Mental Health and NHS Performance Update
(Limited Text - Ministerial Extracts only)
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The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, with permission, I will repeat a Statement made by my right honourable friend the Secretary of State in the other place. The Statement is as follows.
“This Government are committed to a shared society in which public services work to the highest standards for everyone. This includes plans announced by the Prime Minister this morning on mental health. I am proud that, under this Government, 1,400 more people are accessing mental health services every day compared to 2010 and we are investing more in mental health than ever before, with plans for 1 million more people with mental health conditions to access services by 2020. But we recognise that there is more to do, and will proceed with plans to further improve mental health provision, including: formally accepting the recommendations of the independent Mental Health Taskforce, which will see mental health spend increase by £1 billion a year by the end of the Parliament; a Green Paper on children and young people’s mental health to be published before the end of the year; enabling every secondary school to train someone in mental health first aid; a new partnership with employers to support mental health in the workplace; up to £15 million extra invested in places of safety for those in crisis following the highly successful start to this programme in the last Parliament; an ambitious expansion of digital mental health provision; and an updated and more comprehensive suicide prevention strategy. Further details of these plans are contained in the Written Ministerial Statement laid in the House this morning.
However, turning to winter, as our most precious public service, the NHS has been under sustained pressure for a number of years. In just six years, the number of people over 80 has risen by 340,000, and life expectancy has risen by 12 months. As a result, demand is unprecedented: the Tuesday after Christmas was the busiest day in the history of the NHS, and some hospitals are reporting that A&E attendances are up to 30% higher compared to last year. I therefore want to set out how we intend to protect the service through an extremely challenging period and sustain it for the future.
First, I would like to pay tribute to staff on the front line: 1.3 million NHS staff, alongside 1.4 million in the social care system, do an incredible job which is frankly humbling for all of us in this House. An estimated 150,000 medical staff, and many more non-medical staff, worked on Christmas Day and New Year’s Day. They have never worked harder to keep patients safe, and the whole country is in their debt.
With respect to this winter, the NHS has made more extensive preparations than ever before. We started the run-up to the winter period with over 1,600 more doctors and 3,000 more nurses than just a year ago, bringing the total increase since 2010 to 11,400 more doctors and 11,200 more hospital nurses. The NHS allocated £400 million to local health systems for winter preparedness; it nationally assured the winter plans of every trust; it launched the largest ever flu vaccination scheme, with over 13 million people already vaccinated; and it also bolstered support outside A&Es, with 12,000 additional GP sessions offered over the festive period.
The result has been that this winter has already seen days where A&E departments have treated a record number of people within four hours, and there have been fewer serious incidents declared than many expected. As Chris Hopson, head of NHS Providers, said, although there have been serious problems at some trusts, the system as a whole is doing slightly better than last year. However, there are indeed a number of trusts when the situation has been extremely fragile. All of last week’s A & E diverts happened at 19 trusts, of which four are in special measures. The most recent statistics showed that nearly three-quarters of trolley waits occurred in just two trusts. In Worcestershire in particular there has been a number of unacceptably long trolley waits and two deaths reported in the media while patients were in A&E. We are also aware of ongoing problems in the North Midlands, with extremely high numbers of 12-hour trolley waits.
Nationally, the NHS has taken urgent action to support these trusts, including working intensively with leadership and brokering conversations with social care partners to generate a joined-up approach across systems of concern. As of this weekend, there are some signs that pressure is easing both in the most distressed trusts and across the system. However, with further cold weather on the way this weekend, a spike in respiratory infections and a rise in flu, there will be further challenges ahead.
NHS England and NHS Improvement will also consider a series of further measures which may be taken in particularly distressed systems on a temporary basis at the discretion of the local clinical leaders. These may include: temporarily releasing time for GPs to support urgent care work; clinically triaging non-urgent calls to the ambulance service for residents of nursing and residential homes before they are taken to hospital; continuing to suspend elective care, including, where appropriate, suspension of non-urgent out-patient appointments; working with the CQC on rapid reinspection where this has the potential to reopen community health and social care bed capacity; and working with community trusts and community nursing teams to speed up discharge. Taken together, these actions will give the NHS the flexibility to take further measures as and when appropriate at local level.
However, looking to the future, it is clear we need to have an honest discussion with the public about the purpose of A&E departments. There is nowhere outside the UK that commits to all patients that it will sort out any urgent health need within four hours. Only four other countries—New Zealand, Sweden, Australia and Canada—have similar national standards, which are generally less stringent than ours. This Government are committed to maintaining and delivering that vital four-hour commitment to patients. But since it was announced in 2000, there have been nearly 9 million more people visiting our A&E departments, up to 30% of whom NHS England estimates do not need to be there, and the tide is continuing to rise.
If we are going to protect the four-hour standard, we need to be clear it is a promise to sort out all urgent health problems within four hours, but not all health problems, however minor. As Professor Keith Willett, NHS England’s medical director for acute care, has said, no country in the world has a four-hour standard for all health problems, however small, and if we are to protect services for the most vulnerable nor can we. So NHS England and NHS Improvement will continue to explore ways to ensure that at least some of the patients who do not need to be in A&E can be given good alternative options, building on progress under way with the streaming policy in the NHS England’s A&E plan. This way, we will be able to improve the patient experience for those with more minor conditions who are currently not seen within four hours as well as protect the four-hour promise for those who actually need it.
Taken together, what I have announced today are plans to support the NHS in a difficult period but also plans for a Government who are ambitious for our NHS, quite simply, to offer the safest, highest-quality care available anywhere for both mental and physical health. But they will take time to come to fruition, and in the meantime all of our thoughts are with NHS and social care staff who are working extremely hard over the winter, and throughout the year, both inside and outside our hospitals.
I commend this Statement to the House”.
Baroness Walmsley (LD)
My Lords, I also welcome the Minister to his first appearance in his new role. I add thanks from these Benches to all the health and care staff who gave up their Christmas holidays to care for patients.
We welcome the Prime Minister’s attention being turned to mental health, and the emphasis on the roles of schools and the workplace. The NHS of course cannot do the job alone. However, many people are not getting mental health treatment, getting it late, not getting the right treatment or getting it many miles from home, which prevents their families and friends supporting them. As the noble Lord, Lord Hunt, said, the money is not getting through to front-line mental health services, despite the £1.4 billion secured from the previous Chancellor by my right honourable friend Norman Lamb when he was coalition Health Minister. Why is that?
Is it not true that if there were not a shortage of funding for other services, CCGs would not be tempted to raid the mental health budget? That is what they are doing. FOI requests by Young Minds, as has been mentioned, show that half of CCGs are using money allocated to children’s mental health to prop up physical health services, which are also in crisis. That is wrong. A recent survey of child and adolescent psychiatrists show that a whopping seven out of 10 of them thought that mental health services for children and young people were inadequate. By any calculation, that is a national disgrace.
Will the Minister ring-fence the money that has been promised to mental health and improve transparency with the publication of the mental health dashboards, which are meant to show how much is being spent on mental health services in every area and on what services? The £1 billion that has already been announced for adult mental health is back-loaded to the end of the Parliament. Will the Government bring it forward to deal with the current crisis? Will they at last acknowledge that there must be a cross-party discussion about how to raise the money needed for health and social care? Will they ensure that the lessons learned in Manchester about integration are spread to other areas? That could save money and provide better service. Will the Government provide more funding for social care? As the noble Lord, Lord Hunt of Kings Heath, has said, without that, nothing will improve.
To return to mental health, I acknowledge that funding is not the whole story. The main point of the report from the values-based CAMHS commission, chaired by my noble friend Lady Tyler of Enfield, was that there needs to be a shared set of values and a shared language across all those involved with children and young people’s mental health, thereby enabling the system to have widespread change and a far more joined-up response to mental health issues. Does the Minister agree with that? How could it be achieved?
Lord O'Shaughnessy
My Lords, I thank noble Lords for their kind welcome. First, on mental health, which is clearly the subject of the Prime Minister’s Statement today, I think this is a good news day for mental health services. We know that this part of the system has suffered from not being seen by some people as as important as physical health. We have now legislated for parity of esteem, but of course parity of esteem comes about through practice, not just through law, and part of that is about a series of changes to ensure that this is a high-quality system that is available not just for some but for all.
With regard to performance, there is a lot of strength within the system. My predecessor, my noble friend Lord Prior, whose abilities I pay warm tribute to, would always say that there is lots of innovation and quality in the health service. One of the challenges that we face is diffusion. Part of the purpose of the strategy today is about taking best practice and moving it around the system. There is good practice. We have fantastic dementia diagnosis rates, the IAPT system is being copied by other countries and we have a record number of psychiatrists.
As someone who has spent the best part of 15 years working in schools, I think we finally have recognition that something significant and serious is going on with our young people that needs a new approach. With the promise of a Green Paper on children and young people’s mental health, I am optimistic that we have an opportunity to deliver what the noble Baroness said—getting everyone who cares about this subject around the table and making sure that we deliver the kind of strategy that is going to do two things. The first is to help schools and young people to identify mental illness where it exists and to access treatment; the second and, arguably, more important, is to build resilience so that young people are better able to resist the various pressures that they are under and to stay in good mental health, because that is our ultimate goal.
There is £1 billion to implement the plan. It is reasonable to ask how it will get to the front line; clearly, this money should not be being diverted to other services. The noble Baroness said that transparency was critical here. CCGs need to report in a much more detailed, open and honest way about where that money is being spent, so that we can ensure that it is going to front-line mental health services.
There is a challenge every winter; that is not unique to this Government. The Statement pays tribute to the incredible work of the staff in the NHS and social care system, and I add my voice to that. They are working at an extraordinary level and under a lot of pressure. Clearly, unacceptable things are going on, such as trolley waits of more than 12 hours. The key is being prepared and, where there are problems, working out what to do about them. The NHS has been well prepared for this winter, with £400 million going into preparedness plans, which it has tested to ensure that they are robust. Although I have been in the department for only five days, judging by the interest, passion and application of Ministers and officials, I can say that a close eye is being kept on this not just in the department but in NHS England and NHSI. As we say in the Statement, we will continue to support trusts to deal with challenges, particularly in fragile areas—some of which, as the noble Lord, Lord Hunt, said, we have known about for some time. Help is going in.
On social care, there was more money in the Autumn Statement, which I am sure was welcome, and a change to front-load the precept, which will make a difference, and we have the better care fund, so funding is increasing. However, more people are accessing the service, and we know why: because of the demographic pressures. Since 2010 there are now some 1 million more over-65s, so the system needs the extra support the Government have provided. The noble Baroness was quite right when she talked about integration. One opportunity that we have in the five-year forward view through the sustainability and transformation plans is the creation of much better integrated systems which focus not simply on the number of beds, although that is important, but on delivering the best outcomes. As we know, lots of people in hospitals would be better cared for if they were in the community or at home. One challenge that we face is ensuring that those patients who would be better treated in that environment have the opportunity to move out, freeing up those beds for those who need them.
We are committed to the four-hour target, as my right honourable friend outlined in the Statement, and have delivered many more doctors and nurses to ensure that we can deliver a high-quality service. We are dealing with 9 million more visits to A&E every year than we were in 2000. We need to ensure that we are delivering a service which continues to provide the best quality care in whatever setting is most appropriate, and never lose sight of the fact that A&E is there for a specific purpose, particularly for the support of the most vulnerable. About a quarter of A&E admissions are from the over-65 age group, which is growing, so this will get more challenging.
On the specific issue in Worcestershire, it is of course a terrible tragedy. The trust and NHS Improvement are investigating, and I do not think it would be appropriate for me to comment at this time, other than to say that we will be watching very closely what happens as a consequence of those investigations. Plans are already in place to support the trust and ensure that it can improve, but it is not appropriate for me to comment on the specific deaths that occurred.
We know that additional resource is not just about money; it is about service configuration and how we deliver a better service. We are providing £10 billion more in real terms to the NHS over the course of this Parliament. That is what we were asked to deliver, and that is what we are delivering, in concert with NHS England. It is the responsibility of everyone within the system to ensure that we deliver the best possible service.
Lord Ribeiro (Con)
My Lords, from these Benches I welcome my noble friend to his new position on the Front Bench and pay credit, as he did, to the work that the noble Lord, Lord Prior, did before him.
The Statement suggests that, during this period of exceeding challenge to the hospital sector, with clinical leaders attempts will be made to,
“suspend elective care, including, where appropriate, suspension of non-urgent out-patient appointments”.
I was rather distressed to hear on the “Today” programme of a patient with oesophageal cancer having either his treatment or his admission delayed—it sounded like it was his admission. As a surgeon, I felt particularly uncomfortable about that. I hope that the Minister can give some reassurance that when it comes to treating patients with cancer, irrespective of the pressures a hospital is under, provision must be made to admit those patients, because any delay can have a long-term effect on them.
Although I accept that there have been 11,400 more doctors since 2010—and that is a very reassuring figure—we must also remember that the intake into medicine has changed significantly over the past 10 or 20 years. There is now probably a majority of female doctors coming into medical school, so the workforce is feminising and changing. Whether we like it or not, many of them will have children, will have family commitments and will wish to work part-time, or less than full-time. When we talk about numbers, it is important that we talk about whole-time equivalents rather than the ballpark figure. It looks like a lot of doctors coming into the system, but we must take into consideration that many of them will work less than full-time, so we may well need to increase the medical workforce, perhaps asking them to work in a different way than they do currently.
I would be grateful if the Minister would comment on that, but I welcome his comments about mental health. I hope that greater provision will be made to ensure that patients with mental health issues have as much support as possible, as he said.
Lord O'Shaughnessy
I am grateful to my noble friend for his kind words of welcome. On the specific issue raised on the “Today” programme, which I believe is the subject of a documentary, and how it relates to the Statement made by my right honourable friend, there is an important distinction, which is that it is at the discretion of local clinical leaders. It is not a blanket mandate to delay treatment where the ethical and clinical responsibilities of those treating a given patient require it to be done speedily.
On the issue of the workforce changing, I take my noble friend’s point about what in the education world we called FTEs—full-time equivalents—and will make sure that the workforce figures I use are always expressed in those terms.
Lord Kakkar (CB)
My Lords, I declare my interest as chairman of University College London Partners, and join others in welcoming the Minister to his new responsibilities. With regard to the current performance in accident and emergency departments, part of the explanation in the past has been the lack of access to and availability of primary care services. What thought have Her Majesty’s Government given to the potential for the provision of GP primary care services within accident and emergency departments? How is that work going forward and how might it be integrated with the broader provision of primary care services in the community?
Lord O'Shaughnessy
I thank the noble Lord for that question; he speaks with a great deal of knowledge and wisdom on the subject. Clearly, to ensure that we have the best possible services, the system needs to be as flexible as possible to local requirements. As is already happening in some areas, having GPs in A&Es as part of the triage, the streaming service, will provide that kind of efficiency and effectiveness, so that everyone is treated properly. I do not have the detail on where NHS England is on that process, but I will be happy to write to the noble Lord with more detail.
Lord Scriven (LD)
My Lords, I also welcome the Minister to his new post and declare my interest as a member of Sheffield City Council. As 80% of those who are in hospital for two weeks or more are aged 65 or over, many require social care rather than healthcare. What is the timescale for the Government to deal with the crisis in healthcare funding rather than the short-term sticking plaster of bringing forward the precepts?
Lord O'Shaughnessy
I thank the noble Lord for his question. There are many strategies, going forward. One is the reform of social care, which includes additional funding, with the precepts being front-loaded now. The second is making sure that, in hospitals, those people in beds who would be better served in a different care setting are able to leave through step-down services, or other such services. Of course, the other factor is to make sure that there is appropriate general practice, and not simply A&E departments, although these can be effective in some areas. We want to make sure that there are more GPs and that we spend more on general practice, as we will in the spending review period, for patients who would be better dealt with without going into A&E, if the kind of care that they are receiving would be more appropriate in a primary care setting. We have to remember that, for patients such as those with dementia, the prospect of going into A&E could in itself be frightening and worrying.
Baroness Pitkeathley (Lab)
My Lords, I cannot resist the opportunity to remind the new Minister, as I always used to remind his predecessor, about the importance of Britain’s 6 million family carers, when we look at both the issues that he has brought to our attention today. First, he talks about speeding up discharge. You cannot speed up discharge in the social care sector unless you also provide support to the family carers, many of whom are elderly themselves, who will provide that care, when somebody comes out of hospital who is still barely recovered and those carers are expected to perform nursing functions, such as changing catheters. As for mental health, carers are often expected to be full-time carers for young people with very challenging behaviour, and they are often deprived of any information that would help them, on the grounds of confidentiality. What is the Government’s position on helping those informal carers in both these situations?
Lord O'Shaughnessy
I thank the noble Baroness for her question. She is absolutely right: millions of people across the country care for a relative who has some care need, be it a spouse, somebody at retirement age or a child with mental health problems. I do not have the specific details to answer her question; I shall write to her with those details—but through the social care reforms being delivered by local authorities and the reforms going forward through the five-year forward view in community health, there is more focus on that ground-level support, in a way that is much more difficult to do from Whitehall. So we are seeing through the early drafts of the STPs—one of the new bits of jargon that I have had to learn—ideas for how to provide family support that goes beyond the statutory support that is available through the benefits system or the community health system.
Baroness Berridge (Con)
My Lords, I welcome my noble friend to his new role and welcome particularly his comments on the parity in practice, as well as in law, of mental and physical health. I welcome the Government’s commitment of money and the Green Paper on young people’s mental health. Can my noble friend please comment on whether there will be a focus on the disparities of outcomes that persist for many in the black and minority ethnic community, who are often diagnosed late, are more likely to be detained for their condition and overall suffer poorer outcomes as a result in mental health? Could some focus be given to these issues of disparity?
Lord O'Shaughnessy
I thank my noble friend for her warm welcome. I take that point very seriously. Clearly, parity of esteem is no good unless it is applicable to everybody who is suffering from a particular illness. I am not fully aware of the details of the nature of the disparity with black and minority ethnic families but, if there is a problem, making sure that we fulfil this ambitious and I hope welcome strategy is going to make sure that we can lift performance of those services for people in minority ethnic groups.
Lord Bradley (Lab)
My Lords, I declare my health interests. Can the Minister explain why it will take at least four years to stop the appalling situation where children have to go out of their local area to receive their mental health treatment?
Lord O'Shaughnessy
I thank the noble Lord for his question. I was not aware that it would take four years for that to stop. What we are dealing with here is an historic challenge, which is that mental health services not just in this country but in countries all over the developed world have not been at the same level as services for physical health. The strategy that we have set out today and the further elements to come will be one way of making sure that those young people can be treated close to home. Clearly, there will always be cases and instances where they need to travel. On Friday, I had my first ever ministerial visit to Oxford mental health trust and was able to observe the fantastic work that it is doing across a wide area but with a specific residential school and, interestingly, linking up with the university psychology research department. There were young people who were coming to take advantage of that from all over the country. I realise that this is, if not unique, an unusual coagulation of good factors. As part of making sure that you can get treatment for mental illness or support to build mental health locally, we need to make sure that there are more centres of excellence that can be accessed by those who are in acute need.
Lord Willis of Knaresborough (LD)
My Lords, we welcome very much indeed any Statement that the Minister or indeed the Prime Minister makes about mental health. The issue of parity of esteem has gone through legislation, but in reality we have seen very little in terms of progress towards that parity of esteem.
I welcome the Minister to his place and wish him every success in this key role. One thing that is not mentioned in the Statement is how we train and educate the workforce to deliver the sorts of plans that we have. For instance, in training our nurses, unless they do a specialist mental health programme they might receive less than a morning’s training in a three-year graduate programme in terms of mental health. The same applies to children and people with disabilities. What efforts are going to be made to make sure that we have the workforce in place with the right skills and training to deliver the sorts of ambition that he and the rest of the House rightly share?
Lord O'Shaughnessy
I thank the noble Lord for his welcome. He is quite right, of course, that to deal with the problems of mental illness in every setting the staff need to be trained to spot them and do something about it. In the announcement today, a couple of things are relevant to his question. The first is on supporting schools and every secondary school having a mental first aid trained teacher, so they can spot the signs of mental illness and then refer them on if necessary, if they cannot deal with them themselves—although they will have the skills to deal with some instances. The other is the investment of £60 million—£30 million from government and £30 million from trusts—of digitally assisted mental health services, which will bring global digital exemplars for mental health. That will mean that we will be able to provide better information for both staff and patients about the quality of care and safety and effectiveness.
Lord Warner (CB)
I welcome the Minister to his new job and raise the issue of CAMHS and the security of funding for CAMHS. It is no good making fine words in this area. The raiding of budgets in this area has taken place in the NHS over a very long period of time. It is not just a question of ring-fencing for a short time; it is guaranteeing budgets over a longish period, so that staffing levels can be built up with people who are expert in this field. Will this issue be addressed in the Green Paper?
Lord O'Shaughnessy
I thank the noble Lord for his question. He speaks with great knowledge and experience, particularly from his work in the Department of Health. There are two separate issues here. First, there need to be more resources, and we are providing those. Secondly, we need to make sure that those resources are applied in the right setting, so that money designed to support mental health goes there. The primary way we deliver that is through transparency: making sure that CCGs—which are, of course, independent of government and making clinical commissioning decisions based on local need—are reporting on the money they are spending and the services they are commissioning in mental health and then making sure that we work with NHS England to look at any CCGs where that is not happening. It is clearly wrong that money which is intended to support mental health does not do so, but the way to deal with that is to work with the CCGs where it is not happening and to make them report on their own performance.
Baroness McIntosh of Pickering (Con)
My Lords, I welcome my noble friend to his position and declare an interest as an adviser to the board of the Dispensing Doctors’ Association, having been the daughter and sister of dispensing doctors in rural practice. Are my noble friend and his department aware of a chronic shortage of psychiatrists in rural areas, which has particular implications for children waiting to be statemented and treated? Is he also aware that there may be a spike in retirements of GPs over the next five or 10 years? The Government have addressed the issue of new doctors coming through; is there a second round, bearing in mind that it currently takes seven years to train a GP?
Lord O'Shaughnessy
I thank my noble friend for her welcome. The global number of psychiatrists across England is increasing: I was not aware of the particular shortage in rural areas. I will certainly investigate and write to my noble friend about it. I know, from my past work in education and the example of head teachers, that the shape of the public sector workforce is now such that senior positions are weighted towards the over 55s. Although I realise that separate pension arrangements are available in the health service, now that retirement and pension ages are increasing we have a reasonable expectation that people might work longer than they did in the past. Therefore the problem described by my noble friend may not be as acute—not just in health but in other sectors as well—as she says. However, there is clearly an issue about the demography of the service and we are backing up GP recruitment with quite a big increase in extra funding for primary care over the course of this spending review period. A large part of that will go on both recruiting new staff and paying those who are in the system now.
Baroness Hussein-Ece (LD)
Is the Minister aware of whether GP referrals to CAMHS are now improving? Last year a number of reports highlighted the fact that in some 15 trusts up to 60% of GP referrals were not being dealt with. Only the very urgent, critical cases—those children who were self-harming or attempting suicide—were being dealt with. Has this situation improved and is there now proper access? GPs are the gateway to these services and if their referrals are not being taken seriously, these problems will mount up and we will be failing the next generation. Can the Minister give that assurance?
Lord O'Shaughnessy
Mental health is an issue that spans education and health. I recognise the problems that the noble Baroness is describing. I do not know the specific details about the performance of referrals but I will write to her with that information. One of the purposes of the strategy, and the adoption of all the recommendations of this review, is to make sure that we make the system work better so that what the noble Baroness describes—which is not what we want to happen—happens less frequently.
Lord Brooke of Alverthorpe (Lab)
My Lords, I too welcome the noble Lord to his new appointment and wish him well. I place on record my gratitude to his predecessor, the noble Lord, Lord Prior, who was always open and honest in his dealings with us and straightforward in answering our questions. I hope we are going to have an open and honest discussion about the role of A&Es in the future and whether there is any likelihood that we are going to lose the four-hour limit. Over the holiday period, Sir Simon Stevens commented that A&E is not to be used as a “national hangover service”. Is there a possibility that we are to lose some of the terms we have had in the past because of the number of drunks who are being treated on Fridays, Saturdays and Sundays throughout the year—not just over bank holidays? This is creating immense problems within A&E, yet the Government refuse to do anything about the fundamental cause of that: to use Mr Cameron’s phrase, “cheap booze”. Back in 2012 he was advocating a change to try to stop this. Unless that is addressed, there will be a scandalised outcry about changes in the fundamental terms relating to A&E.
Lord O'Shaughnessy
I thank the noble Lord for his welcome. On A&E, the Statement is very clear that the Government are,
“committed to maintaining and delivering that vital four-hour commitment to patients”.
As the noble Lord described, there has been a change in the case load going into A&E. You only need to spend a bit of time in an A&E to know that alcohol is a factor. I do not know whether this is increasing, but I shall endeavour to find out. I absolutely agree that any proper strategy for relieving pressure on A&E must include cracking down on problem drinking.