Coroners (Determination of Suicide) Bill [HL]
Wednesday 9th June 2021
(3 years, 5 months ago)
Lords ChamberRead Full debate Coroners (Determination of Suicide) Bill [HL] 2021-22 Read Hansard Text
The Lord Bishop of St Albans
My Lords, I declare my interest as a vice-president of Peers for Gambling Reform.
Coroners (Determination of Suicide) Bill [HL]
Friday 19th November 2021
(3 years ago)
Lords ChamberRead Full debate Coroners (Determination of Suicide) Bill [HL] 2021-22 Read Hansard Text
The Lord Bishop of St Albans
My Lords, I declare my interest as a vice-chair of Peers for Gambling Reform. The focus of this Bill is on gambling-related suicide; indeed, I have heard one Member of your Lordships’ House describe it as a “gambling Bill”. It is no secret that gambling reform is a major concern of mine, but I start by stressing that the scope of the Bill extends far beyond gambling-related suicides and can include a wide range of factors that contribute to death by suicide.
I will give some background to set the scene. Under the current legislative framework in England and Wales, once a suspected suicide is reported, the death is classified as “sudden and unexplained” until an official determination is made. The coroner is then required to undertake an inquest alongside a jury to make a determination as to the cause of death and whether the death is to be registered as a suicide—a process that often takes up to six months from the confirmed date of death of the deceased.
The benchmark for making a determination of suicide was lowered in 2018 from the criminal standard of “beyond all reasonable doubt” to a civil standard of balance of probabilities, although it is still a high benchmark to make that determination. My reason for outlining the current framework for determining whether a death by suicide has occurred is to emphasise that the Bill I propose does not alter this framework. One Member of this House expressed the concern that a determination of suicide might affect life insurance claims. While it is clearly upsetting and deeply regrettable for the families who are denied life insurance claims on those grounds, the remit of this Bill would occur only once a coroner or jury has already made a determination of suicide, which would therefore have no bearing on this particular matter.
The Bill would amend the Coroners and Justice Act 2009 to allow for the coroner or juries in inquests to record an opinion as to any factors that were relevant to a death in the case of a suicide. It would also amend the Coroners (Inquests) Rules 2013 to insert a new rule that would legally require the coroner or jury to record an opinion as to any factors that were relevant to the death by suicide and that explicit consideration be given as to whether the deceased had an addiction to gambling. The intention is that, by collecting more reliable data on the underlying factors that cause suicide in the UK, suicide prevention efforts by the Government can therefore be targeted at the underlying risk factors which cause suicides and allow for better interventions for those characterised as at risk.
Having spoken many times on suicides due to gambling-related harm, again and again I have heard the Government say that they do not have reliable statistics, and I keep asking them to help us to get some. Absolutely nothing has come back. I am hopeful that out of this some noble Lords will come up with even better suggestions, but this is my stab, and I hope that it will help us as a way forward. I realise that I may need a lot of help to look at exactly the best way forward.
Coroners are not required by law to record factors relevant to a death by suicide, but can do so on a discretionary basis. Since it is not legally required, there exists an inconsistency in how suicides are registered between those coroners who record the relevant factors and those who do not, which prevents reliable data being gathered on factors that were pertinent to the death. According to the ONS figures for 2020, there were 5,224 registered deaths by suicide in England and Wales. We know that 75% of them were males and that suicide rates were highest among those aged 45 to 49. ONS figures also highlight the regional variations in suicide rates: the death rate per 100,000 in London was nearly half that in the north-east of England, followed by Yorkshire and then the south-west.
Although they are not recorded in official registration, the Government do recognise many of the risk factors that lead to suicide. Before I continue, I echo the sentiments of the fifth progress report on suicide prevention, the most recent one, where it states:
“There are many complex factors driving suicide rates”
and expands on this further to say that rarely can a suicide be reduced “to one factor alone”. At the same time, I do not believe that this is an argument against recording the risk factor, or factors, underlying a suicide, especially when there are circumstances, the extent of which are unknown, where one or two risk factors were particularly prevalent.
The fifth progress report recognises that self-harm is a major risk factor in suicide, with evidence suggesting that 50% of people who have died by suicide have previously self-harmed. The report also recognises the risk posed through exposure to harmful online content, something that caught the public attention after the tragic case of Molly Russell.
Other risk factors that the report outlines include economic risks, with evidence suggesting that during the last recession the suicide rate rose 1.4% for every 10% increase in unemployment within men, and social risk factors such as homelessness, which the ONS is able to have official records on. Most of these assertions, however, do not rely on concrete data collected during the registration, which in reality means that we do not know how many suicides are attributable to these factors.
Coroners currently have the option to mark the relevant risk factors underlying a suicide. I have a copy of a sheet from one of the coroners in my diocese, which lists various options. You can tick financial difficulties, marital difficulties, recent or past mental health involvement, bereavement in the last 12 months, self-harm, physical health issues, a history of violence or being under investigation for criminal matters, and so on. I will not read them all; indeed, there are some caveats in brackets, which are important to take into account. The document I have dates from 2018, and I may need to defer to the Minister if I have an outdated version.
Some may argue that to record comorbidities is fraught with difficulties, yet doctors record them and the data has proved very valuable for medical research. This method of marking predetermined risk factors would allow accurate data on the relevant risk factors in a suicide to be accurately recorded; it is the approach that I favour. But conspicuously missing from these options is gambling-related harm, which, according to Public Health England’s evidence review on gambling harms, just published, is estimated to be responsible for 409 suicides annually. That translates to nearly 8% of the recorded suicides in 2020.
It is for this reason that included in the Bill is a specific requirement on the coroner to consider whether the deceased had an addiction to gambling. However, I recognise that the inclusion of gambling-related harms in the options of risk factors might be more appropriately set out in regulations or official guidance than in primary legislation. I am sure that I will get some advice in this debate on that provision. What matters is that it is included within these options, so that we can get accurate data on all the relevant risk factors, including gambling-related harm. We should collect them and publish them anonymously. This would be invaluable to the Government’s strategy to drive down the number of suicides. You do not drive them down in general but work out the reasons why they are happening, then have a strategy for a range of things, of which gambling-related harms is just one.
I believe that the Bill would be a great asset to the Government’s suicide prevention efforts. I hope it will allow us to give much more support and earlier intervention to those who are at risk of suicide. I beg to move.
Baroness Bakewell of Hardington Mandeville (LD)
My Lords, I declare my interest as a vice-chair of Peers for Gambling Reform. I congratulate the right reverend Prelate the Bishop of St Albans on securing this debate and on his excellent introduction to this important issue.
Addictions of whatever sort, whether alcohol, drugs, or gambling, have a devastating effect on those suffering, and their friends and relatives. Perhaps gambling is the most invidious, as it is often hidden. It is relatively easy to see when someone is an alcoholic or a drug addict. Those with gambling addiction will be locking themselves in their bedroom with a computer, betting long into the night. This is not a social activity which brings friendship and camaraderie among sufferers. Quite the opposite: it is a lonely, deeply depressing activity, where the participant thinks that just one more chance will bring a better result.
Currently, coroners are not required to record whether those who take their own life are suffering from a gambling addiction. There is, therefore, insufficient information to judge accurately just how prevalent the problem is. From the information on the Gambling with Lives website, it would seem that those most at their wits’ end are young men under 30, on the threshold of their adult lives, who become trapped and feel unable to escape through any other means than ending their own life.
In order for both national and local government to be able to ensure that they have sufficient resources and programmes in place to help those afflicted with gambling addiction, it is necessary for them to be able to assess correctly the scale of the problem. Requiring a coroner to record an opinion on any factors that are relevant to the death, including whether the deceased had an addiction to gambling, is critical. The right reverend Prelate listed the role of the coroner in the investigation of deaths due to suicide and other factors.
Recording factors relevant to a death could provide a wealth of information about addiction, without releasing the identity of the deceased. It seems to me that this would not place unreasonable burdens on the coroners’ courts. Preserving the anonymity of the deceased is critical for the bereaved family. They have lost a treasured son or daughter and are desperate for answers. They will not want others to suffer in the way that they have. The collection of data on gambling-related suicide is the only way in which we as a caring society can be sure that we are providing sufficient resources to help those suffering from this crippling addiction.
I will give just one example of someone known to me: a young man, in his late 20s or early 30s, married, whose wife had just given birth to a baby. His gambling addiction came to light only when his wife discovered that their house was about to be repossessed to cover his gambling debts. Sadly, this was the end of his marriage and the family home. He lost contact with his baby and subsequently lost his job. Luckily, he had a friend who picked him up and took him in. Not everyone in this situation is so lucky. Others might have ended up on the streets, self-harming or worse.
A recovered alcoholic who takes back control of his or her life does not drink alcohol ever again, even at Christmas. A drug addict who has achieved the status of being clean does not willingly reuse. A gambling addict who thinks they have turned the corner easily becomes a victim of enticement to have online VIP designation and multiple free cash bonuses. They become entrapped again, realise what has happened and feel that they have failed, resulting in extremely low self-esteem and sometimes even suicide.
I will touch briefly on Armed Forces personnel. Those returning from serving their country in extreme conditions in Iraq, Afghanistan and other places of conflict are often suffering from post-traumatic stress disorder and unable to find employment. The online gambling sites advertised widely on television, and the slot machines that promise so much but deliver so little, are both readily available to them. Sadly, this only increases their sense of isolation and desperation, resulting in self-harm and, ultimately, suicide in some cases.
Gambling with Lives conducted research that indicated that between 250 and 650 gambling-related suicides occur each year—roughly a minimum of one every working day. That is 365 families who have lost a treasured relative, a son, a daughter, a husband, a colleague or a friend. The effect on those left behind is devastating, as they often feel that they should have realised and done more to help. Until such time as we have reliable data on the number of gambling-related suicides, society will not be able to provide sufficient, effective services to help those suffering from problem gambling. The right reverend Prelate’s Bill would provide the answer. Prevention could be available, but only if we understand the scale of the problem.
Baroness Meacher (CB)
My Lords, I rise to support this excellent Bill, so strongly introduced by the right reverend Prelate the Bishop of St Albans. In order to achieve a reduction in the number of suicides and the number of attempted suicides—which is thought to be about 20 times higher—it is crucial to know more about the factors that lead a person to consider this course of action. The right reverend Prelate gave clear examples of the role of gambling addiction in suicides, and I welcome his efforts to ensure that this is recorded as a factor by coroners when appropriate.
I agree with the approach outlined in the Bill and I very much welcome its breadth. It is not simply about gambling, though that is profoundly important. The approach is that the coroner must record an opinion about the factors which were relevant to the death. It should of course be noted, as Samaritans explains clearly and as the right reverend Prelate said, that there are rarely single causes or factors that lead someone to consider ending their own life. However, where there are common themes, we need to understand them so that we can make every effort to reduce the number of suicides and—as I have said—often very violent and dangerous attempted suicides, which can leave the person with serious injuries and profound medical problems, at huge cost to the NHS apart from anything else. If coroners’ records included the information envisaged in the Bill, they would be a priceless source of information for the development of preventive measures.
I am personally aware of the appalling consequences for families of the gambling addiction of the breadwinner. When I was organising the campaign for child benefit for CPAG in the 1970s, when the Government of the day were planning to abolish family allowances and merge them with child tax credits, which of course often then benefited the breadwinner, I received at least 2,000 letters from frantic mothers—I think they were all mothers in those days; they would not be today—telling me that their family allowance, which was a pittance, was the only money they could totally rely on each week to feed their children. A vast number of these women had gambling-addicted partners, so I became very conscious at that time of the importance of this issue—and here we are, 40-odd years later. It is a terrible social problem, and we need to have better data about it and act to reduce it.
Another great potential benefit of the Bill—I hope the right reverend Prelate will forgive me for introducing this—is that terminal illness as a major factor in suicides would be recorded. As your Lordships know, I have a Private Member’s Bill on assisted dying. During my speech to introduce the Second Reading debate, I spoke of the experiences of dying people who take their own lives, generally alone and at great risk to themselves if they fail, as I have already mentioned. As noble Lords know, the current law bans assisted dying, hence the wretched experience of dying people who face unbearable suffering at the end of their life deciding to end it prematurely while they have the physical ability to do so, and to do it without consulting their loved ones, and certainly completely alone.
The organisation Dignity in Dying—I should declare my interest as its chair—published in October its report Last Resort: The hidden truth about how dying people end their own lives in the UK. That report details the stories of dying people who have taken their own lives in this country, told through the words of their nearest relatives. These are people who have had access to specialist palliative care but for whom palliative care, through no fault of the carers, doctors and others, cannot eliminate or adequately alleviate their appalling suffering. They have felt that the current law does not offer them the choice of a dignified death, so they try to create it for themselves, usually disastrously.
The Last Resort report estimates that between 300 and 650 recorded suicides every year involve a person experiencing a terminal illness. The breadth of that estimate is similar to the Gambling With Lives estimate on the number of gambling addiction-related suicides, and for similar reasons: we simply do not have enough data to understand the scale of these problems—and without understanding the scale of the problems, we cannot properly take action to tackle them.
I do not wish to revisit the very thorough Second Reading debate on my Bill, but I emphasise one of the great benefits of this Bill: that terminal illness would be recorded by coroners when it is the relevant factor leading to death under Clause 1(3), in proposed new rule 35(1). I also want to clarify the difference between the suicide of a terminally ill person who may have months or years to live on the one hand, and the choice of a dignified death supported by a doctor and loved ones when death has become inevitable and imminent and life is deeply unbearable to the individual. The term “suicide” is not appropriate in that situation; it is about controlling the nature of one’s own death.
Finally, I mention in closing that the Office for National Statistics is currently investigating the rates of terminally ill people who take their own lives. From discussion with colleagues, I understand that this has become an extremely complex challenge, simply because of the discrepancy in recording these issues. There is no doubt that if we had this Bill in place and terminal illness was recorded by coroners where relevant, the ONS research would be straightforward, almost unnecessary; the data would all be available.
I warmly welcome the Bill and hope the Government will adopt its key recommendations. We all know that Private Members’ Bills in this House have a certain life, but Ministers really could do something about this. I congratulate the right reverend Prelate.
Lord Brown of Eaton-under-Heywood (CB)
It is always a pleasure and a privilege to follow my noble friend Lady Meacher. I join her in congratulating the right reverend Prelate on his compelling introduction of the Bill.
I bring to this debate very little expertise about gambling. I have not served on any recent committees, nor played any part in the legislation that governs this process. I was lucky enough to be cured of any possible inclination to gamble 60 years ago when, as I was just reaching adulthood, an occasion arose when I was given 20 French francs to visit a casino at Cannes. At that time, 2 francs—getting on for a fiver today—was the minimum stake at the smallest roulette table. I placed, and lost, 10 straight 2-franc even bets and have never felt tempted since.
I recognise that gambling is a huge attraction to some—a craving, an addiction and, in truth, a cancer in our society today. While I have little knowledge about gambling, for a great number of years in the law I had a good deal to do with coroners, coronial law, inquests and verdicts. As Treasury counsel 40 years ago, I used to represent coroners in all the prominent legal cases of the day. I was later involved in most of the leading judgments on coroners; the proper scope of inquisitions and determinations; the critical differences that developed, not least under ECHR law; and the difference between a Jamieson inquest and a Middleton inquest—but do not worry: I will not weary your Lordships with all that.
It is critical for the purposes of the Bill to make it plain that throughout this mass of law down the years on the scope and purpose of inquests, one cardinal principle has remained intact:
“The function of an inquest is to seek out and record as many of the facts concerning the death as the public interest requires.”
That is a citation from a judgment of the then Lord Chief Justice, Lord Lane, in a case called Thompson way back in 1982.
I will mention one other case. The right reverend Prelate suggested that it was from 2018, but I think it was 2020. It is the case of Maughan in the Supreme Court. Here, by the narrowest of majorities—three to two—the Supreme Court finally decided on what had been differing views expressed over many years as to the standard of proof required for a coroner or a coroner’s jury to bring in a verdict or determination of suicide. It was established in Maughan that it is the civil standard, the “balance of probabilities”, not the criminal standard, “beyond reasonable doubt”.
In giving the judgment of the majority, Lady Arden, among much else—the judgments extend to some 40 pages—said:
“The criminal standard may lead to suicides being under-recorded and to lessons not being learnt … The reasons for suicide are often complex … There is a considerable public interest in accurate suicide statistics as they may reveal a need for social and medical care in areas not previously regarded as significant. Each suicide determination can help others by revealing how suicide risks may be managed in future.”
I suggest that the Bill is wholly consistent with that line of thinking. By the same token that it is important to get the standard of proof right, so as not to underreport suicides, so it is important to record as many of the relevant facts or factors as would ensure, in the public interest, that social evils such as problem gambling are not underrecorded.
I have formed no view about whether the precise language currently in the Bill could be improved. I refer in particular to where draft new Rule 35(1) refers to
“any factors which were relevant to the death”
and where draft Rule 35(2) refers to “an addiction to gambling”. Still less am I suggesting that any scheme of guidance such as the right reverend Prelate suggests may be forthcoming.
The important thing for now is that the Bill will ensure that, overall, the coronial process provides altogether more reliable figures than at present for assessing and thereby later, hopefully, assuaging the scale of this appalling social problem. We must give it a Second Reading.
Baroness Bennett of Manor Castle (GP)
My Lords, I rise, like other Members of your Lordships’ House, to first thank the right reverend Prelate for presenting us with the Bill and giving us such a clear outline of the reasons for it. We have had a very useful debate—I particularly note that the noble Baroness, Lady Meacher, stressed that this is about much more than gambling. The noble and learned Lord, Lord Brown, summed it up in quoting two words: this is about the “public interest”. This is about changing the law to ensure that the coroners’ courts act more in the public interest.
However, I will focus on the gambling industry aspects of this and declare my position as a member of Peers for Gambling Reform. As in the debate on the last Bill, I begin by reflecting on the political situation in which we find ourselves. There is a great deal of public concern about the impact of corporate lobbyists on government policy and decision-making. We have seen the gambling industry scream to previously unknown levels of economic returns and size as a result of deregulation that has happened over decades. It is obviously a very rich industry with a great deal of money—very often stashed in tax havens—and the public are watching this to see what happens and what controls will be put on this out-of-control industry that is causing so much damage to both individuals and communities.
Very often in your Lordships’ House, we hear about the Government’s levelling-up agenda. The poorest communities are suffering the most from the impact of the gambling industry being out of control. Taking control of the gambling industry would be a step towards levelling up.
However, I come to the very specific issue of the relationship between gambling and suicide. There was a useful report from Public Health England in 2019 on stakeholder perspectives on gambling-related harms. It says that the gambling industry, like other “unhealthy commodity industries” such as alcohol, tobacco and junk-food producers,
“frame health behaviours as complex problems as a strategy to argue against effective primary prevention policies”.
So, it is really important that the right reverend Prelate, in introducing this Bill, stressed that the complexity of suicide is understood. This is talking about a range of factors and recording what may well be one of a range of factors.
The report from Public Health England notes that the gambling industry often tries to shift the blame on to other addictions that problem gamblers might face, such as alcohol and drug abuse. Again, what the Bill allows for is an understanding of the complex interrelationship, but we also need to acknowledge, as the PHE report did, that the gambling itself might have led to the other addictions.
Looking again at the report, it is interesting to see the conclusions drawn by non-commercial stakeholders —people not from the industry. They call for a
“broadly adopted a public health perspective”
and
“action to treat gambling-related harms as a public health issue”.
It is worth stressing that the Bill will not cause any direct government action; it will not change policies in respect of the treatment of the gambling industry, nor will it directly improve treatment for people with gambling addiction or problem gambling more generally. However, if we can quantify the problem and if we simply had the information, that would create the evidence, which would surely be a powerful push against the force of the lobbying industry. How can we argue against having that information?
Others have referred to this, but we have to look at the actual numbers and see just how deep a concern this is. The charity Gambling with Lives believes that between 4% and 11% of suicides in the UK might be gambling-related—that comes from a report from 2020. The report of the Adult Psychiatric Morbidity Survey of 2007, which is one of the last extremely science-based, peer-reviewed-type studies that we have, concluded that, among people who had made a suicide attempt in the previous year, one in 20 were problem gamblers and another one in 20 were at-risk gamblers. So we get there to a total figure of about one in 10, which is very much in the range of the figure put forward by Gambling with Lives.
We also have to look to a study from 2019, published in the journal Addictive Behaviors, which suggested that the problem was getting worse and:
“A higher proportion of individuals entering treatment had attempted suicide in more recent intake years.”
It further stated that in
“each year since 2013, approximately 30% of individuals accessing treatment for gambling problems … have attempted suicide prior to starting treatment”.
There is a great deal of evidence there. It is of varying ages and comes from varying sources. I suggest to the Minister that bringing this evidence together through the coroners’ courts is a very obvious and simple step, and I hope we will hear a positive response from the Government to this debate.
Baroness Finlay of Llandaff (CB)
My Lords, I add my congratulations to those offered to the right reverend Prelate the Bishop of St Albans on all the work that he has done to shine a light on the devastation that gambling addiction has wreaked in our society.
I must declare that I am a patron of the Louise Tebboth Foundation, which aims to support the mental health of doctors, particularly those who are at risk of suicide. It has already been said that gambling addiction is often associated with other addictions, such as to alcohol, and sometimes with different types of substance abuse and abnormal behaviour such as sex addiction. There is a problem, too, of suicide contagion, of which we have had clear examples in our society at times.
The noble Baroness, Lady Bakewell of Hardington Mandeville, spoke about veterans from the Armed Forces. It has been suggested that the buzz that they get from gambling when they are traumatised mimics some of the buzz they got in the battlefield. Then they get the “down” afterwards and seek to compensate for that, so they become particularly at risk of the psychology of gambling.
We must recognise that coroners’ services have been poorly supported for many years. Inquests are often held in situations which are far from ideal to inquire into whether distressing background factors contributed to a person’s suicide. As has been said, the coroners have to establish who, when, where and how, through evidence, a person had taken the action to end their own life. The question of why they did so may be a speculative parameter on the evidence before them and may be difficult to piece together as factors from the things that a person left behind.
The coroners to whom I have spoken—I have had the privilege of attending the Coroners’ Society of England and Wales on a couple of occasions—do all they can to act in the public interest and to establish and recognise the burden of responsibility that sits very heavily on their shoulders. They are often conducting an inquest in the face of an extremely distressed family, with the family asking the question why. Known, obvious and contributory factors, including gambling, alcohol use, domestic abuse, financial problems, a raft of other things and perceptions of inadequacy, are often promoted through online platforms and the person may even have been goaded or manipulated into suicide. We have just debated the urgent need for age-assurance minimum standards in the Second Reading of my noble friend Lady Kidron’s Bill. I have to say that the Government’s response to it has been deeply disappointing.
There is clear evidence that loneliness is associated with many factors, including gambling addiction. Loneliness is associated with depression. A recent paper, published after a 12-year study, showed that about one-fifth of depression could be prevented if the loneliness and social isolation in our society were tackled.
Coroners take evidence in open court so it is very important that, should the Bill be adopted, speculative evidence of underlying causes is recognised to be important, but that it does not carry the same burden of proof as some other factors that coroners are asked to record. When someone has had a difficult life, the coroner will try to conduct the inquest in such a way as to give them dignity in death and help the family to celebrate their life and humanity, rather than focusing on the problems they lived with. That is not to deny the real problems in society, which are often multifactorial, leading to a person’s suicide, and an inquest in open court may make it very difficult to expose contributory factors. I wonder, therefore, whether the right reverend Prelate is right to think that it may be better to go for regulation and guidance than to enshrine this in primary legislation. There are many complex factors and coroners’ inquests are held in different places.
As well as that, we must change the language. We must stop talking of “committing suicide” and talk about “died by suicide”. The stigmatisation of “committing” is a hangover from the days when it was a criminal offence. Those days are long behind us, and how heartless they were, yet sui cide—self-killing—is what the action is. Some years ago, I undertook a study of suicide in patients receiving hospice care. We found a low incidence of suicide. It was no higher than in the rest of the population, and certainly lower than in other groups of patients. Suicide in cancer patients is generally compounded by chronic disease, advancing age, multiple losses and all kinds of reasons for their suffering. It is not possible to draw a direct causative link between one factor and another. The background to suicide is multifactorial in many circumstances.
When data on suicides is collected, there is a danger, if it is not classified hierarchically, of double counting, so such data needs to be presented very carefully. The multiple known factors may make it difficult or impossible to discern which was the main trigger, but unless we are able confidentially to record all known risk factors, we will not be able to tackle the public health disaster of suicide. When it comes to the overwhelming destruction from addiction, the sense of personal shame and the failure of social support, combined with demoralisation, can lead to the downward spiral that is the public health problem that we face today. As has been said, we just do not have enough data.
Baroness Greengross (CB)
My Lords, I thank the right reverend Prelate the Bishop of St Albans for this Private Member’s Bill, which raises many important issues, and for the very moving way he presented them. Too often when we look at mental health issues or suicide, we fail to look at the cumulative effects of things such as addiction to understand what has happened. Through collecting data on things such as gambling addiction, we get a greater understanding of the problem and, hopefully, can try to reduce the harm currently being caused.
Earlier this year, this House debated the Domestic Abuse Bill, when I and others raised concerns about the abuse of older people. One very common form of abuse against older people is financial abuse. Studies have shown a direct link between gambling addiction and financial abuse. A recent example of this was reported to Hourglass—formerly Action on Elder Abuse —where a grandparent aged 88 suffered economic abuse. In this case, their adult grandchild, who had both gambling and drug addictions, stole £100,000. However, that story is all too common, and we know that gambling addiction is one of the key motivators of financial abuse. Gambling is bidirectional: it can be a risk factor in both the perpetration and the victimisation of domestic abuse. A recent study by Australia’s National Research Organisation for Women’s Safety found that gambling was often a contributing factor in physical as well as financial abuse. This study also found that it was often older women who were the most vulnerable and had the least support.
We know that gambling addictions often lead to abuse, but we do not know how often this then leads on to suicide, either by those who have the gambling addiction or those who have been victims of abuse from someone with this addiction. A first step is to start collecting data on gambling addiction and suicide.
I briefly conclude by saying that I do not believe the solution to these problems is to ban gambling, any more than I think abuse, mental health issues or suicides caused by alcohol would be solved by alcohol prohibition. Instead, we need to have a better understanding of the harm it can cause and how we as a society best mitigate it. The first, important step in this is to collect relevant data.
Baroness Brinton (LD) [V]
My Lords, I add my congratulations to the right reverend Prelate the Bishop of St Albans on introducing this important Bill to your Lordships’ House. He helpfully outlined the scope of the Bill—that it starts only once a coroner has determined that death by suicide has occurred, and it requires the coroner to give their opinion on the underlying factors of suicide.
I am pleased that he also reminded your Lordships’ House that this is not just about suicides by people with gambling addictions. I am mindful of the families of young people who have taken their own lives, including Molly Russell, following encouragement from others on social media. This is a particularly unpleasant trend that has resulted in an increase in attempted and successful suicides in the past few years. That this Bill would require a coroner to also comment on underlying reasons for such suicides is important. My noble friend Lady Bakewell of Hardington Mandeville outlined that young men are the most likely to take their lives, but the right reverend Prelate is right to say that collection of data is vital, not just the ONS style of characteristics data, but also the softer, more underlying reasons for their suicide that would enable assistance to be targeted at people at risk.
The noble Baroness, Lady Meacher, reminded your Lordships’ House about those who know that they will die soon face and the problems they face without an assisted dying law. They are obliged, if they wish to, to kill themselves not just on their own but in a way that protects their loved ones from being involved in their death. The noble Baroness, Lady Finlay, was right to remind us of the higher level of suicides amongst doctors, service staff and veterans. Her arguments for how data need to be dealt with in a coroner’s court were extremely helpful.
All speakers have talked about the catastrophic effects of gambling on individuals and wider society, as well as the estimated number of gamblers. The noble Baroness, Lady Greengross, talked of the importance of harm reduction, especially with the links between gambling problems, violence and financial abuse, especially domestic and familial.
The noble Baroness, Lady Bennett, reminded us of officials deciding whether it was gambling or addiction to drugs and/or alcohol that caused the individual to end their life. The problem of the addiction and the mental health difficulties that arise from that is key. There is a particular additional problem with gambling because of the compulsive need to continue to source more and more money to fund the addiction. That is why this is a public health emergency.
From these Benches, we are clear that there need to be further measures to protect individuals, their families and communities from problem gambling. Our party policy is to see a compulsory levy on gambling companies to fund research, education and treatment of problem gambling, and also to ban the use of credit cards for gambling.
In September last year, the parents of Jack Ritchie succeeded in widening his inquest to look at support for addicts and industry regulation. However, the journey they had to travel to get the coroner to agree to that is deeply shocking, and explains exactly why the right reverend Prelate the Bishop of St Albans is right to bring forward this Bill. Lawyers for the Government and the gambling regulator had sought to persuade the coroner that the death of Jack Ritchie from Sheffield could be dealt with in a 15-minute inquest without any discussion of possible state failures.
The parents were asking for three key areas of investigation. This would have been impossible in the short inquest proposed, which would have confirmed only that he had died by suicide. The first was how Jack’s gambling addiction was treated in the UK and whether he had been sufficiently warned of the risks. The second was to explore any shortcomings in the Government-backed regulator, the Gambling Commission, and how the industry had been regulated when he became addicted. Both of these issues were granted by the court. The third was not, but it is perhaps the most significant. The parents wanted the inquest to look at the failures of UK authorities to treat gambling issues and how those directly contributed to Jack’s death.
It is extraordinary that the Government and the Gambling Commission fought against the parents asking for that information. If the Government, the Gambling Commission and gambling companies had this underlying data available, I suspect it would spur them to action to help reduce the problem.
There is another point that I have not heard discussed in today’s brief debate: the cost to the public purse arising from a suicide by someone who has gambled. The public health evidence review mentioned by other noble Lords, which was updated this year, notes in the section on mental and physical health harms that:
“The overall estimated excess cost of health harms is estimated to be £961.3 million. This is based on the direct costs to government of treating depression, alcohol dependence and illicit drug use, as well as the wider societal costs of suicide.
The estimated excess cost of suicide is £619.2 million (with 95% confidence that the precise estimate is between £366.6 million and £1.1 billion), based on the wider social costs of an estimated 409 suicides associated with problem gambling.”
This includes things such as benefits that surviving families will have to access. I will repeat that: of the total estimated health costs of £961 million, £619 million is ascribed to the excess cost to society of suicide. That is for an estimated 409 suicides.
As much as this is a real and personal tragedy for the people who have taken their lives and the families and friends that are left behind, this is also a real public health emergency that is costing the NHS and other public services a large amount of money. The loved ones of the person who has died deserve to know if there were underlying issues that led to the suicide. The Government, Parliament and the country need that information too, as the noble and learned Lord, Lord Brown, emphasised, to ensure that targeted interventions can be made to provide help and support. I do not think anyone minds whether the Bill progresses or this ends up as a regulation, but the clear message is that we need that data to deal with this crisis.
Lord Ponsonby of Shulbrede (Lab)
My Lords, I thank the right reverend Prelate for introducing this Bill. It would enable coroners to record gambling addiction as a relevant factor when recording a suicide.
At present, according to the Library Note, data on the correlation between problem gambling and deaths by suicide remains limited. As we have heard, Public Health England’s recent review concluded that problem gambling should be seen as a public health issue. As the right reverend Prelate has said, the purpose of this Bill is to better understand gambling-related suicide and its victims. This will help to inform future policy and more appropriate medical interventions aimed at treating problem gambling. I would be interested to hear from the Minister what progress has been made since the right reverend Prelate introduced his previous Bill, in January 2020.
The Bill would make changes via amendments to the Coroners and Justice Act 2009 and the 2013 rules. These rules provide a national framework for current good practice. From the Library Note, the chief coroner’s current guidance states that the conclusion of a hearing, or verdict,
“should be based on facts and must not include the coroners or jury’s opinion, other than on those matters which the law allows”,
such as the identity of the deceased and when and where they had died. The mechanism of death can be recorded as “suicide”, rather than the broad circumstances of the suicide. The right reverend Prelate showed a coroner’s form, where he gave various examples of things that can be recorded, but this did not include gambling-related harm.
The report by PHE shows that the people most at risk of harmful gambling are concentrated in areas of higher deprivation and are likely to already be experiencing greater health inequalities. The Government’s rhetoric is that of levelling up, so surely this should include a better understanding of the effects of gambling on suicides. This was a point made by the noble Baroness, Lady Bennett.
A significant proportion of the population gamble. Most do it as an occasional hobby that is enjoyable, social and fun—I occasionally gamble. However, for a worryingly high number of people, particularly young people, it can lead to harm. Researchers believe that online gambling carries a higher risk of harm; that is based on figures from before the pandemic and lockdowns, and there is every reason to believe that the situation has deteriorated as a result of the lockdowns. Free betting introductions are relentlessly promoted online, through our leading sports teams and international advertising. It is a whole world of excitement, risk and glamour, which sucks people in for an occasional triumph—or probably another loss.
There have been a number of studies seeking to link problem gambling and suicide. The Library Note mentions a 2019 study by the Gambling Commission and GambleAware, which concluded that there is a link. However, the study was based on data from 2007—the noble Baroness, Lady Bennett, referred to that data—and it was recommended that further and better data should be made available. Also, there was a Lancet journal article in 2021, concerning young people and gambling, which pointed towards a link between problem gambling and suicide. Many Peers have referred to the PHE review, which considered a host of gambling harms, including suicide, and recommended that this should be seen as a public health issue.
I want to introduce a note of scepticism into this debate, and I hope my scepticism can be seen as constructive. I am a long-standing member of the all-party group on drugs and alcohol, and, on a few occasions, we have had speakers from the ONS talk to us about the recording of deaths from drug overdoses. The figures show that about double the number of men die from drug poisoning than women, and that, roughly speaking, there are three times as many male suicides as female suicides.
However, the point I took from the ONS speakers at the all-party group was the difficulty in recording reliable data over time because of the changes in the recording mechanism. So, although the headline conclusions are stark, there is genuine difficulty in seeing the impact of different types of drugs leading to deaths, for example. In fact, I think it is fair to say that the more one goes into the detail of the data regarding drug deaths, the more difficult it is to draw sound conclusions. So I wonder what the right reverend Prelate thinks should be recorded in the case of a suicide. Should it be the opinion of the jury, the coroner, the doctor or the family and friends that gambling was a factor in the suicide? What about other factors, such as drug and alcohol use, mental health, family break-up and physical health? The list goes on. This is essentially the point made by the noble Baroness, Lady Finlay.
My point is that gambling does indeed seem to be a factor in many suicides, but how to quantify that on a statistical basis is a difficult question that would, and should, have an enduring effect on government health policy. I do not know what the Minister is going to say, but I hope she will use her influence to get the ONS, or perhaps another government body, to look at the substance of the right reverend Prelate’s proposal and either respond positively to the Bill or tell us that regulational guidance is a more appropriate way forward.
Turning to the various speakers in today’s debate, I was amused to hear about the noble and learned Lord, Lord Brown, placing 10 straight bets at a casino in Cannes and losing all 10. That may well have been the luckiest day of his life. I was also particularly sympathetic, if that is the right word, to the point made by the noble Baroness, Lady Bennett, about the way in which the gambling industry seeks to argue its case in this arena by pointing to the complexity of the issue. In a way, I have been pointing to the complexity of the issue—I understand that—and, in a sense, it is muddying the waters. But that is not a reason for not making progress; it is a reason for acknowledging the complexities and trying to come up with a good, statistically based approach to recording the data.
Finally, I wish the right reverend Prelate a very happy International Men’s Day today.
Baroness Scott of Bybrook (Con)
My Lords, I congratulate the right reverend Prelate the Bishop of St Albans on bringing forward this Bill and securing its Second Reading. I thank all noble Lords who have participated in what I consider to have been a considered and thought-provoking, if not complex, debate.
This legislation would require a coroner or inquest jury to record gambling addiction, and any other relevant factors, in a case of death by suicide. As a member of the Lords Gambling Industry Committee, I know that the right reverend Prelate has been a staunch advocate in advancing this Bill to help us to understand the impact of gambling on mental health and gambling-motivated suicide.
At the outset, I have to say that the Government are absolutely determined to prevent gambling-related harm and suicide. Gambling is one of our society’s major ills. It causes untold misery and distress to countless families across this land. The Government recognise that gathering quality information on the circumstances leading to self-harm and suicide, including gambling issues, can help prevent future deaths and support better outcomes. However, we do not agree that this Bill will achieve the desired effect as intended.
During the course of their investigation, a coroner may be made aware of motivating or contributory factors in a suspected suicide. However, the legislation is clear on the coroner’s jurisdiction, which does not include determining why, in the sense of deeper or more sociological explanations, someone died. Under Section 5 of the Coroners and Justice Act 2009, the scope of the coroner’s investigation is to determine who died and how, and when and where they died. “How”, in most cases, equates to “by what means”. The investigation is designed to be a limited and proportionate fact-finding exercise, and under Section 10 of the 2009 Act, coroners are prohibited from appearing to determine any question of criminal liability against another person or civil liability.
If the Government were to support this Bill and change the scope of what the coroner would determine, to include why a person took their life, this would also have to apply to all other types of inquest conclusions. As many noble Lords have noted, including the noble Baronesses, Lady Meacher, Lady Bakewell of Hardington Mandeville, Lady Finlay and Lady Greengross, there are many multifactorial reasons and complexities within the Bill that has been put forward—changes that would cover veterans, terminal illness and addictions. As the noble Lord, Lord Ponsonby, clearly said, it is a very complex area of recording for the coroner.
In addition, it would be impractical or difficult for coroners to collect consistent data on identifying whether a gambling addiction or other reasons were factors in a person’s suicide. While a coroner may be made aware during the course of their investigations of information about the motivation or contributory factors in a suicide, this will not always be the case. Medical practitioners may apply different criteria in determining whether they consider gambling a factor in a death, and not all deaths which the coroner investigates, including deaths by self-harm or suicide, are notified by a medical practitioner. The coroner may gain information from a wider range of sources—family, partners, friends and police—who might mention gambling as an issue when understanding the circumstances of the death. The data collated would therefore be incomplete at best, inconsistent in quality and not useful for delivering the interventions needed in this space.
While the Government understand the good intentions behind the right reverend Prelate’s Bill, unfortunately we are unable to support it. Nevertheless, we remain committed to tackling gambling-related harms and understanding the wider lifestyle factors associated with gambling addiction that impact on individuals’ poor mental health and well-being. Indeed, the Government are tackling the issues that the right reverend Prelate aims to address with the Bill by other means. In March, the Government published their fifth progress report against the national suicide prevention strategy. This included a refreshed cross-government suicide prevention work plan that included factors such as gambling. The Government recognise that the need to address gambling-related harms is a public health issue. There is also a continued government focus on expanding and improving mental health services so that 2 million more people can access support by 2023-24.
There has also been an increase in funding for suicide prevention through the NHS long-term plan, with an additional £57 million by 2023-24 to support local suicide prevention plans and develop suicide bereavement services in every area of the country. In addition, Public Health England—now the Office for Health Improvement and Disparities—and the Local Government Association have published guidance for local authorities on tackling gambling-related harm, encouraging public health teams to consider the potential links between their work on suicide prevention and harmful gambling. The Government have worked to ensure that every local authority has a multiagency suicide prevention plan in place and the Department of Health and Social Care is providing funding to support local authorities to strengthen those plans.
On gambling specifically, the NHS long-term plan has committed to expand the geographical coverage of NHS services for people with serious gambling problems. In addition to the existing National Problem Gambling Clinic in London, the NHS has committed to opening an additional 14 new gambling clinics in 2023-24.
On 30 September Public Health England published the first ever comprehensive review of the evidence on gambling-related harms and their impact in England, which will be considered in the Government’s Gambling Act review. In October the Department of Health and Social Care launched the new Office for Health Improvement and Disparities, with the aim of tackling health inequalities across the country.
In addition, the Department for Health and Social Care has commissioned NHS Digital to procure the 2022 adult psychiatric morbidity survey. A consultation on the content of this survey has been carried out, which considered the inclusion of questions on gambling. This may answer one of the questions that the right reverend Prelate asked. The survey could help establish the prevalence of suicidal tendencies linked to gambling and improve the existing evidence base. The consultation findings have been published, and the survey team is now liaising with experts on problem gambling to decide the best measures to use. Content for the adult psychiatric morbidity survey will be finalised in due course.
The Government are also delivering on our manifesto commitment to review the Gambling Act 2005. The review launched with a wide-ranging call for evidence last year and we will publish a White Paper in the coming months. The review aims to ensure that the framework for gambling regulation is right for the digital age and that people are protected wherever they are gambling. Together, all this presents a unique opportunity to bring together policy and evidence experts to support the development of effective and implementable responses to gambling-related harms.
In May 2021 the Justice Committee published the report of its inquiry into the Coroner Service. During the course of its inquiry, the committee received a wide range of written submissions and oral evidence from a large number of stakeholders, which led to 25 recommendations for the Government to consider, of which five were for the Chief Coroner. However, the issue raised in the Bill was not considered by the committee in its detailed report.
I will try to answer one or two questions that noble Lords asked, but I will also go through Hansard next week and write to anyone whose question I have not answered. First, to the noble Baroness, Lady Finlay of Llandaff—whom I thank for her support of the Coroner Service—coroners do try to increase dignity in death; that is very important to them. They also spend time and have the resources to support the families of the bereaved. I am happy to write in more detail if she would like, but that is an important part of their work and I thank her for saying how well they do it.
The noble and learned Lord, Lord Brown of Eaton-under-Heywood, cites a judgment in Thompson that suggests a wider scope for the coroner’s investigation, but the coroner’s investigation is not wide-scoped. It is a summary hearing to determine only four statutory questions: who died, how, when and where—not why. I am happy to send further information on that if the noble and learned Lord would like me to.
The noble Baroness, Lady Brinton, brought up the complexities of this issue. She asked that the coroner should, essentially, provide softer data, but that would be quite difficult and, as I have said a number of times, is out of the scope of the coroner’s responsibilities. She also said, as did many noble Lords, that it is not always just about gambling; it is a complex issue and can be about personal relationships, addiction, mental health issues et cetera. That is why the Government feel that it is not the responsibility of the coroner to look into all of that. I cannot comment on the Ritchie case as we do not comment from the Dispatch Box on individual cases.
I think I have answered all the questions and will end on a lighter note. The right reverend Prelate showed me a form. My officials say that they do not know of this form. We will have a look at it, but we rather think that it is that particular coroner who produces that form.
I assure noble Lords that, while the Government cannot support this Bill, we remain committed to understanding the circumstances that lead to self-harm and suicide, including gambling. We recognise that there is more work to do to reduce it, and we recognise the devastating impact of gambling-related suicide. We feel that we have a programme in place to do just that.
The Lord Bishop of St Albans
I thank the Minister for her response and I am glad to hear that more attempts are being made to find out the data for us. I have been involved in this area for six or seven years now, and it feels as though the Government are constantly dragging their feet—as though we are having to pull them along. I am currently in contact with the Ministry of Defence. We have had to ask endless questions to try to find the information that we want; in fact, the MoD is putting down a Statement today because it has got confused too. This is an area that is not being attended to by Her Majesty’s Government.
I am grateful to all noble Lords, who have brought out some really interesting points; I have made notes. I am hugely grateful and will think about those things. I would say to the noble Lord, Lord Ponsonby, that, as I understand it, it is down to the coroner or jury to record a relevant opinion. Although the Minister said that she did not recognise this form, the coroner who gave it to me said, “All of us coroners starting out are using this; it is the old ones who won’t do it.” She was quite frustrated about it. I will go back and find out more information.
From what I can see, we are already recording this data. I know that the law is all about where, who, how and when—not why—but we have some of the “whys” already. We use “whys” widely in the world of medicine. It is complicated but, when we bring forward, for example, regulations to do with finance, and there is complexity, we just get our heads down and get our minds around the complexity. We do not say, “Because it is difficult, we are not going to try to do it.”
I do not pretend to know the best way of doing it. I would be hugely grateful if those of your Lordships who are much more expert in this could point me to the relevant people. I particularly like the idea of talking with others who also want this sort of data; I think there would be quite a groundswell of people saying that, while it may not be perfect, this form of data could give us some helpful ways forward. I am, of course, disappointed that Her Majesty’s Government cannot support the Bill. I will think very carefully about the points that have been made, but I will be minded to take this on to the next stage and work with others if they are willing to work with me.
Coroners (Determination of Suicide) Bill [HL]
Wednesday 2nd March 2022
(2 years, 8 months ago)
Lords ChamberRead Full debate Coroners (Determination of Suicide) Bill [HL] 2021-22 Read Hansard Text
The Lord Bishop of St Albans
My Lords, I understand that no amendments have been set down to this Bill and that no noble Lord has indicated a wish to move a manuscript amendment or to speak in Committee. Unless, therefore, any noble Lord objects, I beg to move that the order of commitment be discharged.
Coroners (Determination of Suicide) Bill [HL]
Friday 25th March 2022
(2 years, 8 months ago)
Lords ChamberRead Full debate Coroners (Determination of Suicide) Bill [HL] 2021-22 Read Hansard Text Read Debate Ministerial Extracts
The Lord Bishop of St Albans
My Lords, I shall make just one or two brief comments. I am sure everybody is greatly relieved that the timing is going so well this afternoon, and I really shall not delay your Lordships for too long, but this gives me an opportunity to say one or two brief things and then give some thanks.
The reason behind the Bill is that, seven or eight years ago, a couple came to see me, sat in my study and told me how their son had taken his life because of a gambling problem. The sad thing about that story was the way they talked about the fact that they could see what was happening. He had gone in and out of treatment, but they just could not reach out to him. They knew what was going to happen, and they watched as he slowly spiralled down until that fateful day when he took his life. That led me on a journey. Eventually, we managed to get a Select Committee here. As your Lordships may be aware, Peers for Gambling Reform is now, I think, the largest lobbying group in the House of Lords.
That is what inspired me to work on this; that is the background. It is a very human story. The Bill has what sounds a rather calm, dispassionate title. The issue before us is that, whenever we try to grapple with this, we are told by the Government that we simply do not know the nature and size of the problem. Last year, Public Health England gave the most comprehensive estimate to date of the number of annual gambling-related suicides: 409 in one year. That accounts for 8% of all suicides in 2020.
In the recent inquest into the tragic death of Jack Ritchie, the coroner’s conclusion was that warnings, information and treatment of problem gambling had been “woefully inadequate” and failed to meet Jack’s needs. The coroner said that he could not be blamed for his gambling problem. That brought home to many of us something that we already knew: that many of these online products have been designed to be addictive and are having a devastating impact on people. The suicide headline is just the tip of the problem, but it is the most dreadful part of it.
I have learned an awful lot from putting the Bill forward. I am grateful for the help I have had from other Members of the House, but particularly from the Minister, who very kindly met with me. He has been very honest about the problems he sees with it, and I understand that. If we had had time, I would have brought amendments to address some of those points. I intend to put another Private Member’s Bill in the ballot for the next round, which will be a much broader Bill that will pick up many of the concerns of coroners, some lawyers, and indeed the Government.
Fundamentally however, my motivations behind the Bill have not altered. Suicide is a terrible thing and the best way to tackle it is to identify the underlying causes and put in strategies to address them. So I am grateful for all those who have helped it get this far and I will be returning to this later on. However, with those final words I draw to a close.
Lord Ponsonby of Shulbrede (Lab)
I too have no wish to delay the House, but I will say a couple of words to congratulate the right reverend Prelate on the progress he has made with the Bill and on his expressed wish to take the matter further with a further Private Member’s Bill. My experience of Private Members’ Bills is certainly that it is an attritional process that he is engaged in, and I am glad to hear that he is working constructively with the Minister. As we heard in the earlier debate, the Minister is very keen on data and he will no doubt be focusing his question—if I can put it like that—on how the coroners’ service can address the concerns which the right reverend Prelate has quite rightly raised.
The right reverend Prelate told a very moving story when he introduced the debate today and gave some statistics on the reality of addictive online gambling products. I have to say that anyone who has had anything to do with young men will know that such products are absolutely ubiquitously used, and there are all sorts of ways of enticing people into gambling further. So I wish the right reverend Prelate—and the Minister—well with future Private Members’ Bills.
The Parliamentary Under-Secretary of State, Ministry of Justice (Lord Wolfson of Tredegar) (Con)
My Lords, I too have no wish to delay the House but, like the noble Lord, Lord Ponsonby of Shulbrede, I also thank the right reverend Prelate the Bishop of St Albans for highlighting this important issue and enabling us to have the time in the House today. I thank him for giving me his time earlier in the week. With all respect to other meetings which I had during the week, that was one which I found really interesting and from which I learned a lot.
I will say word about the legislation and, as the right reverend Prelate indicated, the Government’s approach. The legislation would require a coroner or inquest jury to record gambling addiction and any other relevant factors in a conclusion of death by suicide. Of course, the Government endorse the sentiment behind the Bill and recognise the importance of gathering quality information on the circumstances leading to self-harm and suicide, including the role that gambling can play. However, the Government do not agree that these proposals are the appropriate way to tackle the issue. As my noble friend Lady Scott set out at Second Reading, they would result in a significant expansion of the coroner’s jurisdiction to identify the perceived reason—the “why”—behind an individual’s suicide death, and we do not consider this to be appropriate for the fact-finding summary process of a coroner’s investigation, which is really focused on the hard factual questions of who, where, how and when. We also have a concern that information gathered in this way would likely be both incomplete and inconsistently obtained and therefore would not provide a sound basis for delivering the interventions needed to secure improved outcomes in this important area.