Health: Endoscopy and Bowel Cancer

Lord Winston Excerpts

Monday 2nd July 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Baroness for raising that question and am sorry to hear about her mother. As she will know, bowel cancer is unfortunately the third-most prevalent cancer and the second-biggest killer, and we need to go a long way to improve treatment. I have already mentioned the increase in the number of endoscopists, and that will help. There are also plans to make sure that existing staff within the cancer workforce have the necessary specialist skills. The size of the cancer workforce has increased over the last few years but there is a goal to dramatically increase it further. We know that the test that the noble Baroness mentioned is much more effective and can be administered much more easily. The rollout will take place from December this year.

[Lord Winston (Lab)]

My Lords, there is an increasing interest in capsule endoscopy, which of course is less invasive as it does not require an instrument to be put down into the abdomen. However, it requires training, which the medical literature clearly shows is insufficient. Can the Minister indicate whether the NHS is planning to provide more training for the provision of capsule endoscopies? Also, what is the risk of a large number of false positive results with all these endoscopies?

[Lord O'Shaughnessy]

I will have to write to the noble Lord with an answer to his question about the type of endoscopy he mentions, as I do not have the details of it. The risk of false positives is one reason that we have to be extremely careful with screening programmes of all kinds, whether it is the faecal immunochemical test or an endoscopy. As he knows, whatever screening programmes are implemented, the National Screening Committee tries to reduce the number of false positives wherever possible.

Health: Online Services

Lord Winston Excerpts

Monday 23rd April 2018 Lords Chamber

[Lord O'Shaughnessy]

That is an excellent point: the entire country is preparing for the advent of the GDPR on 25 May. We are engaged in a large programme of work with the Information Commissioner’s Office and others to ensure that everyone working in the health and care services understands their obligations and informs patients accordingly.

[Lord Winston (Lab)]

My Lords, a large number of reproductive clinics publish their wares by advertising on the London Underground, often at great cost, sometimes making claims about their treatments. If I did that as a doctor, I would be struck off the register. They get round it because they are private clinics. Is that appropriate? Does the Care Quality Commission have any involvement in this process, and should it?

[Lord O’Shaughnessy]

I would have to look at the specific clinics that the noble Lord is talking about. The subject of the report was those providing online services. One of the things it discovered was that certain regulatory issues are unique to the provision of online services, an example of which is when the data is held offshore and what that means for regulation. As the CQC says in its report, it is reviewing its regulations to make sure that it can account for the unique aspects of online provision, so that the critical aspects, whether they are about truthful advertising or other aspects, are dealt with properly.

Health: Flu

Lord Winston Excerpts

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

My noble friend is absolutely right. Back in September, Simon Stevens, the head of the NHS, warned about the impact of the flu epidemic in Australia and New Zealand. The feedback on that was that the particularly vulnerable groups were the over-80s and five to nine year-olds. We have talked about helping younger children through school-based immunisation. We also have the highest uptake in Europe of over-65s getting flu jabs. There is clearly more to do because around one-third of people still do not.

[Lord Winston (Lab)]

My Lords, will the Minister reconsider his statement, in answer to the Question, that the NHS has never been better ready for a flu outbreak? The problem with viral infections, like pandemics, is that they are completely unpredictable and often hit in a way that we never expect. They remain one of the biggest single threats to humanity. I hope he understands that this unpredictability is a very real issue with all these infections, including influenza, as history has shown us.

[Lord O'Shaughnessy]

The noble Lord is, of course, quite right: we cannot know what will hit us. However, we can prepare in advance as much as possible. That was the sense I meant to convey—namely, that a huge amount of preparedness has gone on for not just flu but the winter. That work started in the summer—earlier this year than ever before. The flu vaccination on offer covers the strains that Public Health England thinks are most likely to come, but, of course, we cannot predict exactly what will happen.

Brexit: Risks to NHS Sustainability

Lord Winston Excerpts

Wednesday 12th July 2017 Lords Chamber

[Lord Clark of Windermere (Lab)]

My Lords, I am delighted to participate in this debate and to follow the noble Lord, Lord Cormack, and his clear, erudite and free-thinking contribution to the debate. I especially congratulate the noble Lord, Lord Warner, on allowing us an opportunity to debate this issue. When he approaches anything, he approaches it in a meticulous manner. Securing this debate today and concentrating our minds on sustainability and the risks involved with Brexit is a useful exercise for us to undertake, so I thank him for that.

I approach the debate with some hesitation, and I am sure that other noble Lords will feel likewise. At one level, none of us wants to say or do anything that will shake people’s confidence in the National Health Service. It is indeed the most efficient health service in the world, and it still delivers a wonderful service to the general population of the United Kingdom. I would hate to think that anything that I might say might cause distress to patients. However, as the noble Lord, Lord Cormack, hinted, as parliamentarians we are privy to information that is not available to other people. I suspect that I know quite a lot more about what goes on in hospital than even the Minister, whom I hold in the highest regard. I understand his sincerity and his commitment to the NHS, but so much of his information is, naturally, fed to him by his civil servants—I understand that, and I am not attacking civil servants. I looked after the Civil Service in my previous existence.

As the Minister may have noticed, I have tried to take a different approach to collecting information. Of course I accept the facts and look at the statistics but over the years, through my friends and associates, I have tried to build up contacts in the health service. People who work in the health service and in hospitals give me the picture as they see it—how it actually is—and it is up to me whether I believe it or not. I have to say that the picture is far worse than I had imagined, and I will try to develop some of those points today.

However, I start with a point raised by the noble Lord, Lord Warner—Euratom. I spent seven years as a director at Sellafield and I suspect that I know a little more about nuclear reprocessing than perhaps most of the general public do. I simply do not understand the Prime Minister’s obsession with leaving Euratom. Perhaps she does not understand what it is—Euratom is a legal entity separate from the European Union—yet she took a decision on it, apparently against the advice of other Cabinet Ministers. I hope that after this debate the Minister will feel empowered to feed the information up to the Secretary of State.

The issues surrounding Euratom are very serious, and I want to spell them out in words of one syllable because that is the only way that I can understand them. Quite simply, leaving Euratom could—I emphasise “could”—restrict the UK’s access to radioisotopes, which are critical to scans and treatment for cancer. It is as serious as that. We do not have reactors in this country capable of producing radioactive isotopes. We import them largely from France, Germany and Holland, and the control and safety monitoring of those isotopes is carried out by Euratom. By cutting our links with Euratom, we expose ourselves.

To put this issue in context, half a million scans are performed every year in Britain using imported isotopes and, on top of that, over 10,000 cancer patients have treatment involving their use. I just think that it is too big a gamble to take a decision on what I can only think are ideological grounds. That is a big, big error and I hope that the Government will rethink their position.

Going back to the basic issue, I suppose there are two basic problems. One is clearly finance. We spend less on healthcare than any of the other G7 nations, with one exception. I believe that the Government should make a commitment to go for at least the average spend on health among the G7. That would give us an opportunity in the years ahead to start an expansion.

A second problem is staffing—at every level. Throughout the National Health Service there is a panoply of overwork, low morale and staff working in what I can only describe as desperate conditions. Nurses finish their shifts in tears time after time. They are frustrated because they simply do not have the time to perform their job—their vocation of care—and they feel that they let the patients down, simply because they are understaffed. I have heard reports of nurses working a 12-hour night shift—that is the average length of a night shift—without being able to stop to have something to eat. That is happening regularly. The Minister might say, “Ah, but the numbers are made up with agency nurses”—and they are. But one only has to think about it to realise that, as the reports I get confirm, agency nurses can do the mundane things but most of them are not familiar with the work of the hospital or ward in which they are working. So even with the numbers increased by agency nurses, the onus on the regular staff of the hospital is increased.

It is not only about nurses, where we are 40,000 short of what we need, let us consider doctors. Where I live, the north Cumbria trust has 48 vacancies for consultants—we cannot get any consultants or nurses to work on the west coast of Cumbria. Right next to Sellafield, the largest industrial site in Europe, there is no hospital of any quality within an hour-and-a-half’s drive. That is the seriousness of the problem.

For the first time ever, more nurses are leaving the profession than joining. The worry is that the greatest drop was among the English or British-trained nurses, which was far higher than among the European-trained nurses.

I hope the Minister will consider looking again at the abolition of the bursary scheme if the indications at the beginning of September show that there is going to be a fall in the numbers. We cannot stand another decrease in the number of nurses. I say this to the Government because they need reminding: their track record is not good. They were the Government who cut nurses’ training by 10% in the years following 2010, and it has taken us a long time to recover.

I end with a thought on the residency of European Union-educated nurses. From exchanges with the noble Baroness, Lady Williams, I understand that after five years of working in the health service, or any permanent employment, European Union citizens can get the right to residency. Then, after a further year—six years in total—they are entitled to UK citizenship. That seems straightforward, but what concerns the nurses and the European Union is this: can those rights be withdrawn willy-nilly by any British Government in the future? That is a serious problem that the Government have to address in order to reassure people working in the health service.

[Lord Winston (Lab)]

Before my noble friend sits down—

[Noble Lords]

Order.

Gene Editing: Agriculture and Medicine

Lord Winston Excerpts

Monday 27th March 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right to talk about the important therapeutic benefits that can come. I do not think this has anything to do with Brexit, other than the fact that the UK has been and continues to be a leader in the world of genomic sequencing, which of course enables us to identify the genetic issues that lead to some of the diseases and illnesses she has described. Within our regulatory framework, it is possible to use gene editing for therapeutic reasons but in ways that do not impact on inheritability, which is of course ethically an incredibly difficult question.

[Lord Winston (Lab)]

My Lords, can the Minister confirm that the Government have no plans to extend gene editing to germ cells, as was suggested in the Times only three weeks ago, with the idea that we could wipe out genetic disease using gene editing? This seems an extremely dangerous idea, given that there are epigenetic and other issues with gene editing, which may not be quite as precise and effective as is sometimes claimed.

[Lord O'Shaughnessy]

The noble Lord is quite right to make that point. So-called germline gene editing, which creates the opportunity to pass on changes to later generations, is highly controversial. It is illegal in this country and there are no plans to change that position.

Abortion (Disability Equality) Bill [HL]

Lord Winston Excerpts

Report stage (Hansard): House of Lords
Friday 24th February 2017 Lords Chamber

Moved by

[Lord Winston]

1: Clause 1, page 1, line 2, at end insert—
“( ) After section 1(1)(a) insert—“(aa) that the pregnancy has exceeded 24 weeks and there is a high probability that the fetus will die at, during, or shortly after delivery due to serious fetal anomaly; or”.”

[Lord Winston (Lab)]

My Lords, in rising to discuss the Bill, I first pay considerable tribute to the noble Lord, Lord Shinkwin, whose courageous approach to these matters is massively appreciated on all sides of the House, irrespective of the argument that we may have about the nature of termination of pregnancy in different circumstances. His tireless work on disability is of massive importance to our society, and I very much hope that he will continue that work—even though I disagree with some aspects of the Bill, to which my Amendment 1 refers.

I feel I need to correct a particular impression that the noble Lord gave in the Second Reading debate. Unfortunately, I could not be here; I was lecturing in the United States. Very far from the Bill being modest, reasonable or logical, there are all sorts of flaws which are not modest in their effects on women and their families and are not reasonable for women who are suffering with these hugely difficult decisions about what to do in their interests and the interests of their family—and I do not believe that the Bill is in any way logical. As noble Lords will see from the amendments I have put down, I do not intend to try to prevent the Bill going through, but it must at least be adjusted and, in one aspect, Amendment 1 does that.

One thing that concerns me about the Bill is that the noble Lord, Lord Shinkwin, talks about discrimination against people who have a disability. One problem here is that it is surprising that he has produced the Bill for termination of pregnancy where a minor number of babies are being aborted but has avoided a much bigger issue. For example, he has not discriminated against pre-implantation genetic diagnosis, which is going on worldwide in every in vitro fertilisation centre and is designed to screen out foetal defects where families suffer from those defects.

I have to explain to the House exactly what happens in that situation, because it is relevant to my amendment. There are some 6,000 to 6,500 severe foetal disorders of different kinds caused by mutations in DNA. It so happens that in the debates so far only two have been described, neither of which is fatal. Neither muscular dystrophy nor brittle bone disease is generally fatal, but most of the 6,000 diseases are fatal—they kill mostly children, and they kill them mostly at an early age, usually before the age of 2 or 3.

Noble Lords might say that we can screen DNA, and people have been talking about eugenic screening, but we cannot do that because, for example, even in the case of muscular dystrophy, which was cited, at least one-third of those mutations occur de novo in families without any previous history, so they cannot be detected and families will not expect them to be there until the woman is pregnant. Added to that, in, for example, the case of muscular dystrophy, which affects mainly males, there are about 700 different mutations in the dystrophin gene which causes that disease. So this is a seriously complex situation which is being looked at in a rather simple and, as the noble Lord, Lord Shinkwin, said, modest way, in the legislation that he is proposing—but it is very far from that.

The other thing that very much concerns me in his words and language is the charge that we have become search and destroy. To the noble Lord, Lord Shinkwin, I say this: in my professional life, although I have been mainly involved with reproductive medicine, I have been a professional obstetrician and a fellow of the Royal College of Obstetricians and Gynaecologists. I have been involved with pregnant women and their families for more than 40 years, and I find it objectionable to consider that we undertake search and destroy during early pregnancy. What we try to do in pregnancy is what we should do as obstetricians, which is to diagnose and discuss. That is very different from search and destroy.

What we do with screening in pregnancy is to try to make certain that the foetus is healthy. If the foetus is not healthy in some way or suffers from an anomaly, what we can then do, having made that diagnosis, is discuss that at great length with the woman concerned—along with her husband where appropriate and if necessary with her family—and then decide with her what is in the best interests of the family. Hopefully, that pregnancy will continue whether the foetus is disabled or not, but knowledge of the disability means that we can have appropriate medical resources available at the time of birth. This is far from destroy: on the contrary, it is in fact designed to protect, promote and enhance life wherever possible. That is a basic issue that we have dealt with.

--- Later in debate ---

However, should the noble Lord decide not to withdraw his amendment and instead to divide the House, I humbly ask that all noble Lords stand with me and people with congenital disabilities and affirm that we are all equal.

[Lord Winston]

My Lords, I shall not use unparliamentary language. I reject the charge that my view of this matter is in any way cynical. I believe that it is compassionate. Perhaps unlike the noble Lord who has promoted this Bill, I have been in constant contact with pregnant women who have had to go through these difficult decisions throughout their pregnancy throughout my professional life. I have been a practising doctor—I am now not on the register as a full practitioner—for more than 40 years, and I have tried to listen rather than interrupt; I have tried to be non-judgmental rather than to judge; and I have tried to find a way through what are very difficult decisions for both the patient and her family and for my team and myself.

Sometimes there have been very long arguments and sometimes we have debated these issues repeatedly among ourselves and tried to internalise the arguments to come to the right decision. I do not think that my moving this amendment is in anything other than good faith, and I am sorry that it seems, at least to the noble Lord, to be merely a cynical adjustment to his Bill. If it was, I would have tried to have the Bill talked out, but that is not my intention. My intention is to discuss and examine some of the things that have been said during the passage of the Bill, to which a very large number of people will have a strong objection—and also of course because there is a great deal of misinformation.

The noble Lord, Lord Shinkwin, is under the impression that DNA diagnosis is the next generation of diagnosis. Believe me, it is not. I tried to explain that to him but he probably did not understand. If you have 6,500 different genetic disorders and you have, let us say, 500 different mutations that can cause each of those disorders, you end up with hundreds of thousands of different mutations for which you cannot screen at seven weeks, or even 24 weeks. The problem is that they come at different times. Unless the patient has already had and is bringing up, with great difficulty, a child with one of these problems, who is going to die, they do not know that they are carrying a mutation.

So one reason for this amendment—I thought it would have been quite obvious—is that one of the big problems for families is that a large number of women are, in all good faith and as great parents and wonderful people, trying to bring up children with Down’s syndrome, or with conditions that are far worse than Down’s syndrome in their impact on the child, and they frankly cannot manage to bring up another child, and there is a risk of those children having even more difficulty in their upbringing, adding great damage to those families. That is partly the purpose of this amendment.

I did not understand the interjection by the noble Lord, Lord Alton. He comes from Liverpool, where a large number of pregnant women do not present at an antenatal clinic until they are beyond 24 weeks. This happens in the East End of London as well. I remember that I was once called down to casualty to see a patient with abdominal pain. I went down there, and the casualty officer said, “I don’t know what’s wrong. She’s got a large swelling in her abdomen and she’s in abdominal pain”. This 22 year-old was in the second stage of labour at 40 weeks of pregnancy, but she denied that she could be pregnant because, given the background she came from, she would not have undergone antenatal screening. Sadly, we do not live in a society that always has the same values that we have. Very often, women do not present at antenatal care for all sorts of reasons. One of the reasons for tabling this amendment is to protect those women.

The noble Lord has mentioned this before, but I am surprised that he raised the question of cleft palate, Down’s syndrome and club foot. With all due respect, most of us would regard these as being relatively minor and certainly not, on the whole, life-threatening conditions. However, cleft palate can be; there is a mistake about understanding this. Very severe central line defects are incompatible with life and, in spite of surgical operations on the foetuses, many of these foetuses will die in utero with such serious defects, even though they are diagnosed as cleft palate.

I will tell the House of one patient I heard about from a colleague of mine at Imperial College only a couple of weeks ago. This woman has now reached just beyond the 24-week limit and there is a question whether the child has hydrocephalus. The woman does not want to terminate the pregnancy but dreads the thought that she is going to have a baby that might have the most serious cranial defects. The advice that we gave, after great difficulty and a lot of discussion, is to wait to see how the pregnancy develops, because some of these babies do not end up with severe deformity, while others have a monstrous head that cannot even be delivered through the birth canal. The solution is to do some kind of horrific delivery with an operation on the foetus at term—in a woman who is now anaesthetised—or to do a caesarean section. We have to understand that this is not a simple matter of just obstetrics and medicine solving everything.

One or two noble Lords talked about the word “probability”. I would have thought it pretty obvious what that meant. We have a definition of the perinatal period, which is what I am referring to. That would normally be defined as the first month after birth, but if noble Lords feel that it should be the first week, which is why I did not define it, I would be happy to accept that in the amendment. That perhaps should be considered. But these things are defined: death before delivery is quite clear, death during delivery is quite clear and I would argue that death in the first stage of the perinatal period is also perfectly clear. I have no problem with any of the issues about it being shortly afterwards.

As for a serious abnormality, let us just look at the Abortion Act as it is written. As it stands, it is full of these rather gentle allusions and is very carefully worded. The noble Lord used the word “insensitive”. I find that truly astonishing, because with the best of faith I do not feel that I am insensitive. I do a huge amount of outreach in schools. The noble Lord may not realise, but much of that outreach is in schools with children who are severely disabled. I go into those schools regularly because I feel so strongly about disability rights. I do not feel prepared to have the finger pointed at me saying that I am not trying to do my best, in a small way, for a society where disabilities occur.

Claus 1(1)(a) of the Abortion Act refers to the situation where,

“the pregnancy has not exceeded its twenty-fourth week and … the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated”.

That is a judgment; it is not an absolute. We cannot say exactly what the risks might be. No doctor can say for certain that a termination of pregnancy will be safe. Terminations can occasionally result in the death of the individual, completely surprisingly. I have seen people haemorrhage profusely after termination, which is not always easy to recognise and document. One has to say that we make a judgment—that was my point about the ethical considerations in trying to do good rather than harm. I was hoping that that would be understood in this amendment.

However, I have listened carefully to your Lordships and do not want to prolong this debate any further. I am concerned of course about the women of Northern Ireland, who do not have equality with women in the rest of Britain. I feel that there is a question of discrimination, but for the moment I beg leave to withdraw the amendment.

Amendment 1 withdrawn.

Medical Students

Lord Winston Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Winston (Lab)]

My Lords, is the Minister aware that, although there may be enough people wanting to apply to medical school, many of the brightest and the best are now completely turned off doing medicine because of the relationship with the Secretary of State for Health? This is a very serious mistrust and, whether they are male or female, the brightest and best are often not applying. There is increasing evidence for this in most medical schools, and indeed in schools as well.

[Lord Prior of Brampton]

I respect the views of the noble Lord but I have looked very carefully at the number of applications coming into medical schools in 2016 compared with the previous year. In 2016, there were 20,100 applications for all medical schools, including in Scotland. The previous year the figure was 20,390, so there is no firm evidence to support the view that the noble Lord expresses. There were some rumours that St George’s was having trouble filling its places. I have investigated that and understand that it was a result not of any lack of demand but of the fact that it wanted to wait until A-level results had come through so that it could choose the best candidates based on those results. So I do not think there is any evidence to substantiate the noble Lord’s point.

Public Health England: Alcohol

Lord Winston Excerpts

Tuesday 5th July 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the CMO’s guidelines are 14 units of alcohol per week, which is based on 67 different independent systematic reviews of what constitutes low-risk drinking. That is the best advice that we have available to us and it is entirely up to people whether they take it or not.

[Lord Winston (Lab)]

My Lords, the Chief Medical Officer famously said recently, “When I reach for a glass of wine, I think of cancer”. Does the Minister seriously think that exaggerations of that kind actually help the public perception of alcohol or mean that as a consequence our experts are completely ignored?

[Lord Prior of Brampton]

My Lords, as I said earlier, I think that the CMO’s guidelines are based on independent scientific advice. How that advice is communicated to the public is a different issue and the CMO is currently consulting on how we should express that scientific advice in ways that will have the maximum impact so that the public will take due notice of it.

NHS: New Junior Doctor Contract

Lord Winston Excerpts

Monday 18th April 2016 Lords Chamber

[Lord Prior of Brampton]

I think that all good employers recognise that having the trust and confidence of their staff is fundamental. No employer, government or private, would wish to have the outcome we have in this situation. As I said earlier, there are absolutely no winners from this dispute, and the Government regret as much as anybody that we have come to this particular pass.

[Lord Winston (Lab)]

Does the noble Lord agree—I am sure he does—that the great majority of junior hospital doctors, whatever the situation, are deeply altruistic people and remain so? They see this strike as part of that altruism, as is very clear from talking to them, and I am sure the Minister would agree about that. Does he not feel that one risk is the long-term damage not just to the health service but as regards people who are thinking of coming into the health service in the future? The young people whom I see in universities and even in schools are now asking me, “Should I actually be doing medicine?”. Does the noble Lord agree that some kind of compromise at this stage would be better, as it might well save money, rather than cause more anguish and more money to be spent in the long term?

[Lord Prior of Brampton]

My Lords, I certainly agree that some of the best and finest young people in Britain go into medicine. It is a wonderful vocation—I use the word “vocation” advisedly. We have had three years of trying to come to a compromise and there comes a point in any negotiation when you have to draw stumps, although it is very unfortunate and very sad when that happens. Over that three-year period there were opportunities for both sides to come to an agreement and it is tragic that we did not do so, but I feel that after three years the Secretary of State had little option but to accept the advice of Sir David Dalton.

NHS: Junior Doctors’ Pay

Lord Winston Excerpts

Wednesday 27th January 2016 Lords Chamber

[Baroness Brinton (LD)]

My Lords—

[Lord Winston (Lab)]

My Lords—

[The Lord Privy Seal (Baroness Stowell of Beeston) (Con)]

My Lords, I am sorry to intervene, but I know that the noble Lord cannot see that the noble Baroness, Lady Brinton, is trying to get in.

--- Later in debate ---

[Lord Prior of Brampton]

The noble Baroness raises a very important point that we are highly dependent in a whole range of medical specialties on overseas doctors and of course overseas nurses as well. Health Education England is expanding the number of training places, in particular for GPs; we hope to have an extra 5,000 GPs in place by the end of this Parliament.

[Lord Winston]

My Lords, I apologise for interrupting the noble Baroness. The Government’s stated objective is essentially to cover NHS hospitals 24/7—that is, with weekend working. Many hospital managers—for example, those in Birmingham—have pointed out that they are perfectly able to staff their hospitals fully under the existing contract. Can the Minister tell us how many NHS hospitals in the United Kingdom have closed as a result of inadequate staffing at weekends?

[Lord Prior of Brampton]

My Lords, it is not a question of hospitals closing at weekends because of inadequate staffing; it is a question of whether hospitals are able to offer high-quality care throughout the weekend. Some hospitals can but some cannot. We have seen, for example, the reorganisation of stroke care in London. Providing high-quality seven-day services for stroke care can have a significant impact on the quality of patient care. This seven-day issue is not just about junior doctors by any means; it is a question of having diagnostics, senior doctors and a whole range of other specialties on duty over the weekend.