way the brain handles proteins, or its turnover—its generation and then its clearance—goes wrong. What that means is that, if you have interventions that deal with the protein or inflammation problem, it is relevant for a range of conditions, if that makes sense. The UK Dementia Research Institute works across all of these neurodegenerative disorders, because what we are driven by is delivering for people who have these conditions. What do they need? I am still a practising neurologist and I work in NHS Lothian. I was on call this weekend. Patients are not interested in which institute or doctor is doing what. What they want is fast, accurate diagnosis and a route into a streamlined pathway that will begin to give them personalised, tailored intervention. If you want to do that, you have to invest in the discovery science. The only way we are going to make a difference is better understanding and unpicking the complexity of the disease.

On a point of clarification, you said that all dementia diseases were age‑dependent.

The vast majority are.

We have heard examples of early onset of dementia. I just want to clarify that.

The vast majority of dementias are age-related, the older we get. Just looking at the numbers, it goes from one in 600‑odd at the age of 60 to 65, through to one in six when you are over 85. The exception to the rule is that most of these conditions are what we call complex disorder sporadic—there is not a single faulty gene that causes it—but others are purely genetically driven, and one dodgy gene causes it. When that happens, it tends to occur earlier—in the 30s, 40s, 50s—but that can shed light on the common problem because, apart from it coming faster, the basic underlying biology is common.

That is very interesting—just so that we know where the prevalence of these terrible diseases is.

We have seen in recent months that a number of drugs have become available that would be helpful in treating and stopping the progression of dementias. Is your view that these should be prescribed and offered on the NHS? The other question is that, if we want to treat people, it is important to identify those who might be at risk of developing dementia. What more work needs to be done on screening? Obviously, if we can identify those people and delay onset at an earlier phase, it is much better than when you are already seeing quite severe side effects.

You should come and write my grants. You have asked quite a lot. I will just go through your points. The first thing to say is that, as an adult neurologist having been at medical school deep into the last century, we are at a tipping point for neurodegenerative disorders and dementias. This really is a story where there is change; it is at a point of inflection. The reason for that is decades of discovery science that is now beginning to surface. The UK has had, and continues to have, an important role in that. The question is, can we be absolutely in the box seat with the change that is coming? You have asked me about two things: prevention—potentially screening—and current treatment. There are some current treatments. You will be familiar with MHRA’s announcement about two drugs, but they belong to the amyloid class of drugs. I have already referenced that as one of the proteins. There are a few points to be made here. First, and again this is good news for the UK, the entire amyloid hypothesis originated from the UK. The person behind that is a guy called John Hardy, who is part of the Dementia Research Institute. The second is that it is very important because these drugs show for the first time—this is why it is genuinely transformative—that the disease, the problem, is tractable. It has shown that you can shift the signal; you can shift the dial. You might not be able to shift it enough, but you can shift it. It is the beginning of something, rather than the end of something. The moment you show you can shift it, that it is tractable, you then get a tsunami of investment from pharma, industry and Government. Then the question is whether it is appropriate for the population today. As we know, that requires two decisions: MHRA, and then there is a cost‑effectiveness evaluation by NICE. The initial view was no, but they are reviewing that. It is very important to make the following point. When I was at medical school, for conditions like multiple sclerosis there were no treatments. But those began with beta interferons. Today, in under 20 years, it has undergone a transformation. A newly diagnosed person with multiple sclerosis—I saw two of them yesterday—has 15 multibillion-dollar licensed drugs. Steve, you mentioned earlier HIV and the spectacular advances over 40 years, but it is 40 years, and that is when you know what the problem is, what the cause is—the virus. There is a reason why brain degenerative disorders are a bit further behind, but we are absolutely at a tipping point on prevention. One of the things that we have been able to do in the Dementia Research Institute—I have to emphasise that this is partnership working with NIHR, industry, the NHS and many other people—is harness technologies and other British assets, like cohorts and AI. There is some brilliant research by a person called Cynthia Sandor, which shows that, using wearables and other data, you can predict Parkinson’s, which we will hear more about, five to seven years before it starts. There are also other ways to predict people at high risk. The moment you have that, you can begin to think of screening for interventions. One day, could there be the equivalent of the cholesterol tablet but for healthy brain ageing? The other major breakthrough, apart from disease-modifying therapies, is all about metrology. It is a bit dull, but you have to be able to measure stuff. Imagine if there was a simple blood test to give you a brain score—the equivalent to a blood test telling you that you have diabetes, not a complicated hospital visit with expensive scans and a needle in your back. That blood test is here now. That is led by a global leader called Henrik Zetterberg, based in the UK at the Dementia Research Institute. He also highlights that when you have brilliant research institutes, you recruit people internationally. He is from Gothenburg and UCL. I think the future is about prevention and identifying people at high risk. You could have one day of screening, with accurate, rapid diagnosis today, so that when you go to your GP, there is the equivalent of a blood test, maybe something on your phone, and then the beginnings of targeted, personalised treatment. It is a journey, but we are on that.

Thank you, Professor Chandran. That is very inspiring. The comparison with the progress on HIV/AIDS is well made. Also, an HIV/AIDS diagnosis initially was seen as a death sentence, and that increased both the shame and reluctance in terms of testing. Now dementia is little understood by many of those who fear it most, and you are holding out a kind of pathway to understanding it, diagnosing it and, critically, treating it.

One other thing I might add about HIV/AIDS, which is very important, is that when we think about these conditions and treatment, and we think about single interventions, these are complicated diseases. It will not be single interventions. The reason we have breakthroughs in cancer is combination chemotherapy. HIV treatment is combination. The future for these conditions will be prediction, where appropriate, rapid and accurate diagnosis, and combinatorial treatment bespoke to the individual, depending on stage and sub-type. That will change depending on where they are. That is where we will get to. The question is, how do we ensure that the UK retains its leadership position end to end, from discovering mechanistic science through to delivery and translation? That is the challenge.

Can I challenge you on one of the reasons why we may not be as far ahead as we are on HIV, for example? I have great concern that we have a very narrow focus on familial Alzheimer’s mouse models, particularly the Swedish double mutation, and I also have a query about the focus on the amyloid beta hypothesis. Just so you know, that was my PhD topic.

No pressure then.

My job was to develop an AI model to predict the various mutations of all the amyloid proteins that can occur. There are more than just tau and A beta. Do you feel that we are inhibiting our research by this heavy focus on familial Alzheimer’s mouse models and models like that and on the A beta hypothesis, and that we need to broaden our view and research base?

In a nutshell, your instincts in what you are covering are correct, but let me first address a couple of things. The DRI covers a range of conditions. Synucleinopathy is Parkinson’s. There is small vessel vascular dementia, which is 20%. TPD-43 is MND. I suspect that you will know better than I that, in terms of amyloid—for the rest of the Committee—there are what used to be called the tauists and the baptists. There is a crowd who believe in amyloid; there is a crowd who believe in tau. Chair: In tau?

This is the other protein, hence the tauists and the baptists—the beta amyloid protein—

Can you describe what the schism is for those who are not familiar with it?

What we know is that these diseases, including amyloid, have pathological signatures. Two of the pathological signatures in Alzheimer’s are these proteins: one is called amyloid and one is called tau. The debate is whether these are causal—

Yes, or consequential.

—or are they some sort of consequence of the phenomenon? If John Hardy was here, he would argue, with a lot of evidence, that there is strong evidence that amyloid is causal. Is it causal for the whole way? There is a distinction between causing the initiation of something and something else that is necessary to set the fire alight, but you need something else to fan the fire. Just to be clear, to come back to your wider question, one of the reasons I and the field are hopeful for the future is that we have a greater range of models to study human disease. In the end, if you want to solve human disease, you have to study people at scale, and you have to use people as your primary research tool, if you like. This is why the UK, if we get it right, would be very strong, because we have a unitary healthcare system and amazing cohorts. If you link that to biomarkers and human stem cell research, which is my own area of research, you can start to model human disease using human systems. The role for animal research is necessary but limited. The shift has been into human-anchored research. That is where the DRI is.

Thank you very much for that.

Thank you for this session; it has been really informative. I want to drill down on the kind of research science. Professor, you have talked extensively about the importance of discovery science here. You said we were potentially at a tipping point. You talked, interestingly, about multiple sclerosis, which is something I care about a lot. I have a very close family member who has an MS diagnosis and has been profoundly and positively affected in the past couple of years by the medications he is taking. Focusing on today’s theme of positivity and forward outlook, I would like your thoughts on what the big breakthroughs and innovations on the horizon are, and when we can expect to see some of these things coming forward.

I think that some of those breaks are already happening, but there are two other ways we might think about that. In the end, our job is to transform people’s lives, so we need to address what people want; we need to democratise things. We need to make any breakthroughs relevant to people, wherever they are, whoever they are. Poorer people and people from ethnic minorities are less well served by advances. They also participate less in research studies. We need to fix all of that. The UK can. What the UK and the DRI need to do is make this country the destination of choice for investment from industry, to ensure and cement two of our country’s priorities: maintaining brain health in an ageing society, and cementing our role as a global leader in life science dementia research, driving inward investment. I give the UK Dementia Research Institute as an example. There has been terrific investment from the MRC and others. That has leveraged two and a half times in a short time, seven or eight years. If you put 100 quid in your bank and in seven years’ time it is 250 quid, you would think that is a result. It has also driven company creation. There are several, but one stands out: colleague Chris Shaw and AviadoBio—gene therapies for rare disorders. There has been $80 million of investment in the past five years. There is also AI-driven technology to improve people’s lives at home and prevent them going into hospital. There is that leftward shift of healthcare: prevention, prediction and protection, keeping people out of hospital—community-delivered and compatible with O’Shaughnessy. One in six hospital beds is occupied by people with dementia and related neurodegenerative disorders. A lot of that is due to infections. We can now monitor that and prevent it at home and never get into hospital. The other reason is discovery science; notwithstanding the very reasoned comments about amyloid, it shows that the problem is potentially soluble. There are many serious trials on the way; there are many trials that we as a country could and should lead. The business of having a blood test so that your GP can make a diagnosis and put you on the right pathway without going into hospital has to be right. The idea is that we might then be able to identify anybody over 50 at high risk with targeted intervention, even if it is going after their cholesterol, blood pressure and diabetes, which we know are drivers. These things are all here now. If I was sitting here in the next 10 or 20 years, we would be talking a very different game. Change is coming. The key question is not whether change will happen—it will happen—but whether Britain will be in the vanguard leading it or a late adopter. We need to be on the peloton and right at the front.

I am certain that I speak for all of my colleagues when I say we completely agree with that. What do you see as the major barriers between where we are now and what you have just described?

I hope you have a sense of hope and optimism from me. As a country, we should be more confident about this. The reason is this: we have world-class science; we have world-class universities—we have four of the top 10. If we could triangulate that with the NHS, a still brilliant unitary healthcare provider, around a challenge-led investment, which is what the dementia research neurodegenerative institute is, we would be unstoppable. If I had policy asks, one is data, which you have heard about in this Committee. Data is in many ways the lifeblood of research and care. We need to understand that health data is a national critical infrastructure. We need to organise it, curate it, put in place proportionate governance and never compromise primacy of public benefit. If you get that right—the Sudlow review covered a lot of this—you can then drive much better research and much better care. There is a convergence of care and research. Good care cannot be separated from good research. Data saves lives; data improves lives. That is why.

Thank you, Professor Chandran. That is an appeal that we are very cognisant of. I am going to move on to Parkinson’s now because time is running out. Members can put any other questions if we have time afterwards but, Emily, you have questions now on Parkinson’s.

Yes, for Dr Stott. Parkinson’s is an issue very close to my heart; my father has Parkinson’s. We know that we are looking at, potentially, a doubling in the next 50 years. I wanted you to give us some hope about where you saw some of the breakthroughs, as well as some of those we have seen in the past five to 10 years, which have been incredible as well, and what Britain’s role in that has been.

We can talk about the improvements in the development of symptomatic treatments, but given my focus I would prefer to talk more about the disease-modifying therapies. Any curative treatment for Parkinson’s will require three things: first, a disease-halting mechanism; secondly, some sort of neuroprotective approach; and, thirdly, some form of restorative therapy. What is really exciting at the moment for Parkinson’s researchers is that we have research at the clinical level going across all three of those domains. Twenty-odd years ago, in fact in 1997, we got the first indications of genetic risk factors for Parkinson’s that are not necessarily causal but infer vulnerability, and that gave us insight into the associated biology. For the first 10 years of this century, we were looking at what that biology is and what it is doing inside cells. During the second 10 years, we were looking at building up assays for analysing the biology and screening of drugs. Now, in this third decade, we are in the very exciting phase of clinically testing those drugs. Parkinson’s is not a genetic condition. Those variants affect only about 20% of people in the Parkinson’s community. The rest are considered idiopathic or spontaneous. But when we look at the biology associated with those variants, in many cases it is affected in idiopathic Parkinson’s as well. Right now, we have ongoing clinical trials even in this country looking at, first, disease-halting mechanisms. We have Dario Alessi and colleagues in Dundee. They are the best in the world with regard to a protein called LRRK2. There is a clinical trial focused on inhibiting LRRK2, which becomes hyperactive in Parkinson’s. We also have neuroprotective approaches. Recently, Tom Foltynie at UCL has been looking at GLP-1 agonists in Parkinson’s. In Bristol, research groups are looking at neurotrophic factors such as GDNF, first with a direct infusion into the brain and now looking at a gene therapy approach. Finally, groups in Cambridge such as Professor Roger Barker and colleagues are collaborating with Swedish researchers on stem cell transplantation for Parkinson’s, replacing the dopamine cells that have been lost. It is never a good time to have Parkinson’s, but it is a really exciting time for the research focused on halting the condition. Just to add to that, we also have efforts to go prodromal. The Michael J. Fox Foundation in America is setting up a clinical trial—the first of its kind—looking at preventing the condition before it is diagnosed. Markers such as constipation and sleep disruption affect many people. They lose the sense of smell, for example. It does not necessarily mean you will get Parkinson’s, but the Michael J. Fox Foundation is putting resources towards trying to prevent the condition. It is doing it in the shape of a MAMS platform, which is a multi-arm, multi-stage clinical trial platform. This is pre-diagnosis of Parkinson’s. Just one final detail with regard to this type of clinical trial: in the UK, we are setting up a large MAMS platform—multi-arm, multi-stage—for people living with Parkinson’s called the Edmond J Safra Accelerating Clinical Trials in Parkinson’s, and it will be recruiting next year. That is not the only MAMS platform. We have MAMS platforms for MS. We have MAMS platforms being set up for dementia and ALS. Siddharthan sitting beside me here is the principal investigator on the motor neurone disease SMART MAMS platform, and that is leveraging the resources that we have with the NHS. If we were to try to do these sorts of clinical trials in the US, we would have to add an extra zero to the funding that is required. That is one of the major advantages we have here in the UK. I feel like I am ranting.

No, I think that addressed the first question. We keep hearing the term “trifecta”, as I think you described it, Professor Chandran, about the NHS and the accessibility to patients’ data and clinical trials. There has been some allusion to the fact that there are some sticking points within that process or things that we could do better to exploit the world-leading resource that we have in Britain. In terms of Parkinson’s and your platform for the clinical trial, are you having any difficulties? Are there things that could improve that that would also go across the other diseases that we are talking about today?

Sorry, is the question with regard to the data?

In regard to data, but also the accessibility to the patient pools and running the trials at the appropriate times in the disease development.

At the moment, multiple platforms are being set up looking at encouraging participation in clinical trials for the Parkinson’s community. Data access is an issue with that—providing patients with the data first, and then giving third-party access to that data.

If we are going to make the advances that we should, we need to change the proportion of people who are given voluntary opportunities to participate in research and trials. It is less than one in 100, or five in 100, for all these conditions, which is crazy, given how awful they are. We need to learn from the experience of cancer. Everybody who is given this diagnosis should walk out of the room with an opportunity to participate in research or trials. That is very important.

That is a very specific challenge. I will go back to Emily because we are running out of time.

One of the interesting developments in Parkinson’s is also around technologies and wearable technologies potentially stimulating the parasympathetic nervous system and others. How do you see that developing? How do you see the UK’s role in that? Are we leading or are we behind?

Absolutely, we are one of the leaders. There is a lot of really exciting data coming out of Newcastle at the moment. There is a programme called Mobilise-D. It is not just here in the UK but is a huge multinational study being run by Lynn Rochester. One of the advantages of Parkinson’s is that it is primarily a motor-related condition. It manifests itself in the clinic with motor symptoms. We can measure the tremor and the slowness of movement. This provides us potentially with outcomes for clinical trials of the disease-modifying therapies that we are developing at the moment.

Fantastic.

Thank you. Thank you very much, Emily. I am going to go to Lauren and then Kit, and that is all we will have time for in this session. Thank you so much for your responses.

Thank you, Chair. My question on Parkinson’s is about the treatment of schizophrenia, which can lead to Parkinson’s. My uncle has schizophrenia, and we can see the visible Parkinson’s that has been developing there. Is that a space and a place that really needs better treatment for schizophrenia, to avoid the inevitable Parkinson’s? I would like to have your views on that and about the environmental factors such as sports and the impact later on.

I will come back to the environmental factors. I am not a clinician; I am just a research scientist, so I will hand over the clinical question to my comrade here.

With schizophrenia and some other mental health disorders, the treatments available, first, are fairly blunt, and we have not made much progress. They have not changed largely over 50 years, and that is linked to some of the principles we have rehearsed already. A key side effect of what is called the major class of phenothiazines, which are still the standard for schizophrenia, is Parkinsonism. It is not quite the same as causing Parkinson’s disease in terms of the pathology, but they shut down a lot of the key pathways. We have talked about this being a problem with the dopamine. These drugs work indirectly by dampening the dopamine. They can freeze the patient as well as cause other cognitive issues and, in some people who have a vulnerability, unlock that, sadly.

With regard to the environmental factors, a lot of evidence is coming through suggesting the impact of environmental factors, such as pesticides, viral infections and so on. We do not really have good clarity on that. It is a very heterogeneous population of people. The primary correlate with Parkinson’s is ageing.

Just a final question on dementia. When I was at City Hall in 2014, I was involved in the thinking that eventually resulted in the Dementia Research Institute. At the time, there was a big advantage and a big stimulus to its creation. The big stimulus was that up to that point industry had collectively spent about £30 billion on research and got nowhere. The reason was that everyone had all been pursuing broadly the same dead ends without collaborating with each other. What does that picture look like now? The big advantage that we also had was the UK dementia challenge, where there was a strong political lead from the then Prime Minister, David Cameron, around dementia. Dennis Gillings was our international dementia envoy. Everybody was training to be dementia friends, including me. There was a big political push that resulted in the establishment of the institute. It was initially supposed to be international. I assume you are doing lots of international work, nevertheless. What does that look like now? What does the political structure look like? Do we still have a dementia envoy? What does private sector collaboration look like?

The momentum that you describe has been maintained, if not accelerated. What has the institute achieved? It has brought together a necklace of UK-wide efforts. Cracking this is a team effort and it is cross-sector. There is engineering, technologies, data, neuroscience, clinicians and NHS. It is doing that. One of the ways the Dementia Research Institute might be judged is growing a more integrated, connected UK ecosystem leading for the world. Industry is absolutely here. We want more of it. The reason it comes is because of the power of the science connected to the opportunities of population-based research, analysis and then impact, hence that triangulation of science, universities and the NHS, but there are a few wrinkles that need to be ironed out there.

The issue with industry always was that it does not want to show other people its homework because there is money involved. It was all researching the same dead ends and coming to the same conclusion, without people necessarily telling each other. The point in 2014 and 2015 was to say, “Look, this is such a challenge for the world. We just can’t afford to have this approach.” Has that eased now?

I think the barriers and walls have begun to come down. One of the accelerants of that is the first glimpse of what is possible with the two drugs. These two drugs are approved. In some countries they are being prescribed. In this country they could be prescribed privately, potentially. Going back to MS, it means that, within 10 years we will have 10 or 20 of these drugs. People know that the UK is often the testbed to validate and further refine.

I am not sure I heard you say this. Do you think there is a prospect of us hitting the WHO deadline for curing Alzheimer’s by 2030?

No, that is unrealistic. Going back to HIV, this is a journey. By 2030 we will have licensed medicines that are beginning to get into this disorder—

Help us to manage it.

—but it will take longer. The big wins will be prevention and the early diagnosis.

Thank you so much. You have given us a lot to think about, and particularly a lot of hope. Dementia, Parkinson’s and Alzheimer’s are diseases that strike terror into many people, and you have set out pathways to real change and real hope. We are also all better informed and can take our own positions on the tau/amyloid schism in the community.

The tauists and the baptists.

It is fantastic to be able to talk positively about the future of dementia and Parkinson’s research, so thank you very much. Witnesses: Professor Ketan Patel and Dr Torode.

Welcome to this final session of our Christmas inquiry into eradicating diseases. We are very pleased to be joined by experts in cancer research and development. I am going to ask Professor KJ Patel and Dr Julie Torode to introduce themselves. Just briefly, first say your names and your institutions, and then the Committee has some questions to put to you.

I am KJ Patel. I serve as the chief scientist for Cancer Research UK. I am also an academic and a professor at Oxford University, where I head an institute of molecular medicine.

Good morning. My name is Julie Torode. I am director of strategic partnerships at the Institute of Cancer Policy, which is part of King’s College London, and a global cancer advocate particularly interested in improving cancer research in low and middle-income countries.

Fantastic. As you may know, this morning we have been looking in a Christmas spirit at the good news on eradicating diseases and spreading treatments across the world in different areas. We are coming to you to talk about cancer eradication. Let me ask you, KJ, how close are we to eradicating cancer? Which ones are better candidates for eradication than others?

The first good news is that we have made huge inroads into eradicating cancer. To give you a couple of very striking examples, where we have known what the initiating cause is in viral-induced cancers—human papillomavirus and cervical cancer—and thereby the vaccination of that, there has been a dramatic decline in the prevalence of this cancer in populations that have had systemic vaccination programmes. It is a similar story with hepatitis infection in the liver. Those are very extreme examples where the impact has been very clear and tangible. Another aspect that we must look into is exposures, the most famous being cigarette smoking. The decline in cigarette smoking has compositely led to a decline in an important class of lung cancers. However, here lies a paradox because, as lung cancer due to cigarette smoke has declined, we have realised that a new form of cancer has emerged. Well, the term “new form” would be a mistake; the appearance of cancer in non-smoking individuals has come to the fore, particularly in south-east Asia and in women. It means that we have to better understand how that comes about and identify what those risk factors are in order to have a similar impact as we have had with those two other examples that I have given you. I am just citing some examples for what was quite a broad question.

Thank you very much. You talk about social advances such as the decline in smoking. Are there particular scientific advances such as genetics, machine learning or personalised medicines that particularly contribute to the eradication of particular cancers?

It is important to separate the initiation of early cancer from when a person presents with advanced cancer. Let us take the two examples. In early cancer, we have had great impact in early detection. Can we detect the cancers earlier by screening and hence intervene much earlier so that more drastic interventions are not required later? The most famous example is mammography for breasts. If you think of colon and prostate cancer, and those screening processes and approaches, much more work needs to be done and research conducted. At the same time, we have continued to innovate. The UK is a remarkable place to do cancer research, simply because of the way we are funded from the charities as well as from the Government and our institutions. One of our important recent innovations is the early screening of oesophageal cancer by the swallowing of a sponge, which when pulled back will trap cancer cells that you can detect—it is very similar to the cervical smear. This is undergoing a large trial right now, and we will know whether it confers a benefit. That is one example in play. What may happen in the future in this space is vaccination. In a way, a cancer is a self-parasite, but you have to have an alteration of self in order for that cell to become cancerous. That means that a cancer cell has an imprint of foreignness to it, and in principle the immune system should be able to see it. If you are able to identify that foreignness, you might be able to harness vaccination against that in order to eradicate cancers. This works in animal models, but needs to be rolled out in humans. There has been a lot of press recently about cancer vaccination. That is the sphere of early detection of cancers. The other element is what happens when you present with advanced cancer. There has been dramatic impact here. When I started as a doctor, if you had colon or breast cancer that had spread, you would count your mortality within a year or possibly six months. It is not unusual for people to live up to several years, and that is because of targeted treatment, identifying drugs that will attack the altered gene products present in these cancers. These treatments do not afford a cure, but they improve both the quality and the length of lifespan. The flip side is that this is an extremely expensive modality of treatment. There is an important question here: as we go into the space of personalised medicine with these bespoke therapies, what is the cost that is going to be involved? The final point I would make is that it is not conceivable to think that you would ever eradicate cancer. Cancer occurs in all kingdoms of life. It is an inevitable process of ageing in the human population. The burden of cancer in our populations will increase as the demographics change. The emphasis should be on reducing your risk of developing it, on early detection and then possibly, in the later phase, on more targeted advanced therapy.

Thank you. That has given us hope in terms of the different areas of progress that you have mentioned and, realistically, the difficulty in eradicating cancer. What we are talking about is the impact it has on wellbeing. With the combinations that you are talking about, of vaccination, early detection and personalised treatment, it sounds like we can certainly go a long way in reducing the terrible toll that cancer takes on so many people’s lives. We have the pleasure of welcoming Layla Moran, the Chair of the Health and Social Care Select Committee. She is guesting on our Committee. I am going to ask you to put some questions, Layla.

Thank you very much. Thank you very much, both of you, for being here today. I will be focusing, as you might imagine, a little bit on the here and now and how we can get the NHS to really embrace these innovations. Perhaps I could start with a relatively broad question to both of you. From where you sit, what are the greatest barriers to the NHS adopting many of the innovations that Professor Patel outlined and others besides?

Thank you. There are two aspects. One is the health system itself, and making sure that we find a patient early enough and that early detection is linked to the right decision on treatment. Completion of treatment is also so important. That means that the referral system needs to work and the supportive care around patients needs to work. The other aspect is the social system. A lot of people still do not know enough about the opportunity to reduce their own cancer risk, the opportunity to detect early and the life-saving opportunities of detecting early. There is also a level of complacency. Because we are doing well on so many cancers, people are less engaged with screening. Since covid we have seen screening rates go down. Are they recovering enough? There is a lot of public awareness, and it needs to be much more than just basic information—a real engagement with the public so they can understand how they themselves can contribute to eradicating cancer.

Thank you. Professor Patel.

The great thing about the NHS is that it is a public health system with the ability for medical information to flow across it to centres, unlike in North America, where you have isolated hospitals. The second great element that we have is the referral system through general practice, the first tier, although we could certainly improve our ability to get both those to deliver better. At the general practice level, that allows an ideal platform for screening, for early detection. Much of this could be done in the primary care setting rather than in big hospitals, where expenses rise and so forth. Turning towards the hospitals, as we go into a landscape where cancer care becomes more intensive and requires specialised centres, you can have the ability or the freedom for people to travel across that so that we are able to provide the best and most comprehensive care to people who have advanced cancers. We should not forget what we do about the other aspects of cancer, which is better and more effective pain control and end-of-life care. We just need to be better joined up in all these aspects, and we should be able to deliver. The final thing I would say is that in the UK we have this great repository of health records that we could harness to understand the origins of cancer. As you know, the famous project of the UK Biobank, which has transformed the study of human disease in populations, and now Our Future Health, are two very powerful platforms that can only happen in the UK ecosystem.

I was heartened to hear from the Department that it is intending to bring back a cancer plan. That is good news. I hear from both of you themes around detection. Can we focus on that just for a moment? I think £70 million has been earmarked for new radiotherapy machines. Off the top of your head, do you know how much a radiotherapy machine costs? I don’t.

It is a very difficult question to answer. There is not a lot of transparency there.

Will £70 million for new radiotherapy machines make a dent—that is the question I am really asking—given that many of them are old? What in this detection space will be needed to shift the dial, as opposed to tinkering around the edges, in terms of funding? Is that a question you feel able to answer?

I can provide a follow-up response for you on that.

That is helpful. Yes, cancer rates have improved certainly recently, but we also know that the UK is behind a number of other comparable countries. What are they doing differently?

That is a very good question. Our cure rates and our survival rates are the ones taking the biggest impact. Certainly, when you present with more advanced cancers, the treatment requirements are intensive. In certain countries, they have much greater centres of specialism to do this. We have great inequalities of provision of healthcare in the UK. Taking the coastal part of Britain compared to the south-east and the big epicentres and the cities, and certainly the university cities, the disparity there is much greater. My guess is that that has an impact, but we really need to better understand why it is that we lag behind. The other element is, of course, the delay in referral. If a GP suspects you have cancer, the speed at which you get to the hospital and then have your diagnostic tests and your definitive treatment plan may be shorter in countries that have more successful outcomes. We need to get to that space.

Dr Torode, do you have anything to add?

I would just like to reiterate that radiotherapy is a curative modality. We often get focused on the medicines, but both surgery and radiotherapy add to the cure. Particularly in head and neck, cervical and prostate cancer, radiotherapy is quite a critical modality. Why are we not doing so well versus other high-income countries? You have to look at the cost-benefit. There is a lot of over-treatment. At what point do you stop treatment and support patients in a palliative situation? You have to think of the time toxicity for a patient. Maybe those last few months and weeks are better spent at home with family living a productive life rather than on a fifth-line, sixth-line or seventh-line treatment that is likely to give a poorer return. We should consider having a broader conversation about the last period of life and what survival means for patients, and it is very much something that patients should be contributing to. I agree that we need to look at the referral process. There are hidden delays between detection and confirmed diagnosis, and between confirmed diagnosis and starting treatment, which can be looked at. There are inequities that we need to look at in the country as well. You can refine and refine, but that cannot be focused only on those patients who are getting good access. You need to look at those pockets of the population who are not coming for early detection or are not engaging and completing treatment, and what reasons they have. Is that remoteness? Is English not a primary language? There are lots of different factors, such as low socioeconomic and educational status. We know those factors. How do we integrate more targeted activities with those key populations? That may be pulling our overall survival statistics down, rather than the intervention.

The focus of the Committee’s report in the last session was on future cancer. The theme that we have been speaking about today is future innovations, and it is very exciting. When we get to the nub of this, it would seem that getting some of the basics right is going to make a massive difference. You are both nodding your heads. I am looking for specifics. Let us take the GP point. They have 10 minutes in which not just to focus on this but also mental health, stroke and cardiovascular disease. What is needed to help the GPs get those referrals right first time?

I cannot speak authoritatively in this area because I am a basic cancer researcher. We need a more comprehensive approach to how we roll out screening and to make sure that all the people on a GP’s list who enter are offered screening, that the cut-through happens and that people are communicated with clearly and then referred, whether it is breast mammography or something else. That is one area that we could improve. When it comes to referring people to a hospital from the GP base, it is to do with the pressure points of the local hospital and maybe the ability to cross-refer to hospitals that have more capacity than those that are locally positioned. I cannot speak authoritatively in this area.

You are not clinicians, so I fully understand that. Just to go back to the research side of it, they will not be able to fund everything all the time. Of the many innovations, of which you have already listed a number, what are the ones you would bet on? If the NHS was to have any extra money in this space, where would you bet?

A couple of areas could be transformative. The first is AI machine-learning approaches to interpret radiography or biopsy or smear specimens. The error rate, in some papers that have been published, is much lower than the human eye. You do not need to employ a person. You could get more turnover and speed through these approaches. That is one very positive way one could go forward. The second is slightly more speculative. However, in trials now, there is a blood test that can detect cancer earlier. When you form a cancer, it sheds its DNA into the circulation, and there are several innovative switches that seem to be able to detect this DNA and essentially warn us that you might have an early cancer somewhere in your body. We are not quite there yet, but I can see that being transformative in the future.

Linking into the past point is understanding the risk in the population. We can tell already through some genetic markers whether a family is at risk, which gives us an ability for heightened surveillance of family members who do not yet have cancer. That area will be increasingly an area of research and learning. It comes back to the GP managing a population that has varying cancer risk and varying age and opportunity to engage with early detection, and incentivising GPs to look at their community around them, to keep cancer away from these people rather than waiting until something happens.

Thank you.

Thank you very much, Layla. The theme is to get the basics right. We heard this morning from AMLo, an innovative diagnostic company that was having challenges diffusing its new technology into the NHS. I certainly like the idea of GPs as protectors of their community from cancer. I am sure, Layla, you will be looking at the cancer pathways and the GP primary care pathways. Now we are going to move on to what I hope is a good example of the different factors involved in eradicating or reducing significantly a particular cancer. I will ask Allison to move us on to cervical cancer, which is a relative success story, I hope.

Thank you. You mentioned earlier the HPV vaccination. Because of the shortness of time, I will jump straight to that. How important is public awareness and education for the global eradication of cervical cancer, but also in terms of the fact that this vaccination can deal with other cancers that would be relevant to boys and their vaccinations?

It is crucial to have awareness of this. In many rich countries, we are much ahead because people understand the opportunity of HPV vaccination. On the flip side, we sometimes give too much press to unpasteurised scientific views in this arena. We are not that effective at closing this down. Once you see doubt in a population, as in the famous case of the MMR vaccination, it is very difficult to shift that. It is about controlling misinformation in rich societies so that we are able to form a very good, informed and clear choice. In the more general world, it is more complicated because cultural issues come into play. It is a shock to think that here is a very simple intervention that takes away a dreadful disease, and nobody should really suffer that. No woman or man should suffer HPV-induced cancers, because it is completely preventable. It will be bespoke for different countries and different societies, and the level of investment that might go into that. In the end, how do you roll out a national vaccination programme?

Dr Torode.

Cervical cancer is a good example of a global disparity. Today in the UK it is quite a rare cancer. Screening, in particular, has brought those rates down, and vaccination is now adding to that. In lower and middle-income countries, and particularly sub-Saharan Africa, we see it as the No. 1 killer of women and a high-ranking cancer in their cancer burden overall. That is quite tragic when, as Professor Patel has said, it is a completely preventable cancer. The World Health Organisation has a global elimination initiative, and it takes a three-pronged approach: 90% coverage of HPV vaccination, 70% coverage for screening, and 90% coverage of treatment, whether that be pre-cancers or cancer itself. That is quite an ambitious set of targets for countries to reach, but during the consultations the high-burden countries, in particular, were quite motivated because they will uniquely benefit. HPV vaccination is obviously a crux of that because you can have a cohort of young people becoming adults and coming into the risk age for cancer having been protected with HPV vaccination. In the cervical cancer screening programmes in higher-income countries—Scotland and Australia, in particular, have shown data here—we now have women of cancer-forming age in whom we are not seeing those pre-cancers that we would have seen in screening programmes earlier. The ambition globally is for that new generation of people to grow up being protected against HPV. The importance there is getting that vaccination before onset of sexual debut, because it is a prophylactic vaccine; it has to be given before HPV infection. If you get a high enough coverage in the population of girls, you can in fact also prevent boys from getting HPV. If you can remember, we had three doses of HPV vaccine some time ago. We are now shifting to a single dose as the price of HPV vaccination is coming down. It is an absolute game changer for low and middle-income countries, in terms of affordability and the logistics of delivering that single dose, and there certainly will be enough in the UK.

I have one final question because I know a colleague wants to ask a little more about the HPV vaccine and we are running out of time. You referenced the fact that, in terms of cervical cancer, HPV can be sexually transmitted. Do you find that we need to do education awareness or rebrand things beyond that narrow focus, because it is seen as shameful in some countries and cultures to talk about sexual activity? It might help to look at the fact that the vaccine will help prevent a broader range of cancers.

That is a good example of segmented messaging to different populations and their risk. The driver of cervical cancer in low and middle-income countries is in fact HIV. Women living with HIV have six to 10 times the likelihood of getting cervical cancer. In fact, if you have an HIV infection, you are twice as likely to get HPV, and vice versa. There is that sexually transmitted route, and education is certainly important. What we are finding, though, in low and middle-income countries is that the anti-cancer story is motivating people to take up HPV vaccination. That includes explaining to people what cancer is and what the cervix is. These are all new terminologies for people. They see people dying of cervical cancer, but they do not necessarily know what that means. The strong message from international work is that it is the anti-cancer message that motivates people to take the vaccination. It takes away that complex discussion around sexually transmitted infection when you are trying to get parents to vaccinate their young children. With older cohorts, particularly people with high-risk profiles like sex workers, or people who might be engaging at an older age with the opportunity to have catch-up vaccines, such as the LGBTQ community, you can have a more differentiated message around sexually transmitted risks.

Thank you, Allison, and thank you, Dr Torode and Professor KJ Patel. It is useful to finish on cervical cancer, which you described, Professor Patel, as an entirely preventable disease. It gives us all hope to see its elimination in our lifetimes. I was very struck looking at the take-up of cervical screening in my constituency some years ago that there was a 50 percentage point difference between two wards. In one ward, it was 24% and in another it was 75%. You have spoken about communication, about access to different populations, as well as what was described as a trifecta of prevention, vaccination and treatment. Those are all really important messages that give us a sense of the challenges with all the different diseases, and it has been fascinating to look at them this morning. It is very hopeful. You have been spreading Christmas cheer in many areas, as well as an understanding of the hard yards still to be run before we see the eradication or the reduction of these diseases that are such a huge burden on so many in so many different countries around the world. Once again, it is science at its best. Thank you so much for spending the time with us, and thanks to the Committee for your questions and engagement. Merry Christmas and a happy new year to everyone.