The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)
My Lords, I thank both the noble Baronesses for extremely perceptive and thoughtful contributions and I will try to get through as much data as I possibly can.
I completely and utterly agree with the noble Baroness, Lady Thornton: we are all on the same side. As I said earlier, I pay tribute to the huge efforts across the nation of national and local politicians and officials working collaboratively. There are the occasional lightning points that hit the headlines, but that completely disguises the overall picture up and down the country of a huge amount of collaboration that is going on to great effect. I will talk later about the impact of the local restrictions, lockdowns and infection-control efforts that are making a big impact on this disease.
The noble Baroness, Lady Thornton, is absolutely right to raise the question of capacity for testing because the testing that we have got is proving to be incredibly effective. It is being put to work extremely hard. The marketing that we have done to the population took a massive reboot recently and is proving much more effective. The take-up of testing is up 63% since June. The amount of surveillance that we do now has been hugely upgraded in order to give local authorities and local actors the data that they have cried out for. We provide that data for them in as much quantity as we possibly can.
The regular testing in hospitals and social care, which has been the subject of a huge amount of comment here in this Chamber, is up enormously. Testing is allocated to outbreak management in areas such as some of the cities that have been mentioned here earlier and has had huge effect. Our ambition is to have 500,000 tests by the end of October. Earlier today, the Secretary of State made announcements in detail of how we are going to achieve that. I would particularly like to mention the Lighthouse Lab in Charnwood, which is exactly the kind of modern, impressive, industrialised outfit that is going to help us achieve a huge amount of capacity over the next few months.
The noble Baroness, Lady Thornton, was absolutely on the money when she mentioned saliva tests. Saliva tests are an incredibly exciting opportunity because they are much more usable. For any of those in the Chamber who may have had a swab test, they would know that it was okay, but you do not necessarily want to have a load of them. Saliva tests are much more accessible. The Yale study she mentioned was incredibly impactful when it was published earlier this year and it surprised everyone with conclusive evidence that saliva tests would be just as accurate as a nasal or swab test. That has opened up a huge amount of interest in this area. That is one of the ideas for which we put £500 million into the innovative tests kitty. There is a huge project in Southampton, and hopefully another one in Salford, which will be using saliva testing. I pay tribute to the Southampton authorities, the hospital, and OptiGene and its LAMP test, which uses saliva, and we are really hopeful about that.
The noble Baroness, Lady Thornton, mentioned pool tests. I suspect that she meant multiplex testing, which is the combination of testing in the same well. That is, again, another technology that has the opportunity to massively increase our capacity for testing. It is exactly these kinds of innovations that we have spent the spring and summer pushing really hard on in order to get our capacity up to do the kind of mass testing that has been mentioned by several noble Lords in the discussion.
We have worked really hard in order to get access to GPs for registering patients for testing. This is a not inconsiderable technical challenge. I remind everyone that it is not that difficult for a GP to register a patient on the normal coronavirus testing page. It takes about 45 to 50 seconds. We have worked hard in order to ensure that all testing results go into the GP records and to upgrade the booking system to give GPs that special access.
In terms of the testimony of the noble Baroness, Lady Thornton, it is very difficult for me to comment on an individual’s experience. I do not in any way question any of that testimony. What can I say that is constructive? I share completely the frustration of the experience of the person involved. In particular, there are millions of people who want to know whether the symptoms they have are Covid or not. The ONS data suggest that a lot of people who think that they might have Covid do not actually have it. It is extremely frustrating for them not to be able to clarify that. That is one of the reasons why we are pushing so hard in order to get our capacity up. The long-distance question of when you book a test and get sent to Inverness to have your test is an odd thing to happen, but we are trying to make as many tests possible to as many people as possible. It is up to the individual to decide whether they want to travel a long distance.
The noble Baroness, Lady Jolly, mentioned home testing, which has proved hugely effective. We recently celebrated 1 million home tests. On the whole, that experience has been extremely positive for the vast majority of people, and we have worked hard with our contractors to get the turnaround time down to 20 hours, although there is more that we could do. Not everyone is able to drive to a test site; test sites are not available in many city centres. That is why home testing is important and why we continue to prioritise it.
The noble Baroness, Lady Jolly, is entirely right about cancer. It is a huge problem that, over the last six months, cancer screenings and referrals, and the attendance for cancer procedures, have not kept up with the needs of patients. We are working incredibly hard. I pay tribute to colleagues in the NHS, Sir Simon Stevens and others who are working hard to open up facilities, to use marketing to get people back into hospitals and to create community-based facilities, so that people do not have to travel to hospitals for some of their diagnostic and procedural treatments. Those efforts are making a massive difference. Referrals in June were up by 90%, and 92% of the referrals in June were seen within two weeks. We are working through the backlog more quickly than the current numbers seem to suggest.
The noble Baroness, Lady Thornton, raised important questions about PHE. PHE is incredibly important to both the science and organisation of our response to this public health challenge. We do not blame anyone at PHE for anything—quite the opposite. The Prime Minister, the Secretary of State and others have paid tribute to the expertise and effectiveness of PHE—the staff, the scientists and the organisation—but there are immense operational benefits in getting PHE, test and trace and the joint biosecurity centre to work more closely together. I see that in my own life in the department, in the collaborative working we can do. You can decide to wait to do these things, maybe until after the epidemic, but it is right that we have used the summer months to mend the roof and to take the tough decision to pull through this organisational change now, in preparation for the second wave. No criticism is implied. We want to see these three important organisations working closer together, under joint leadership. I pay tribute to all who have collaborated in this change.
The noble Baroness, Lady Jolly, asked about mass testing. It presents an enormous opportunity, but our capacity needs to meet its needs. As Innovation Minister, I have been blown away by the rate of progress and innovation of our partners in the NHS, business and the big medical organisations on the scale, price, speed and accuracy of tests. It has been phenomenal, and we are beginning to see a route towards mass testing opportunities that we would not have been able to dream of in February or March, when we began this odyssey.
We are conscious of testing of a diagnostic or preventive fashion to break the chain of transmission. That needs to be swift, accurate, prompt and specified on individuals who either are at risk or present symptoms. But, as alluded to by the noble Baronesses, Lady Jolly and Lady Thornton, there is also an opportunity to use testing to provide reassurance that someone is not carrying the infection and perhaps is not infectious to others. This would give them the confidence to return to the workplace and to areas where social distancing is challenging, or to see people who are at risk. We are looking at avenues to develop that kind of testing in every way possible.
We are hugely encouraged by progress made on a vaccine, not only by our own teams in Oxford and Imperial, but by vaccine teams around the world. But let me be frank with the Chamber: vaccines for coronaviruses are notoriously difficult. Vaccines for anything to do with the respiratory system are also very complex, difficult to deliver and unreliable in their long-term impact. The macro challenge is enormous but, given its size, the progress made by some of the vaccine teams is phenomenal. We are giving them all the resources they need to continue making that progress.
The delivery of a vaccine, when it arrives, will be a massive national challenge and the noble Baroness, Lady Jolly, is entirely right to raise it as something worthy of scrutiny. We will need all the resources that our National Health Service, private partners and the whole nation can provide. A huge number of personnel will be required to deliver one or two doses to a large proportion of the population. Certainly, pharmacies and the pharmaceutical profession will play a pivotal and important role in that. We are deeply engaged in consultations with all parties that have a role in delivering vaccines, and we are putting plans together to do that.
We are making great progress with track and trace. I mention the outbreak in Herefordshire because it does not exist. There is no outbreak in Herefordshire: when we spotted a contagion among migrant workers on a farm in Herefordshire, we used track and trace to break the chain of transmission and close down that mini-outbreak. As a result, it did not expand widely into the community and there is no communal outbreak in Herefordshire. In the last week, 81.4% of people transferred to the contact system were reached, 80% of contacts on whom we had information were reached and 452,679 people have been newly tested under pillars 1 and 2. These are incredibly impressive numbers. Track and trace comes in for much scrutiny and attack, but I reassure noble Lords that it is an incredibly important system that provides an important tier in our fight against the epidemic, and has proved effective already.
Baroness Prashar (CB) [V]
My Lords, why do we not have testing at airports yet? Leading figures in the aviation industry are expressing frustration and it is having a detrimental impact on the industry. Other countries have managed to introduce testing at airports; why are we lagging behind?
Lord Bethell (Con)
My Lords, I completely hear the frustrations of the airport and airlines industries about testing, but I cannot hide from them the simple epidemiological facts. If someone arrives at an airport, they may not test positive if they are harbouring the infection deep inside themselves. It may take days—up to 14 days—for that infection to manifest. I wish it were different; I wish we could set our airports free. Until we find a system that can handle that complexity, I am afraid that we will have to live with the system we have.
The Lord Bishop of Bristol
My Lords, North Bristol NHS Trust has recently reported on an audit of 110 patients discharged after being severely ill with Covid-19. Of these, 75% were still experiencing serious symptoms three months later. This is just part of the mounting evidence of the long-term effects of Covid-19 even on those with mild infection in the acute phase. What steps are the Government taking to raise public awareness of so-called long Covid and to invest in the care of those who are now chronically ill?
Lord Bethell (Con)
The right reverend Prelate is entirely right to raise this point; it is emerging as a massive concern. The idea that Covid will somehow pass through Britain and leave people untouched, a bit like simple winter flu, is beginning to prove worryingly untrue. Her anecdote from Bristol is completely consistent with what we are seeing across the piece. In particular, those who have had acute infection but also, I fear, some who have had relatively asymptomatic or low-symptom Covid have found in later weeks and months symptoms of fatigue, arrythmia, renal impact, scarring on the lungs and memory loss. These are extremely worrying symptoms. Sir Patrick Vallance, the Government Chief Scientific Adviser, is running an operation to understand what the right reverend Prelate rightly calls long Covid; we are using big data to analyse the scans we have collected from acute patients and to understand the impact of asymptomatic infection. This is an extremely worrying manifestation of Covid, one that we are acutely aware of, and we are investigating very urgently.
Baroness Browning (Con) [V]
My noble friend will be only too aware of the consequences of non-Covid patients’ reluctance to present themselves at hospitals and even to GPs for treatment and support. With the winter months approaching, what can he do to make sure that, at a local level, in advance of people having symptoms, they are reassured that they will be safe to approach the NHS? The idea that “it will be all right on the night” and just requires encouragement has clearly not been enough in the past and, I fear, will not be enough in the coming months.
Lord Bethell (Con)
My Lords, my noble friend is entirely right that confidence in attending NHS venues is hard hit by Covid. One of the inspiring and interesting things that has happened has been the switch to using telemedicine—video and telephone calls—for referrals. This has been particularly and interestingly used in mental health, where attendance at clinics is something that many patients would wisely seek to avoid, but in fact the delivery of mental health therapy through telemedicine and calls has proved to be incredibly effective and has worked very well. We are working hard, through the NHS, to try to de-weight attendance at venues, particularly big central hospitals, and move much more towards attendance in the community, or through technology, in order to give patients a choice and to increase our engagement at a time when people are fearful of going back to their GP surgeries.
Baroness Armstrong of Hill Top (Lab) [V]
My Lords, one of the reasons for the Statement is to look at lessons learned. As the Minister and others have already discussed, the trust of the British people in what they are being told and advised is important. Therefore, what was said yesterday about Bolton and Trafford and their local spikes was not very helpful. Because transparency is really important in building trust, can the Minister tell us what happened between 9 am and the Statement from the Minister after noon to change his mind? He tells us that it was data. What was the data?
Lord Bethell (Con)
The noble Baroness is entirely right that trust is critical, and we have to forge a system where local authorities, local MPs and central government work together on these local restrictions. The only thing that changed was that that group of people sat down at 9 am yesterday and looked at the data, and the data was deeply uncomfortable—it did not tell the story that everyone wanted it to tell. No one wanted to lock down those areas, but the data pointed in only one direction. That is the story that is playing out in communities around the country and it is a story that we will all have to get used to. One of the frustrating aspects of this epidemic is that the disease moves incredibly quickly and does not always go the way one would like it to go. That creates turbulence, as discussed earlier, but that turbulence is something that we have to get used to. Politicians, local officials and central government mandarins are all learning to work together in order to interpret that data and apply its implications in a thoughtful and trusted way.
Baroness Scott of Needham Market (LD) [V]
Is the noble Lord aware of the situation at Banham Poultry in Norfolk where, as of this morning, 104 people at the factory have tested positive and the public health director has reported that only 52% of contacts have been traced? This has led to the local authority bringing in a company to see if it can improve that figure. What conclusions are being reached as to why, in this instance, there is such a low rate of positive contact with people who may be affected?
Lord Bethell (Con)
The truthful answer to the noble Baroness is that I know that there is an outbreak at Banham but I do not know the operational details of the kind she describes. What I can say is that the system is deliberately constructed so that a local director of public health, or the local authority, has the option, if they think it has local relevance, to bring in the resources that are needed for any particular arrangement. If, for some reason, a local director of public health, or the local infection control team, sees an opportunity for bringing in outside resources—a charity, a company, a technology—that is entirely appropriate and welcome. That is exactly the kind of local intelligence and expertise that we depend on to be effective. A central track and trace operation cannot do everything; that point that has been made in this Chamber hundreds of times and is a point that we entirely embrace. I am, in fact, hugely encouraged by the anecdote the noble Baroness tells.
Baroness Neville-Rolfe (Con)
My Lords, I was not surprised to see a report in July that a majority of postal tests were not really working. My husband received a surveillance test, but the lancets did not make a hole big enough to provide enough blood, the little bottle for collecting it was too narrow, and follow-up tests were equally problematic. However, my question today is about masks, which were not mentioned in the Statement. On what scientific advice are government recommendations on the wearing of masks based? This is a subject of heated debate in my household—my positive experience of masks in Asia against the scepticism of the scientifically trained.
Lord Bethell (Con)
My Lords, I am terribly sorry that my noble friend’s husband had a tough time with the home testing kit. That is not the experience of hundreds of thousands of people who have taken those surveillance kits, and we know that for a fact because hundreds of thousands have been returned, providing incredibly valuable information that is informing all the conversations and decisions that we discussed earlier. As for masks, the CMO has made it very clear that the scientific evidence is not conclusive, but it is reasonably evenly balanced. It is extremely difficult to prove one way or the other the efficacy of masks, but the experience of countries that are fighting the epidemic effectively has often involved masks in one way or another, and my own experience in Asia reinforces that. That is why we have made the recommendations that we have, and we keep it under review until further science emerges. The British public have shown for themselves an interest in and a relatively high commitment to wearing masks, which I think is instructive.
Baroness Andrews (Lab)
My Lords, I take the Minister back to airports. I have three questions. First, what is the science telling us about the likely impact—I know that this is a difficult question—of people coming off planes from highly affected countries? Have we done any research on that? Secondly, the Minister said that it is very difficult to test when people come off aircraft because the disease may be inhabiting them but not presenting. Other countries, however, are testing at five-day and even 10-day intervals: have we considered that? Thirdly, if our only strategy is quarantining, are we collecting data on how people are conforming? Are they staying in isolation? How do we know that? Can the science and the data be made available to us? If there is an unknown or even a known loophole, how do we fill that if quarantining is our only strategy?
Lord Bethell (Con)
The noble Baroness asks three extremely perceptive questions. With regard to the science of testing at airports, a huge amount of work is being done on this, and I pay tribute to the work of the scientists at SAGE, who have, I think, published several papers on this matter.
The number that sticks in my mind is SAGE’s estimate that of those infected who pass through an airport only 7% would be captured by what is called day zero testing—a tiny proportion. That uncomfortable and inconvenient statistic holds us back from doing what we would love to do—it just does not work. We are looking at seven-day testing, eight-day testing and 10-day testing. This is a lot about risk management: there is a risk curve. I would be happy to share a copy of the SAGE report, which is public, that shows that curve.
The noble Baroness is right to raise quarantine implementation: it is a cause of concern. Quarantine is critical to the effective implementation of our epidemic management. It is a trust-based system. Anyone who has read the papers will know that that trust-based system is under pressure. We are keeping it under review and will be looking at whether it needs to be updated.
Baroness Benjamin (LD) [V]
My Lords, it has been widely acknowledged that Covid-19 has disproportionately affected the black, Asian and other diverse communities, with many dying—especially men. There is also a high risk of suicide among these groups. Sadly, I personally know of two people who have taken their lives because they could not cope with the uncertainty of the future. What measures, therefore, are the Government putting in place to ensure that suicide prevention is a government priority and that this group receives the support it needs to face the Covid-19 pandemic?
Lord Bethell (Con)
My Lords, on behalf of the House I pass on our sympathy to the noble Baroness, Lady Benjamin, for her experience with the friend who committed suicide. It is a touching story and we feel sorry them.
Suicide is important for this Government and we have a number of programmes that address it. One of the peculiar aspects of the epidemic is that the mental health tsunami that we were all braced for and deeply concerned about has not manifested itself in the way we thought it might. There is currently no evidence that the suicide rate has increased in any way. We keep a careful eye on this. When a major epidemic such as this happens, we worry that it will have a huge impact, particularly on the young—particularly young girls—and those groups, such as BAME, who may feel that the prevalence is higher in their community. To date, however, the statistics suggest that we are blessed by having avoided harsh effects so far.
Baroness Verma (Con) [V]
Will my noble friend tell the House what communication plans are in place to ensure that, as winter approaches, all communities are well informed on what measures need to be followed to prevent or reduce the impact of a second wave, and that where spikes are found in local communities, wider immediate testing is available to everyone in that locality? I also thank my noble friend for the funds that the Government gave us in Leicester to ensure that communications were sent out in languages other than English.
Lord Bethell (Con)
I thank the noble Baroness, Lady Verma, for her comments. What happened in Leicester has informed our response to the epidemic in many ways, including a much greater emphasis on languages. Many of the publications and technologies that we are rolling out in preparation for the second wave will use a hugely increased number of languages, so that we reach those communities which might otherwise have been overlooked.
In answer to the overall question put by the noble Baroness, I would place massive emphasis on our preparations for the flu vaccine. If we can spare the NHS the pressure of the annual flood of flu infections, we will do the country a huge favour. If we can spare patients the impact of flu that runs down their immunity and leaves them vulnerable to Covid, we will do them a huge favour. If we can get flu vaccine take-up higher, that will be a huge benefit for the system and the country.
Lord Mackenzie of Framwellgate (Non-Afl) [V]
My Lords, can the Minister advise the House whether self-isolation—in any setting—is enforceable, and if so, by whom? If it is not a legal requirement, is the moral obligation to isolate sufficient in such a serious public health crisis?
Lord Bethell (Con)
My Lords, we have limited powers to isolate individuals under the very initial regulations that were published, I think, in March. Our overall approach, however, has been a trust-based system. I pay tribute to the British public, who, on the whole, have gone along with this approach hugely, and it is a tribute to the British way of doing things that we have not been using the police or fines like some other countries have. As the second wave approaches, we must acknowledge that there is more social exhaustion with the disciplines of isolation, quarantine, hygiene and social distancing, and assess whether that approach will last the course. That review is going on now and in the near future we will be putting in place the measures we think are necessary and proportionate.
Lord Greaves (LD) [V]
My Lords, yesterday the Minister praised Pendle Borough Council—I repeat my interest—for its work on Covid, which now includes local tracking of positive cases; that is, the kinds of cases that the national system has failed to reach. Can the Minister explain why passing cases to the local level, which should be done within 24 hours, has in some cases taken four or five days? Furthermore, when a case has been reached, and more local contacts have been discovered, why do they have to be passed back to the national level and not quickly followed up locally? They might even be in the same street. Why are district councils such as Pendle not being provided with sufficient funding to cover all the costs of this work?
Lord Bethell (Con)
My Lords, once again I pay tribute to Pendle Borough Council, which is an absolute model of local collaboration in the handling of a local outbreak. I am greatly encouraged that Pendle has stepped forward to do local tracing. I do not know the precise details and will not pretend otherwise, but the story the noble Lord tells illustrates a harsh truth: not everyone wants to be traced. Not everyone participates in the system with the kind of enthusiasm one would like. It sometimes takes persistence and determination to track people who may be recipients of some very difficult news about their isolation and how they are going to spend the next 14 days—news that may either have an economic impact on them or seriously disrupt plans for them and their family. It is tough to track and trace people. That is why we work with local authorities to do it, why I was proud to announce the numbers earlier and why I am grateful to the noble Lord for illustrating the point with his story from Pendle.
Baroness Ritchie of Downpatrick (Non-Afl) [V]
My Lords, reference has already been made by the Minister to the quicker saliva tests for Covid-19. For the avoidance of doubt, can he outline to the House the timeframe for these trials and an implementation timeframe if they are successful?
Lord Bethell (Con)
The noble Baroness is completely talking my game here. I wish I could be 100% specific about the timeframes, but we are still going through the validation process. Personally, I am hugely optimistic. The noble Baroness, Lady Thornton, mentioned the work in this area of Yale University, which really changed our perceptions of the role that saliva testing could play. It can be used in the big PCR machines, it may be used in point-of-care machines and there is even a possibility that it could be used in the small plastic lateral-flow machines much loved by the husband of the noble Baroness, Lady Neville-Rolfe. I hope very much indeed to be able to update the House soon and to lay out a framework, but I afraid that at present the validation results have not come through and it would be premature of me to try.
Lord Balfe (Con)
Although the Minister mentioned the need to get back to face-to-face visits, it is not mentioned in the Statement. In our local hospital, Addenbrooke’s, the instruction has been that no people are to be seen unless it is absolutely necessary. Indeed, one consultant told me they had been forbidden to see a patient unless they needed to. Our local GP service provides no face-to-face meetings other than after you have been triaged and jumped through some hoops. It even had a tent outside for a time. Can the Minister assure us that some pressure will be put on local hospitals and GPs to get back to normal and start seeing people? As letters in the Times have proved, the fact that you do not see people means you miss serious diagnoses.
Lord Bethell (Con)
My Lords, massive pressure is on the NHS from every level to get back to normal. Attendance rates are increasing dramatically in every area of the NHS. I pay tribute to those who have gone through enormous hoops to create safe and protected protocols to have people back in the system, but I cannot hide from my noble friend the fact that the health system will not be the same, going forward. We will have to change our approach to infection control and hygiene and have face-to-face contact in a completely different way. It makes no sense for lots of ill people to congregate in a GP surgery and to spread their disease among one another. We have to rethink the way we did our healthcare in the past in order to protect healthcare workers and patients from each other’s infections and to afford a sustainable healthcare system that can afford to look after everyone.
Lord Taylor of Warwick (Non-Afl)
My Lords, one in five NHS staff is from black and ethnic-minority communities, yet six out of every 10 UK health workers killed by Covid-19 have been BAME. What progress are the Government making in urgently finding out why so many BAME health workers have been so vulnerable, even to the point of losing their lives in the cause of serving others?
Lord Bethell (Con)
The noble Lord is entirely right to raise the terrible statistics on BAME health workers. It is not conclusively understood why the numbers are as dramatic as he articulated. I am afraid we are still speculating, and a huge amount of work is being undertaken by PHE in this area to understand it better. Some of it is because BAME front-line workers selflessly put themselves in harm’s way in environments where there are higher risks, despite the extraordinary efforts of trusts and CCGs to protect them. Part of it is the living arrangements and part is the behavioural arrangements. These things are explicitly explained in the PHE report, but it is a matter of huge concern. Trusts and CCGs have been urged to put risk-management practices in place according to local needs and arrangements, and the numbers have changed as a result of these policies.
Lord Bradshaw (LD) [V]
I want to talk about areas other than London. The bus industry has made huge efforts to make its buses safe for people to use, yet people who put in local lockdowns are still advising people not to use public transport. What is the scientific basis for that advice?
Lord Bethell (Con)
My Lords, I do not support that advice. I took the bus to work today and encourage others to do the same.
Baroness Jones of Moulsecoomb (GP)
I asked the Minister about this earlier and will send details to him so that it can be checked. Somebody complained that when they went to get a home test for Covid, they were asked to share their information with an American credit-check company called TransUnion, which sounds like data harvesting. I am sure we are all against that. My question is this. The Government have promised regular, weekly tests for care home staff from 7 September. Is that still happening?
Lord Bethell (Con)
My Lords, I would be grateful to the noble Baroness for sharing with me the specific detail. It seems extremely strange to me; I do not recognise it at all. The way in which we put together our test registration protocols is to encourage the greatest number of people to register as possible. I am sometimes asked why we do not have more information on the gender, ethnicity and background of people tested. It is for exactly that reason. I would be grateful if the noble Baroness could send me those details and will be glad to check them out.
Huge progress has been made on care home testing. We have massively prioritised the delivery of testing kits and services through the packaging of large numbers of tests to the kinds of care homes that can deliver tests themselves; the attendance of mobile testing units to those that need that kind of support; the connection with local trusts and hospital services so that NHS resources can be used for care homes; or the attendance of care home workers at local NHS trusts for their tests if that is more convenient for them. A huge operation has gone into place, massive progress has been made and I am extremely grateful to all those concerned.