Puberty-suppressing Hormones
Lord Kamall Excerpts(10 months ago)
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Lord Kamall (Con)
My Lords, I thank the Minister for the Statement and the right honourable Secretary of State for the careful and sensitive way in which he delivered the Statement in the other place. In line with my right honourable friend the shadow Secretary of State in the other place, from these Benches we welcome the Government’s announcement. Whatever your politics, most people believe that one of the first duties of any Government is to protect their citizens, especially our children.
As the Secretary of State said, there has been too much heat, and perhaps toxicity, around the issue of services for children experiencing gender dysphoria, so I welcome the tone with which His Majesty’s Government have approached this issue—less heat, more light—and that they continue to take an evidence-based but compassionate approach. I also take this opportunity to thank the noble Baroness, Lady Cass, for leading the review on gender services for children. The Cass review highlighted the importance of putting scientific evidence above ideology and laid out the fact that we simply do not know enough about the long-term impacts of puberty blockers on children. That is why my right honourable friend in the other place, the Member for Louth and Horncastle, when Secretary of State, banned the routine prescription of puberty blockers for gender dysphoria, and later extended that ban to private clinics.
We welcome the decision of the Government to follow the recommendations of the independent Commission on Human Medicines to extend the banning order until a safe prescribing environment can be established for these medicines. This is a common-sense approach, and allows time for more evidence to be examined to consider the holistic and long-term impacts of puberty blockers on children. The Secretary of State announced the clinical trials to gather evidence but, given understandable concerns about the risks of any clinical trial, can the Minister reassure your Lordships that these trials will have robust safeguards to ensure the well-being and safety of any children taking part, while recognising the importance of having these trials in the first place?
The Secretary of State in the other place also spoke about alternatives to puberty blockers for children suffering from gender dysphoria. As someone who takes an interest in social prescribing, I welcome the Government’s recognition that medication is not always the best solution, so will the Minister share details of some of the alternatives to puberty blockers that will be offered to children?
Finally, noble Lords will be concerned that, despite the lack of evidence, puberty blockers were prescribed to children with gender dysphoria when their safety could not be guaranteed. What steps are the Government and the NHS taking to ensure that a similar situation does not occur again and that future decisions are led by evidence? I look forward to the Minister’s responses.
Baroness Walmsley (LD)
My Lords, on these Benches we welcome the tone of the Secretary of State’s Statement. I have often said that there are many ways of being human. Growing up can often be a very trying time for teenagers. How much more difficult, then, for those young people with gender distress who are struggling with finding out who they are while being different from their peers, and all without adequate support? It is high time that proper services were put in place for young people struggling alone with these issues. Their families too need help to support them at this difficult time. For too long, children and young people who are struggling with their gender identity have been badly let down by a low standard of care, exceptionally long waiting lists, even by the standard of mental health waiting lists, and an increasingly toxic debate.
We always want to see policy based on the evidence. With any medical treatment, especially for children and young people, the most important thing is to follow the evidence on safety and effectiveness. It is crucial that these sorts of decisions are made by expert clinicians, based on the best possible evidence. It is also important that the results of the consultation and the advice of the Commission on Human Medicines are made public.
Some might wonder why the treatment is deemed not safe for gender dysphoria patients but safe enough for children with early-onset puberty. More transparency might clear up the confusion and give more confidence to patients and their families. However, the Secretary of State himself admits that he does not know what effect the sudden withdrawal of this treatment for young people already embarked on a course of puberty blockers will have. These are the young people with the most urgent need for other types of care in the current situation, so what clinical advice have the Government taken about the effect of withdrawing these drugs on the physical and mental state of young sufferers of gender incongruence already on the drugs, and what physical and psychological support will be offered to them?
In the current circumstances, plans for a clinical trial are welcome, but we would like to know the criteria for those eligible to participate. What assessment have the Government made of the recent Council of Europe report, which raises the ethical and rights implications of offering participation in the trial to only a small group of patients? If the only way to continue access to these drugs is through participation in the clinical trial, whose scope, length and start date have yet to be announced, this lays the Government open to accusations of coercion and breaches of human rights.
We welcome the plans for additional treatment centres in Manchester and Bristol as well as London, but can the Minister say why they will not be up and running for two years? Is it lack of funding, lack of premises or lack of sufficient therapists with the appropriate specialist training? This is a very sensitive area, so the wrong people could do more harm than good. If that is the reason, is there a plan for training up more qualified therapists in time for the opening of the regional treatment centres? I very much look forward to the Minister’s replies to these questions.
NHS: Patients with Allergies
Lord Kamall Excerpts(10 months, 1 week ago)
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Lord Kamall (Con)
My Lords, I begin by thanking the noble Baroness, Lady Ramsey of Wall Heath, for securing this important debate, as well as for having some discussions before the debate so that I could better understand the issue. I am also grateful to the House of Lords Library for its briefing and to others who have sent briefings.
The noble Baroness and the noble Lord, Lord Mendelsohn, spoke passionately about their personal experiences as parents, and especially about the care that patients with allergies receive during the transition from childhood to being considered adults. I myself know family members whose children decided to go to a local university rather than go elsewhere because they knew that their local hospital had the best treatment and were not sure what the treatment would be like if they moved to another university town. Other noble Lords have alluded to a postcode lottery.
The noble Lord, Lord Scriven, said that such stories bring the statistics to life, but it is really important for us to talk about numbers. I read one report, I think by ITN, which said that 44% of adults in the UK have at least one allergy, but that includes asthma; other noble Lords have said it is one in three. Whatever the figure, it is far too high. We have seen, as the medical journal the Lancet has found, that the rate of food allergies has increased over the past decade. The noble Lord, Lord Mendelsohn, also mentioned that.
Plenty of those with allergies can continue to live normal lives, but there are an ever-increasing number of people whose allergies are debilitating. They cannot eat certain foods, and they are unable to use certain medications. They must constantly scan the list of ingredients of the food they wish to eat, either by reading the small print on labels or accessing companies’ or third-party websites, or, as the noble Baroness, Lady Keeley, said, they have to pay more for gluten-free or other foods according to their dietary requirements.
This may seem obvious, but food is one of humankind’s basic needs. It is an integral part of our daily lives, and so it is only right that we take the necessary steps to help those with allergies. It was reassuring to hear from the noble Baroness, Lady Burt, about the advice that was in her hotel room should you encounter someone suffering a severe allergic reaction. The question is how we spread that from hotel rooms to schools and more places.
The noble Lord, Lord Mendelsohn, and the noble Baroness, Lady Keeley, spoke about the sad story of Natasha Ednan-Laperouse, who tragically died in 2019 due to anaphylactic shock. Her case led to the so-called Natasha’s law, requiring all foods to carry a list of ingredients. I am proud, and I am sure that noble Lords are grateful, that swift action was taken by the previous Government. Indeed, it is a measure that has since helped countless sufferers of allergies to understand the food that they are consuming and the harms that they may cause.
We know, however, that more needs to be done. It is therefore welcome that the new Government are developing an allergy strategy. But what of the National Health Service’s role? As noble Lords will be aware, before the general election, Allergy UK published a list of steps that it wanted the new Government to take. As the noble Baroness, Lady Healy, has said, one proposal was that there should be an allergen specialist or dietician at the primary care level—the rationale behind this being that it would allow those with allergies to access specialised care, no matter where they may live. This seems a common-sense proposal, since it would enable those living with serious allergies to seek help with managing their allergies early in the process of diagnosis so that they can have a better quality of life and are not unnecessarily constrained by their allergies.
Noble Lords will also understand that there are resource constraints and that the Government of the day have to consider carefully where they allocate taxpayers’ money, given competing demands. I want to reassure the Minister that I understand from my time as a Minister the difficulties due to resource constraints and, sometimes, the practicalities of implementation, but that does not stop noble Lords asking the questions. Is this a policy idea that has been discussed within her department and with the NHS to work out its feasibility? I would be grateful for her assurances.
Like other noble Lords, I too wonder what more can be done within existing NHS structures. Some of the information is there, but how do we spread it nationally from ICB to ICB? How do we get it into schools? How do we get it beyond the hotel rooms? How do we make more people aware, so that when it is announced on a flight that nuts will not be served on a flight because someone has an allergy we avoid the collective groan and hear more understanding of those who suffer from these conditions?
Can the Minister explain what plans there are for all clinicians, including in primary care, secondary care and accident and emergency departments, as well as for other hospital employees, to be suitably trained and made aware of how to deal with patients who have serious allergies, as the noble Lord, Lord Scriven, alluded to? Has any thought been given to an allergy tsar, as the noble Lord, Lord Mendelsohn, mentioned? What safeguards are in place to ensure that no one with allergies slips through the net and is administered medication that contains ingredients they should not take? The noble Baroness, Lady Keeley, and the noble Lord, Lord Scriven, spoke about preventative strategies. What explicit preventative strategies are the Government and the NHS considering?
I know that all noble Lords are grateful to the noble Baroness, Lady Ramsey of Wall Heath, for securing this important debate and we look forward to the Minister’s responses.
Bread and Flour Regulations 1998
Lord Kamall Excerpts(10 months, 1 week ago)
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Baroness Merron (Lab)
As I mentioned earlier, while 24 months is a realistic transition, not everything will wait that long. It is the case, as the noble Baroness says, that there is still advice to women who could become pregnant to take folic acid supplements, and it is important that we keep that message going. However, 50% of pregnancies are not planned, so it is not possible to prepare by taking supplements. We are looking at all ways of effectively getting the message across.
Lord Kamall (Con)
My Lords, I congratulate the Government on publishing the regulation. I pay my own tribute to the noble Lord, Lord Rooker—although he may not welcome it—for his tenacity on this particular issue. One of my frustrations when I was a Minister on this was how long the processes and consultations took. For future reference, if other supplements are to be introduced into our food, I wonder whether the department has looked at ways in which it could possibly shorten the process without compromising patient safety.
Baroness Merron (Lab)
Patient safety is at the forefront of this. I do not want to look backwards, but I gently suggest that there are all sorts of reasons for delays. Still, we are where we are now, and what is important is moving ahead. We are working closely with the Chief Medical Officers across the UK. We are very much in lockstep with the devolved Governments, and I think that will also assist.
Anti-depressants: Cost, Risks and Ramifications
Lord Kamall Excerpts(10 months, 1 week ago)
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Lord Kamall (Con)
May I express my gratitude to the Chief Whip for reminding me that there were no Prayers?
Lord Kennedy of Southwark (Lab Co-op)
My noble friend Lady Merron is now here.
Baroness Merron (Lab)
We have already made a number of commitments, but the noble Baroness is quite right to observe the excessive numbers on the waiting list. We are deeply aware of the distress and continuing difficulty that this causes for many. The noble Lord, Lord Darzi, in his independent investigation, confirmed that about 1 million people are waiting for mental health support as of April 2024. Moving to the 10-year plan will be an opportunity to put mental health services in a different place. In addition to the commitments that the noble Baroness has mentioned, we are providing access to a specialist mental health professional in every school and providing open-access Young Futures hubs.
Lord Kamall (Con)
My Lords, I am grateful to the noble Lord, Lord Alton, for organising a recent meeting with the Minister, the MHRA and some psychiatrists, who raised the issue of SSRIs and their side-effects. One concern was that patients need to be aware that one side-effect of SSRIs is to have suicidal thoughts. Therefore, I was surprised to see on the NHS website’s page on the side-effects of anti-depressants that you have to scroll down four or five pages before seeing the warning signs about suicidal thoughts. While we await the review from the MHRA which it discussed with us, will the Government and the NHS look at the advice on the website so that those who are prescribed SSRIs are clearer about the risk of suicidal thoughts?
Baroness Merron (Lab)
I would be happy to look at that. However, there have been warnings on the leaflets accompanying medication for some 20 years. It is always a cause to review to ensure that it is most effective. There are at least two sides to this. One is the clinician doing their job to discuss side-effects, including on withdrawal from the medication, but it is important that patients understand it as well.
Health: Quad-demic
Lord Kamall Excerpts(10 months, 1 week ago)
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Baroness Merron (Lab)
My noble friend has campaigned tirelessly for the vaccine rollout in respect of RSV, for which I thank her, and I know that many others would wish to thank her for that too. With regard to the other vaccines about which my noble friend asked, we will continue to work with the JCVI and, as there are further developments, I will update your Lordships’ House.
Lord Kamall (Con)
If the spread of any of the four viruses listed by the noble Baroness, Lady Morgan, were to turn into a pandemic, hospital capacity would be an issue of concern. Hospital capacity is already an issue in most winters. With that in mind, figures released last week show that NHS hospitals are operating at 95% capacity. Therefore, what discussions are the Government and the NHS having with the independent healthcare sector to utilise its spare capacity to help to alleviate the pressures, both this coming winter and in the face of future pandemics?
Baroness Merron (Lab)
The noble Lord will be aware that being prepared for winter is crucial. It has felt for too long as though winter crises have almost become normalised. Certainly, our move towards a 10-year plan will ensure that we have an NHS that can provide all year round. To give one statistic on Covid, in the week beginning 1 December there were 1,390 hospital beds occupied by confirmed Covid-19 patients per day, which was 41% lower than in the same week last winter. However, we are absolutely aware of this issue and we are not expecting a difficulty in respect of beds.
Physician and Anaesthetist Associate Roles: Review
Lord Kamall Excerpts(10 months, 2 weeks ago)
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Lord Kamall (Con)
My Lords, I refer noble Lords to my interests as set out in the register. As a precaution, I will say that I work for a university that has just applied to open a medical school. I also used to be a research director at a think tank that wrote about medical issues, including physician associates.
I thank the noble Baroness, Lady Bennett, for securing this important debate, and other noble Lords who spoke. I am also grateful to the House of Lords Library and others who sent their briefings, the health professionals I spoke to, and the journalists who wrote the articles I read in preparing for the debate.
From this reading and from listening to the arguments, it is sad to see that the debate on physician associates and anaesthetist associates has descended into one that is polarised. Some have described it as toxic. We now read about lawyers being consulted and legal cases being launched. On one side, we hear from some doctors and their trade union, the BMA, that PAs and AAs are performing tasks for which they are not trained, that there is mission creep—indeed, that they are sometimes substituted for doctors—that patients are not always told that they are seeing a PA or an AA, not a fully qualified doctor or nurse, and that having PAs and AAs affects the training of some doctors. We also hear that PAs and AAs are blamed for poor medical treatment and even patient deaths. We heard about the sad case of Emily Chesterton from the noble Baroness, Lady Keeley.
On the other hand, I have heard and read about doctors praising these associates; PAs and AAs being bullied or shunned by doctors and health professionals, as the noble Lord, Lord Scriven, referred to; and, in some cases of medical accidents or deaths, that it is not always clear who is at fault and that it is unfair to pick on PAs and AAs when qualified nurses and doctors have also caused deaths and put patients at risk. Others have called for a no-blame culture if we really want to get to the bottom of these incidents.
I have also heard from managers who agree that PAs and AAs should perform only tasks for which they are trained, but who feel that opposition to PAs and AAs is based on doctors and nurses protecting their interests. After all, maybe that is their job. I read a letter from a retired doctor who wrote:
“Physician associates can be a huge asset to the NHS if trained, regulated and supervised appropriately … some of the antagonism from the medical establishment seems protectionist rather than in the best interests of patients”.
In another letter, a cardiac consultant wrote:
“The dispute about the role of physician associates in the NHS is rooted in dogma. Whether the person delivering treatment is a medical doctor is not the issue. What matters is that anyone delivering healthcare is trained and qualified to do so, practises within the correct guidelines and has access to support and guidance whenever a situation arises that falls outside the routine. This should apply to PAs, resident doctors and experienced consultants alike”.
At the same time, though, another consultant wrote that he was
“puzzled by the need for physician associates”
when there are already
“well-trained nurses in speciality roles”.
With that great British understatement, I acknowledge that opinion is divided. But on delving deeper into this debate, there is some hope and some consensus. After all, it seems common sense that physician associates and anaesthetist associates should perform only tasks for which they are trained, but our system of health and care has to continue to evolve, as it has done since the founding of the NHS in 1948. Where appropriate, we may see more tasks delegated from doctors to other medical professionals, but with clear regulations and delineation, as the right reverend Prelate the Bishop of London said.
When I went to a GP surgery as a child, I always saw a GP, but these days, as a patient, I do not always need to see a GP. I may sometimes see a nurse, a physiotherapist or a pharmacist at the surgery instead. It seems reasonable for PAs and AAs to be trained to perform more tasks on the job, under the supervision of qualified doctors.
I am also sure that there is consensus on the need for total transparency when patients see PAs and AAs, and on what they are qualified to do. I have heard from former hospital employees who stress the importance of a clear delineation of what PAs and AAs can and should be allowed to do in a clinical setting. One gave the example of an ECG. A nurse or a healthcare support worker will perform the ECG, but they then need sign-off from a clinician. I was told by that former employee that not all nurses or healthcare support workers know who is authorised to sign that off. So there must be absolute clarity of responsibility for clinical duties, such as the guidance issued by the Royal College of General Practitioners, which states that PAs should explain that they are not doctors when they introduce themselves to patients, and wear clear name badges.
In some ways, what noble Lords have said today will be superseded by the independent review announced by the Government last month to be led by Professor Gillian Leng. We acknowledge that she is a respected expert in evidence-based healthcare, something the noble Lord, Lord Scriven, called for, and a former chief executive of NICE.
I hope the Minister will acknowledge that, since I was appointed as a Lords shadow Health Minister, I have sought to get away from point-scoring on health and social care. I hope to build some sort of consensus on modernising our system of health and care. In this spirit, these Benches welcome the independent review. In fact, I worked with Professor Leng when I was a Health Minister and look forward to her report. I understand it will be published in the spring. As the noble Baroness, Lady Bennett, said, we may need some definition of “spring”, but, as I said in a debate last night, at least it is better than “in due course”.
While it is reassuring to have a definite timeframe for the publication of the report, in the spirit of co-operation, I have a few questions about what happens between now and then. What interim measures have the NHS or the Government announced to address the concerns of the BMA and its supporters over the use of AAs and PAs, as well as the concerns of United Medical Associate Professionals, which represents PAs and AAs, about the treatment and bullying that some of them have faced from doctors, nurses and other medical professionals? What guidance will the NHS give on the responsibilities of PAs and AAs?
I understand that the Minister cannot comment on legal cases, but does she know whether there are any discussions with the various plaintiffs about suspending legal action until after the publication of Professor Leng’s review? Will these legal cases be complete by the time of its publication in spring next year? How do the Government plan to take account of any legal cases that may be resolved after Professor Leng’s report? Will the NHS and the Government have to wait for the legal cases to be resolved before issuing any clear guidance that might be recommended by the report? I acknowledge that there are a lot of questions there. I hope that the Minister can answer them, either today or in writing to all noble Lords who took part in this debate.
Whatever our view on PAs and AAs and the toxicity of the debate, I am sure that we all want to see a system of healthcare that continues to modernise and evolve, in which associates, doctors and nurses offer the best medical care and in which patients feel safe.
Fracture Liaison Services
Lord Kamall Excerpts(10 months, 2 weeks ago)
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Lord Kamall (Con)
My Lords, I thank my noble friend Lord Black for securing this debate. As noble Lords have acknowledged, he has championed this issue in this House and outside. In fact, I recall that during one of my earliest Oral Questions as a Minister, my noble friend explained to me the vital role that fracture liaison services play in identifying and treating osteoporosis; that osteoporosis is considered a silent disease, causing over half a million broken bones each year—one every minute; and that there are as many deaths from fractures as from lung cancer and diabetes.
As my noble friend Lord Black and indeed the noble Baroness, Lady Bull, said, fractures caused by osteoporosis affect half of all women and a fifth of men over 50. As the right reverend Prelate mentioned, those from lower-income households have a 25% higher risk of fractures, a higher mortality rate and slower recovery times from hip fractures. As the noble Baroness, Lady Donaghy, said, it can be unexpected. Each year, 1 million acute hospital bed days are occupied by hip fracture patients, and around £2 billion is spent on hip fracture care. I pay tribute at this point to my noble friend Lord Shinkwin, the noble Baroness, Lady Ritchie, and others for sharing their experience. That really brought it home and made it about more than figures.
As we move to a system of preventive healthcare, FLS have a huge role to play since they systematically identify people aged 50 or over who have had a fragility fracture in order to reduce the risk of further fractures. The Royal Osteoporosis Society, to which many noble Lords have paid tribute tonight, estimates that fracture liaison services reduce the risk of a patient refracturing the same bone by up to 40%.
Unfortunately, despite the attempts of previous Governments, only 51% of trusts in England currently provide fracture liaison services, covering only 57% of the population, as alluded to by the noble Baroness, Lady Quin. Earlier this year my right honourable friend Victoria Atkins, then the Secretary of State for Health and Social Care, pledged to expand fracture liaison services to every integrated care board in England and achieve 100% coverage by 2030, a target repeated in the Conservative Party manifesto. But as the noble Lord, Lord Rennard, and others have said, there is consensus—there is no political disagreement on this issue. Indeed, the Minister used to press me from this Dispatch Box when I was in her position.
In June this year, the then shadow and now current Secretary of State for Health and Social Care said that delivering a rollout plan for fracture liaison services would be an area for “immediate action” if Labour won the election. Noble Lords understand that these are still early days for the Government, but I am sure that my noble friend Lord Black and other noble Lords who have spoken in this debate wish to understand what the Secretary of State for Health and Social Care meant by “immediate action”. I have to concede that that sounds a lot better than “in due course”—a phrase I tried to avoid when I was a Minister, but not always successfully.
Unfortunately, no plan for the rollout of these life-changing diagnostic and preventive services has yet been released by the Government. Are they working on a rollout plan for fracture liaison services and, as the noble Baroness, Lady Donaghy, said, when do they intend to publish it—preferably avoiding the answer “in due course”? Can I tempt the Minister into sharing some clues or details on what might be in the plan? I know that many noble Lords of all parties and none support expanding this vital, preventive and effective service to as many people who need it as possible. Fracture liaison services are a world-beating preventive approach that we can all be proud of. If expanded, it would be good for those suffering from osteoporosis, good for the NHS and good for the Treasury.
NHS Plan: Consultation
Lord Kamall Excerpts(10 months, 2 weeks ago)
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Baroness Merron (Lab)
I am very grateful to all those, including pharmacists, who have used all their networks and contacts to spread the word. That is why we have had over 60,000 responses and more than 1 million visits in what is the largest ever consultation in the history of the NHS. I call on all groups to continue their efforts to ensure that voices across all communities are heard loud and clear.
Lord Kamall (Con)
During the vaccine programmes for Covid, the NHS and the last Government put a lot of effort into looking at ways to reach people who are vaccine hesitant—often from some black and Asian communities and other excluded communities. What lessons have been learned by the Government and the NHS to ensure that the consultation on the 10-year plan reaches as many people as possible from these communities, so that their voices are heard?
Baroness Merron (Lab)
The lessons that have been learned are that there has to be a whole range of ways of consulting: in person around the country; online, where people can access the website; and through toolkits such as the “workshop in a box”. As I mentioned in an earlier answer, the consultation also needs to be tailored to the needs of those who need to speak up. We are asking the public, staff and organisations what is important, and we want, as the Prime Minister said, their fingerprints all over the 10-year plan.
Drug-related Deaths in England and Wales
Lord Kamall Excerpts(10 months, 3 weeks ago)
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Baroness Merron (Lab)
The noble Baroness will have heard me say before that we had to take some tough decisions at the Budget to fix the foundations in the public finances, and that enabled a settlement for the Department of Health and Social Care of some £22.6 billion. As she knows, the employer national insurance rise will be implemented in April 2025, and in due course the department will set out further details of the allocation of the funding I referred to for next year.
Lord Kamall (Con)
My Lords, I know this Government take drug-related deaths seriously, as did the previous Conservative Government when we awarded 12 projects a share of a £5 million fund to reduce rates of fatal drug overdoses, adopting a similar approach to that of the Vaccine Taskforce to tackle health challenges. Has there been any evaluation of how successful those projects were? What plans are there to continue or expand them?
Baroness Merron (Lab)
Our continuing work in this area is part of the Office for Life Sciences programme. This Government continue to fund research into wearable technology, virtual reality and artificial intelligence, all in a bid to support people with drug addictions. Since coming into office, we have awarded £12 million to projects across the UK that are showing innovation in respect of technology, because we want to support people with addictions.
NHS: Dentistry Provision
Lord Kamall Excerpts(10 months, 3 weeks ago)
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Lord Kamall (Con)
My Lords, the Minister said that it was not only about rocking up to the General Dental Council, as the noble Lord, Lord Harris, said, but about having conversations. Can the Minister confirm what specific conversations the Government have had with the NHS, with the General Dental Council and with other dental bodies to encourage the opening of schools of dentistry in so-called dental deserts, especially in areas such as Norfolk, which my noble friend Lord Fuller described as the Sahara of dental deserts?
Baroness Merron (Lab)
As the noble Lord will know, we are very keen to see that the areas that are most underserved—as I know from my own experience in Lincolnshire—are targeted. One of the reasons is the problem of recruiting and retaining dentists, as there is not a dental school to call upon. That point is well understood. We are keen to target the areas that need the most, as well as providing additional urgent dental appointments. Early conversations have also taken place with the Minister for Care, Stephen Kinnock, about reforming the dental contract, which is absolutely key, and that work will continue at pace.