Funding of Care and Support

Baroness Tyler of Enfield Excerpts

Thursday 24th November 2011 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I rise as a very recent recruit to the usual suspects and as someone still very much serving her apprenticeship but very proud to be a member of this group. First, I congratulate the noble Baroness, Lady Pitkeathley, on securing this hugely important debate. I do not think that I am exaggerating when I say that, despite all the challenges the country faces, the funding and the future of social care is the greatest social challenge facing the country, which we know we will all face in a very personal way as we move through our lives. I very much agree with the noble Baroness that it is a matter that has been put into the too-difficult-to-deal-with in-tray for far too long.

I should like to explain why this issue must be at the top of the political agenda. It is impossible to escape the fact that chronic underfunding of care has led to a crisis in our social care system and is putting huge pressure on existing care services, the NHS and, in particular, on families providing care. As we think of the challenges we face, a couple of statistics have really brought that home to me. The first is the fact that the number of over 85 year-olds is set to double over the next 20 years. The second is that 11 million people who are alive today will live to the age of 100. The third is that the number of carers is expected to rise from 6.4 million in 2011 to 9 million in 2037.

The extent to which social care funding has failed to keep pace with demographic change—in marked contrast to NHS funding—has already been well covered, so I do not intend to repeat those comments. Instead, I want to say a word or two about who is really feeling the burden of this underfunding. First of all, there is the cost to families. The result of demographic changes outpacing spending is that growing pressure is placed on family members who provide care. I was interested to see that statistics produced by the NHS Information Centre show that the proportion of carers providing over 50 hours of care a week has doubled in the last 10 years. That has all sorts of implications for people’s health, finances, their availability for work and, indeed, for the economy.

I turn next to the issue of the cost to businesses, which we hear less about. The peak age range for caring is 45 to 65, which often represents employees’ peak of training, skill and experience. Employers are at risk of losing these employees at short notice if the social care system cannot enable families to juggle work and care, and the average cost to businesses of recruitment, training and lost productivity is around £11,000 per staff member lost. As we know, there are many enlightened employers who are working hard to try to promote flexibility and workplace support for employees who are juggling work and care responsibilities, but flexibility in the workplace cannot compensate for poor quality, unreliable or inaccessible social care, and over 40 per cent of carers who have given up work say that they did so due to the lack of sufficiently reliable or flexible services.

Lastly, I mention the cost to the NHS. As we all know, an insufficient supply of social care in the community also results in additional pressures and unavoidable costs for NHS services, particularly through things like emergency admissions and bedblocking—a term that I absolutely hate, but recent statistics show that these issues are currently getting worse.

Like many other noble Lords, I am attracted to the recommendations made by the Dilnot commission. I notice that they have also attracted the support of many influential bodies in the sector and beyond. I believe that, if implemented properly, the recommendations have the potential to help people to prepare and plan for a better older age and take away the terrible fear that so many have. I will not run through the individual recommendations in detail because others have done so, but what is important is protecting families from catastrophic care costs by capping lifetime care bills, and we have already heard very interesting arguments about the level at which the cap might be set. I also welcome the commission’s clear recognition of the need for additional resources for social care to overcome the historical shortfall, as well as the proposed national system of eligibility and portable assessments in order to create a more standardised system across London and across England. That will help families if they move to different parts of the country. Another recommendation has been made which perhaps is not very sexy—we have not heard about it so far today, but I think it is potentially very important—is for a new awareness, advice, information and advocacy strategy to help families plan for care and to access private, state and voluntary sector support.

So where is the money going to come from in the very difficult current climate? I shall highlight a couple of possible areas. First, those of us who are involved in the consideration of the Health and Social Care Bill have heard a lot recently about the importance of the integration of health and social care, and I thought we had a good debate on the subject earlier in the week. The Bill is entitled “Health and Social Care”, which is very good, but I have to say that we do not talk that much about the social care aspect, and it still often feels like the country cousin. It was said earlier this week that it will require a really big shift of existing resources from the NHS to the social care system to make a reality of integration, and that is going to require huge political will at both the national and the local level.

There is also the issue of investment in more preventive work, which covers all sorts of things these days. We have reablement packages, telecare and the like that can make a big difference to older and disabled people and their families in terms of enabling them to remain in their homes. That is very welcome, but where is the money for these preventive services going to be found? Is it really going to be made available from ring-fenced public health budgets? We also need to do more to stimulate the care market and to think carefully about what these proposals will mean for current providers. It was interesting to note that a poll carried out in February 2011 of the social providers of community care showed that 25 per cent of them expected to face closure before the end of this year because of cuts in local authority fees. Finally, we need to do more to improve the quality of care available, in particular by supporting the development of a skilled, flexible and valued workforce. The point about members of the workforce feeling valued is so important.

I shall finish by saying that I believe we must be brave both as politicians and as a political class, and here I offer my apologies to the Cross-Benchers. We need a real political consensus on this. The report sets out the basis for a lasting and long-term settlement, and as a class we will not be forgiven if we duck the challenge because it is too difficult.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Tuesday 22nd November 2011 Lords Chamber

Each of these criteria would admirably test any proposal, but any change meeting all three would have a powerful endorsement to be carried through. To accept changes that meet some but not all the criteria could result in the desired objectives not being met. I suggest that, with the criteria, commissioners will be able to judge whether the providers of choice will be able to collaborate to deliver co-ordinated, integrated care pathways.

[Baroness Tyler of Enfield]

My Lords, I will speak to Amendment 135CA in my name. We have already had a very interesting debate about what we mean by integration. Obviously, different people mean different things. The sense in which I will talk about integration is how we can encourage integrated care pathways for people who experience some of the worst inequalities in terms of access to healthcare.

Clause 20 states that the NHS Commissioning Board will encourage integrated working between clinical commissioning groups and local authorities. This is clearly welcome. However, it needs to go further. Those with the worst health outcomes often have the most complex needs and can often benefit most from integrated care. However, as is so often the case, disadvantaged groups can easily be overlooked in the overall system. The fundamental aim here is to ensure that integrated care pathways can be set up that specifically target those with the poorest health.

I will briefly explain why integrated care pathways are important for those with complex needs. A number of patient groups experience health inequalities. We all know about that, and heard about it in our previous debates. In their 2010 report, the Cabinet Office and the Department of Health identified a number of groups of people who have complex needs and as a result carry a disproportionate cost to the NHS. The report states that,

“socially excluded people often make chaotic and disproportionate use of health care services, and experience a range of barriers and issues relating to their access and quality of primary care”.

As we know, these groups include homeless people, people with mental health problems, people with drug and alcohol addictions and others.

I will give a specific example of why this is a very important issue. Homeless people have some of the poorest health outcomes in our communities. I will give noble Lords a couple of facts and figures. Eight in 10 homeless people have one or more physical health need. Seven in 10 have at least one mental health problem. Between 50 and 75 per cent of rough sleepers experience mental health disorders, including anxiety, depression, dementia and psychosis. Research by the Department of Health, again in 2010, estimated that the average age of death of a rough sleeper was between 40 and 44. I find that statistic shocking. Finally, the Department of Health estimated that this had a knock-on cost to the NHS that was four to eight times greater than that of a person in the general population.

As a result of these patients’ complex needs, barriers often exist that prevent them getting the treatment they need. Some services simply exclude them because they are deemed too difficult to deal with—too chaotic or complex. Evidence was found that one in 10 homeless people is refused access at primary care level. Integrated care pathways are crucial to provide personalised and accessible services that treat multiple problems at the same time.

I shall give a very brief example of how this can really make a difference in practice. The average age of homeless people dying while living in a St Mungo’s hostel is just over 40 years. Back in 2009 St Mungo’s began an intermediate care pilot at one of its hostels in south London. It was run by a full-time senior nurse and a health support worker. Together they worked with residents to help improve their health and well-being and particularly to prevent unnecessary admission to hospital. They also arranged appropriate discharge from hospital. As a result of this pilot there has been a marked increase in attendance at HIV services, chest clinics, dental appointments and mental health services. Calls to the London Ambulance Service have gone down by 13 per cent and hospital admissions by 40 per cent, which I think is a very significant figure.

This fits very much with the Government’s approach. Indeed, this amendment builds on the commitment to improve the health of the poorest the fastest, which has been part of these health reforms since the White Paper was published in 2010. It also builds on evidence presented by the NHS Future Forum, which stated:

“We need to move beyond arguing for integration to making it happen whilst also exploring the barriers. We would therefore expect to see the NHS Commissioning Board actively supporting the commissioning of integrated packages of care”.

In their response, the Government agreed that integration of commissioning health and social care should be the ambition for all local areas. The Government have made a number of welcome commitments to strengthen local development of pathways between health and social care providers, and we have heard about some of them this evening. They obviously see an important role for the NHS Commissioning Board working with senates and CCGs in taking this forward. Can the Minister explain how—in achieving better outcomes for those with the poorest health, as is required to reduce health inequalities—the aims of improving integrated working and the health of the poorest the fastest will be achieved in practice?

[Baroness Finlay of Llandaff]

My Lords, I have several amendments in this group. Amendment 203A has been spoken to fully by noble friend Lady Hollins, who has supported other amendments in this group. Amendment 135C would require a biannual report by the board to the Secretary of State on what has been done to promote integration. The other amendments are all designed to promote collaboration, decrease duplication and bring together primary and secondary care and public health and the diagnostic services to have better diagnosis and management of disease.

Integrated working allows patients and their carers to benefit from good primary care provided by GPs and others in the team, to have help and support provided by those working in social care, and to access early referral, appropriate investigation and treatment as required from specialist services. Good integrated care needs to see the patients and their experience in the context of their lives, social support, relationships, cultural experience, gender and a range of other factors. Bringing together an integrated social and clinical approach should include holistic plans for diagnosis, treatment, rehabilitation, support and long-term follow-up.

In their report Teams without Walls, the Royal College of Physicians, the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health highlighted the recommended use of patient pathways as the building blocks for services, with the right balance between prevention, early identification, assessment, intervention and, where necessary, long-term support. They also pointed out that this had implications for commissioners, providers and regulators of services. Multi-professional working with the patient at the centre of everything provides the opportunity for a wide range of professionals, including those outside an organisation, to monitor care delivery and challenge standards. This will help prevent trusts and professionals from becoming insular. Insular practices can result in negative cultures developing and poor standards becoming tolerated.

The clinical commissioning groups have quite a challenge facing them if they are really to commission and develop integrated as opposed to fragmented care. Much has been said on this already, and I will not repeat the points made by previous speakers. However, patient needs will be better met if we move to a tariff structure that better reflects clinical complexity. The Government’s response to the Future Forum report seems to recognise this, but the current tariff structure overcompensates for simpler conditions and consistently under-compensates for more complex and unpredictable areas of care. To encourage integrated working, consideration needs to be given to a system in which payments are received over a longer term and for the achievement of integration and good clinical outcomes. To do that, it will be crucial for Monitor and the Commissioning Board working closely with royal medical colleges and specialist societies to develop a tariff that will provide integrated care.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Ribeiro]

I want to pick up on something that the noble Baroness, Lady Greengross, mentioned; namely, elderly patients perhaps being denied treatment. There is a real danger in not recognising that the clinical decision is based on the quality of the patients rather than their age, which is important. We are all aware of 60 year-olds who are basically crumbling with significant code morbidity and who would not be considered for surgery. Yet, there are many fit and self-caring people in their late 80s who may fracture a hip and would be worthy of surgical treatment. In fact, many people in your Lordships’ House in that age group may have benefited from that type of treatment. It is very important that we should see this in the context of clinical need rather than just one of age.

Similarly, as regards cancer and the point I made about the older generation, not that long ago in the United States a carcinoma of the prostate was open season for anyone to have a radical prostatectomy practically at any age, be it 80 or 90 years old. The morbidity and mortality associated with that radical surgery was very high. The American College of Surgeons, at recent meetings I attended, recognised that patients over the age of 75 should not be offered this type of surgery unless there is a very good reason. It is also a well known fact that 80 per cent of males aged 80 and over actually have—not just probably have—carcinoma of the prostate. But on whether they should have treatment for it, they are more likely to die from other conditions than from their cancer. Although age is important, it should not be a specific criterion for determining whether treatment is given or not.

[Baroness Tyler of Enfield]

My Lords, I, too, should like to speak in support of this raft of amendments which are all designed, to use the words of the noble Baroness, Lady Murphy, to give greater teeth to reducing health inequalities. We have already heard various statistics from a number of noble Lords and those for life expectancy are generally the most stark. The statistic that means the most to me relates to London, probably because that is where I live; namely, that the life expectancy of men ranges from 71 years in one ward in the London Borough of Haringey to 88 years in one ward in Kensington and Chelsea. That is a huge difference of 17 years. It is worth also pointing out that even within Kensington and Chelsea, there is a difference of nearly 12 years in life expectancy across different parts of the borough.

As many noble Lords have said, there is a whole range of reasons for this, including the social and the economic. It is one of the things that underline the critical need in our debates to put more focus on public health interventions. I also very much welcome the establishment and the role of Public Health England, and the fact that the public health function at a local level will sit with local authorities.

In discussing the need to strengthen these duties, it is important to recognise and welcome that having explicit duties placed for the first time on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups is a landmark, representing a major shift from the current position. There is something very significant about the whole raft of these NHS reforms.

The phrase “have regard to” health inequalities for the clinical commissioning groups is not sufficient because we need to make sure that they act and behave to secure real improvements, which need to be in both access to NHS services and in outcomes. I want those CCGs to account publicly for their progress, not simply as part of normal accountability but as part of sharing good practice and workforce development, and in the training of NHS employees. It should become part of the everyday currency and language of the NHS, part of the DNA of the way in which the health service operates. I believe that this strengthening is necessary if the NHS reforms are to become a real game-changer for some of the most disadvantaged group in society—to borrow from the words of the public health White Paper, Improving the Health of the Poorest Fastest.

Perhaps I may give an example in relation to homeless people who experience some of the worst health inequalities of any group in society. They are more likely to die young, live with a long-term condition, have multiple health problems and have mental health or substance use issues. They are also far less likely to have regular contact with a GP or other health professional and are much more likely to access healthcare through A&E, which is inappropriate and, as we know, causes all sorts of problems for A&E departments. In short, they are the most likely to have very poor health and the least likely to benefit from what the NHS has to offer.

Of course, many services are needed to help homeless people to improve their outcomes, including housing, employment, family support and other things. But it is particularly important that the NHS is able to cater for the needs of these groups. Appropriate services are far more likely to be commissioned where clinical commissioning groups have a duty to take account of these health inequalities in their plans and reporting mechanisms and the standards to which they are held to account, and that they are ensuring that these arrangements are incentivised through the commissioning arrangements.

I very much support the principle of the amendments put forward and I look forward to hearing the Government giving an even stronger commitment to tackling health inequalities and to making this a key outcome of the overall package of reforms that we are discussing.

[Baroness Armstrong of Hill Top]

My Lords, I seek only to intervene briefly on this. The whole issue of how to tackle inequalities in health is an extremely complex and difficult one. When I was a Member of Parliament, I looked forward to receiving from the department reports on a regular basis on how inequalities had been addressed and how health had improved throughout the constituency. What was clear was that the more effective our public health interventions were, such as on reducing smoking, the more difficult it was to tackle inequalities. The people who automatically responded best to those interventions were those on higher wages, with better qualifications and who were likely to be in higher class groups than those in the poorest parts of the constituency. That could always be seen clearly in those reports. The amendments that support better information are very important because clinical commissioning groups in particular are not well placed instinctively to tackle inequalities. It is generally not part of the training of GPs to look at these issues and work out how to address them.

We have already discussed the second issue today, and it is important—the issue of access. Unless we open up access much more sharply to the disadvantaged we will not have a chance of addressing inequalities. The noble Baroness opposite talked about homelessness. I have discussed this issue with the Minister on a number of occasions, and I am not content that the Bill deals with it adequately. It is not fair to ask clinical commissioning groups to address this issue. Sometimes they will simply be too small to do so. Also, homeless people tend to be fairly mobile, so in London they will cross authority areas. From my experience in the north-east of England, a single PCT—or what will now be the smaller clinical commissioning groups—does not have the people available properly to offer the sort of services that are needed to open up access effectively to those who are not normally registered on a GP list.

I am also concerned that clinical commissioning groups may be responsible for areas with poor GP coverage and there will be a need to bring in salaried GPs. It will need someone other than a clinical commissioning group to address the issue of GP shortages—and it is always the poorest areas which have the poorest access to GPs. It is an issue that continues to have to be addressed time and time again. I was pleased when the last Government introduced many more salaried GPs, but we have to keep on top of that agenda.

I also support the amendments that look to the responsibilities of the NHS Commissioning Board. There will be occasions when the board has to come in specifically to address inequalities in a range of ways. I am not sure that it is really geared up to do that at the moment. But because I certainly do think that clinical commissioning groups are not going to be able to do this on their own, and indeed it would not be appropriate for them to address some areas of clinical commissioning, it is very important that the department, the Secretary of State and the Commissioning Board think about how they are going to do this effectively.

Tobacco Advertising and Promotion (Display and Specialist Tobacconists) (England) (Amendment) Regulations 2011

Baroness Tyler of Enfield Excerpts

Monday 11th July 2011 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, it is the clear policy of this Government—and the last one—to put tobacco products out of sight in shops. That must be right. As your Lordships heard when this issue was previously debated, lives are at stake here. There is clear evidence that some 300 lives are lost every day in this country resulting from tobacco-related illnesses. We need to do everything in our power to both prevent young people from taking up the habit and help people trying to quit. Every time we delay implementing this policy, further lives are at risk and more young people will start smoking.

It should also be the policy of this Government to put an end to tobacco industry interference in public health policy—the subject of this Motion. Behind-the-scenes lobbying by the tobacco industry undermines the Government’s clear intent in this area and is bad for the health of our democracy. Decisions of this nature, affecting people’s lives and livelihoods, should be taken transparently. While I know that opinion was mixed during the passage of the Health Bill which became the 2009 Act, there is now broad cross-party consensus that the evidence justifies the prohibition of tobacco displays and that the cost to retailers will not be unreasonable.

The tobacco industry has continued its campaign to undermine the Government’s resolve. Thankfully, it was not permitted to interfere in the development of the tobacco control plan for England—we have already heard about that from the noble Baroness, Lady Thornton. The Government should receive credit for taking seriously their duties in that respect. Those commitments include publishing details of meetings between the tobacco industry and government departments. I look forward to that happening in practice.

However, consequently the tobacco industry has used its large profits to seek to obstruct the Government’s progress, through the use of front groups and in the courts by the use of judicial review. The combination of legal challenge and what is often called front-group advocacy is used widely by the tobacco industry overseas. Australia is a case in point here. A 5 million-dollar television ad campaign during Australia’s recent general election purported to be by the newly formed Alliance of Australian Retailers but was revealed to have been funded by tobacco companies.

Smoke-free legislation, in place in England since July 2007, is among the most popular of recent laws, supported by some 80 per cent of the population. Just as the vast majority of people understand and support the reasons for a ban on drink driving and the compulsory wearing of seat-belts in cars to reduce road traffic deaths, most people understand why a ban on point-of-sale tobacco advertising is needed to improve public health—not least those trying hard to kick the habit because of the harm it is having on their own health and their loved ones. However, the tobacco industry continues to campaign against the law through industry-funded groups. With almost no chance of reintroducing smoking into pubs, the well funded campaigns have been described as a pre-emptive defence against further legislation.

We have already heard about what happened when Mr Stephen Williams MP, chair of the All-Party Group on Smoking and Health, revealed how the tobacco industry used retailers as a front for its campaign through direct cash payments and by paying for the services of lobby firms. What makes this practice particularly objectionable and unjust is that, when tobacco companies pay for secret lobbying to protect the promotion of their products, it is the poorest who suffer most—and not just in terms of cash. Research shows that poor smokers are just as likely to want to, and try to, quit but much less likely to do so successfully. Research also shows that tobacco displays are not only linked to youth smoking but also trigger relapse among smokers trying to quit.

We have heard different accounts of the evidence from the introduction of tobacco advertising bans in countries such as Canada, New Zealand and Norway. There is plenty of evidence to show that they lead to a considerable reduction in smoking—indeed, by figures well in excess of the official estimates of the likely impact of the measures coming into effect. This is a Motion of regret. I can think of nothing more regrettable than the fact that behind-the-scenes lobbying has led to the delay in the introduction of these much needed display regulations and that lives will be lost as a result.

[Lord Palmer]

My Lords, the noble Baroness, Lady Thornton, will know full well how I abhor the habit of smoking, albeit that I am a smoker. I must declare an interest as the convenor of the Lords and Commons Cigar and Pipe Smokers’ Club. We ought to be very careful about the hypocrisy of the last Administration. If smoking was completely outlawed, the entire British economy would literally collapse. As such, as much as I admire the noble Baroness, I regret this Motion—particularly in these hard pressed times, most especially for very small retailers.

NHS: Consultation on Reform

Baroness Tyler of Enfield Excerpts

Tuesday 26th April 2011 Lords Chamber

[Earl Howe]

My Lords, I think there is widespread agreement that the principles on which the Bill is based, such as devolving control of the NHS to local levels, placing patients at the heart of decisions about their own care and improving public accountability are the right principles for us to be guided by, but that there are also, as the noble Lord said, questions and concerns, some quite deep, about what we are doing and the mechanics of putting the principles into practice. As the Prime Minister and Deputy Prime Minister made clear, this is a genuine chance to make a difference. Where there are good suggestions to improve the legislation, those changes will be made.

[Baroness Tyler of Enfield]

My Lords, what steps are the Government taking to plug the gaps in the membership of the NHS Future Forum? Will the minutes of the forum be made available to the public?

[Earl Howe]

My Lords, the forum, as I understand it, is now fully composed. The appointments were made over the past 10 days or so. I am not aware of any further appointments. The plan is for the forum to produce a report which will be published at the end of the day. I will, however, write to the noble Baroness as regards the minutes, which are a matter for the chair of the forum, which is independent of the Government, as she will know.

NHS: Standards of Care and Commissioning

Baroness Tyler of Enfield Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, that is a hard act to follow. I congratulate the noble Lord, Lord Turnberg, on securing such an important debate at a time of far reaching reforms to our National Health Service. These reforms should be judged by the extent to which they lead, first, to better health outcomes for adults and children; secondly, to consistently higher standards of care for all; and, thirdly, to a more responsive and personalised service. Given the scale and pace of reforms, the most radical in a generation and beyond, it will be crucial to give close attention to the quality of care during this period of immense change.

I would like to illustrate this by talking about the standards of care and commissioning practices within mental health services, still seen in some quarters as a Cinderella service. I am indebted to the briefing and support that I have received from the charity Mind.

One in four people is likely to experience a mental health problem every year and the cost of poor mental health to the economy is estimated to stand at £105 billion. As will be well known in your Lordships' House, mental health problems are inextricably linked to social factors such as debt, unemployment, poverty and poor housing.

The Government’s recent No Health without Mental Health strategy sets out a clear vision for the future of our mental health services. This is to be welcomed. The strategy also makes it clear that the provision of high-quality services is dependent on high-quality commissioning.

To make a reality of that strategy, it will be important to ensure four things: first, that commissioning bodies have a proper understanding of mental health services and service users; secondly, that mental health services are fully integrated both within the health service and across social care, public health and areas such as housing and policing; thirdly, that every opportunity is taken to increase patient and public involvement and that those who need extra support to get involved in decision-making are given it; and, finally, that there is parity of esteem between mental and physical health services.

In response to a recent survey by the charity Rethink, 42 per cent of GPs said that they lacked knowledge about services for people with mental illness and lacked confidence in commissioning those services. The abolition of the National Mental Health Development Unit this very day will create a real gap in mental health advice for commissioners and providers. What plans do the Government have to fill that gap in expertise?

The Government have recently announced plans to invest around £400 million over four years to ensure that adults with depression and anxiety across England have access to a wider range of effective psychological therapies. This investment will also enable the expansion of much needed psychological therapies for young people, older people, people with severe mental health problems and people with long-term physical health conditions. All this is greatly to be welcomed but it is vital that this funding is not seen in these tough financial times as an opportunity to cut existing mental health services.

As already referred to, only this week the Care Quality Commission released its latest report on the state of health and adult social care. I was concerned to see that, despite the welcome advances across the board, care standards for people experiencing mental health problems are being left behind, particularly in acute and crisis mental health care.

I would have liked to have finished by saying a few more words about the commissioning of children's mental health services—an area that I know something about. I am chief executive of the charity Relate, a declared interest of mine, which has experience of providing what is called early intervention counselling services. Time will elude me, but the one thing that I will say is that far too often the voluntary sector finds itself left to pick up the pieces because statutory services such as children and adolescent mental health services, which try to do a good job in very difficult circumstances, are vastly oversubscribed with very long waiting lists. More needs to be done to give this area higher priority.