NHS: Waiting Times

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Tuesday 18th December 2018 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what assessment they have made of the effect of NHS Foundation Trusts offering private healthcare services on waiting times for NHS patients.

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

My Lords, since the founding of the NHS in 1948, NHS hospitals have been able to generate small amounts of additional income by treating both international and British private patients. Since 2010, this has remained well below 1% of hospitals’ total income. Any surplus created is used to improve the services that NHS patients receive.

[Lord Brooke of Alverthorpe (Lab)]

I am grateful to the noble Lord for his Answer. I declare an interest: I am an ordinary user of the NHS. I do not have any private medical care, nor do I make any private payments. Is it not true that there are now over 4 million people on queues waiting for treatment in the NHS? Did he see the article in the Times last Thursday headed “Patients pay £1bn to jump NHS queues”? Chelsea and Westminster Hospital recently offered me insurance, terming it the best of both worlds. How many trusts offer opportunities for people to go private, and what is the effect on ordinary users of the NHS? Surely with the shortage of resources, it can mean only that they will wait longer than at present.

[Lord O'Shaughnessy]

I am not familiar with the type of insurance the noble Lord is talking about, but would be delighted to see what he has been offered. The 2012 Act obliges income from non-NHS activities to be tied to a foundation trust’s principal purpose, which is,

“the provision of goods and services for the purposes of the health service of England”,

and that is the standard by which it should be held. He is right that waiting lists have been growing. The NHS is doing more than ever—2 million more operations in 2017-18 than in 2010—but we realise that we need to do more, which is why the Prime Minister made the historic commitment to increase funding in the NHS by £20 billion in real terms in five years’ time.

Childhood Obesity

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 13th December 2018 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what progress has been made, if any, in discussions between the BBC and Public Health England regarding a joint strategic plan on childhood obesity.

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

My Lords, Public Health England and the BBC are firmly committed to working together on childhood obesity. Since July, the teams have met three times for discussions and are currently working on the detail of future plans.

--- Later in debate ---

[Lord Brooke of Alverthorpe (Lab)]

I am grateful to hear that there have been three meetings since we met in July. Unfortunately, the latest statistics on obesity in children aged from 12 to 16 show a further deterioration. It is time we really got something moving in the form of a national campaign on obesity. The BBC has an important part to play in that. Will the Minister persuade his Secretary of State to lean on the BBC and Public Health England to get a move on so that we can see programmes being introduced, and then issue chapter 3 of the obesity plan to incorporate that into it?

[Lord O’Shaughnessy]

I agree with the noble Lord about the importance of the issue and I am grateful to him for the role he has played in bringing that relationship together. He knows very well that the BBC has played a critical role over decades in many very important health campaigns, such as on HIV or the “Just Say No” campaign on drugs. The BBC is absolutely committed. Of course, it would be inappropriate for Ministers to lean on the BBC, which has editorial independence that I am sure we are all anxious to protect. However, it is committed to doing more. It is doing a number of activities through its programming, including the “Blue Peter” cooking club, various CBBC programmes and so on. I do not think anyone doubts the BBC’s commitment to this, and we will see the fruits of that soon, I am sure.

Diesel Emissions

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Wednesday 5th December 2018 Lords Chamber

[Lord O’Shaughnessy]

We provide a range of support. In fact, my colleague, the Parliamentary Under-Secretary of State for Public Health and Primary Care, wrote to directors of public health in October to remind them of their responsibilities and to make sure that they focus on this issue. Just yesterday, our Deputy Chief Medical Officer held a round table with stakeholders and others in local government to think about how we can improve policy and communicate locally with people to make sure that they understand the consequences of things such as idling and other unnecessary uses of diesel.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I welcome the news that there will be research in London. Will any assessment be made of the number of deaths and the damage to health in London due to Boris Johnson’s refusal to apply the congestion charge to west London?

[Lord O’Shaughnessy]

The important issue is that, whoever holds the post, the Mayor of London has the power to take action. It is notable that that has not been reinstated by a Labour Mayor of London, so maybe there was something in that decision in the first place.

Childhood Obesity Strategy

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Monday 25th June 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for her questions. I salute the work she has done and the leadership she has shown on this issue. As to the content of the consultations, that will depend on when they are launched but it refers in the paper to consulting before the end of 2018 on a number of issues, so that will go through the normal process, I suppose, of a three-month consultation.

I shall look at the issue of the “eatwell plate”. It is worth pointing out that, under the “Schools” heading, there is a desire to update school food standards, reduce sugar consumption, strengthen nutrition standards and the government buying standards for food and catering services. So there is a desire to look at the official guidance that goes out and to make sure that it reflects the best science and enables any institution that is looking after children, families, schools, adults and others to give the best possible nutritional food that they can.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I welcome the proposals for further action, but I am sorry that the Government have not seen fit, if they are taking this really seriously, to make a Statement about it without the requirement for an Urgent Question to elicit a response. I have two points. I regret that there is still no mention of the point that the noble Lord, Lord McColl, has been pressing so vigorously—that we need to bring together these numerous initiatives and try to present a single campaign for parents and children. I also regret that there is still no mention of the Government dealing with the major broadcasters, in particular the BBC, to see how a longer-term plan might be produced which would make a direct link with children and thus try to ensure that effective changes take place.

My second point is that last week the Minister was kind enough to reply to my Question for Written Answer about the extent to which the Government are aware of how much children between the ages of 12 and 16 weigh. I am surprised to hear that while we weigh children at the ages of four and 11, nothing is done about weighing children beyond that age. We do not know what the scale of the problem is up to the age of 16. A survey has been undertaken in which only 2,000 people were involved. There is a requirement that we move towards weighing these children. Is the Minister prepared to consider doing that?

[Lord O’Shaughnessy]

There is a single campaign which is exemplified in the document and we need to put that across. I know that the noble Lord is working with broadcasters. I am not sure about the merits of weighing teenagers, but I will look into that and write to him.

Childhood Obesity: Yoga

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 21st June 2018 Lords Chamber

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

My Lords, while there is some evidence that regular yoga is beneficial for people with high blood pressure, heart disease, aches and pains, depression and stress, no central assessment has been made of its benefits for obese schoolchildren.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful for the noble Lord’s observation. Is he aware that the largest NGO in India, the Kripa Foundation, uses yoga as a means of attracting young drug addicts, drunks and people with HIV into recovery? Given the success there and the problems we have with our current obesity plan, which fails to get into the heads of young people—we have great difficulty in making connections so that they can become more self-aware about the need to take responsibility for their own health—might we explore methods such as yoga with them? It might be a means whereby they could take a closer look at themselves, their problems and the opportunities they have to make a better life in the future.

[Lord O’Shaughnessy]

I am not aware of the charity that the noble Lord mentioned, although after university I spent six months in India as a teacher. The school I taught in practised yoga with its children and it seemed to have a calming effect on them—which is just as well, because I am not sure my teaching skills had such an effect. I am sure many noble Lords know personally the benefits of yoga. It has not been proven to have any impact on obesity, although it has many other benefits, as the noble Lord pointed out. It is something that schools can and do use as part of their repertoire in the PE curriculum to provide exercise for children, although it does not count towards the moderate and higher levels of activity demanded by the PE curriculum.

Psychiatrists: Referral Fees

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 7th June 2018 Lords Chamber

[Lord O'Shaughnessy]

We do not have any detail on further cases at this point. Of course we would always welcome any evidence, as would the GMC, in order to investigate that. It is important to point out that doctors are revalidated medically every year and fully revalidated every five years. In that process, they are asked to demonstrate that they have stuck by the ethical guidelines in the GMC practice and, if any evidence alights contrary to that, it would put their registration at risk.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, as someone who has been in this area for quite some time, this exposure in the Sunday Times comes as no surprise whatever—it has been going on for many years. More importantly, is the Minister aware that there is a growing crisis in the private sector provision of alcohol and drug treatment centres? The numbers are declining and many are closing. The CQC produced a very critical report on the standards, which showed that 60% to 70% of them are failing to meet the appropriate level of performance, and that there is a distinct possibility that even less money will be available to provide for this kind of service in 2020, when the funding shifts to business rates. Is the Minister concerned about these kind of developments, and if so, would he be willing to talk to people who are equally concerned about it to try to find some way forward with better prospects for the future?

[Lord O'Shaughnessy]

I am as disturbed as the noble Lord is, not only by the stories we have seen in the press but by his view that this came as no surprise. If substantiated, from a professional perspective this is clearly a great cause of concern. I would be interested to meet him to talk about the overall support for the private sector. Clearly the CQC has a role in providing for patient safety and quality, but we need to make sure that publicly funded services are available for people recovering from alcohol and drug addiction.

Children: Obesity

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 10th May 2018 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what plans they have as part of their review of the Childhood Obesity Plan for Action to work with the BBC to ensure that efforts to reduce obesity involve schoolchildren nationwide.

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

My Lords, broadcasters have an important role in shaping the national conversation about reducing obesity and promoting healthier lifestyles, as has been demonstrated by recent programming. Officials from my department are in discussions with those in the Department for Digital, Culture, Media and Sport to explore how we can work together with broadcasters on this important issue.

[Lord Brooke of Alverthorpe (Lab)]

I am grateful to the Minister for that helpful and hopeful reply. Like the noble Lord, Lord McColl, I believe that we need a major overarching campaign that must be focused on children, and principally the BBC would be the organisation to lead it. I hope the discussions that are taking place will produce a positive programme so that we can see that the 8 million children, many of whom have a serious problem and face difficulties ahead, are given the assistance they need to get to better health in the future.

Children: Obesity

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 19th April 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is absolutely right: parents are of course the first educators of their children and it is about them being able to set an example. I would focus on a couple of things: first, the national curriculum in schools, which is encouraging parents to get involved in understanding what good nutrition is, how to cook well and so on. The second is Public Health England’s new One You campaign, posters of which are up now, which talks about the 400, 600, 600 of calories per meal per day to encourage parents to get into good habits, because of course, if they have good habits and are well informed, their children will too.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister believe that within the plan there may be a greater role for the major broadcasters in this country to give a stronger lead against these problems? The BBC, in particular, has major flagship programmes which are primarily about eating, putting on weight and calories, but the same applies to the other channels. Will he join me in a conversation with the BBC to try to persuade them to produce a major flagship programme that addresses the issue, particularly with regard to children?

[Lord O'Shaughnessy]

That is rather an interesting idea and suggestion from the noble Lord. We would need to speak to colleagues in the DCMS—which I would be delighted to do. I think that broadcasters such as the BBC have traditionally played a very important and positive role in public health issues and continue to do so, and I am happy to encourage them to do so in this area, too.

NHS: Winter 2017-18

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Wednesday 18th April 2018 Lords Chamber

[Lord O'Shaughnessy]

I think the structure of our GP service and primary care is envied around the world. It has many strengths, such as the partnership model being based in the community, but it is changing. For example, more GPs are employed in hospitals. There is a major programme of investment going into primary care, including new models of care around how GPs are structured, but the presence of primary care doctors in the community is one of the great strengths of the NHS.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I welcome the review which the Minister has announced. Does he agree that it would be beneficial if we had a debate in this House on the review when it is out, and will he commit to trying to ensure that his Chief Whip gives us the time to have such a debate?

[Lord O'Shaughnessy]

I am not sure how much pressure I can bring on the Chief Whip for anything, but I look forward to debating the review in whatever form we can when it comes out.

Prescription Drugs: Dependence

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Monday 19th March 2018 Lords Chamber

[Lord O'Shaughnessy]

I think the link between mental illness and GP prescribing will be investigated in the review. We know that we need to do better in mental health services in this country, but it is worth pointing out that we are increasing investment and introducing new waiting-time standards, so services are getting better.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is there not a case for a wider review of addictions in general? Public Health England did a review of alcohol and the Government ignored the report. A public health review in this area may be ignored entirely and there is nothing to make the Government do anything about it. We have just heard about what is happening with gambling; the Government have succumbed to the blandishments of the gambling industry and are not doing what many people in this House wanted on it. It is another addiction. Should we not have a review right across the board on addictions?

[Lord O'Shaughnessy]

The Government are taking steps to deal with addiction in a number of areas. We are obviously focusing on prescription drugs and the dependence on them. I hope the noble Lord will welcome the review and have the opportunity to contribute to it, as I know he feels strongly about these issues.

Emergency Hospital Admissions

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Wednesday 7th March 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord makes an important point. It was good to study the report and the noble Lord is right about avoidable hospital admissions. Two changes are happening. One is GP extended access, which now has 95% coverage across the country—that is, evenings, weekends and so on—as primary care. We also have interesting results coming from the new models of care programme. I highlight one that is happening in mid-Nottinghamshire. It is called PRISM and it is a virtual ward for at-risk patients which enables multidisciplinary teams to look at vulnerable people before they come to hospital. It has reduced A&E attendance for those aged over 80 by 17%, which is significant. It is precisely this kind of thing that will make the difference that we need.

[Lord Brooke of Alverthorpe (Lab)]

Is the Minister aware that in 2016-17, 30% of admissions to A&E of people aged 65 and over were alcohol-related? Is he further aware that, given the need for the services of psychiatrists to look after those people, training for psychiatrists has reduced dramatically in the past 10 years and we have no facilities available to look after them? Turning to a longer-term public health policy, when will the Government do something about the increasing number of people going into hospital due to alcohol problems?

[Lord O’Shaughnessy]

It is now the case that thousands of GPs and hospital staff have been trained to screen for the signs of alcohol abuse and to provide intervention. So not only are there dedicated staff and dedicated public health programmes, but hospital and primary care staff have now been specifically trained to look for the signs and to signpost people to care when they need it.

Alcohol: Minimum Unit Pricing

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Wednesday 28th February 2018 Lords Chamber

[Lord O’Shaughnessy]

The statistic mentioned by the right reverend Prelate is in a way even more alarming because 4.4% of the heaviest drinkers account for a third of all alcohol drunk. A lot of people are drinking sensibly, within the guidelines. We need a system capable of targeting those who are sensitive to both price and health interventions, among those drinking in a way that is very deleterious to their health. We are doing that for a range of interventions—public health and taxation. As I said, we will look at the progress of minimum unit pricing in Scotland as it takes place.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, has not the Minister just made the case for minimum unit pricing? Could I remind him to cast his mind back to all the arguments advanced by his side against changes to tobacco and smoking—that everybody was going to be hurt by it if we increased the price? We had to increase the price for the benefit of everyone, and the same now applies to alcohol. All the evidence that he is getting from all his senior medical advisers is that he should introduce a minimum unit price. Why will he not move on this?

[Lord O'Shaughnessy]

I do not recognise the picture of obstruction about tobacco and smoking. This Government have done a huge amount, and smoking levels have never been lower. In terms of increased pricing, history tells us, if you go back hundreds of years—think about “Beer Street” and “Gin Lane”—that taxation has a really important role to play in promoting better drinking habits. That is the approach that we have taken with changes in duty for drinks that are particularly problematic, such as white cider. As I have said, we will look at how minimum unit pricing in Scotland progresses.

NHS: Charitable Donations

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 22nd February 2018 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government, further to the Written Answer by Lord O’Shaughnessy on 20 December 2017 (HL4078), why they have no plans to provide patients with the costs of their treatment in order to encourage charitable donations to the National Health Service.

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

My Lords, the NHS is based on the principle of access to treatment regardless of your means and according to clinical need. As a consequence, it is important that patients should not be exposed to the costs of care as it might deter them from seeking treatment. Where costs have been provided, such as the cost of missing GP appointments, this has been in an attempt to prevent waste.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister agree that we have a great gift in the NHS and that great gifts become even greater if one can make a return contribution to the giver? Why will the Government not reveal the cost of treatment to people—after they have had it, not before, and only to those people who request it—so that in turn they may make a voluntary contribution, either in full or in part, towards the cost of that treatment? Why is there such difficulty in encouraging people to play a greater part, to give more and to get more involved with the NHS in a way that the Government are refusing to do at the moment?

[Lord O'Shaughnessy]

I agree with the noble Lord that it is a gift. I also absolutely understand the sentiment behind what he is saying, which is a desire for people to contribute back to the NHS not just through the tax system. It is important to point out that there are more than 250 NHS charities, with an annual income of £400 million. One of the other great gifts we have in this country is people’s willingness to donate time and money not just to the NHS but to a range of health causes. So we do provide an opportunity for that and those gifts are supported by gift aid. With regard to itemising the bill, we worry about deterrence. Many users of the most expensive health services are older people. Itemising a bill could put some of them off and that would be the wrong thing to do.

Nurses: Tuition Fees

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Wednesday 29th November 2017 Lords Chamber

[Lord O'Shaughnessy]

It is important to point out that there are 10,000 more nurses on wards than there were seven years ago. One of the things that we are trying to do is encourage nurses to return to practice—3,000 of those nurses have been on the return to practice programme. In regard to attracting them to hospitals, the main thing is that we need to train more nurses to fill those places so that we fill the demand that we know that we have from a growing and ageing population. That is why there are going to be 5,000 more funded nursing training places from 2018 onwards.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is it not necessary to offer the most attractive terms to get more nurses into training? Will the Minister reflect on the very helpful suggestion made by the noble Lord, Lord Forsyth, that there is a possibility that a fair number of these people will never repay the full amount? Will he tell the House what the estimated write-off is of the repayments that will apply to nurses? If it is a high figure, will he reflect on the answer that he gave to the noble Lord?

[Lord O'Shaughnessy]

I shall certainly write to my noble friend, and indeed all noble Lords, about the proportion of the write-off. Let us remember, however, why the student loans system exists. It exists because those people who earn enough over the course of their working lives end up paying more than those who do not. Therefore, if somebody has gone into nursing but has then gone on to work in another profession, earning more money and being able to pay it off, it is equitable that they pay it off. That was the policy of the Labour Government, and it has been adopted by the Conservative Government precisely on the point of equity. It is only right that the loan is written off for those who have not earned enough but, for those who have earned enough, that they pay it off.

Brexit: Mental Health Research Funding

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 23rd November 2017 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government whether they intend to match the current European Union contribution towards United Kingdom mental health research funding after the United Kingdom leaves the European Union.

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

My Lords, the Government have made clear that UK businesses and universities should continue to bid for competitive EU funds while we remain a member of the European Union and that we will work with the Commission to ensure payment when funds are awarded. The Government will underwrite the payment of such awards, even when specific projects continue beyond the UK’s departure from the European Union. This will include mental health research funded by the Horizon 2020 programme.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister recall the Government’s promise in the May manifesto:

“We will make the UK the leading research and technology economy in the world for mental health”?


I am reassured by some of the Answer he gave, but he has not given a firm commitment that this will continue after Brexit. Will he give such a commitment; and given the promise that was made in the manifesto, will he outline how the Government intend to increase the amount of research that will be undertaken in mental health in the future?

[Lord O'Shaughnessy]

In our future partnership paper we have set out that we want an ambitious agreement on science and innovation and that we will continue, albeit in a new form, to collaborate with the European Union on health research, including mental health research. On honouring the bids that were underwritten, I should point out that that applies not just to bids or projects that are taking place but to bids that have been submitted up until exit day, so there is a long lead time. It is also important to point out what the Government have been doing domestically. For example, the National Institute for Health Research has increased by over 50% the amount of funding that it puts into mental health research, so the Government have been going a long way in increasing the amount of funding in this area.

Young Women: Self-Harm

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Thursday 16th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I congratulate the centre the noble Earl works for on its anniversary. He is absolutely right about the pressures of adolescence. Unfortunately, the causes of self-harm are not well understood. One of the hypotheses is that the motivation appears to be stress relief, which is an incredibly disturbing idea. I am aware of Lucy Crehan’s work from my previous work in schools. I do not think you can link school accountability with the kind of pressures we are describing today and how they manifest in self-harm. We want schools to be successful. It is vital that children are well educated. It is also true that that can be done in a number of ways. The best schools, including ones that I have been involved with in the past, practise something called positive education which emphasises not only the academic aspect but also character and well-being. I think that is the approach that we need to follow.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, if I may bring the Minister back to his area of responsibility, is he aware of recent research indicating that at primary level, references by doctors to mental health services are least in the deprived areas in the country and those are the areas where the self-harming is rising most of all? Can he tell the House what steps he is taking to halt that and move it in the other direction?

[Lord O'Shaughnessy]

I would be interested to see that evidence. It is not something that I have seen. All I can say is that mental health funding has increased by more than 8% in the last couple of years so there is more money going into it but clearly it is vital that it is properly spread.

Child and Adolescent Mental Health Services

Debate between Lord Brooke of Alverthorpe and Lord O'Shaughnessy

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

That is an incredibly important point because good relationships are very influential on young people’s mental health, and the Green Paper will look at the role of family conflicts. My noble friend will be pleased to know that the Department for Work and Pensions is launching a programme to reduce parental conflict in conjunction with the Early Intervention Foundation. I hope that it will have some positive benefit in reducing parental conflict, which is, of course, one of the causes of mental illness.

[Lord Brooke of Alverthorpe (Lab)]

Does the Minister accept that there is a wide variation in the offering of services between one geographical location and another? Will the Green Paper which is being prepared address this, and how quickly will it be resolved?

[Lord O'Shaughnessy]

The noble Lord is right about variation, sadly. We had the CQC thematic review on mental health provision at the end of last week, which showed that 80% of specialist in-patient care is good or outstanding but that that is true of only two-thirds of community care provision, with around a third either requiring improvement or inadequate. That is clearly not good enough. Patchy provision is absolutely one of the things that we need to deal with. The best way of doing that is by expanding both the number of children being treated and the size and quality of the workforce, to help us to meet our targets.