Jimmy Savile: NHS Investigations

Baroness Hollins Excerpts

Thursday 26th February 2015 Lords Chamber

[Earl Howe]

I take my noble friend’s point. However, I would hesitate before committing to a situation where, in every instance that a doctor or nurse examined a patient, they had to have somebody with them. In the real world, I do not think that is going to be practical. What one should have, however, is an assurance that whoever examines the patient, or performs some intimate caring service with the patient, should have been checked for both a criminal record and a previous employment history. I will take my noble friend’s point away, but I think that what I have said would be accepted by those in the National Health Service as the only practical way forward.

[Baroness Hollins (CB)]

My Lords, senior hospital administrators were criticised in these reports, but senior civil servants were also responsible for facilitating Savile’s influence and access to Broadmoor and Stoke Mandeville hospitals. Have the civil servants been identified? How have they been held accountable? Have the survivors received an individual apology for the governance failures that allowed this catalogue of abuse to take place? I understand the Secretary of State’s general apology, but I think an individual apology would be appropriate for each and every survivor.

Human Fertilisation and Embryology (Mitochondrial Donation) Regulations 2015

Baroness Hollins Excerpts

Tuesday 24th February 2015 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I take a rather different view from some of my eminent medical colleagues. I have worked for over 30 years with families of severely disabled children. As a psychiatrist—and as the mother myself of a child born with a severe developmental disability—my heart goes out to those parents facing the prospect of inherited mitochondrial disorders. As a mother, I understand what is called the moral imperative to try to help. However, our first responsibility must be to the children who may be created through these proposed interventions: the most important moral imperative must be to do no harm.

A new technology of such potential importance must take as long as is needed to be as sure as possible of its safety. Being first is not always best. I have carefully read the HFEA 2014 review of scientific methods. It has been implied that the scientific reviews have not raised any concerns, but in paragraph 3.7.25 the review states,

“although the results with the two techniques continue to be promising, further experiments need to be carried out before introducing either into clinical practice to provide further reassurance about efficiency and safety”.

I asked a Written Question in December asking whether clinical trials were being planned and I am grateful for the helpful reply from the Minister and the mention he made of it in his opening remarks—although I disagree with his interpretation of medicine, which is defined much more broadly in the European directive. The Minister also explained that,

“for any new IVF technique there will need to be careful monitoring of the procedure and, subsequently, any pregnancies”.

But we are not talking about pregnancies primarily; this is me as the psychiatrist talking now. As the noble Lord, Lord Deben, pointed out, we are talking about children—children who will, we hope, grow up to be healthy human beings, and who will themselves be able to have healthy children. But what if they do not?

In paragraph 3.7.29 the HFEA expert panel said:

“Until knowledge has built up that suggests otherwise, the panel recommends that any female born following MST or PNT”—

maternal spindle transfer or pronuclear transfer—

“should be advised, when old enough, that she may herself be at risk of having a child with a significant level of mutant mtDNA, putting her child, and if female, subsequent generations at risk of mitochondrial disease”.

The science is complicated, but there is apparently a real possibility that resulting embryos from a woman born after MST or PNT could be heteroplasmic—

[Lord Patel]

May I ask the noble Baroness what experiments she would propose to determine that the children born through this procedure will be healthy in every way, including reproduction-wise?

--- Later in debate ---

[Baroness Hollins]

My Lords, I do not think that intervention is very helpful as it is not relevant to the point I am making. The issue of heteroplasmy was spoken about earlier, and it simply means two or more different mitochondrial DNA types coexisting in a single cell. The review panel concluded:

“These levels may still not be sufficient to cause her children to have a problem, but subsequent generations could be affected”.

In paragraph 4.3 the panel stresses that,

“it should be accepted that there will always be some risk and unknowns associated with the use of MST or PMT in humans until it is tried in practice”.

I understand that and agree with it.

One argument for agreeing the recommendations now is to enable the HFEA to license these techniques as soon as it is convinced that there is sufficient evidence of safety without then having to seek parliamentary approval, thus possibly delaying implementation. In 2008, Dr Evan Harris, the former Member for Oxford West and Abingdon, a champion of the 2008 Act, said:

“Safety is clearly a concern… If Parliament decides that it is not safe enough to allow the HFEA to consider licensing something, Parliament would not draft, confirm or pass the regulations”.—[Official Report, Commons, Human Fertilisation and Embryology Bill Committee, 3/6/08; col. 35.]

Agreeing the recommendations now seems to be putting the chicken before the egg. Supporters of the techniques—

[Viscount Ridley]

The noble Baroness made the point that heteroplasmy, and therefore the carryover of the diseased mitochondria, is possible under this technique. Does she agree that experiments show that the likelihood is less than 5%, whereas pre-implantation genetic diagnosis has it at up to 40%? That is a legal procedure, so we are talking about trying to legalise a safer procedure than something that is currently legal.

[Baroness Hollins]

Again, I do not think that is the point that I am trying to make. Maybe I am not being quite clear enough.

[Lord Tebbit (Con)]

Would the noble Baroness not agree that there is only one absolutely safe way to ensure that this disease is not handed down from generation to generation, and that is for those women who are carriers of the genetic fault not to have children? That may be an appalling thing for me to have said, many people would think, but there are many people who for various reasons cannot have children.

[Baroness Hollins]

That is a good point.

Supporters of the techniques simplify the impact of these proposed procedures by saying that mitochondrial donation is like changing a battery. Their argument runs that mitochondrial DNA relates only to power production in the cell but does not affect the DNA, which encodes our characteristics, and therefore that exchanging mitochondria should not be seen as ethically significant. In a debate last September, the honourable Member for Havant in another place summed up this position well when he said that the techniques represented,

“a change in the membrane of the cell so that the battery function continues, but it does not affect human identity even by 0.1%. That is why I do not believe that there is an issue of dignity or integrity of the individual”.—[Official Report, Commons, 1/7/14; col. 98.]

The Government underlined how important this point was to their policy in their consultation response when they said:

“Most importantly, mitochondrial donation techniques do not alter personal characteristics and traits”,

of the person, the implication being that if this technology were to affect personal characteristics then the Government would withdraw their support.

So the ethics and the safety of the science are inextricably linked. Unfortunately, it seems that we are still at the beginning of understanding the complex interactions between mitochondrial and nuclear DNA. Some recent empirical studies on animals have suggested that mitochondria indeed affect characteristics, and that there is a relationship between mitochondria and memory, temperament and behaviour. As a psychiatrist, I see temperament as a personal characteristic, and I think it was for that reason that the New Scientist withdrew its support for the techniques. In an editorial last year it said that,

“we may have seriously underestimated the influence that mitochondria have. Recent research suggests that they play a key role in some of the most important features of human life”.

I note that the Government’s own consultation document acknowledged the diversity of problems associated with mitochondrial disease, including learning disabilities, neurological problems, autonomic dysfunction and dementia, and that every person’s symptoms are different. The Government’s response to the consultation concluded that they do not alter personal characteristics. One problem that I have with the current proposals is the idea that mitochondria are mere batteries, which is what has been quoted in so many of the papers that have been circulated to Peers. The New Scientist leader comment in September last year said that most debate around the issue had worked on the assumption that mitochondria were simply cellular powerhouses. However, given their newfound influence over our bodies, the implications of this technology may be far more radical than we have assumed. The leader made the point that it seems that mitochondria, far from being passive power plants, influence some of the most important aspects of human life, from memory and ageing to combating stress and disease. They even have influence over the DNA in your cell nuclei and change and evolve during your lifetime.

I have been inundated by emails, as I am sure we all have, from people who are concerned. I had an email from a cell biologist working in California, Professor Paul Knoepfler, who contributed to the HFEA’s call for evidence. He said that,

“mitochondrial transfer might be proven safe, but then again it might not. From my perspective as an impartial (scientific) observer … putting myself at some risk by publicly opposing this technology … its approval at this time would be a … risky gamble with children’s health and lives”.

He says that many scientists have told him that privately they share his concern.

I have one question for the Minister: would he withdraw his support for the regulations if he thought that the role of mitochondria was more than mere power production? Would he then support the amendment of the noble Lord, Lord Deben, for further consideration of this matter?

Until recently, the Wellcome Trust had on its website a statement suggesting that the procedure would be able to go ahead in late 2014, when the science was ready. But is the science ready? I am not quite convinced yet. As noble Lords may be aware, I chair the BMA board of science, which has not yet discussed this matter. I have discussed my support for the noble Lord’s amendments with senior officers of the BMA, and perhaps I may clarify the BMA’s position. Its support for the principle of such reproductive technologies has been expressed as an ethical principle to allow the cautious exploration and development of such technologies. I have concerns about the timing of these regulations, and for that reason I welcome the opportunity to debate them presented by the noble Lord, Lord Deben.

[Lord Ribeiro (Con)]

My Lords, we have heard from legal and medical experts. I am happy to say that I am not an academic and I know very little about the subject. However, it strikes me that if we look at the practicalities from the point of view of the parents who are afflicted by this condition, and we turn back to 1978 when baby Louise Brown was born as a result of the in vitro fertilisation undertaken by Steptoe and Edwards—

Mental Health Services: Sign Language Users

Baroness Hollins Excerpts

Monday 2nd February 2015 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I would like to add a couple of points to the debate from my experience as a psychiatrist. We have heard that deaf people continue to face unacceptable inequities in access to mental health services, and that is particularly the case for the estimated 25,000 deaf people in the UK who use British Sign Language as their first or only language. Deaf BSL users from black and minority ethnic communities, or who have additional needs arising from co-morbid visual impairment or intellectual disability, encounter even greater obstacles to accessing mental health services.

We have heard that deaf children are more likely to experience emotional, physical or sexual abuse, which contributes to later mental health problems. Deaf adults are much less likely to know how to report suspicions of abuse. Thus, children living in deaf communities are more likely to have their experience of abuse go unnoticed and unreported. The community interest company, Books Beyond Words, which I chair, has been commissioned by the NSPCC to help it develop pictorial resources to improve the reporting of such abuse to organisations such as the NSPCC.

We have heard that many deaf people leave GP consultations with no understanding of what went on, and consequently avoid going to see their GP altogether. Research has shown that a shocking one in seven people with hearing loss has missed a healthcare appointment because they did not hear their name being called in the waiting room. Those access problems continue despite the Disability Discrimination Act’s requirement for reasonable adjustments to be made, and they are compounded by a lack of deaf awareness training for professionals working in healthcare settings.

Within mainstream mental health services, few staff possess the BSL skills and experience needed to work effectively with deaf BSL users. Mental health services frequently fail to arrange for BSL interpreters to be present at appointments, often relying on family members, including children, to act as informal interpreters. That practice is unjustifiable, particularly in mental health services, where sensitive and personal issues, sometimes including abuse, may be disclosed. There is also an ongoing shortage of BSL interpreters in healthcare settings and a lack of specialist training for those who wish to work with people with mental health needs. What steps will the Government take to increase the number of BSL interpreters within mental health services?

The Sign Health charity highlights that over the past three years, it has trained 18 deaf and three hearing BSL users to work as psychological well-being practitioners in several geographic regions, but only seven are currently employed, reflecting a lack of recognition of the need for their services. Does the Minister agree that such provision would constitute a reasonable adjustment, and can he assure the House that action will be taken to improve deaf people’s access to IAPT services provided by therapists sufficiently fluent in BSL?

Deaf people are also overrepresented in secure mental health settings, and are thought to be overrepresented in the prison population, which may reflect a prior failure to address their mental health needs. It suggests the need for specialist prison in-reach services, so that deaf people with mental health needs can be identified and supported.

I highlight the importance of addressing the social determinants of mental well-being in deaf people. The exclusion, isolation and barriers that deaf people experience in education, employment and the community can negatively impact on their social and emotional well-being, along with their education and employment outcomes, thus perpetuating the cycle of adversity which puts them at greater risk of mental health difficulties. Can the Minister assure the House that recommendations to address those factors will be included in the Government’s forthcoming action plan on hearing loss?

A couple of examples were given to me by a psychiatrist working in one of the national deaf mental health services of children who he visited in mainstream schools. One child was using only BSL in a mainstream school where nobody else knows BSL. A young person in a special school whose only language was BSL was in a class with seven young people with learning disabilities, none of whom was deaf or knew BSL. That is clearly unacceptable. I look forward to the Minister’s response and thank the noble Lord, Lord Ponsonby, for raising these important matters.

Health: Human Papilloma Virus

Baroness Hollins Excerpts

Tuesday 20th January 2015 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I thank the noble Lord, Lord Patel of Bradford, for initiating this important debate. It comes at a time of growing consensus within the medical community that now is the right point to extend HPV vaccination to all boys. It is the only effective and equitable solution to protect against HPV infection. I want to focus my remarks during this debate on the role of HPV in a range of cancers affecting men and the growing evidence that the best way to target HPV in boys is to vaccinate them in school. I shall also raise concerns about a group which is often overlooked in discussion: men with learning disabilities. I ask the Minister to remember this group of men in his response.

There is no doubt that incidences of cancers associated with HPV are going up. The UK has seen a recent rise in the incidence of HPV-related oropharyngeal carcinoma among men, and I understand from the research of Professor Margaret Stanley, who has already been mentioned in this debate, that this has the fastest rising incidence of any cancer—15% a year. Over the past four decades, rates of anal cancer in both men and women in the UK have risen steadily. It is estimated that 90% of anal cancer in men is related to HPV infection, and roughly six people die every week in the UK from this cancer. Infection with HPV is also responsible for nearly all cases of genital warts.

Men who have sex with men are especially at risk of exposure to HPV infection because they are completely outside the vaccinated herd. Reflecting on the comments of the noble Lord, Lord Patel, I presume that if only 80% of girls are vaccinated, since girls are only half the population, that must reduce the effectiveness of the herd to 40%. Does it? The incidence of anal cancer in this group is estimated to be similar to that of cervical cancer in an unscreened population of women.

A not insignificant number of boys will be sexually abused before reaching adulthood, including boys with learning disabilities, who are at much higher risk of abuse and are less likely to have received sex education or to know how to report abuse. Although some improvements have been made, the sexual health needs of those with learning disabilities have, for the most part, been overlooked. This is particularly worrying as evidence suggests that men with learning disabilities who have sex with men are less likely to identify themselves as gay and therefore are less likely to have access to formal or informal sexual education, which places them at even greater risk of getting STIs or even HIV.

It is against this backdrop that HPV Action has been formed. It is a coalition of organisations that support gender-neutral vaccination. It includes the British Dental Association, the Royal College of Obstetricians and Gynaecologists, the Royal Society for Public Health and the Faculty of Public Health, among others. All agree that the case for vaccinating both sexes against HPV is growing stronger. The House will wish to be reminded that my interests include being chair of the board of science of the British Medical Association. The British Medical Association, which represents doctors, has also said that it now believes that there is an overwhelming case for expanding the school-based HPV vaccination programme to include boys. This was debated at the 2014 annual representatives’ meeting, and members voted to accept this evidence and advocate for equity in the vaccination programme.

It is clear that scientific and medical opinion now largely believes that HPV vaccination will prevent many cases of head, neck and penile cancer, and an increasing number of clinicians and public health organisations in the UK recommend HPV vaccination for boys. There is also a growing consensus that the most effective approach to providing this protection to boys would be to provide vaccination in school. To ensure that vaccine recipients are protected, they must receive the immunisation prior to the initiation of sexual activity. As such, there are concerns that providing immunisation only at GUM clinics would not do this effectively. It is not practical to offer HPV vaccination only to men who have sex with men because, to be most effective, boys should receive the vaccine prior to the age of sexual activity. The optimum age for this would be 12 or 13. It is clear that 12 or 13 year-old boys would not attend GUM clinics. We have already heard that the median age for first attendance is around 28 or 29. Boys of 12 or 13 may be unaware of their sexual orientation.

In the existing school-based vaccination programme, we already have an appropriate mechanism for vaccine delivery. From September last year, the HPV vaccination schedule was reduced to two doses. This reduction now provides capacity—this is an important point—to extend the school-based HPV vaccination programme to include boys. I believe that this presents us with a real opportunity, and providing HPV vaccination to all boys in schools will guarantee that high vaccine coverage rates are achieved. If we were to take this step, we would not be the first. Australia, Canada and the USA already offer HPV vaccination to boys.

The introduction of HPV vaccination to protect women against cervical cancer has made a significant contribution to reducing incidences of HPV infection among young women in the UK. This undoubtedly represents a significant health gain. However, there is now overwhelming evidence—and consensus—that there is a case for expanding the school-based HPV vaccination programme to include boys.

Alcohol: Addiction

Baroness Hollins Excerpts

Monday 12th January 2015 Lords Chamber

[Earl Howe]

My Lords, Public Health England has a programme of work to ensure that all the bases are covered. It is producing a report for government that will be published later this year. Over the next 18 months, there will be a longer programme of work on such things as a framework for liver disease, setting out the evidence base for the introduction of a minimum unit price for alcohol and using alcohol as the trail-blazer for a new whole-system approach that establishes what works and is clear on the return on investment, to enable government to take action based on evidence.

[Baroness Hollins (CB)]

My Lords, the Board of Science at the BMA, which I chair, believes that the availability of cheap alcohol, such as white cider, is one of the main causes of the rise in addiction. We believe that the sale of cheap alcohol needs to be tackled through the introduction of a minimum unit price and that prevention really is better—and cheaper—than cure. What does the Minister think about that?

[Earl Howe]

Minimum unit pricing remains under consideration while additional evidence becomes available. We are not taking it forward at the moment. We need to give careful consideration to any possible unintended consequences of minimum unit pricing, such as the potential impact on the cost of living, the economic impact of the policy and increases in illicit alcohol sales. It is, and has only ever been, part of the Government’s alcohol strategy—although, as I mentioned a moment ago, Public Health England will be assembling the evidence base for the introduction of a minimum unit price for alcohol to advise the next Government.

Learning Disabilities: Health and Care Services

Baroness Hollins Excerpts

Wednesday 3rd December 2014 Lords Chamber

Asked by

[Baroness Hollins]

To ask Her Majesty’s Government, in the light of the report Winterbourne View—Time for Change, what steps they are taking to address the care of people with a learning disability whose behaviour challenges services.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government’s report into Winterbourne View included actions for government and partners to provide safe, high-quality care for people with behaviour that challenges. Time for Change acknowledges that the report identified the key steps clearly. We and NHS England will look carefully at the further recommendations in Time for Change.

--- Later in debate ---

[Baroness Hollins (CB)]

I thank the Minister for his reply. Providing day-to-day support for people with learning disabilities whose behaviour challenges services is a complex task which requires specialised skills. Given the difference that the Dementia Challenge has made to raising knowledge and skills across the health and social care workforce, and the Prime Minister’s public endorsement of Sir Stephen Bubb’s report last week, will Her Majesty’s Government consider introducing a learning disability challenge, and will the Minister give his personal support to campaigning and encouraging the setting up of such a challenge?

[Earl Howe]

My Lords, that is a very interesting idea; the noble Baroness is right to draw attention to the Dementia Challenge programme, which has been hugely successful. At this point, once we and the system have delivered on our Transforming Care and concordat commitments we will consider how the lessons learnt from the Dementia Challenge programme might be applied in the next programme delivery phase, and indeed in other policy areas as well.

Health: Mental Health

Baroness Hollins Excerpts

Tuesday 28th October 2014 Lords Chamber

[Earl Howe]

If the noble Lord looks across the piece at the workforce statistics he will perhaps be more reassured than he is at the moment. The £400 million that we are putting into talking therapies, for example, will result in a workforce of 6,000 practitioners trained to deliver IAPT. Health Education England has increased the number of mental health nursing training places by 1.5%. In delivering a multidisciplinary workforce, the aim is to have skills that are transferable between different care settings. NICE will be publishing its authoritative guideline on safe staffing. We have already mandated NHS organisations to publish ward-level nursing with midwifery care staffing levels so that there is an incentive for them to make sure that they have their staffing levels right.

[Baroness Hollins (CB)]

The Government’s five-year plan to improve access to mental health services makes no mention of people with intellectual disabilities who have mental health problems. What steps will the Government take to improve access for this group of patients who have a higher prevalence of mental illness and treatable mental disorders?

[Earl Howe]

I hope that the noble Baroness will agree that the five-year plan is truly ground-breaking in many respects. We have identified £40 million to spend this year to support people in mental health crisis and end the practice of young people being admitted to mental health wards. Another £80 million has been freed up for next year to ensure that waiting time standards become a reality, not just for those with mild mental health conditions but across the piece. I will write to the noble Baroness if I can glean any further information about those with a specific disability.

Learning Disabilities: Premature Deaths

Baroness Hollins Excerpts

Wednesday 30th July 2014 Lords Chamber

Asked by

[Baroness Hollins]

To ask Her Majesty’s Government what progress has been made with regard to the recommendations of the Confidential Inquiry into the premature deaths of people with learning disabilities in the year since their response to the Confidential Inquiry.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, actions are under way with a range of national delivery partners and at local level in response to the inquiry’s recommendations, including improvements in the identification of people with a learning disability, the auditing of reasonable adjustments, and the provision of health checks. Progress is monitored through the Learning Disability Programme Board.

[Baroness Hollins (CB)]

My Lords, I welcome the commitment in the NHS business plan and the Department of Health mandate to try to reduce premature mortality in people with learning disabilities, and in particular to establish a national mortality review function, but until the necessary data linkages have been made, the review cannot begin. What action is being taken to ensure that the Health and Social Care Information Centre will prioritise the collection of the data required, such as identifying people with learning disabilities and their causes of death, so that the review can indeed begin?

[Earl Howe]

My Lords, the specification for the mortality review function is under development, and we all wish to see that work proceeded with rapidly. Data to support the function will be needed from both national and local sources. Work is under way with NHS England, the Health & Social Care Information Centre and Public Health England to derive data to underpin both the mortality review function and the NHS Outcomes Framework. However, it is important that this should take full account of wider developments in the collection and sharing of patient data, and this will inevitably impact on the pace of progress. As I am sure the noble Baroness recognises, it is vital that we get that right.

Mental Health: Beds

Baroness Hollins Excerpts

Tuesday 29th July 2014 Lords Chamber

[Earl Howe]

The noble Baroness referred to people with moderate health needs, which is departing slightly from the Question on the Order Paper. However, I can tell her that mental health policy and its delivery is now a major focus. We have a mental health system board to ensure that all the elements of the health and care system work as effectively as possible together. There is a ministerial advisory group in operation. Parity of esteem is reflected in the NHS constitution and in the Health and Social Care Act 2012. We have challenged NHS England through the mandate to make measurable progress this year towards achieving parity of esteem between mental and physical health.

[Baroness Hollins (CB)]

My Lords, in 2013 a census found that three-quarters of people with a learning disability admitted to a specialist in-patient facility were subject to the Mental Health Act. For a third of these, learning disability was the only reason given for their admission, without any of the additional requirements under the Act for detention being met. What action are the Government taking to ensure that the Act is being used correctly in the care and treatment of people with a learning disability?

[Earl Howe]

My Lords, if people with a learning disability are detained under the Act, this must be for assessment or treatment of mental illness. The person must satisfy the strict criteria laid down in the 1983 Act. When a learning disability is identified as well as a need for assessment or treatment of a mental disorder, the important thing is that alternatives to the use of the Mental Health Act are considered—for example, use of the provisions of the Mental Capacity Act and whether reasonable adjustments would assist the person with learning disabilities fully to access the assessment and treatment. This is an area we have explicitly covered in the draft code of practice, which is currently out for consultation.

Learning Disabilities: Community-Based Support

Baroness Hollins Excerpts

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My Lords, the Government’s mandate for NHS England in the current year includes an objective which covers Winterbourne View concordat commitments. He is right that the deadline was missed. We are not satisfied with that and we are working very hard with NHS England to set out our expectations for progress and improved rates of discharge from in-patient settings. NHS England is going to produce an action plan this August but, in the mean time, it is doing three things. It is complying with the transforming care and Winterbourne View concordat commitments, which we have tasked it to do. It will set out what progress it expects to make and by when, with milestones, and it will provide real clarity on what success looks like—an important issue if we are trying to hold it to account—and how progress will be measured.

[Baroness Hollins (CB)]

My Lords, is the Minister aware that in the first six months of this year, 544 new people were admitted to assessment and treatment units and only 338 were transferred? Does he agree, therefore, that prevention is as important as discharge, and that in order to achieve both of these, skilled community support and skilled specialist support in the community are urgently needed and need to be funded?

[Earl Howe]

I do agree with the noble Baroness. For people who, with the right support, could and should be living in community-based settings, there is a variety of reasons why sometimes that does not happen. The lack of appropriate housing can be a barrier. For others, we know that clinical decisions are preventing discharge. NHS England is looking very carefully at how to strengthen second opinion to support people in in-patient settings to challenge the reasons for their placement as and when they need to. We are looking at making some capital funding available to support the transfer of people from in-patient care to community-based support.