HIV Treatment

Martyn Day Excerpts

Wednesday 29th March 2017 Westminster Hall

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mrs Main, and to take part in today’s debate. I am grateful to the hon. Member for Finchley and Golders Green (Mike Freer) for securing the debate, and for his detailed and informative speech, as well as for the work of the all-party group on HIV and AIDS in producing an excellent report, “The HIV puzzle”. The report notes, on the basis of evidence from charities, civil society groups and the pharmaceutical industry, significant upheaval to HIV and sexual health services since the Health and Social Care Act 2012 was implemented.

The findings of the report are very worrying. A joined up, multi-sector approach to support and care for those at risk of or living with HIV is crucial to its prevention. The UK Government should reflect seriously on how they can improve HIV services in the light of that body of evidence. The report is concerned with HIV services in England, but its findings will be of interest throughout the UK. Communicable diseases do not, after all, recognise administrative or national borders. The report recognises:

“In Scotland sexual health sits under Blood Borne Viruses in the health system, which Dr Gordon Scott argues makes it easier to set priorities.”

In that spirit, and given that the issue is devolved, I hope that the comments of a Scottish Member about HIV in Scotland will also be of interest to Members from other parts of the UK.

There were 6,095 new diagnoses of HIV across the UK in 2015, and 300 of those were in Scotland. The latest figures for NHS Lothian, which covers the West Lothian part of my constituency, tell us that there are 1,589 people diagnosed and living with HIV, and that 70 of those were diagnosed in the past year. At the other side of the country, Glasgow has experienced its biggest rise in HIV infection for three decades. The issue will affect every community in the country. We all have our challenges, especially when we consider that it is estimated that about 13% of people may be undiagnosed, with all the consequent risks of onward transmission, as well as the impact on those people of being unable to get access to care and treatment.

Lifetime treatment costs the NHS between £280,000 and £360,000 per patient—a not insignificant amount. Prevention of HIV infection remains a priority for the Scottish Government. There is no room for complacency on communicable diseases such as HIV. We continue to provide funding to NHS boards for HIV prevention, as well as supporting organisations such as HIV Scotland, with £270,000 in funding this year. There is of course no one-size-fits-all approach to HIV prevention. That is why in Scotland we are providing Waverley Care with £45,000 in funding this year for its HIV prevention and support work with African communities.

A joined-up approach to HIV care is vital to ensuring that infected people can get the care they need to live life as independently as possible. The Scottish Government’s sexual health and blood-borne virus framework 2015 to 2020 is continuing to build on achievements made under the original framework document of 2011. The HIV Testing Kits and Services Revocation (Scotland) Regulations 2014 lifted the ban on the sale of instant-result testing kits in Scotland. In the light of that change, and following leadership on the issue by HIV Scotland, a subgroup of the executive leads group published a questions and good practice document on instant-result self-testing in March 2014. The good practice document was the first of its kind in the world and has since been recognised internationally as an example of good practice by the World Health Organisation.

All NHS boards in Scotland have protocols in place in relation to HIV post-exposure prophylaxis—PrEP—for sexual and non-sexual exposures. The framework makes clear the importance of a multi-agency approach to sexual health and blood-borne viruses. Truly delivering on the framework outcomes in the long term will require the involvement of patients and service users, NHS boards, local authorities, the third sector, academics, the media and, indeed, the general public. The integration of health and social care in Scotland is one of the most significant reforms since the establishment of the NHS. We are the only UK nation to have legislated to put NHS boards and local authorities under statutory duties to work together. That is helping to tackle priorities in the framework to work towards as joined-up an approach as possible to caring for people with long-term conditions and disabilities, such as HIV.

Evidence generated in late 2014 and early 2015 indicates that the HIV infection is being transmitted among a small population of highly chaotic, vulnerable and often homeless people who inject drugs. These transmissions reinforce the importance of prevention work with such populations. The Scottish Government are working with health boards, schools and the police service to ensure that vulnerable groups can get the right support to prevent and treat infection. The framework update includes commitments on development of care services with local authorities; tackling social stigma through education; encouraging HIV testing to be regarded as routine; and NHS boards and partners offering testing to vulnerable groups using innovative approaches such as delivering testing in the communities themselves.

The Scottish Government are also considering the recommendations of an independent review of PrEP. The European Medicines Agency has granted a licence for Truvada as PrEP for HIV in adults at high risk. The Scottish Government’s chief pharmaceutical officer has written to its manufacturer to ask it to make a submission to the Scottish Medicines Consortium. The Scottish Government’s position is that all medicines must be licensed before they can be made routinely available on the NHS, but we recognise that some people are already buying PrEP drugs privately in Scotland. It is important that people who are doing so receive appropriate advice from and are monitored by clinicians. The executive leads network for the sexual health and blood-borne virus framework is considering the findings of the PrEP short life working group, which considered a range of issues associated with the use of PrEP. I look forward to hearing about the outcomes.

In conclusion, I commend the work of the APPG and its report on this issue. There are undoubtedly lessons for us all within it.

Rare Diseases Strategy

Martyn Day Excerpts

Tuesday 28th March 2017 Westminster Hall

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship today, Mr Pritchard, and I am grateful to the hon. Member for Bath (Ben Howlett) for securing the debate, for his informative speech and indeed for the work that he has undertaken with the all-party group.

As we have heard, rare disease affects considerably more people than we would at first imagine, with over 3 million people across the UK likely to suffer from a rare disease at some point in their lives. The Scottish Government’s implementation plan for rare diseases in Scotland recognises this fact in its title: “It’s Not Rare to Have a Rare Disease”.

My own constituency has had, as I am sure every other constituency has had, several fairly high-profile rare disease cases. These cases attract media attention and affect entire communities, not just the family directly affected; often, communities have to raise funds to help with treatments and raise awareness. Such a case was that of Kirsty Reid from Whitburn. In 2015, after being diagnosed with pseudomyxoma peritonei—it is one of those conditions where the acronym, PMP, is slightly easier to say—Kirsty raised over £7,000 to help others diagnosed with the rare condition, which affects only two people per million.

We also have a charity called Shavon’s Journey, which was set up in 2012 following the death of Shavon Morton from Grangemouth after a long fight with aplastic anaemia, a condition in which bone marrow does not produce sufficient new cells to replenish blood cells. I could go on with other examples, but I think we all get the point— rare diseases touch the lives of many, and therefore the importance of raising awareness, and of improving diagnosis and ultimately the services and treatments to sufferers, cannot be overstated.

[Stuart Blair Donaldson (West Aberdeenshire and Kincardine) (SNP)]

I thank my hon. Friend for giving way and I congratulate the hon. Member for Bath (Ben Howlett) on securing this debate. The Teddington Trust, which is jointly run by one of my constituents, supports people living with xeroderma pigmentosum, who lack the DNA repair mechanism necessary to repair damage caused to the skin by exposure to ultraviolet sunlight. Does my hon. Friend join me in commending the work of the Teddington Trust and the work of many other rare disease charities in supporting those living with rare diseases and keeping rare diseases on the political agenda?

[Martyn Day]

I do indeed join my hon. Friend in commending the work of so many good charities and organisations in this field.

The Scottish Government’s implementation plan, which I have mentioned, sets out the Scottish approach to delivering the UK strategy commitments. Key to the plan is recognising the importance of timely and accurate diagnosis, and allowing treatments to start as soon as possible. The Scottish Government have substantially increased access to new medicines, particularly for cancer, due to reforms and investment in recent years, which has led to a marked increase in uptake of orphan, ultra-orphan and end-of-life medicines.

Last year, the Scottish Government launched a review of the way drugs are assessed for NHS use, which was led by the former NHS Fife medical director, Dr Brian Montgomery. His review looked at how changes made to the Scottish Medicines Consortium process in 2014 had affected access to medicines for rare and end-of-life conditions. The review’s recommendations set out how the process for appraising medicines can be made more open, transparent and robust, and the Scottish Government have committed to implement all 28 of its recommendations, such as a new approval pathway, outwith the standard SMC process, for these high-cost medicines for very rare conditions.

The Scottish Government’s peer-approved clinical system, or PACS, has helped to give patients and clinicians a better say in which new medicines are approved by the SMC for use in NHS Scotland, particularly those used for rare or life-limiting conditions. PACS was first piloted in Glasgow in 2015 and has been successfully rolled out across Scotland, and a second tier of PACS will now be introduced to replace and build on the existing individual patient treatment request system. A new national appeals process will be introduced through this new tier of PACS, which will include consideration of equity of access with other parts of the UK as a material part of the decision-making process.

It is also perhaps worth saying at this point that the Scottish Government are happy to work with the National Institute for Health and Care Excellence, and indeed with any other countries, to improve access to medicines in Scotland and to obtain a fair price from the pharmaceutical industry. I emphasise that last point, because we now need the pharmaceutical companies to do their bit by bringing forward fairer prices for new medicines, so that access can be as wide as possible.

Finally, we know that the Health Secretary has said that he does not expect the UK to remain within the European Medicines Agency, which raises a number of concerns about potential delays in new drugs reaching patients in the UK. Sir Alasdair Breckenridge, who was the chairman of the UK’s drug regulator—the Medicines and Healthcare Products Regulatory Agency—for almost a decade, said last month:

“The UK market compared to the European market of course is small and they may decide not to come to the United Kingdom. So therefore there will be delay in getting new drugs—important new drugs, anti-cancer drugs, anti-infective drugs—for patients in the UK.”

He is not alone in saying that; David Jefferys, vice-president of Japanese drugs firm Eisai, has also warned that UK patients could face delays of up to two years. I would be grateful if the Minister could advise in his response to the debate how these dire warnings can be prevented from becoming a reality.

O’Neill Review

Martyn Day Excerpts

Tuesday 7th March 2017 Westminster Hall

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Streeter, and to take part in this important debate, which has been well informed and highly consensual. I am grateful to the hon. Member for Thirsk and Malton (Kevin Hollinrake) for securing it. This issue is one of the greatest global health challenges facing our generation. I agree thoroughly that it is potentially devastating and that it is already happening.

[Mr Philip Hollobone in the Chair]

Worldwide, antimicrobial resistance currently kills an estimated 700,000 people annually, and approximately 70% of known bacteria have developed resistance to one or more antimicrobials. The O’Neill review sends a clear and stark warning to us all that we must act for the sake of our economy and, more importantly, our health. Lord O’Neill estimates that by 2050, 10 million people globally could die each year because antibiotics are losing their power to tackle common infections, and that a quarter of those deaths will be caused by tuberculosis, whose attributes make TB bacteria more likely to develop resistance. It is worth noting that the O’Neill review final recommendations highlighted that

“tackling TB and drug-resistant TB must be at the heart of any global action against AMR.”

It is also projected that antimicrobial resistance could cut global GDP by 3.5% in the same time period, which amounts to $100 trillion. I am not even sure how many zeroes that is, but it is a frightening sum. Action is needed at a local, national and global level to improve knowledge and understanding of antimicrobial resistance, to conserve and steward the effectiveness of existing treatments and to stimulate the development of new antibiotics, diagnostics and therapies.

To those ends, the Scottish National party-led Scottish Government are taking their role seriously. Last March, the Scottish Government announced a £4.2 million research grant to investigate the prevention and control of healthcare-associated infections, as well as to research new ways of using existing antibiotics more effectively and efficiently. Scottish Government funding was provided to a consortium of researchers led by the University of Glasgow, working with other Scottish universities, to establish a new Scottish Healthcare Associated Infection Prevention Institute.

Antibiotics are not only critical for treating bacterial infections, they are a cornerstone of routine healthcare, as they prevent infections following surgery and cancer chemotherapy. In Scotland, more than 80% of antibiotic use is within primary care. Overuse and inappropriate use of antibiotics can unnecessarily increase the development of AMR. As limited new antibiotics are under development, it is vital that health professionals and the public work together to optimise how antibiotics are used to preserve their effectiveness for future generations.

Some progress is being made. The latest Scottish figures for 2015 show a 2.4% fall in one year in the number of antibiotics prescribed in primary care, a reduction of 84,490 items compared with 2014. As per the recommendations of the UK five-year antimicrobial resistance strategy, a Scottish “One Health” report will be published in 2017. The report will contain antimicrobial use and resistance data for humans, animals and the environment, in line with the aims of the global “One Health” approach, which spans people, animals, agriculture and the wider environment. There is little doubt that a present and serious challenge faces us; what is less clear is how best to tackle it.

It seems to me that we have two principal problems, both of which have been covered by hon. Members who have spoken in the debate. First, pharmaceutical companies do not have a financial incentive to develop new antibiotics. Even if a company invests in developing a new antibiotic, it needs to be held back until we are resistant to other antibiotics. However, while the antibiotic is being held back, the time on its patent is still ticking down, meaning that the company has less time to recoup the money that it has invested developing it. Therefore, the SNP would like the UK to accelerate its leading role in developing solutions to incentivise the development and management of new antibiotics, promote re-investment in antibiotics and appropriate use and reduce the risks for both payer and investor. I look forward to any comments that the Minister might have on that aspect.

Our second major problem is the use of antibiotics in livestock, which we then consume via the food chain. The evidence suggests that the amount of antimicrobials used in food production internationally is at least the same as in humans, and in some places is higher. For example, in the US, more than 70% of antibiotics that are medically important for humans are used in animals. This form of antimicrobial usage is likely to rise as a result of economic growth, increasing wealth and food consumption in the emerging world.

When properly used, antibiotics are essential for treating infections in animals, but excessive and inappropriate use of the drugs may be a problem. It is therefore important that we play our part in working towards the O’Neill recommendation of

“a global target to reduce antibiotic use in food production to an agreed level per kilogram of livestock and fish, along with restrictions on the use of antibiotics important for human health.”

The SNP encourages everyone to play their part in reducing the unnecessary use of antibiotics, raising awareness and pledging to be an antibiotic guardian. I have not yet followed the example of my hon. Friend the Member for Glasgow North (Patrick Grady) and registered, but now that I know it is easy to do, I will do it today.

In November 2015, Scotland’s Health Secretary, Shona Robison, said that the rise of drug-resistant infections is an issue that must be tackled in Scotland and around the world. Marking European antibiotic awareness day, Robison also pledged to be an antibiotic guardian, in a scheme run by a joint UK initiative to encourage everyone to become an antibiotic guardian by making a personal pledge. As part of European antibiotic awareness day, the Scottish Antimicrobial Prescribing Group, alongside UK partners, launched a target of 100,000 people signing up to become antibiotic guardians, including one in 10 prescribers and one in 100 other healthcare professionals.

Inevitably, any solution will have to be multi-factorial and involve a large range of stakeholders including Governments, non-governmental organisations, industry, the pharma, food and agriculture sectors, academia, research, health professionals and the public at large. If we become completely resistant to antibiotics, operations and procedures currently considered routine will become a lot more dangerous. The medical profession in Britain has become a lot better at not prescribing antibiotics unnecessarily. We must maintain that stance, develop it further and encourage others to follow.

My final plea to the Minister is not to allow UK contributions to international efforts to tackle AMR to become diminished. I seriously hope that the issue does not become a casualty of any post-Brexit isolationism.

Draft Nursing and Midwifery (Amendment) Order 2017

Martyn Day Excerpts

Wednesday 22nd February 2017 General Committees

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Paisley. I thank the Minister for his clear and concise explanation of the order. I will not oppose the order and, indeed, I welcome the changes in general because I believe that they strengthen public protection and bring midwifery regulation into line with that for other healthcare professionals.

Alcohol Harm

Martyn Day Excerpts

Thursday 2nd February 2017 Westminster Hall

[Patricia Gibson]

There is indeed a bigger picture. Laws do not necessarily change attitudes, but what they do over time is change a culture. They send out a clear signal. The point was made earlier that when people are out and using a car, they tend not to drink. They are more likely not to drink at all due to the reduction in the drink-driving limit. It has also been a great educator for people who are out drinking and not driving, but who might be driving the following day. They decide, “I had better not drink tonight, because I might still be over the limit tomorrow when I get in my car.” We know that many of the people who have been pulled over, had their blood alcohol level tested and been found to be over the drink-driving limit were simply not aware of it, because it was from the previous evening; they had not considered that they might still be over the limit.

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

On that point, does my hon. Friend agree that the lower drink-driving limit has been particularly effective with younger drivers?

[Patricia Gibson]

Indeed. Our younger drivers are the most likely to be inexperienced. They are therefore not willing to risk it, after all the blood, sweat and tears to pass their test. The limit is helping to reduce the alcohol intake of young people for a whole variety of reasons.

Alcohol is killing too many people in our communities prematurely—I do not think anyone in the Chamber would dispute that. It is splitting up too many families. Its pervasive, insidious influence is the context in which too many of our children grow up. It is costing our NHS billions. It is exacerbating mental health challenges for too many people. It is rendering too many people economically inactive.

Alcoholism is a disease and, as with any disease, we need to find the cure. One silver bullet will not cure the disease. We need minimum unit pricing. We need all our high streets and neighbourhoods to look at how they can support and contribute to good health. There must be a presumption against an over-concentration of outlets selling alcohol, preying on our socially disadvantaged communities. All those things combined can make a difference, because they tackle price, availability and consumption. A serious problem and disease such as alcohol addiction or misuse requires a serious, bold solution. I urge the UK and Welsh Governments to look at the measures and the determination of the SNP Government in Scotland to tackle the issue head-on. It is one of the most serious health challenges of our time.

--- Later in debate ---

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Ms Buck, and to take part in this important debate. I congratulate the Backbench Business Committee on securing it and I praise the hon. Member for Congleton (Fiona Bruce) for leading it. She mentioned that we have as many as three all-party parliamentary groups relating to alcohol. I had not realised that, but it reminded me of a lyric from an old country and western song:

“One drink is one too many and a thousand not enough”,

which highlights the problem that many have—apologies for the corny remarks.

I am grateful for the hon. Lady’s points. Although they relate to the English and Welsh alcohol strategy, they will strike a chord north of the border in Scotland. Many of the points are totally applicable and I agree with much of what she said, particularly with regard to minimum unit pricing and drink-driving limits.

It will come as no surprise to anyone that Scotland has a long-standing and problematic relationship with alcohol. The damage that misuse causes is indeed stark. It causes harm to individuals’ health, employment and relationships, as well as to community wellbeing and public safety. Then we have the financial burden on the economy through costs to the NHS, police and emergency services, and lost productivity to businesses. Many points that illustrate that have been highlighted today by various speakers.

The hon. Member for Congleton advised us that 70% to 80% of accident and emergency admissions at weekends are alcohol-related, and that 80% of police officers have been assaulted by drinkers, which is absolutely shocking. The hon. Member for Luton North (Kelvin Hopkins) gave us a wonderful summary of the lifetime damage to babies and the costs that obviously creates through foetal alcohol spectrum disorders. He also highlighted the drink-driving statistics, which paint a totally frightening scenario.

The hon. Member for Sefton Central (Bill Esterson) included the risks to young women who drink. He highlighted the 40% of the prison population with FASD and the 41% of women who drink during pregnancy. Again, that is truly shocking in this day and age, given the knowledge we now have. My hon. Friend the Member for North Ayrshire and Arran (Patricia Gibson) reminded us that not every cost can be measured, which is entirely true. I am an ex-banker and I always think in terms of numbers and statistics, but it is the human tragedy that is more important. The problem falls disproportionately on the sections of society with the fewest benefits, and the most disadvantaged are at the greatest risk. In fact, the simple horror story is that alcohol is 60% less expensive than it was in the 1980s. Some things have not kept pace.

The right hon. Member for Birmingham, Hodge Hill (Liam Byrne) gave a powerful personal account that dealt with the psychology of the issue. One of the inspirational points that he made was that we can change things for the next generation. That is a message we must all take away from the debate. The hon. Member for St Helens South and Whiston (Marie Rimmer) highlighted the many avoidable conditions related to alcohol—they could so easily be prevented—and the need to improve health professionals’ knowledge. I fully agree on that; there is great consensus in the Chamber today.

You will have noticed, Ms Buck, that I am male, Scottish and a Member of Parliament, which must be three of the worst demographics for alcohol harm, so perhaps I should confess that I finished a bottle of whisky last night, and when it comes to enjoying occasional refreshment I am certainly not teetotal. However, perhaps I should clarify that I opened the bottle in June 2015—I hope that I will be seen as an example of moderation, not excess. Sadly, not everyone’s experience with alcohol is moderate. Excessive consumption has been responsible for many issues in society, including, at worst, the rates of alcohol-related deaths. Scotland’s figures have shown higher death rates for males over the past 20 years than the other UK nations. The 2014 figures put that at 31.2 deaths per 100,000 compared with the English rate of 18.1.

[Kelvin Hopkins]

Another horrifying statistic is that Russia’s population has been in fairly serious decline in recent years, and the major factor in that is alcohol consumption, which is epidemic.

[Martyn Day]

I thank the hon. Gentleman for making that point.

There is sufficient evidence to show a clear link between levels of consumption and of harm. My hon. Friend the Member for North Ayrshire and Arran has already given several examples. It is particularly worrying that retail sales data show that sales in Scotland are higher than in England and Wales—they were 20% higher in 2014—particularly for low-cost spirits. It might surprise Members to hear that since 2008 vodka has outsold blended whisky by about 20% in Scotland. In 2015, 10.8 litres of pure alcohol was sold per adult in Scotland, which is equivalent to 41 bottles of vodka, 116 bottles of wine or 476 pints of beer. When I consider my consumption rates, or those of my friends and family, many of whom take less than I do, the average means that there are people out there consuming a phenomenal amount of drink. On average, alcohol misuse causes about 670 hospital admissions and 22 deaths a week, and it is costing Scotland £3.6 billion each year, or £900 for every adult in the country. How much better that would be spent on other aspects of the NHS.

I served for 13 years on the West Lothian licensing board and in that role learned a lot about the licensed trade and alcohol issues within many of the communities that I now represent in Parliament. One of the more encouraging developments that I saw during those years was the Best Bar None award scheme, which is a great example of partnership working. It has operated in West Lothian since 2008 and has 20 accredited venues, with the Glenmavis Tavern in Bathgate nationally winning overall best bar at the awards in 2015. Best Bar None is administered by the Scottish Business Resilience Centre, whose remit is to create a secure Scotland for business to flourish in. It promotes responsibly managed licensed premises in Scotland, with the aim of partner agencies working together with licensed premises to create safer and more welcoming city and town centre environments. The crux is that it is also about changing Scotland’s relationship with alcohol—something that I believe can be achieved only by working together as a society.

The Scottish alcohol strategy, published in 2009, recognises that a whole-population approach is needed to reduce alcohol harm. Harry Burns, who was the chief medical officer of the Scottish Government at the time, said:

“Every one of us must ask frankly, whether we are part of the problem and whether we are going to be part of the solution.”

I wholeheartedly agree with that comment. The approach is correct, and indeed we have encouraging signs that it is working. Scotland had the steepest fall in alcohol-related deaths between 2004 and 2014. The rate fell from a staggering 47.7 per 100,000 to the current 31.2. Significantly, the fall in death rates over the period was greatest among the lowest income groups, which helped with some of the country’s inequality issues.

A measure that has been particularly effective is the multi-buy discount ban, which has accounted for a 2.6% reduction in consumption, as my hon. Friend the Member for North Ayrshire and Arran has pointed out. In December 2014 the drink-drive limit was reduced from 80 mg to 50 mg, bringing Scotland into line with the majority of European and Commonwealth countries. There is international evidence that lower limits are effective in preventing alcohol-related road accidents.

Controlling availability through licensing has also been a feature of the Scottish strategy. There is a presumption against granting 24-hour licences to on-trade premises, and off-sales are allowed only between 10 am and 10 pm. There are also strict controls for displays and marketing materials, which are limited to single designated areas in supermarkets and shops. I agree with the point made by the right hon. Member for Birmingham, Hodge Hill about sports advertising, and the UK Government should take that on board. We have seen the effectiveness of limiting marketing in supermarkets; cutting it out of people’s bedrooms would have a massive effect. Scottish licensing legislation puts the objective of protecting and improving public health into the mix, and licensing boards may consider that when making decisions. My understanding is that there is no such public health objective in England and Wales. That is something that UK Ministers might want to consider.

Several hon. Members have mentioned the fact that pricing to reduce affordability is a key component of tackling alcohol harm. I believe that taxation is a means of doing that, but it does not deal with the reality that the availability and relative affordability of the cheapest and strongest drinks is at the heart of the problem. Minimum unit pricing is a more effective tool in targeting those cheap, high-strength products that are excessively consumed by heavy drinkers.

As my hon. Friend the Member for North Ayrshire and Arran informed us, evidence from Canada suggests that there is a direct link between changes in minimum price and changes in consumption. It is estimated that a 10% increase in minimum price might be associated with a 32% reduction in wholly alcohol-attributable deaths. That is significant, and it is an approach worth taking. As we heard, using updated modelling from the University of Sheffield, it was estimated that a minimum unit price of 50p would result in 121 fewer deaths and a fall in hospital admissions of about 2,000 per annum in Scotland. Significantly, 51% of off-sales are sold for less than 50p per unit—some for as little as 18p.

The Scottish Government will ensure that a minimum price policy is implemented as soon as possible. The policy had overwhelming support in the Scottish Parliament and it has twice been approved by the Scottish courts. The Court of Session’s Inner House granted the Scotch Whisky Association and its partners permission to appeal to the United Kingdom Supreme Court in December 2016. The appeal will be heard in 2017.

In conclusion, our nations have a long history with alcohol, and somewhere along the way things have got out of hand for many in our society—often those from the most disadvantaged areas. There is much that can be done, and we must all take responsibility. There are many reasons why we need to take action, including the impact on police workloads and the weekend A&E admissions, all fuelled by alcohol. Perhaps the most important reason is premature death—20 years earlier than the average for a heavy drinker—and its impact on families and communities. Tackling that issue alone would greatly help reduce inequality in society.

Breast Cancer Drugs

Martyn Day Excerpts

Thursday 26th January 2017 Commons Chamber

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to take part in today’s important debate and I thank the hon. Member for Mitcham and Morden (Siobhain McDonagh) for securing it. I am grateful to her for her contribution and the cases that she used to illustrate it. She eloquently put a human face to the problem.

The debate about access to Kadcyla and other breast cancer drugs is of immense interest to the public on both sides of the border. Breast cancer is the most common cancer, which was shown by the many individual constituency cases cited by hon. Members of all parties today.

As has been said, Kadcyla is an effective life-extending treatment, which gives some women with incurable secondary breast cancer up to nine months longer than the alternatives, and has fewer side effects and a cost of around £90,000 per patient. In Scotland, Kadcyla has never been available on the NHS.

The Scottish Medicines Consortium, which makes its decisions independently of Ministers and Parliament, decided in October 2014 not to approve Kadcyla for routine use in Scotland. After considering all the available evidence, it felt that the health benefits were not sufficient in relation to the treatment’s cost. Patients have, therefore, been able to access the drug only in exceptional circumstances through individual patient treatment requests—IPTRs. It is estimated that more than 100 women in Scotland could benefit from Kadcyla annually.

A Kadcyla discount has been offered by the pharmaceutical company Roche and it recently wrote to Scottish Government officials about a patient access scheme. Roche has now resubmitted its application to the SMC, so that it can be considered for routine use in the NHS across Scotland. That is currently being assessed—

[Kirsten Oswald (East Renfrewshire) (SNP)]

Will my hon. Friend join me in hoping for a positive outcome in relation to Kadcyla for our constituents who are affected by secondary breast cancer, to whom this debate means so much?

[Martyn Day]

I thank my hon. Friend for that point and I join her in hoping for a positive outcome. We expect a decision to be made in March with an announcement on 10 April.

The SNP Scottish Government have substantially increased access to new medicines, particularly for cancer, with plenty of reforms and investment in recent years. The Scottish Government will build on recent reforms and make further improvements, in collaboration with patients and NHS staff, by accepting the recommendations of Dr Brian Montgomery’s review. Shona Robison, Cabinet Secretary for Health, Wellbeing and Sport, has announced that the Scottish Government will take forward all 28 of the review’s recommendations. Dr Montgomery was tasked to examine how changes made to the Scottish Medicines Consortium process in 2014 affected access to medicines for rare and end-of-life conditions. His recommendations set out how the process for appraising medicines could be made more open, transparent and robust.

Among the Montgomery recommendations—the House need not worry; I will not list all 28 of them—is to give the SMC an additional decision option of an interim recommendation for use subject to ongoing evaluation, which will allow collection of more data on a medicine’s real-world effectiveness. Another is the introduction of managed access agreements, under which medicine would be provided at a discounted price for a period of time, again to collect real-world data on its effectiveness. Another recommendation is to make greater use of national procurement in NHS National Services Scotland— NSS—to lead negotiations on cost with the pharma industry to get the fairest price possible. Better capturing of patient outcome data in the real world is vital to enable us to determine whether medicines are bringing the expected level of benefits to patients.

Beyond the recommendations of the review, Ms Robison has also announced improvements to the processes for non-routine access to medicines on an individual case-by-case basis. The peer approved clinical system or PACS, piloted in Glasgow in 2015 to handle applications for ultra-orphan medicines, has been successfully rolled out across Scotland. A second tier of PACS will now be introduced to replace and build upon the existing individual patient treatment request system. A new national appeals process will be introduced through the new tier of PACS, and that will include consideration of equity of access with other parts of the UK as a material part of its decision-making process.

In November Gregor McNie, Cancer Research UK’s senior public affairs manager in Scotland, said:

“SMC does a difficult but necessary job to assess whether new cancer drugs should be made available on the NHS. Following the SMC reforms, we’ve been pleased to see a significant increase in the availability of cancer drugs in Scotland and we support the review’s recommendations to make further progress.”

Breast Cancer NOW has said that

“Scottish Government reforms give fresh hope for a medicines system that will put patients and their families first.”

It also said:

“Scotland’s approach to reform is a useful example to the rest of the UK about ways in which the system can be improved.”

[Kirsten Oswald]

I thank my hon. Friend for his words about the flexibility of approach and the need to continue to keep pushing forward to ensure that we allow access to as many of these drugs as possible for the people who are in such need. Will he join me in commending the Scottish Government and the SMC for that approach, and in hoping that it will continue and make a difference?

[Martyn Day]

I do indeed join my hon. Friend in those comments.

A new and ambitious Scottish cancer strategy, launched in 2016, aims to stop anyone dying from breast cancer by 2050, and breast cancer is of course a priority in the Scottish Government’s Detect Cancer Early initiative. We need to do many things to move forward in that direction.

No debate seems complete these days without reference to Brexit, and this issue is no exception. The Health Secretary has stated that the UK will not be in the European Medicines Agency. If so, there could be implications for the way in which medicines are regulated, and marketing authorisations will be required from the Medicines and Healthcare Products Regulatory Agency for the UK. I am in no doubt that the implications will be less efficiency and possibly longer processes for obtaining authorisations, resulting—I fear—in innovative drugs taking longer to reach patients. Some industry leaders predict delays in the region of 150 days, based on the examples of Switzerland and Canada.

According to a piece that appeared last year in the Financial Times, when Sir Michael Rawlins, chair of the MHRA, was asked whether it would be able to take on all the extra work registering new drugs and medical devices currently carried out by the EMA, he said, “Certainly not”. It seems that considerable investment and recruitment will be required to re-establish it as a stand-alone national regulator. I am keen to hear from the Minister how delayed drug access for UK patients will be avoided.

[Mr Baker]

I have listened carefully to the hon. Gentleman, and of course he raises a perfectly reasonable concern, but the campaign director of Vote Leave had, as one of his particular bugbears, the costs associated with the clinical trials directive and its prejudicial effect on innovation in medicines. I hope that the Government can find a better way through than the previous system and that, in leaving the EU, we will not only solve the problem of the EMA but have a better regulatory system afterwards.

[Martyn Day]

I thank the hon. Gentleman for his intervention, and I look forward to hearing the outcome.

In conclusion, with regards to Kadcyla, I hope the company’s resubmission to the Scottish Medicines Consortium is at a fair price to allow it to be considered for approval for use in the NHS in Scotland. It would give people across Scotland the opportunity to benefit from more treatment options and could give them precious extra time with their families and loved ones. The Scottish Government, the SMC and the NHS have worked hard to reform access to new medicines, but we now need pharmaceutical companies to do their bit by bringing forward much fairer prices for new medicines, so that access is as wide as possible for the people of Scotland. Cost-effectiveness is a key marker in ensuring that drugs are routinely available in the NHS, and I take the opportunity to emphasise that point to the pharmaceutical industry in general.

Pharmacies and Integrated Healthcare: England

Martyn Day Excerpts

Wednesday 11th January 2017 Westminster Hall

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Bailey. I thank the hon. Member for St Albans (Mrs Main) for securing the debate. I found much that I agreed with in her contribution, and I echo her call for a pharmacy-first culture.

It is a pleasure to take part in the debate, although I must admit to feeling a bit of an observer, as the debate is about pharmacies and integrated healthcare in England. We have heard from a number of speakers about the different practices that affect their parts of England; I hope that my observations from Scotland may also be of interest to Members. I have commented in a few debates that there are often lessons that we can learn from one another and good practices that can be shared. This issue provides an excellent case in point.

Community pharmacies were developed in Scotland 10 years ago and are there for minor ailments, chronic medication and public health services. The Scottish Pharmacy Board has stated that more than one in 10 GP consultations and more than 1 in 20 accident and emergency attendances could be managed by community pharmacists using the minor ailments service; that represents huge potential for the future. Although we await the full evaluation of the minor ailment service later in the year, estimates suggest that as much as £110 million could be saved. Further expansion of the MAS is planned.

[Mrs Main]

I do not often agree with what is said by Scottish National party Members, but I looked at the Scottish service, and one of the key things, which I think other hon. Members have raised, is the software functionality that in Scottish pharmacies are obliged to have. That is something we do not have in England—I do not know about Wales—and I wonder if the hon. Gentleman could let the Minister know about that. The ability to input into scripts and the remuneration that comes through that software functionality in Scotland is something that I found very interesting.

[Martyn Day]

The hon. Lady has emphasised the point very well. There is a considerable degree of integration in the Scottish service. It has been around for 10 years and is a fairly mature service.

The Scottish Government work side by side with the medical professions in Scotland and recognise just how important community pharmacies are. They are interested in exploring new ways for pharmacies to offer primary care services to help deliver care across our communities. There are some 1,200 pharmacies throughout Scotland, providing a range of services on behalf of the NHS. As well as dispensing prescriptions, they offer four NHS pharmaceutical care services, which have been gradually introduced since 2006. These are the minor ailment service, which I have mentioned, the public health service, the acute medication service and the chronic medication service. Those new services involve pharmacists more in the community in the provision of direct, patient-centred care, with every community pharmacy in Scotland having patients registered for the minor ailment service by March 2015.

Patients register with a pharmacist in the same way as they register with a GP. The aim is for all people to be registered with their local pharmacist, wherever they consider that to be, by 2020, and for all our pharmacists to be independent prescribers by 2023. Approximately 18% of the population of Scotland are registered for the minor ailment service—a total of 913,483 people. More than 2.1 million items have been dispensed under the service, which is some 2.2% of all items dispensed by community pharmacies in Scotland. Almost 500,000 patients are registered under the chronic medication service.

It is important that retail and dispensing pharmacies in England be encouraged to go in a similar direction to Scotland, because that would bring great benefit for the NHS. In Scotland, we recognise just how important community pharmacies are. We are committed to supporting and developing local GP and primary care services and have recently announced a three-year, £85 million primary care fund to help develop new ways of delivering healthcare in the community, which will involve pharmacists delivering aspects of patient care.

Looking at pharmaceutical services across the two nations, one of the significant differences appears to be how the services have developed, partly as a result of the funding structures. In Scotland, pharmacists do not get a large payment merely for existing, such as the £25,000 in England. Instead, they receive a modest establishment payment of £1,730. However, payments are based on needs that reflect a population’s age, vulnerability and deprivation. That model will see funding in Scotland rise by approximately 1.2%, while it looks likely to decrease by around 4% in England.

Another difference is the almost random way in which pharmacies in England appear to have opened, as a result of anyone being allowed to do so if they open 100 hours a week. A concern must be that there could equally be unplanned random closures, if they are allowed to shut down simply because they can no longer afford to survive. In Scotland we have a system of controlled entry for those who want to open a community pharmacy. Need must be demonstrated and applications approved by health boards. Consequently, we find community pharmacies in areas of deprivation, serving those most in need. Often health boards refuse applications because demand is already met.

Pharmacists are located throughout communities in Scotland, from rural areas to deprived inner-city areas, providing pharmaceutical care on behalf of NHS Scotland. The Scottish Government policy remains that, wherever possible, people across Scotland should have local access to NHS pharmaceutical care. There is much in the Scottish model that is working well and may provide a useful example for study on this side of the border. It is imperative that this successful model of community pharmacies across Scotland should not be put under threat by UK Government health budget cuts, which would impact on the Scottish Barnett formula.

Oral Answers to Questions

Martyn Day Excerpts

Tuesday 20th December 2016 Commons Chamber

[Mr Hunt]

The benefit of Brexit will be that we can take precisely such decisions in this Parliament, because we will get back control of our borders. I am grateful to my hon. Friend for mentioning the very important work done by people from outside the EU in the NHS. Because I happened to meet the Philippines ambassador last week, I want to pay credit particularly to the Filipino workers in the NHS and the social care system, who do a fantastic job.

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

May I start by extending my party’s sympathies to the victims of the Berlin attack?

Much of what we have heard today is about keeping those who are already here, but BMA Scotland has said that insecurity is stopping EU nationals from taking up posts that really need to be filled. This is an urgent problem, so does the Secretary of State agree that it is time to create some certainty for EU nationals and to avoid a self-made workforce crisis?

[Mr Hunt]

I absolutely agree with the hon. Gentleman, which is why it is extremely frustrating that the current signals from the EU are that it is unwilling to bring forward negotiations about the status of EU nationals here, and indeed that of British nationals in the EU. No one from either side of the Brexit debate has ever said that there will be no immigration post-Brexit; they have simply said that we will control that immigration ourselves through this House and through decisions made by the British people at general elections.

--- Later in debate ---

[David Mowat]

My hon. Friend raises an important point, and he is right to say that we must move the community pharmacy network away from just dispensing and into services, which will include minor ailments and repeat prescriptions. I will be encouraging CCGs to do that.

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

Community pharmacies, which were developed in Scotland 10 years ago, are there for minor ailment, chronic medication and public health services. Although the Minister has expressed admiration for the Scottish system, does he not recognise the need to work with the pharmacy profession to develop the full potential within community services?

[David Mowat]

I have mentioned on previous occasions that Scotland has, in some respects, gone further and faster than we have in England so far on community pharmacies. The £300 million that we have set aside in the integration fund for the rest of this Parliament is going to be used to do just the things that the hon. Gentleman has mentioned, in terms of minor ailments and repeat prescriptions. We are determined to make that happen.

Child Cancer

Martyn Day Excerpts

Monday 28th November 2016 Westminster Hall

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Davies. I thank the hon. Member for Bath (Ben Howlett) for opening this interesting and emotive debate, which was scheduled by the Petitions Committee. I am grateful to him for clearly explaining the issue and highlighting that unfortunately, the rarer the cancer, the greater the resource challenges it faces, and that development of paediatric drugs lags behind the development of drugs for adults.

It is a pleasure to follow such informative and powerful contributions by the hon. Gentleman and other participants from both sides of the House. I am particularly grateful for a couple of the points that have been made. I thank the hon. Member for Birmingham, Selly Oak (Steve McCabe) for putting this into the European context. Although we deal with small numbers in our country, childhood cancer is a much larger problem across that wider area. I am grateful to the hon. Member for Bristol West (Thangam Debbonaire) for illustrating the scale and challenge of the financial difficulties that people face. Unfortunately, the burden of relieving those all too often falls to charitable organisations rather than the state.

I offer my condolences to Mr Barnard and his wife on the sad loss of their daughter Poppy-Mai. I thank them for raising awareness of this important issue with the petition that brings us here. It must be very traumatic for them to relive each moment of that tragedy as they hear this debate. Unfortunately, theirs is not a unique case—such cases occur all too often across our countries. We must therefore recognise our shared responsibility to tackle child cancer.

The Scottish National party Government are working hard to improve cancer outcomes for children as well as the entire population of Scotland. As my hon. Friend the Member for Inverclyde (Ronnie Cowan) illustrated, cancer is relatively rare in children. Childhood cancer accounts for less than 1% of all cancers in Scotland, with approximately 150 new cases every year. There are approximately another 180 new cases in young adults aged between 16 and 25. An updated cancer plan for children in Scotland was launched earlier this year, which will complement the ongoing “Getting it right for every child” programme to ensure that Scotland’s children have access to the best possible services.

In recent years, the system in Scotland for supporting children suffering from cancer and their families has been reorganised. All cancer treatment centres now work together as one single managed service network for children and young people with cancer—the MSNCYPC, which may be the longest acronym I have ever used. As a result, young patients have access to appropriate specialist services that are as local as possible and both safe and sustainable. The network ensures that the care pathway is as equitable as possible, regardless of where in Scotland people live.

The SNP Government are focused on improving health outcomes for children, which is at the forefront of the SNP’s health priorities. We are serious about improving cancer care and treatment, which is a key reason why the Scottish Government will invest £100 million over the next five years through their new cancer strategy. As well as providing funding to health boards, we invest in a range of areas to support healthier lives for children and families, such as children’s palliative care, the cost of which is rising—delivering lifeline care and support to seriously ill children cost nearly 10% more in 2015-16 than the previous year.

That support for children’s palliative care charity funding is in stark contrast with what is happening in England. Barbara Gelb OBE, the chief executive of Together for Short Lives, says:

“We believe that ministers should follow the example of the Scottish Government, which has recently committed £30 million funding to Children’s Hospice Association Scotland (CHAS) over the next five years. We’re calling on the UK government to re-examine funding arrangements as a matter of urgency and carry out a national inquiry into the state of children’s palliative care funding in England.”

I hope the Minister will address that comment.

I commend the work of the many charitable organisations that are active in this field. For example, as others have highlighted, CLIC Sargent does tremendous work to support young people and their families as they come to terms with cancer diagnoses and journey through their treatment. In Scotland, leukaemia is the most common cancer in children—leukaemia, brain tumours and lymphomas account for more than two thirds of child cancers. The Brain Tumour Charity conducts various research projects and focuses on understanding the causes of childhood brain tumours. I take this opportunity to commend its investment of more than £18 million in its many research projects. Its commitment and work means that a brain tumour diagnosis no longer means a death sentence. Although that is welcome, it is sadly not the case for everyone, as has been evidenced.

Whole communities in my constituency were devastated by the tragic loss of five-year-old Tilly from Linlithgow, whose case echoes the points made by the hon. Member for North Thanet (Sir Roger Gale). Tilly lost her brave fight against her brain tumour just a few weeks ago, leaving her family heartbroken and touching the hearts of entire communities. A family member spoke to the Journal and Gazette, the local newspaper, about the support the family had received from the local community, which included fundraising to send Tilly to the United States, which is all too often the case. They said:

“We really could not begin to thank people enough for the support they have shown Tilly and the family during all of this. It has been overwhelming and we will be forever grateful. To raise such a massive amount of money shows how much people care and how communities come together when people need them. The money that is left over will be given to raise awareness of the type of brain tumour Tilly had and to help families who find themselves in a similar situation so they can get treatment for their loved ones.”

That action shows the strength of community feeling, which is echoed by the sheer number of people who signed the e-petition. It also shows how a child cancer diagnosis, with all its consequent personal and emotional devastation, affects more than just the child and their immediate family; it affects entire communities.

I thank all right hon. and hon. Members who have taken part in today’s consensual and informed debate, which I hope and trust has helped to raise awareness among the wider public.

Contaminated Blood and Blood Products

Martyn Day Excerpts

Thursday 24th November 2016 Commons Chamber

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

I am grateful for the opportunity to participate in this important debate. Let me start by thanking the Backbench Business Committee for scheduling today’s debate and the hon. Members responsible for tabling the motion. I especially thank the hon. Member for Kingston upon Hull North (Diana Johnson) for leading the debate and for her work on the all-party group. She summarised the situation clearly and forcefully, and I am particularly grateful to her for outlining the risk of private operators administering the scheme. That concern has been raised by several hon. Members on both sides of the House.

Another recurring theme in the debate has been justice and the question of how much was known about the contamination at the time—that question has been asked, so it deserves an answer. Without any doubt, this subject is one of the most terrible chapters in the history of our NHS. It is truly horrific and has had an impact upon tens of thousands of people and their families. In some cases, their experience has been ongoing for more than 40 years. Many people have already died or been left suffering long-term disability and hardship as a result of infections. Relatives have had to sacrifice their careers to provide care and support. In some cases, partners and loved ones have become infected. Indeed, I received an email from a surviving victim of contaminated blood whose partner subsequently became infected and died. Patients, families and carers have had to deal with such difficulties with immense and enduring courage, and I wonder how many have found the strength—physically, emotionally and, indeed, financially.

That brings me on to the proposed changes to the current ex-gratia payments. As my hon. Friend the Member for Glasgow South West (Chris Stephens) illustrated, the proposed new scheme in Scotland will lead to an increase in annual payments for those with HIV and advanced hepatitis C from the current £15,000 to £27,000 per year. That amount is set at a level that reflects average earnings. That point is important as this is not about poverty; it is about a decent standard of living. The payments for those co-infected with HIV and hepatitis C will increase from £30,000 to £37,000 per year, and that amount reflects their additional health needs. When a recipient dies, their partner will continue to receive 75% of the previous annual entitlement. That, too, is important, given how many have had to give up their own careers to look after loved ones. Those infected with chronic hepatitis C will receive a £50,000 lump sum payment, which gives an additional £30,000 to those who have already received the lower payment.

The Scottish discretionary support scheme is set to see its funding more than treble. It will have an independent appeals mechanism, and there is a general guarantee that no individual will be worse off than at present. To simplify the situation so that those affected will no longer have to apply to more than one body for funding, the Scottish Government aim to deliver this scheme through a single body. Full governance arrangements are still to be detailed for this new organisation, but it is likely to be administered by National Services Scotland. It is also worth remembering that the Scottish Government are committed to reviewing the distinction between stage 1 and stage 2 hepatitis C.

There are clear differences between what is proposed for Scotland and the system elsewhere, with many viewing the Scottish scheme as comparatively more generous. That said, it is not without its detractors, particularly those with lesser health impacts who will not receive the more generous payments proposed. It is therefore important that we continue to listen to the views of beneficiaries as we design and implement the new Scottish scheme, so evidence-based reviews of the payment criteria will be carried out. In Scotland, we want to improve the scheme for everyone, but we must give greater priority to those in most severe need.

We have already heard of many tragic individual cases from throughout the UK, but I will spare hon. Members further heart-wrenching examples of cases of which I have received details. Instead I shall focus on some of the questions that have been raised with me by victims and their support groups; I hope that the Minister can assist with some answers. The first relates to the compensation schemes and the fact that there are currently five different organisations funded by UK Health Departments, including the three devolved health authorities. That means that using the existing schemes to make the new Scottish payments requires the agreement of all four nations of the UK. There must also be agreement from the boards of the UK-wide schemes. Currently, only Scotland is signed up. There will be a Scotland-wide payment system, but the timing will depend on the UK Government, Her Majesty’s Revenue and Customs and the Department of Health. I therefore ask that the UK Government do not stand in the way of the Scottish payments.

That brings me to my second ask, which echoes one made by my hon. Friend the Member for Glasgow South West: Westminster must pass tax orders so that none of the payments are liable for tax—that must happen whichever mechanism is used to make the new payments. Thirdly, what more can be done about cross-border infections? The current schemes are based on where the individual was infected, rather than their residency, which means that the English schemes apply to some Scottish residents and the new Scottish scheme will apply to others resident in England. That issue compounds the next point I wish to make: hepatitis C sufferers are acutely aware of the cold, and during the winter their heating bills go through the roof. If they cannot afford to heat their home, they are at greater risk of death through complications due to illness such as flu or colds. There is therefore a clear need for the winter fuel allowance, so perhaps Ministers can advise us on their rationale for wanting to remove it.

It has been suggested to me by the Scottish Infected Blood Forum that the liver damage test is outdated and we should look at the impact the condition has on the whole body. The problem may be amplified among those who have made positive lifestyle choices such as abstaining from alcohol, as their liver may appear to be less affected. Finally, people want some certainty about future funding, so what support will continue after the current spending review period?

I always try to be positive and to look forward to the future, but given the age of many victims and their medical complications, people are dying every week—there are fewer of them every year. Thousands have already died and for them this is all too little, too late. It is difficult to be positive in the circumstances, but I am grateful to have had the opportunity to take part in today’s excellent and generally consensual debate.