Mental Capacity (Amendment) Bill [HL]

Debate between Baroness Wheeler and Lord O'Shaughnessy

Tuesday 26th February 2019 Lords Chamber

[Lord O'Shaughnessy]

My Lords, the rights to information are another good example of the positive change that this House made in the passage of the Bill. I pay tribute to the noble Baroness, Lady Watkins, and Baroness Hollis, for making that argument so persuasively. I am very grateful to my noble friend the Minister and my right honourable friend the Minister of State, Caroline Dinenage, for responding.

I completely understand the desire to create—if I can borrow a bit of terminology—a backstop for why these sorts of cases ought to be considered. It is very easy to see how in practice when perhaps a small institution is caring for people with complex needs, the definition of “practicable” could stretch over time because of urgent or important responsibilities. There is a risk that, without some kind of backstop or time limit, this is too vague. However, I have a big problem with having an arbitrary time limit. I know that the noble Baroness is not attached to any particular time, but any time is by definition arbitrary.

My concern is that if this is in primary legislation it could lead to rushed or poor record keeping if it is not, for example, possible to conclude the review, assemble all the relevant pieces of information and provide that in a readable form—bearing in mind that is not going to be just straight English language for everybody—to the appropriate person, the IMCA, and so on. We should particularly bear in mind that an appropriate person could be somebody appointed by the cared-for person who resides in another country. So there are complexities at the edge of these kinds of cases that mean that if an arbitrary limit—which any limit would be—is set out in primary legislation, it could mean that as institutions bump up against it, they just rush to get the job done rather than making sure that they take care to do the highest-quality piece of work. That is my fear, although maybe other noble Lords do not share it.

I take the point that the noble Baroness, Lady Jolly, made about whether or not—in her view, not—the guidance is the place to do it. It seems to me that it is the right place to do it, because we had not defined “practicable” and “appropriate” before. We can now derive some examples of what that would and ought to look like in normal cases, but also in edge cases. I have listened very carefully to the argument—as noble Lords know, my attitude throughout has been to listen and make sure that we can improve this Bill. However, I have concerns about putting an arbitrary limit in, for the reasons that I have set out. I hope my noble friend, as she has been asked to do by my noble friend Lady Browning, will be able to explain things to us in a bit more detail—and give us a flavour of how the statutory guidance would provide that kind of detail—to provide reassurance to noble Lords that this is not just a boundless commitment that does not have some teeth.

[Baroness Wheeler (Lab)]

My Lords, the amendment on this very important matter in the name of the noble Baroness, Lady Watkins, is fully supported on these Benches. The Minister knows the strength of feeling of support in the House to ensure that the cared-for person, or their carer, relative, friend or other person advocating on their behalf, is fully informed about their rights at the start of the LPS authorisation process. The amendment, carried by a substantial majority, was very clear on this issue. That information should be provided up front to families as a matter of course—information not only about the process, but importantly, their rights to advocacy and to challenge—in an accessible format that they can understand.

The provision in Amendment 25 of a statutory duty for information to be provided “as soon as practicable” does not ensure that this essential up-front requirement for information is met. One of the excellent briefings on this matter from Mencap states:

“Families’ carers have consistently fed back to us that the lack of information up-front meant that they didn’t know what was happening, that it was a process done to them and their loved one, and that set in motion misunderstandings, mistrust and instances of an appeal which could have been avoided had information been provided and explained at the beginning”.


Mencap’s concern is that the “as soon as practicable” provision could mean a system working on the timescales of the responsible body, rather than of the individual body and the families. That is our concern, too.

Amendment 25A addresses these concerns and ensures that the loophole in the Government’s amendment is addressed by requiring a record of the decision and justification to be kept where it has not been practicable to provide that up-front information about the decision to commence authorising arrangements under subsection (1). It also provides a necessary timeframe. We have heard that the noble Baroness, Lady Watkins, is not wedded to 72 hours, but it is important to have a timeframe within which, if a copy of the authorisation record has not been provided, there must be a review of whether the lack of information provision was appropriate. The requirement would provide the necessary safeguard for the cared-for person, and the hard- pressed staff, by facilitating routine record keeping and accountability for the decisions made. The noble Baroness pointed out some very explicit examples of the type of record that needs to be kept; it would not be onerous.

We are in a strange position, which we are slowly getting used to, of having the ex-Minister reassuring the House from the Government Benches that everything he promised has been delivered—before the Minister speaks. Amendment 25A highlights a significant loophole that needs to be addressed and I hope that the Government will accept it. We accept that the Government’s intention is to provide the information needed, and as soon as possible, but the amendment is necessary to reassure that “as soon as practicable” is not as open-ended as it can so often turn out to be.

Brexit: Health and Social Care Workforce

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 13th December 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what assessment they have made of the report by the National Institute of Economic and Social Research, Brexit and the Health & Social Care Workforce in the UK, published on 6 November.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the Government are determined to recruit and retain the staff that the health and social care sectors need. This will include a robust domestic recruitment drive as well as ensuring that EU staff, who play such an important role in caring for and supporting patients, are able to stay in this country. That is why on Monday 3 December, we launched the EU settlement scheme pilot for the EU workforce in health and social care.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. The Cavendish report on the current and potential staff shortages across all the key health and social care professions makes for alarming reading and shows how dependent we are on the work and dedication of EU nationals. I want to focus on social care workers. What is the Minister’s response to the Government’s Migration Advisory Committee, which says that these vital staff fall into the category of “low-skilled” and therefore do not merit preferential rights here in any post-Brexit scenario? In the past he has acknowledged the skilled, caring jobs that these staff do in community services, people’s homes, nursing homes and care homes. Does he agree that they are definitely not low-skilled? What is he doing to convince the MAC otherwise? What is the strategy for recruiting the 130,000 new social care workers that we need each year just to stand still, let alone to address the future demands of the service?

[Lord O'Shaughnessy]

I thank the noble Baroness for her question. First, we want to ensure that EU staff working in Britain are able to do so, and course that is why the EU settlement scheme pilot is so important. The social care workforce in this country has increased a lot, with a mixture of domestic and foreign staff. One of the ways in which we are increasing the attractiveness of that profession is by increasing the living wage, which has benefited so many staff in social care. Of course, many of them are highly skilled, and we want to ensure that we continue to be able to attract such skilled staff. We continue to discuss with the Home Office exactly what the right thresholds are for our future immigration system so that we do not lose out on these kinds of staff.

Diesel Emissions

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 5th December 2018 Lords Chamber

[Lord O’Shaughnessy]

I absolutely agree with the noble Baroness that this is an issue of concern. It is a concern to all of us and it is certainly a concern to those of us with school-age children in urban areas, who experience the pollution every day. First, the UK has made progress on reducing pollutants, although clearly there is a long way to go, and in specific urban areas the problem is much worse than in others. Secondly, I point the noble Baroness to the clean air strategy, which will be published at the end of this year. It will contain a range of measures aimed at reducing pollution and, as a consequence, the public health damage that comes from it. I shall certainly feed in her comments about the importance of targeting these benefits on schools.

[Baroness Wheeler (Lab)]

My Lords, earlier this year the World Health Organization Science Panel reclassified diesel exhaust as a carcinogen, underlining that many cases of lung cancer could be connected to the contaminant and that exhaust could become as important a public health hazard as passive smoking. The European Public Health Alliance has pointed to the urgent need to develop research into the possible impact on other health conditions such as diabetes and dementia. Can the Minister tell the House what action is being taken in response to the WHO declaration and what research funding and programmes are in place to address the growing concerns on this issue?

[Lord O’Shaughnessy]

The noble Baroness is quite right: it is one of the biggest public health problems that we face. It is associated with around 30,000 deaths a year, and that gives us a sense of the scale of the problem. I mentioned the clean air strategy but two specific important pieces of research are also taking place. One is called the Exploration of Health and Lungs in the Environment, which is a London-based study looking at the links between pollution and children’s lung health. The Department of Health and Social Care has also commissioned a review of adverse birth outcomes and early-life effects associated with exposure to air pollution. Therefore, we take this problem seriously and are commissioning research to know not only the consequences but what to do about it.

Health: Stroke

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 14th November 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what progress they have made in developing a national plan for stroke.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, a stroke programme board was established in March 2018, co-chaired by NHS England’s national medical director, Professor Stephen Powis, and the CEO of the Stroke Association, Juliet Bouverie. Following this, the NHS long-term plan will include a focus on cardiovascular disease and stroke, and is set to be published before the end of this year.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. While the promise of including the national stroke plan in the full NHS long-term plan is welcome, nevertheless publishing it in its own entity after the national strategy ran out last year would surely have helped to sustain the progress and momentum since 2010, particularly in the reconfiguration of stroke services. Instead, thousands of stroke survivors say that they feel abandoned after they come out of hospital: 70% of patients are not offered a personalised care plan for their ongoing treatment, care and support; only 30% of CCGs are commissioning the vital six-month reviews of their progress and problems; one in four hospitals does not have access to stroke specialist early supported discharge at home; and, on average, stroke survivors wait 10 weeks for urgent psychological support. What action are the Government taking to ensure that CCGs tackle these problems now?

[Lord O'Shaughnessy]

I understand the noble Baroness’s frustration about the gap between the strategy and the plan but it was right to include the work undertaken on the stroke plan within a long-term plan, because clearly that covers every aspect of how the NHS is working. In the meantime, I point out to her that the NHS RightCare programme for cardiovascular disease has been set up. It is aimed specifically at dealing with some of the variation in service that she talked about. But there is good news in stroke care: not only is there less incidence than 10 years ago but 30-day mortality rates have more than halved, so there is progress which we need to build on.

If the noble Baroness and the House will allow me, I would like to use this opportunity to pay tribute to my noble friend Lord Skelmersdale, who died very recently. He was a predecessor in this role and a great champion of stroke care, both as a Minister and as chair of the Stroke Association for 10 years. I am sure that everyone in the House would offer their sincere condolences to his family and friends.

Child and Adolescent Mental Health Services

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 24th October 2018 Lords Chamber

[Lord O’Shaughnessy]

I do not know the specifics on psychology graduates; I will write to the noble Baroness. If the number of nurses in mental health nurse training at the moment comes through into the profession, there will be 8,000 more mental health nurses by 2020. I am sure we will be keen to recruit them from wherever we can.

[Baroness Wheeler (Lab)]

My Lords, on the issue of 24/7 services, CQC evidence suggests that the number of children visiting A&E departments for mental health treatment has more than doubled since 2010. Earlier this year, a CQC review highlighted growing demand as children, young people, their families and carers find that they have to reach crisis point before they can get help. On top of this, the recent FOI response to the BBC’s “Panorama” programme showed that at least 1.5 million under-18s were estimated to be living in areas where there are no 24/7 child mental health services. What steps are the Government taking to join up services across health, education, local councils and the voluntary sector to ensure that these vital crisis and support services are available and funded?

[Lord O’Shaughnessy]

I recognise that there is variability across the country. Indeed, waiting times vary, which is not acceptable. That is why a new four-week waiting time standard is being trialled as part of the Green Paper I mentioned. I should also point out that new, community-based eating disorder clinics are being set up so that people do not have to go to an A&E environment and can access something that is better for them, frankly, both more easily and locally.

Personal Social Care: Funding

Debate between Baroness Wheeler and Lord O'Shaughnessy

Tuesday 16th October 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what assessment they have made of the report by Independent Age, A Taxing Question: How to fund free personal social care, published in September.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the Government welcome and recognise the contribution of Independent Age and other stakeholders to the important debate around social care reform. The Green Paper that is to be published later in the year will set out proposals for a sustainable social care system that strikes a fair balance between what the state and individuals pay. Reforms must be affordable and fair across the generations, including to working-age taxpayers.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. The report sums it up when it says that,

“today … accessing such support has become a game of chance: based on where you live, your social class, and your ability to pay”,

all of which was echoed in last week’s CQC state of care report, which also made it clear that any future extra funding for the NHS will just be wasted and swallowed up treating people in hospital unless there is a similar major cash injection for social care. Will the Minister confirm that all the options set out for future social care funding in the Independent Age report, particularly the strong case made for free personal social care and support for older people, are under active consideration in the social care Green Paper? How are the proposed 10-year NHS plan and the Green Paper joined together to deal with the integration lottery and fragmented care that the CQC’s local systems reviews have highlighted?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising this important issue. She is quite right that extra funding is needed, which is why we have pledged £20 billion extra for the NHS and want to get this long-term funding settlement for social care. There are many proposals in the Independent Age document—nine, I think—and we are looking at a range of different options. As I said, there needs to be a fair balance between those who are working today and those who need care today, an issue that has evaded a number of Governments and which we sincerely hope to solve. On how the two plans will work together, the intention is that the long-term plan and the Green Paper will be published together around the same time and will therefore be complementary in trying to achieve the goal of integrated health and care.

Adult Social Care

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 11th July 2018 Lords Chamber

[Lord O’Shaughnessy]

I absolutely agree with my noble friend. I know that she speaks from great experience. We have some good working practices now, through the better care fund, between health commissioners and local government, which is an essential part in making sure we have a sustainable system.

[Baroness Wheeler (Lab)]

Will the Minister reassure the House that the Green Paper will address the parity of esteem between mental and physical health in terms of eligibility for social care support at home? Although there is serious concern that many people suffering debilitating mental illness, particularly depression, are not receiving the basic social care support they need, it is very difficult to assess the national scale of the problem because of the very poor data on how the current eligibility criteria are applied in mental health support. How is this key issue being addressed?

[Lord O’Shaughnessy]

I reassure the noble Baroness that it will be addressed. When we have the consultation, there will be more opportunity to explore that.

Hepatitis C

Debate between Baroness Wheeler and Lord O'Shaughnessy

Monday 9th July 2018 Lords Chamber

[Lord O'Shaughnessy]

First, I applaud the noble Baroness for her work on this. We know that hepatitis C is a truly horrible disease that affects some of the most vulnerable people in our society, which is why we want to eliminate it. In terms of the NHS being geared up, we are on track to treat 70,000 people by 2020. We need to keep finding people, and, of course, they become harder and harder to find. She is quite right about the need to raise awareness. We are doing other things as well, such as reaching into hard-to-reach communities. To give one example, there is now a 100% opt-out testing offer for people entering the prison estate, which is one of the areas where hepatitis C tends to be transmitted. There is clearly a need to do more, but we are looking at how to reach those hard-to-reach communities.

[Baroness Wheeler (Lab)]

Can the Minister say a bit more about the steps the Government are taking to support the delivery of hepatitis C treatment in community settings, such as GP clinics, pharmacies, homeless shelters, substance misuse clinics and sexual health clinics? The King’s Fund estimates that spending on tackling drug misuse in adults has been cut by more than £22 million compared with last year, and funding for sexual health clinics by £30 million over the same period. How will the 2025 target for elimination of hepatitis C be met if vital education and work in these services, and the work they do in reducing reinfection rates, are not available?

NHS and Social Care Services: Parity of Esteem

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 5th July 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they will take to ensure that their strategy for National Health Service and social care services recognises the importance of parity of esteem, including pay and professional standing, for staff across hospital, community and social care settings.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy)]

My Lords, having the right number and quality of clinical and non-clinical staff is essential to realising our ambitions for the NHS, community and social care. Last week we agreed an Agenda for Change multi-year pay and contract deal, while the introduction of the national living wage has boosted pay for the social care workforce. Later this year, we will publish a 10-year integrated health and care workforce strategy informed by our recent consultations.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. It is right today to pay tribute fully to the work and dedication of staff across the whole of health and social care. But for the future, both the NAO and our own Long-term Sustainability of the NHS Committee strongly criticised the absence of any long-term joint strategy to secure the well-trained and committed workforce that we need for a fully integrated service. The Minister told the House on 18 June that he is considering the implications of the very recent and welcome NHS staff three-year pay increase for the independent care sector. He recognised the need for the latter to be able to compete on a “level playing field”. Does he acknowledge that for the social care sector in particular that means aiming to level-up pay and professional standing between social care and the NHS, and accepting that parity of esteem is one of the key drivers to building integrated services for both patients and service users?

Cannabis-based Medicines

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 21st June 2018 Lords Chamber

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for her question. Like her, I applaud the speed with which the Home Secretary and the Health Secretary have acted in this matter. It is incredibly important to think about the various stages and actions that have been taken. First, there is an urgent need for the panel which Professor Dame Sally Davies is setting to consider specific licence applications. The second part is to review whether there are therapeutic benefits of cannabis and cannabis-derived products. Then there is the evidence-gathering process, and all the relevant evidence, including the major piece of work done by the US National Academy of Sciences and the paper to be published by the WHO, will be collected as part of that. As the Home Secretary set out on Tuesday, it will make recommendations to the Advisory Council on the Misuse of Drugs subsequent to proposals for rescheduling. That will happen this autumn, if those proposals come forward.

If I may just take the time to say this, the noble Baroness raises a third issue, which is long-term horizon scanning for Schedule 1 drugs for which a therapeutic benefit has not yet been demonstrated but which may be demonstrated in future. We clearly need to set up a device to do that, and the MHRA may be the right vehicle. That is something we are considering.

[Baroness Wheeler (Lab)]

My Lords, can the Minister update the House on the number of cases the expert panel is expected to consider? Assuming they are current cases, can we be reassured that they will be dealt with in a way that avoids the awful situation faced by Alfie Dingley and his parents and ensures they have the best possible medical treatment?

[Lord O’Shaughnessy]

I completely agree with the noble Baroness about the need for speediness. Frankly, at this point we do not know the number of cases. The Home Secretary said on Tuesday that the service will be up and running and receiving applications within a week of his Statement—so from next Tuesday onwards, with a panel constituted rapidly so that it can start considering them.

Carers: Back Pay Liability

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 16th May 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for raising the issue, which we are looking into. The point here is that the change in policy has come about because of decisions made by employment tribunals and a clarification of the law, and the job of government is therefore to help providers to comply with the law. That is how the scheme has come about, and why extra support is being looked into. We are working closely with providers to try to understand the scale of the liability and how it affects organisations differently—we think that up to two-thirds are affected. We will also make sure that any intervention that might follow—I stress “might”—is proportionate, fair and legal.

[Baroness Wheeler (Lab)]

My Lords, Jeremy Hunt told MPs last week that a lot of work was going on in government on this issue to,

“understand the fragility of the current market situation”.—[Official Report, Commons, 8/5/18; col. 520.]

However, we already know that the viability of nearly 70% of the disability care sector is threatened by the sleep-in pay crisis, as last week’s survey by disability charities shows. Homes will have to be sold or more local authority contracts handed back. Is this not enough evidence of the desperate state the care sector is in and why the extra funding is needed from the Government to ensure that already low-paid staff are treated fairly and receive the money they are owed?

[Lord O'Shaughnessy]

The noble Baroness makes an important point about the attention my right honourable friend the Secretary of State is giving this. We are taking this issue seriously, and she is quite right about the number of organisations that are affected. As I said, a scheme already exists which allows providers to defer any payments, and we are investigating whether any further interventions are necessary during that period when they can defer them.

Domiciliary Home Care Support

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 25th April 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they are taking to ensure the provision of domiciliary home care support, in the light of the decision by Allied Healthcare to file for a company voluntary arrangement.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the law is clear that, if services may be disrupted due to business failure, the Care Quality Commission will notify local authorities so that they can put appropriate contingency plans in place. In respect of Allied Healthcare, no such notification has been made to date. The public should be reassured that the Care Quality Commission has been monitoring closely the situation at Allied Healthcare and will continue to do so.

[Baroness Wheeler (Lab)]

My Lords, Allied Healthcare is the latest hedge-fund-owned care provider to have to take drastic action to keep up the huge burden of paying off loans to its creditors. The precarious finances of many domiciliary care companies has already led to large-scale provider closures and to companies handing back contracts in almost half of councils, and we know that residential care is in a similar position. The CVA means that Allied Healthcare has four weeks to come to an arrangement with its creditors. Its closure would have serious consequences for continuity of care and the safety of its 13,500 clients, including many vulnerable older people and people with learning difficulties, and for its 8,700 staff. With local authorities unable to pay fees that cover the actual cost of care or meet the implementation costs of the national minimum wage, let alone address the potential £400 million of deserved back-pay costs for staff sleep-in payments, what reassurances can the Minister give that councils will be able to discharge their statutory duty to deliver care if Allied Healthcare collapses? Does he really think that this is the way to fund the care that people in need of support in their homes deserve?

[Lord O'Shaughnessy]

I thank the noble Baroness for the opportunity to provide that reassurance for people using and benefiting from the care provided by Allied Healthcare. I want to reassure them that the Care Act 2014, passed by the coalition Government, gives local authorities responsibility for continuity of care if a business were to fail. Of course, we are not in that position with Allied Healthcare, because it still has to go through the CVA process. I can reassure people that the LGA has said that councils have “robust”—its word—plans in place to ensure continuity of care if that is required. I put that on record for those who may be worried about it.

We know that extra funding is needed in the sector. Over three years, through a number of means including extra money through the precept and direct funding to local authorities, the Government have increased by about £9 billion the funding available for social care, which we know is required. I also point out that, if you look at domiciliary care provider numbers, you will see that there are 50% more than there were eight years ago. We know that markets have entrants and that providers are exiting, but we have more providers in the market and more packages being delivered than ever before. Ultimately, the backstop is that local authorities have that responsibility to provide continuity of care.

Health: Online Services

Debate between Baroness Wheeler and Lord O'Shaughnessy

Monday 23rd April 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they are taking in response to the Care Quality Commission’s report, The state of care in independent online primary health services, published on 23 March.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the online provision of primary care is a development with the potential to improve patient outcomes. However, it is important that these services are regulated and inspected properly. The CQC will continue to hold online providers to account while sharing good practice. Following its report, we are considering what further action is needed to ensure that the right balance is struck between the provision of safe, effective care and encouraging further innovation.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. We are strongly in favour of technologies and innovations that help to provide the widest possible access to primary health services, particularly when getting a timely GP appointment is so difficult for thousands of patients. The CQC inspection role is crucial but there is no disguising the serious issues to be addressed and resolved. These include checking patients’ identity, sharing information with the NHS GP and the safe prescribing of medicines. Some 43% of companies are failing to meet regulations for keeping patients safe and there are particular concerns about inappropriate prescribing of antibiotics and medicines and about managing long-term conditions. How will the Government ensure that the lessons from the first phase of the CQC inspection are learned, and will they pledge to take swift action on the problems now before the service is further rolled out?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising this important issue. She is right that the CQC report identified some serious issues among this group of online providers, which of course operate in the independent sector. She mentioned safety and safeguarding, and I would add to that. It is worth saying that there were some positive responses, in terms of 97% of the providers being caring and 90% of them responsive, so some strengths were identified as well as weaknesses. Obviously the CQC retains the ability to take regulatory action. As it sets out in the report, it has done so to ensure that standards improve, and in general they improve from one inspection to the next. However, this is of course the independent sector. We are looking at the lessons for the provision of NHS services. The biggest one of those that comes out of the report is around data sharing: to ensure a clear flow of data between an online provider and a GP, if they are different, so that any problems can be spotted early on. That is particularly important for safety.

HPV Vaccinations

Debate between Baroness Wheeler and Lord O'Shaughnessy

Monday 26th March 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend makes an important point, that vaccinations against the HPV virus brings wider health benefits beyond defending against cervical cancers. It is important to state that it is not my judgment that matters here but that of our expert group, and in its interim advice it did not recommend an extension of the HPV programme to boys as being cost effective, not least because of the high levels of immunity and uptake among girls, with the indirect benefit that that has. But that was its interim advice; the final advice is being considered at the moment, and I can tell the House that that advice and the underlying assumptions on cost benefit will be published when the decision is made.

[Baroness Wheeler (Lab)]

My Lords, last year’s interim statement referred to by the Minister mentions referring the issue of equality of access to the HPV vaccine to the Department of Health for consideration. Has that referral been made? Given that the clinical benefits of gender neutrality have been so widely advocated by top medics over a very long period, is the department treating this with urgency? When is a response expected, and has any legal advice been taken on whether the current situation of only directly protecting girls and gay men constitutes discrimination by gender or sexual orientation?

[Lord O'Shaughnessy]

The noble Baroness is quite right that equality is an issue, and an equality analysis will take place. That can be completed only once we have the final advice from the joint committee. I can also promise her that we will publish that analysis, so that will be able to be scrutinised. As for legal advice, it is subject to threats of judicial review at the moment, so I cannot go any further than that, but I can promise that equality considerations are very high on the list of the issues that we are dealing with.

Health: Medical Respite for Children

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 21st March 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right. Many of the children we are talking about are receiving continuing care to meet all their needs, and delivering that is very complex. A national framework for continuing care is being revised at the moment, and it will provide the picture for the skills mix that is needed at local level to ensure that these children are properly served.

[Baroness Wheeler (Lab)]

My Lords, my question is on the specific issue of parent carers, for whom funded respite care is vital to both themselves and the children they care for. The Minister mentioned the continuing healthcare framework guidance coming into force in October, which makes clear CCGs’ responsibilities to fund respite care for parent carers and breaks for families of severely disabled children. The High Court judgment clarifies the law and makes this duty clear now. What action have the Government taken to ensure that CCGs act on the Nascot Lawn judgment now?

NHS: Winter Funding

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 11th January 2018 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, in the Autumn Budget, we allocated £337 million to be available immediately for trusts to use this winter. This package funded more hospital beds, community services, mental health services and urgent GP appointments to manage the expected surge in demand. After Easter, the NHS, as last year, will undertake a full review of this winter and identify any lessons for the future. We expect that that will include an assessment of the impact of this funding.

[Baroness Wheeler]

I thank the Minister for his response. He will have seen the BMA’s stark analysis of one week between Christmas and new year. In just those seven days, bed occupancy rose to 91.4%, 39 ambulances were diverted from A&Es that were too busy to cope, 731 beds were closed due to diarrhoea or vomiting, and by the end of the week, 3,400 escalation beds had to be opened because hospitals were full. Today’s figures and the warnings from NHS Providers tell the same sorry story. Does the Minister accept that announcing extra funding in November/December was far too late to prevent the worst period across the winter so far or the Government having to announce the bombshell of 550,000 cancelled operations? Can he also tell the House how the Prime Minister’s plan will now be revised to reflect these everyday realities and come up with the urgent action and funding that is needed to help the NHS cope with its worst winter crisis in two decades?

[Lord O’Shaughnessy]

I would hope that the noble Baroness would welcome the money that was set aside in the Budget. It is important to point out that in addition to that £337 million, half of which has gone to support plans that were already in place and being actioned before the Budget, there was a further £100 million to support A&E streaming, which is also a way of taking pressure off emergency services. That has had an impact, so I do not accept the accusation that the money came too late, and indeed there is still money in the pot as services come under pressure.

As regards the future, the noble Baroness will know that it was also announced in the most recent Budget that another £2.8 billion would be allocated to the NHS to help it get through the next few years. We know that the pressures are increasing because of the ageing population. The idea of that money is precisely to help the NHS get back on target on A&E waits as well as referral to treatment.

Social Care

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 7th December 2017 Lords Chamber

[Baroness Wheeler (Lab)]

I thank the Minister for reading out the Statement in response to the October Labour Opposition debate on the social care funding crisis.

We are told that the Statement builds on the extra £2 billion over the next three years provided by the Government to “meet social care needs”. However, for the record, the Minister will know that independent think tanks such as the Nuffield Trust and the King’s Fund, care providers across the social care sector, voluntary organisations such as Age UK, and organisations representing the staff who deliver the services have all shown clearly the inadequacy of this sum to meet existing and rising demand and to address the funding crisis. Government cuts to local authority budgets have meant cuts to adult social care funding since 2010, which are set to reach £6.3 billion by March 2018. That is the scale of the funding gap that needs to be addressed, and we know that social care did not get even a mention in the Budget. Can the Minister explain to the House why such a key issue was left out?

On the Green Paper and the Government’s preparations for yet another round of consultation, the Minister will accept that this stop/start Green Paper has been a very long time coming, particularly when viewed in the light of the agreed Care Act provisions that were first promised for full implementation in 2016. On 16 November, the Minister told the House that a group of independent experts, including Andrew Dilnot and Kate Barker, would support government engagement with stakeholders. Today’s Statement says that these two are among a range of experts who will “provide their views”. An inter-ministerial group has also been set up. What role will these key experts—who have widespread respect and authority among key stakeholders —play in overseeing the review and consultation? Will they be involved at the heart of the review or will they just feed their views to Ministers?

The Minister will know that it is particularly upsetting for those of us who were involved in the painstaking work on the Care Act to be lectured again about how complex the issues are and on the need to “build consensus around reforms”. That consensus was part of the Care Act and the Government chose not to go ahead with it. We know, too, that they consulted on their proposed care “floor” during the general election; it was roundly rejected by the electorate, causing huge despair and consternation among the millions of disabled people and their carers struggling to cope. Meanwhile, many people are still faced with the catastrophic and rising costs of paying for care.

I mention carers specifically. The Minister is right to acknowledge that they are vital partners in the health and social care system, but the reality is that they have now been waiting nearly two years for the national carers strategy to be updated, refreshed or called to action, with promised deadlines being set back time after time. Last summer, carers were finally told that the strategy would be morphed into the end-of-the-year Green Paper. It was not a satisfactory situation, but carers organisations put huge effort and time into consulting with carers across the country to meet the deadline—only to then receive the announcement of the delay of the Green Paper to summer 2018.

Katy Styles, a carer and campaigner for the Motor Neurone Disease Association, contributed to that consultation and hoped that her voice would be heard. She said:

“Not publishing the National Carers Strategy has made me extremely angry. It sends a message that carers’ lives are unimportant. It sends a message that Government thinks we can carry on as we are. It sends a message that my own time is of little worth”.


We now have the promise of an action plan in the new year. Does the Minister acknowledge that he now has to be straight and play fair with carers and provide them with a date for the action plan? Can he be more specific about the scope and funding that will be allocated to the action plan?

Finally, Age UK estimates that there are 1.2 million people currently living with unmet care needs and that almost a quarter of all adult social care services receive the poorest safety rating from the Care Quality Commission. Can the Minister tell the House how the Statement will help people going without essential daily care, such as help with washing, dressing and toileting, to receive a better quality of care?

[Lord O'Shaughnessy]

I thank the noble Baroness for her response and her questions; I will deal with them in order.

First, she asked about funding. She is quite right to point out the £2 billion of extra funding that was announced in the March Budget; of course, we have had two Budgets this year, so extra funding was included in a Budget this year. I should also point out that that was the latest tranche of additional funding, which totals over £9 billion over three years, taking into account the additional funding announced in recent financial Statements. The precise purpose of the funding is to address the fact that we have a growing and ageing population. The number of people requiring care packages is rising, and often the complexity of those packages is becoming more acute—hence the need for more funding, as we all recognise.

Experts will be fully engaged in the Green Paper, providing advice to Ministers and supporting engagement. There is no point in having such an august group and not drawing on their expertise. I do not think that there is any contradiction in the way that I have described their role. We would not want to involve those people—and they would not want to be involved—if they were not going to be listened to.

On carers, I acknowledge the delay in the carers strategy and I understand that that must be frustrating for those who have invested so much time in it. I have two things to say in response. First, it is right that the position of carers is considered in the round, with care costs. Secondly, that is why the action plan is important: it provides a staging post between now and the intention to introduce fully fledged policy proposals in due course. I am afraid that I do not have a specific date or a funding package for that, but I will write to the noble Baroness with as much detail as I can find and place a copy in the Library.

Social Care: Sleep-in Payments

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 7th December 2017 Lords Chamber

[Lord O’Shaughnessy]

It is not our position that they will not be funded. That is one of the options being explored at the moment. A huge amount of work is going on with providers and all parts of government. In the end, however, the Care Act 2014 means that local authorities have a responsibility to take on the commissioning of and, ultimately, provision for providers, if they are looking at exiting the market, to make sure there is proper and comprehensive provision in the local area.

[Baroness Wheeler (Lab)]

My Lords, it is absolutely right that sleep-ins are defined as working time and therefore subject to payment of the national minimum wage. However, the Government’s November compliance scheme proposal not only failed to offer support for hard-pressed providers but also means that thousands of care workers, who are among the lowest paid in society, could be waiting until March 2019 to get paid what is owed to them. Does the Minister agree that these low-paid workers should not have to pay the price for the Government’s £6 billion cuts in social care or their failure to take action on addressing the social care funding crisis?

[Lord O'Shaughnessy]

I am grateful that the noble Baroness has raised the compliance scheme. For those providers that enter it, the scheme offers the opportunity to take 12 months for self-review and then report to HMRC, which will then allow a further three months for the providers to pay. That gives a 15-month leeway compared with the usual default enforcement period of 28 days. There is clearly a balance to be struck between the financial challenges posed to providers and the money that staff, rightly, need to take. I think that the compliance scheme provides that balance so that we can do it in a way that is sustainable.

Nurses: Tuition Fees

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 29th November 2017 Lords Chamber

[Lord O'Shaughnessy]

The system that we have means that the people who benefit most from higher education are those who pay for their higher education and, in doing so, they subsidise those who go into the professions that my noble friend has mentioned, which are extremely worth while but might not be that well paid.

[Baroness Wheeler (Lab)]

My Lords, the Health Foundation research has shown that the change in nurse training funding arrangements in England has led to a fall in student numbers, rather than the Government’s promised increase. One of the most alarming statistics shows a 31% shortfall in the number of applicants aged 30 and over, just the group with the background and experience the NHS needs, many of whom are care workers with hands-on experience wishing to develop their skills by becoming qualified nurses. Does the Minister agree that these are the very people whom nursing needs, but for whom taking on a huge debt, often at a time of heavy financial commitment, seems an impossible hurdle? Does this not all underline the need for urgent reinstatement of nurse bursaries?

[Lord O'Shaughnessy]

I think that the figure on shortfalls that the noble Baroness has given is not right. If one looks at the UCAS data, it shows, as I said, a small drop of around 6%, but the numbers going into training are comparable to 2014-15. She is quite right about the need for additional financial support, and there is £1,000 available for childcare support for those who need it, as well as exceptional support funds of up to £3,000.

Mental Health Care: Vulnerable Children

Debate between Baroness Wheeler and Lord O'Shaughnessy

Tuesday 28th November 2017 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they are taking to address the concerns raised by the Care Quality Commission in its review published in October about the particular difficulties faced by children and young people in vulnerable circumstances, such as looked-after children and those with learning disabilities, in accessing mental health care.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, improving children’s and young people’s mental health is a priority for the Government, especially for the most vulnerable. The Government welcome the CQC’s recent report in this area, which was commissioned by the Prime Minister in January. Government initiatives to improve the mental health of vulnerable children include piloting new approaches to the mental health assessments that looked-after children receive as part of their initial health assessment, and testing models for personal budget use for looked after children.

--- Later in debate ---

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his response. With the Green Paper promised before Christmas, I hope we will not have to wait until the next CQC review for the urgent action that is needed, given the scale of unmet need for mental health care among vulnerable children. Barnardo’s recent survey showed that one in four looked-after children faced a mental health crisis on leaving care, and yet nearly 65% of them did not receive any statutory support; and whilst in care, local factors such as a lack of permanent or settled placement can lead to support action being denied. On children with learning difficulties, in all my research for this Question I was truly alarmed at the lack of information that is available on the scale and problems of this vulnerable group of children. What action is the Minister taking to ensure that the CQC, Ofsted and, sadly, the police and probation inspectors combine their efforts to investigate this issue as closely as it deserves?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight these disturbing facts about the mental health of looked-after children. Nearly 50% of looked-after children have a diagnosed mental health disorder, so that is what we are up against. In terms of how we are dealing with it, the increases in funding to raise the number of treatments that are taking place by 70,000 will obviously help vulnerable children, and there is the additional assessment that I have talked about. She asked particularly about children with learning difficulties. I am sure that she is aware of it, but I would point her and other noble Lords to the Lenehan review, which set out several recommendations, all of which the Government have adopted. One of the actions that stems from that includes new guidance from the Local Government Association and NHS England on commissioning mental health services for children with learning difficulties.

NHS: Deficit

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 22nd November 2017 Lords Chamber

[Lord O’Shaughnessy]

The Chancellor has confirmed that he will fund an Agenda for Change, as it is known, pay deal on the condition that the pay award enables improved NHS productivity and is justified on recruitment and retention grounds.

[Baroness Wheeler (Lab)]

My Lords, is the Minister aware that the number of GPs has fallen sharply over the past year, despite the government pledge to increase the supply of family doctors by 5,000 by 2020? How many more targets are likely to be missed by the Government? When did the NHS last achieve the A&E 95% target or the 92% 18-week treatment target? What will the actual impact of today’s funding announcements be on the Government’s performance on these key targets and their ability to ensure that planned improvements in priority areas of care such as cancer and mental health will not be stopped, as Simon Stevens has warned?

[Lord O’Shaughnessy]

The noble Baroness has pointed out the disappointing numbers as regards GPs. I should point out that there has been an increase in training places for future years. It is critical that we deliver those places and bring more staff into the service. I am glad that she drew attention to where the additional funding will go. There will be £340 million to help the NHS through this winter, £1.6 billion of additional revenue in 2018-19 and £900 million in 2019-20. That is precisely, as the Budget pointed out, to improve A&E waits, turn waiting list growth around and improve performance against the RTT targets.

Health: Flu

Debate between Baroness Wheeler and Lord O'Shaughnessy

Monday 30th October 2017 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what preparations are being made to deal with the anticipated rise in flu cases this winter.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, it is too early to predict the impact of flu this winter. As part of the Government’s preparedness, every trust has developed plans for the coming winter season. The seasonal flu vaccination has been offered to those at particular risk of flu, and to all health and social care workers. A nasal spray vaccine will be offered to all children aged two to eight years old to help to protect them and their families.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Last week’s Healthwatch report showed an alarming increase in the number of hospital readmissions, which have risen by nearly a quarter in four years. The survey also showed a rise of 29% of people readmitted to hospital as emergencies within 24 hours. Does not this raise huge concerns about patients being discharged unsafely and before they are medically fit in order to meet the Government’s empty beds targets, not to mention the trauma and upset caused to the patients themselves and their carers and families? Do the targets take account of readmissions? What additional funding and contingency plans are in place across NHS trusts and local authorities, if there just are not enough beds to cope with the winter flu crisis? Is not the Government’s flu preparedness in urgent need of review?

Mental Health Services: Children and Adolescents

Debate between Baroness Wheeler and Lord O'Shaughnessy

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

That is what we are moving towards with the mental health first aid training for teachers in all schools. The noble Lord will recognise that schools come in all different shapes and sizes and that it is easier to do that initially in secondary schools, which are bigger than, for example, rural primary schools which might only have a staff of 10. It is critical to make sure that there is at least one member of staff who is highly trained in spotting and dealing with the initial signs of mental health problems and signposting them to the relevant authority—local health authority or whatever it is—for further care.

[Baroness Wheeler (Lab)]

My Lords, the recent survey by the Children and Young People’s Mental Health Coalition has shown that the problems young people are now presenting with have become even more severe. Can the Minister reassure the House that funding earmarked for local CAMHS transformation plans will reach local services this year? How are the Government making sure that this happens and preventing funds from being diverted to other desperately stretched services?

[Lord O'Shaughnessy]

The transition from CAMHS is now one of the mandatory national indicators in what is called the Commissioning for Quality and Innovation scheme which provides incentives for performance, so I can reassure the noble Baroness on that. She is also quite right to highlight the issue of severity. That is why, under the plans that we have set out for CAMHS, by 2021 the service will be able to see 70,000 additional children per year for evidence-based treatment.

Older Persons: Care and Human Rights

Debate between Baroness Wheeler and Lord O'Shaughnessy

Tuesday 11th July 2017 Lords Chamber

[Lord O'Shaughnessy]

There is a prospect to look forward to. If we will be living to 150, there are a lot of middle-aged people in this Chamber. The noble Baroness is right. There is a particular issue around frailty as people move into old age. That is why the GP contract introduces responsibility to look out for frailty, as well as making sure that there are named GPs for the over-75s and, if necessary, annual health checks, to make sure that there is both health and social care provision for older people.

[Baroness Wheeler (Lab)]

My Lords, my noble friend is to be congratulated on his excellent report, bringing together key issues that would enable older people to maintain their independence, dignity and quality of life and to receive the care that they need. The report underlines the importance of countries having an enabling legal framework for the provision of integrated health and social care. What action will the Government therefore take in the light of the conclusions of last week’s IPPR report, which calls for our existing national legislation to be amended to enable pooled budgets and integration, and also says that if everybody has to carry on working round the 2012 Act, as at present, STPs and accountable care systems could both be blocked?

[Lord O'Shaughnessy]

I will read the report that the noble Baroness mentioned. She is quite right that integration of health and care budgets is the way forward, particularly as the burden of disease changes away from infectious diseases towards lifestyle and complex diseases of old age. The better care fund is beginning to start the kind of integration she is talking about, but of course we need STPs and accountable care systems, as set out in the five-year forward view. We feel there is, at the moment, the legislative freedom we need to move ahead with that.

Adult Social Care Services

Debate between Baroness Wheeler and Lord O'Shaughnessy

Thursday 6th July 2017 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I am grateful to the Minister for repeating the Answer, but once again the Government seem to be in complete denial about the reality of the situation facing us in social care. A year ago, the Care Quality Commission first warned that social care could be approaching a tipping point. Today, Andrea Sutcliffe, Chief Inspector of Adult Social Care, has said that,

“the danger of adult social care approaching its tipping point has not disappeared. If it tips, it will mean even more poor care, less choice and more unmet need for people”.

Why have the Government neglected to tackle the issues facing our social care sector and failed to give it the money it needs? This report highlights safety concerns in one in four care homes. Age UK described choosing a care home as Russian roulette. Does the Minister believe that it is acceptable to force people to take these kinds of risks with their loved ones?

According to the Care Quality Commission report, 4,000 fewer nursing-home beds are now open than in March 2015. Is the Minister concerned about this drop, and what actions is he taking to ensure that there are enough nursing-home beds for those who need them and enough nurses to staff them?

This week marked the sixth anniversary of the Dilnot commission report into social care. The Government accepted the commission’s recommendations; they legislated for them; and they announced that the cap on personal funding would be £72,000, after which the state would intervene. Why did the Government abandon all that in favour of their ill-fated dementia tax? Why are this Government no closer to finding a solution for funding social care? Can the Minister tell the House why his Government have wasted seven years and failed to take any action to solve the social care crisis?

[Lord O'Shaughnessy]

I shall respond to the several questions that the noble Baroness asked. She is right that the CQC made that warning last year, and that is precisely why the Government have chosen to put in additional money—£2 billion extra was announced in the spring Budget—to support the social care system and provide real-term increases in funding.

It is worth pointing out that today’s report shows that 79% of care settings received a good or outstanding rating, compared with 72% last year. There are obviously differences in the kinds of settings that were inspected; nevertheless, it shows an increase in the number of good or outstanding settings.

I completely agree with the noble Baroness’s point about patient safety. I think that the phrase “the Mum test” is both accurate and evocative. Clearly, nobody wants to choose care settings that do not pass that, and any care that is inadequate is unacceptable. However, the reason we have that information about unacceptable care settings is that this Government, in coalition with the Liberal Democrats, introduced a very tough inspection regime in 2014. I believe that today’s report shows that four out of five settings that were judged inadequate on the first inspection had improved on reinspection, so the inspection regime is itself a critical part of dealing with the issue that she rightly points to.

The noble Baroness highlighted the number of beds and staffing. Around 165,000 more staff are working in the care sector, but of course care is moving more from residential homes to domiciliary settings, so the nature of care is changing there. However, more staff are going into the service and they are now being paid the national living wage.

Finally, it is fair to say that no Government have a completely unblemished record in getting to grips with the problem of funding care. The Labour Government had Green Papers, royal commissions, the Wanless review and so on; we have had other investigations. However, to go back to the beginning, the point is that we cannot wait any longer—we need to get on with this—and that is why I set out in the Queen’s Speech debate last week that the consultation that we will publish at the end of this year will look not just at an open question but at very specific proposals around floors and caps, and I hope that we will be able to build a consensus on the need to move forward.

National Stroke Strategy

Debate between Baroness Wheeler and Lord O'Shaughnessy

Wednesday 5th July 2017 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, decisions about the development of disease-specific strategies are made by NHS England. Its current view is that, rather than focusing on specific diseases, it is better to promote plans and policies that cut across several disease areas. So, while there is not going to be a new strategy, stroke is high on the list of NHS England’s priorities in terms of both prevention and treatment.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Stroke is the largest cause of all adult disability in this country and costs billions of pounds in health and social care, disabilities and work and related costs. However, all the evidence from STPs is that they are not prioritising stroke care. They are focused mainly on acute hospital care rather than on commissioning the whole stroke care pathway, which provides the rehabilitation and community support that stroke survivors need. They are also very short on specifics on how preventive services for stroke or any other key services will be delivered or funded. With such overwhelming evidence from STPs that improvements to stroke services will stall or come to a complete halt, will the Government now put pressure on NHS England to review its decision not to renew the national strategy?

[Lord O’Shaughnessy]

I know that the noble Baroness has a deep commitment to ensuring the best possible stroke care. She is quite right to highlight the economic and personal costs of stroke. There is a good picture in this country in so much as mortality from stroke and the incidence of stroke have halved over recent years—so the picture is improving. The stroke strategy the noble Baroness mentioned was superseded in 2013 by a cardiovascular disease outcome strategy that is obviously broader but includes stroke. That builds on the work that has already happened. I am realistic about the fact that there is obviously more to do, but we now have a number of hyperacute centres that are rolling out new treatments, such as thrombectomy, which will help treat stroke and make sure that we bring mortality down even further.