Primary Care: Targets

Lord Patel of Bradford Excerpts

Tuesday 13th October 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness makes a very good point. There is plenty of evidence to suggest that where general practices employ clinical pharmacists, it relieves GPs of a considerable burden. Interestingly, the NHS Alliance produced a report last week called Making Time In General Practice. It identified that up to one in six patients seen by GPs could in fact be seen by someone from a broader skill mix within general practice, so what the noble Baroness says makes a lot of sense.

[Lord Patel of Bradford (Lab)]

My Lords, while one may applaud the intention of the 24/7 NHS service, does the Minister agree that the Government are potentially raising public expectations that are just not going to be achievable, given the deficit of nearly £1 billion that we have seen in the first quarter of this year alone?

[Lord Prior of Brampton]

My Lords, the deficit in the first quarter is indeed a matter of huge concern—I am not going to pretend otherwise—but the Government are wholly committed to seven-day services both within hospitals and in general practice. We are committed to investing £10 billion extra in the NHS over the next five years, and ensuring that we have enough GPs and enough support for them is a key priority.

Police: Ambulance Support

Lord Patel of Bradford Excerpts

Thursday 16th July 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Lord raises a very important point. Apart from being an extra drain on the resources of the police, it can often exacerbate a mental health problem if someone who is already very distressed ends up being transported in a police vehicle. Under the mental health concordat, to which all ambulance services are signed up, they are committed to reducing the number of times that people detained under the Mental Health Act are transported in police vehicles. We will monitor performance against that very carefully.

[Lord Patel of Bradford (Lab)]

My Lords, the Mental Health Act code of practice clearly says that people with mental health problems should not be transported by police vehicles. In the Midlands the ambulance service transports roughly 75% of people with mental health problems—that is reasonably good but not acceptable—while in Lancashire the figure is as low as 5% and in London it is 30%. Have the Government made any assessment of this, given what the Home Secretary said about police cells being completely inappropriate places of safety for people with mental health problems? Police vehicles should not, wherever possible, transport mental patients.

[Lord Prior of Brampton]

The noble Lord is right: it is quite wrong for people to be detained under Section 136 in police cells. It is also wrong that people suffering from severe mental health problems are transported in police vehicles. I am not aware of the figures that he gave for the West Midlands in comparison with other parts of the country but I will look at them very carefully.

Prisons: Mental Health

Lord Patel of Bradford Excerpts

Wednesday 24th June 2015 Lords Chamber

Asked by

[Lord Patel of Bradford]

To ask Her Majesty’s Government what steps they are taking to achieve parity of esteem between mental health and physical health in prisons.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, achieving parity of esteem between mental health and physical health in prisons is a government priority. Following the 2009 review by the noble Lord, Lord Bradley, we ensured that prisoners can access equivalent health services to people in the community. The Government’s mandate to NHS England has objectives to achieve parity of esteem, including in health and justice settings, and to develop better offender healthcare that is integrated between custody and community, including developing liaison and diversion services.

[Lord Patel of Bradford (Lab)]

I thank the Minister for that Answer. I am sure he will be aware that a great deal of effort has been made to improve data accuracy and the quality of recording of mental health diagnosis in NHS trusts, including new coding standards, all as part of preparation for a national payment tariff for mental health, similar to those for people in hospitals with physical health conditions. Can the Minister describe, first, how this will be implemented in the prison setting? Secondly, what support will his department be giving to implement the standards for prison mental health services, which the Royal College of Psychiatrists published recently due to, as it said, the lack of a national blueprint for mental health services for people in the criminal justice system?

[Lord Prior of Brampton]

I thank the noble Lord for his two questions. On the first, about coding, it is very important that we get the tariff right and that it does not become just another measure of activity but that outcome is built into that tariff. Paul Farmer, the chief executive of Mind, is preparing a report for NHS England, which will include proposals for the tariff and payment systems. That will include health in prisons as well as outside prisons.

The second question was about the standards issued recently by the Royal College of Psychiatrists. The noble Lord, Lord Bradley, in his foreword to The Bradley Report Five Years On, referred to the importance of having a national blueprint, which of course is now possible given that NHS England is the commissioner of specialist services throughout the country. I will also draw those standards to the attention of Paul Lelliott, the chief inspector of mental health within the CQC. I am sure that the CQC will wish to incorporate those standards into its inspection regime

Mental Health Services: Young People

Lord Patel of Bradford Excerpts

Tuesday 23rd June 2015 Lords Chamber

[Lord Prior of Brampton]

I thank the noble Lord for that question. He is right that, out of a class of 30 children, three are probably suffering from diagnosable mental health problems. The Government are commissioning a prevalence survey to establish more precisely what that number is. There is a feeling that it will be increasing with the use of social media and more bullying in schools. I agree with the noble Lord that we must make it easier to access talking therapies in particular and the Government have plans to do that.

[Lord Patel of Bradford (Lab)]

My Lords, will the Minister assure the House that children and young people with serious mental health problems are not treated on adult psychiatric wards, alongside fairly dangerous adults, that they can access appropriate child mental health services, and that they do not have to travel hundreds of miles across the country to do so?

[Lord Prior of Brampton]

The Government have committed to spending £150 million over the next five years on children who are suffering from eating disorders. This may partly answer the noble Lord’s question. They have also now committed to spending £1.25 billion over the next five years to develop mental health services for children and young adults. That is against a background of our current spending of about £700 million, so we are talking about doubling the spend. Doubling the spend does not mean doubling the benefit and output, but the noble Lord can be assured that it is an absolute priority of this Government to tackle mental health problems right where they start: when people are young.

Health: Human Papilloma Virus

Lord Patel of Bradford Excerpts

Tuesday 20th January 2015 Lords Chamber

Asked by

[Lord Patel of Bradford]

To ask Her Majesty’s Government what action they are taking to include all adolescent boys in the national vaccination programme for human papilloma virus.

[Lord Patel of Bradford (Lab)]

My Lords, I am most grateful for the opportunity to discuss the very important issue of whether adolescent boys as well as girls should be included in the national vaccination programme for HPV—human papilloma virus. I thank all noble Lords who will be speaking in this short but important debate, and express my gratitude to Peter Baker, former chief executive of the Men’s Health Forum and the current campaign director of HPV Action, for all his expert advice and guidance.

This debate is particularly timely because the Joint Committee on Vaccination and Immunisation—JCVI—is currently looking at whether the national HPV vaccination programme should include boys. I have a particular interest in the outcome through my role as chair of the All-Party Parliamentary Group on Men’s Health. Some two years ago, the all-party group held a meeting jointly with the All-Party Group on Sexual and Reproductive Health in the UK. The chair of that group, my noble friend Lady Gould of Potternewton, and I heard evidence from two distinguished speakers—Professor Margaret Stanley from Cambridge University and Mr Peter Greenhouse, a consultant in sexual health from Bristol—which absolutely opened my eyes to the avoidable risks to the health of men caused by HPV infection.

I realised that HPV is not just a problem for women. It does not cause just cervical cancer but other cancers in women and a wide range of cancers in men as well. We know that HPV can cause, in men and women, cancers in the head and neck, as well as anal cancer. In women it can cause vaginal and vulval cancer, and in men penile cancer. In fact, worldwide HPV is understood to cause 5% of all cancers and is thought to be behind the steep rise in oral cancers in the past 20 years.

Unfortunately, HPV is a very common and easily acquired sexually transmitted infection. The majority of people—probably over 80%—will be infected with HPV at some stage in their lives. The good news is that most people’s bodies clear the virus naturally and it causes no lasting damage. But in others it can persist, especially if they have weakened immune systems, and can lead to potentially life-threatening problems. HPV is not just a cause of cancer; it is also responsible for genital warts and a very unpleasant but fortunately much rarer condition called RRP—recurrent respiratory papillomatosis. This can cause serious breathing problems and is very difficult to treat.

Thirty-six organisations have come together as HPV Action to make the case for gender-neutral vaccination; in other words, protecting both males and females from the consequences of HPV infection. These 36 organisations are major names in the fields of cancer, sexual health, men’s health, oral health and public health; in fact, one of them is the Royal Society for Public Health, of which I happen to be a vice-president. HPV Action has informed me that some 2,000 cases of cancer in men are caused each year in the UK by HPV. Around 48,000 men also develop genital warts as a result of HPV infection, and about 600 men and boys live with RRP. This is a huge burden for the individuals affected and their families, and a significant issue for the NHS, which has to find the resources to treat and care for them.

It seems patently unfair that we exclude boys from a vaccination programme that can easily prevent a wide range of diseases, including several types of cancer. This makes no sense on the grounds of equity or public health. I also wonder if it might even be unlawful to exclude boys from this programme under our current equality legislation. I would be very interested to hear from the Minister whether this is the case and whether an equality impact assessment has been undertaken on this issue.

With regard to the JCVI’s timescale for a decision on adolescent boys, in 2014 it stated that it would be in a position to make a recommendation later this year. Unfortunately, in the past few weeks we have heard that the JCVI will not be taking a view until early 2017. Given the facts and figures that I have just presented, this delay is totally unacceptable. I ask the Minister to meet the JCVI urgently to discuss how the decision-making process can be accelerated. Any continued delay is causing many, many more people to suffer avoidable ill health. In fact, I believe that the case for vaccinating boys is already proven and that Ministers should make a decision now to vaccinate boys as soon as possible.

Of course, as always, there are arguments put forward that seek to justify excluding boys. I will briefly address a couple of these. First, it has been argued that the current vaccination programme for girls is so good that it protects males as well. It is true that the programme reaches over 80% of girls; 80% is the level at which the population as a whole is believed to be well protected. The UK HPV vaccination programme is without doubt one of the best programmes in the world for girls. But it is not perfect. There are some areas, notably in London, where vaccination rates in girls are well below 80%. The latest data for Enfield, for example, show that just 67% of girls received all the doses they needed. A recent study by University College London also found that girls from black or other ethnic minority backgrounds were less likely to have been vaccinated than girls from white or Asian ethnic backgrounds. These shortfalls leave large numbers of unvaccinated girls and women at risk of contracting HPV and limit the efficacy of the wider vaccination programme.

Evidence from Denmark clearly shows that while HPV vaccination for girls is reducing the incidence of genital warts in girls, it is not reducing the incidence of warts in boys. This suggests very strongly that boys are continuing to be infected with HPV, either by unvaccinated Danish girls or by girls from countries without a vaccination programme. Men in the UK, as in Denmark, do not conveniently have sexual contact just with women brought up in their own country. It is also the case that not all men have sexual contact with women of their own age group. For those men who have partners who are older than the first female cohort to receive the vaccination, the risk of HPV infection and disease will remain.

Secondly, there are some who believe that the problem with not vaccinating males is largely confined to those who have sex not only with women but also—or instead—with men. It is true that men who have sex with men are, in general, more seriously affected by HPV. Rates of anal cancer in this group have risen sharply in recent years, and anal cancer rates are even higher in men who have sex with men who are HIV positive. It has been suggested that the solution to this problem could be to offer HPV vaccinations to men who have sex with men, on attendance at a GUM clinic. Indeed, this step was recently recommended by the JCVI. In my view, and in the view of HPV Action and other experts, this is a useful but certainly nowhere near a sufficient response. It might be of some help to individuals who receive the vaccine, but it is not an effective solution for all men, or indeed for all men who have sex with men.

That is because we know that people generally become infected with HPV very soon after their first sexual experiences. That is why it is best to vaccinate before a person begins sexual activity. It is also best because the body’s immune response is greater if the vaccine is administered before the age of 16. But if we wait until men who have sex with men turn up at GUM clinics, they are likely already to have had sex with one or more sexual partners. There is lots of evidence to prove that the median age of men approaching GUM clinics is their late 20s and early 30s.

As we cannot practically or ethically identify and vaccinate the 12 and 13 year-old boys who will in their adult lives go on to have sexual activity with other men, the only effective way to protect men who have sex with men is to vaccinate all boys. This would, of course, also protect all other men and increase the level of protection for unvaccinated girls, especially in those areas where, as I have just mentioned, vaccination rates are below 80%.

The proposal to vaccinate all boys has far-reaching support. In fact, it is now hard to find anyone in the field of public health in the UK who does not support gender-neutral vaccination. Significantly, other countries are already vaccinating their boys. Australia, several Canadian provinces and Austria have already introduced gender-neutral vaccination programmes, and the United States is recommending vaccination for both sexes.

I want briefly to mention the issue of cost. HPV Action estimates that the additional cost of extending the HPV vaccination programme to boys in the UK would be in the region of £20 million to £22 million. This relatively small cost has to be set against the economic impact of HPV-related disease. In England, the cost of treating genital warts alone is estimated to be more than £52 million a year. The cost of treating RRP has been estimated at £4 million a year and there are the costs of treating a rising number of HPV-related cancers.

I serve as chairman of Bradford Teaching Hospitals NHS Foundation Trust, so noble Lords will appreciate that I am very interested in health interventions that are cost-effective, as this one clearly would be. But, ultimately, any decision about whether to vaccinate boys should not be made solely on a financial basis, although that is very clear cut. I believe that public health, equity and, above all, the human costs of HPV-related disease for both sexes must be the primary considerations. I would be grateful if the Minister could assure the House that the Government will act quickly to vaccinate both boys and girls in the UK.

Alcohol-related Disease

Lord Patel of Bradford Excerpts

Wednesday 17th December 2014 Lords Chamber

[Earl Howe]

My noble friend is right. I am afraid that the figures for hospital admissions over the past 12 years make gloomy reading. Admissions relating to alcohol-related illness have more than doubled. We welcome the recent falls in alcohol consumption that we are witnessing, and the falls in alcohol-related deaths, but we should not be complacent—and we are not. Harms such as liver disease, as well as social impacts such as crime and domestic violence linked to alcohol, remain much too high, and Public Health England is giving priority to alcohol issues from this year, particularly through support to local authorities.

[Lord Patel of Bradford (Lab)]

My Lords, on the point the noble Earl made earlier about Public Health England and dissemination of funds to local authorities, he will remember that that before Public Health England was set up, £800 million that was ring-fenced for drug use and drug treatment was given to the new body to disseminate to local authorities. Can he say how much of that funding is now diverted from the essential treatment that drug users need to people misusing alcohol, thus probably raising drug-related deaths, acquisitive crime and drug use generally across the country?

[Earl Howe]

The noble Lord was kind enough to give me prior notice of that question just before we came in. I have taken advice on it, and the advice I have received is that there is no wholesale evidence of a shift of funding from drug treatment to alcohol treatment. There may be the odd example of that, but I can tell the noble Lord that Public Health England is monitoring this issue in local areas, to make sure that that shift does not take place in a disproportionate way in relation to the need in those areas.

NHS: Health and Social Care Act 2012 Reforms

Lord Patel of Bradford Excerpts

Wednesday 22nd October 2014 Lords Chamber

[Earl Howe]

First, let me make it clear that the Government have no regrets whatever about the NHS reforms. These reforms enabled massive savings to be made, all of which have been ploughed into the front line. Without investment in the cost of the reforms—which I concede were considerable—we would not have been able to realise these savings, nor would the NHS have been able to plough those savings back into the front line. This has enabled us to employ more than 7,700 extra doctors, and the NHS is now performing more than 850,000 more operations every year. That is the benefit of the reforms.

[Lord Patel of Bradford (Lab)]

My Lords, if there is so much investment being put into the NHS, as the Minister said, why are mental health services being cut across the country and especially in the north of England? In my own city of Bradford, our mental health care service has been cut by 23%. How do we expect mental health care to have parity of esteem when it is experiencing these kinds of cuts?

[Earl Howe]

The noble Lord raises a very important issue, which results from the fact that commissioning decisions are taken not by the Government but by clinical commissioners across the service. We are very concerned by the reports of lower resources being channelled into mental health services. A lot of work is going on, in my department and in NHS England, to make sure that those services—and, crucially, the outcomes from those services—are maintained.

Mental Health: Parity of Esteem

Lord Patel of Bradford Excerpts

Monday 23rd June 2014 Lords Chamber

Asked by

[Lord Patel of Bradford]

To ask Her Majesty’s Government what assessment they have made to measure the success of their policy No Health Without Mental Health, which undertook to give mental health “parity of esteem” with physical health within the National Health Service.

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

My Lords, our commitment to parity of esteem is explicit in the Health and Social Care Act 2012. As stewards of the system, we hold the NHS to account for the quality of services and outcomes for patients through our mandate to NHS England and the NHS outcomes framework.

[Lord Patel of Bradford (Lab)]

My Lords, I think that the picture is fairly gloomy. There has been a real-terms 1% drop in investment in mental health services for adults of working age, and mental health trusts have reported a real-terms reduction of 2.36% over the past two years. Investment across the three priority areas—crisis resolution, early intervention and assertive outreach—has seen a £30 million drop for the first time. Funding for older people in mental health services has seen a 1% real cash-terms drop, and 67% of councils have stopped child and adolescent mental health services funding. These cuts have come in at a time when more people—almost 8 million—are experiencing mental health problems. In addition, 30% are suffering from a long-term physical health problem, the number of deaths by suicide is increasing and mental health ward occupancy levels are at over 100%. This Government promised parity of esteem and we were assured that that would be in the Health and Social Care Act. Does the Minister agree that we are far from meeting our obligations on this simply because of the cuts and what has happened to these vulnerable people?

[Earl Howe]

My Lords, mental health and mental well-being are priorities for the Government; I want to make that clear to the noble Lord. We have legislated for parity of esteem between mental and physical health, and we mean business on this. Our new mental health action plan, which has been well received, sets out our priorities for essential change. We have the Crisis Care Concordat, which guarantees that no one experiencing a mental health crisis should ever be turned away. We are rolling out choice in mental health, which is an extremely important step forward, and a whole range of other measures, including IAPT and the children’s mental health measures that I outlined a moment ago. I hear what the noble Lord says about funding. We have debated that matter in the House before. We are currently scrutinising local CCG spending plans to make sure that mental health gets the priority that it needs.

People with Learning Disabilities

Lord Patel of Bradford Excerpts

Thursday 12th June 2014 Lords Chamber

[Lord Patel of Bradford (Lab)]

My Lords, I, too, add my thanks to the noble Baroness, Lady Hollins, for having secured this debate on such an essential issue: one that goes to the heart of the kind of society we should be aspiring to be, one that cares for and protects the most vulnerable of its members. As we have already heard from the noble Baroness, Lady Hollins, and others, we are clearly not meeting this aspiration. We are failing to protect those who deserve our constant and vigilant care and protection. In fact, we should all be truly shocked by the stark findings of the confidential inquiry—that more than a third of deaths of people with a learning disability could have been prevented if they had received better healthcare.

I find that completely unacceptable. What is even more unacceptable is that some of the reasons for those shocking figures are that people lacked information about their health—information that they could understand—or the provision of professionals and health advocates to help to explain such information. Yet as my noble friend Lady Andrews said, we have legislation to ensure that this happens. The Mental Capacity Act 2005 set out a comprehensive statutory framework to define mental capacity, help those lacking it to make their own decisions where they can and enable sound decisions to be made for them when they cannot. The Act is there to empower, protect and support people who lack mental capacity and to ensure that professionals, families and friends who care for people who lack it understand more fully and clearly their legal rights and responsibilities. So what has gone wrong?

Implementation of the Mental Capacity Act is clearly failing; it is certainly failing for many people with a learning disability. This was clearly highlighted by the confidential inquiry but also by the post-legislative House of Lords Select Committee that I was a member of, along with the noble Baroness, Lady Hollins, and my noble friend Lady Andrews. The committee heard a huge amount of written and oral evidence from experts, professionals, service users and their families. I shall read just two sentences about the key finding of the committee’s report. It stated:

“Vulnerable adults are being failed by the Act designed to protect and empower them. Social workers, healthcare professionals and others involved in the care of vulnerable adults are not aware of the Mental Capacity Act, and are failing to implement it”.

The committee’s findings are fairly clear.

I am pleased that the Government put out a joint statement earlier this week from the Department of Health and the Ministry of Justice. It said that they,

“share the Committee’s concern at the low levels of awareness and understanding of the Act. Too many people who may lack capacity may be missing out on the legal rights that the MCA gives them. This is not tolerable and we are determined to put this right”.

While I of course welcome this acknowledgement, quite frankly it falls far short of my expectations and, I am sure, those of your Lordships. In the face of the enormity of the problem, we must have clear actions to swiftly ensure that the protections of the Act work as they were intended to: empowering patients to make choices about their healthcare and protecting the rights of those who lack capacity by ensuring that best interests decisions are made.

Some of the practices highlighted by the confidential inquiry are simply illegal and there are numerous instances of the Mental Capacity Act being misapplied or not used at all, including the failure to appoint independent mental capacity advocates where there are no family members present to ensure that the wishes of individuals are understood and respected. I would like to highlight the consequences of what this means in reality by briefly reading a case study from Mencap’s Death by Indifference report that clearly shows how grave the individual circumstances can be when staff fail to understand the Act. I take this opportunity to thank Mencap, particularly Rob Holland and his team, for its expert advice and briefing on this issue.

The case study is about a woman called Anne Clifford, who died of pneumonia on 20 July 2010, aged 53. She,

“had Down’s syndrome and a severe learning disability. Although she had no verbal communication, her sisters, Monica and Mary, describe her as a ‘feisty character who was able to show what she liked and disliked’ … When Anne was first admitted to the Mayday Hospital”,

in Croydon,

“she was put in the intensive care unit … and placed on life support as she was having difficulty breathing. She was diagnosed with pneumonia. From the moment of Anne’s admission, Monica contacted the hospital every day to enquire about the treatment her sister was receiving. She also made it absolutely clear to staff that she and her sister Mary were to be kept fully informed about Anne’s progress”,

which was their right under the Mental Capacity Act.

The report continues:

“When Anne was eventually able to breathe unassisted, she was placed on a general ward. Monica and Mary viewed this as a very positive step and began to believe that Anne could recover. However, during one of Monica’s regular phone calls to the ward, she was told that Anne’s pneumonia appeared to be returning. Monica then naturally enquired if Anne would be returned to the ICU and put on life support. It was then that she learned that Anne’s notes stated that she was not to be returned to the high dependency unit and that she would not be resuscitated. This was the first that the family knew of this. Alarmed, Monica began to seek advice and, with the assistance of the adult safeguarding team, a best interest meeting was called. But the consultant responsible … informed Monica that he had agreement from other doctors”,

on the “do not resuscitate” decision. The Mental Capacity Act states that Anne’s family should have been consulted before the best interests decision was made. This did not happen, resulting in the worst possible consequences for Anne and her family.

Anne is not alone in having been failed by health professionals who did not understand the Mental Capacity Act. There are other examples of “do not resuscitate” orders being used in situations where mental capacity has not been fully assessed.

It is hard to believe that seven years have passed since the Mental Capacity Act came into force. While the expectation, rightly, is that all health and social care professionals should have knowledge and understanding of the Act, evidence has consistently shown this not to be the case, and our committee found that staff continue to be ill equipped with knowledge about the Act. Even with the development of resources and materials for professionals, far too few understand the Act well enough to confidently and successfully ensure that it is implemented correctly.

Knowledge and understanding of the Act must be available for patients, families and staff to ensure that it is applied properly. As such, the confidential inquiry’s suggestion that a 24-hour Mental Capacity Act phone line, staffed by expert advisers in all matters relating to the Act, must be established with some urgency, and I hope that the Minister can give me some good news on that front. In addition, Mental Capacity Act training should be mandatory core training, and minimum training standards are desperately needed; my noble friend Lady Andrews spelt out why. I hope that the Minister can reassure us that this is high on the Government’s agenda and we can see some positive moves very shortly.

Care: Older People

Lord Patel of Bradford Excerpts

Wednesday 7th May 2014 Lords Chamber

[Earl Howe]

The short answer to my noble friend is that it is too soon to say as the plans are currently in formation. However, the whole idea of the Better Care Fund is to enable joint working. It is an opportunity to make the best use of available resources and improve value for money through the collaborative redesign of existing services. The pay for performance element of the fund should incentivise local areas to make efficiencies and will provide initial evidence of the impact of the Better Care Fund on savings and outcomes.

[Lord Patel of Bradford (Lab)]

My Lords, the Minister will be aware that the Royal College of Psychiatrists carried out a recent survey which found that 11% of NHS trusts had cut specialist psychiatric teams that specialise in working with older people. A similar number of trusts are planning to disband their specialist psychiatric teams across the country. That is having a huge impact on older people who have to go all around the country for a specialist service. What assessment have the Government made in respect of those cuts?

[Earl Howe]

My Lords, as the noble Lord is aware, specialised services are the responsibility of NHS England. We have charged it in the mandate and through regulations to make sure that there is comprehensive specialised cover for mental health services and other services throughout the country. For less specialised services, we expect the parity of esteem principle to apply, and CCGs are being held to account by NHS England to achieve that.