Sickle Cell Treatment

Martyn Day Excerpts

Wednesday 8th December 2021 Westminster Hall

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

I am grateful to the right hon. Member for Wolverhampton South East (Mr McFadden) for securing this important debate, for the manner in which he opened it and for the work of the APPG that he chairs. He said we should all be concerned by the lack of understanding of sickle cell disease. I think we all agree with that fact. This has been a consensual debate and a valuable reminder that this issue is about the pain and loss that impacts on many families. That pain was well demonstrated by the personal testimony of the hon. Member for Vauxhall (Florence Eshalomi), who spoke so movingly of her mother’s experience. I am in full agreement that the increasing diversity of our communities amplifies the need for greater awareness of the disease.

The hon. Member for Lewisham East (Janet Daby) used the term “ignorance and neglect”, which summed things up pretty well, given that deaths from sickle cell disease are pretty much avoidable. She also highlighted the cost of sickle cell medicines—a point I will return to. The hon. Member for Streatham (Bell Ribeiro-Addy) also gave a personal account of her experience of the disease and spoke strongly about the institutional racism that has been experienced. This matter should concern all of us from all parts of the country. I commend her for her action on blood donation—something, I must confess, that I have always been too frightened to do myself. We all need to consider the importance of giving blood.

Like the hon. Member for Strangford (Jim Shannon), I was impressed by the APPG’s report, “No One’s Listening”, published in November 2021 with its stakeholder group, the Sickle Cell Society. The report found that sickle cell patients too often receive substandard care; that community care for sickle cell patients is generally inadequate or non-existent, which leads to unnecessary admissions to hospital; and that awareness of sickle cell disease is low, as we have heard repeatedly.

The right hon. Member for Tunbridge Wells (Greg Clark) highlighted the differential impact of geographic factors, even within the same hospitals. That is an important point that I had not properly considered, although I had thought about the race element affecting different parts of the country differently. The hon. Member for Edmonton (Kate Osamor) highlighted the fear of sufferers even of attending hospitals, particularly in areas with a high population susceptible to sickle cell disease. Again, that is a point I had not thought of, so I am grateful for that commentary.

Sickle cell disease overwhelmingly affects people from particular heritage backgrounds, and the report highlighted the role of racism in diagnosing and treating sickle cell patients. People from African, Asian, Caribbean, eastern Mediterranean and middle eastern backgrounds are more likely to have sickle cell disease or to carry the gene, and it is therefore impossible to debate this subject without considering race and the failings to adequately provide equality of treatment within the existing system. It is particularly concerning that many sufferers believe that racist attitudes affect healthcare providers’ perceptions of the disease. A number of Members highlighted the systematic racism that appears to exist.

Sickle cell disease is a genetic blood disease. There are treatments to manage it, but it is a lifelong condition. These disorders are inherited, with the only cure being transplants. Approximately 5% of the world’s population carries trait genes for inherited blood disorders, and around 15,000 sufferers in the UK have sickle cell disease, which affects how the body produces red blood cells. Normal red blood cells around the red blood cells affected by sickle cell disease harden and become sickle-shaped, like a crescent moon. This causes the red blood cells to die too quickly and block blood vessels, leading to symptoms that are often painful, as we heard in a number of testimonies.

The Scottish Government are committed to improving the availability of treatment services in order for patients with sickle cell disease to receive the care they need. The Scottish Government’s NHS recovery plan for 2021-26 sets out the plan for healthcare over the next five years, including investment of more than £400 million to create a network of 10 national treatment centres across Scotland, increasing capacity for diagnostic care. The plan also sets out the Scottish Government’s £155 million investment to provide general practices and their patients with support from a range of healthcare professionals in the community. The plan includes the recruitment of further pharmacists to help with patients’ repeat prescriptions and medicine reviews and of community nurses to assist with the diagnostic tests and chronic disease management.

It is vital that we design and develop services that meet the needs of everyone, with a focus on those experiencing health inequalities, and we have heard much of those inequalities today. The UK Government should follow the lead of the Scottish Government in the provision of free prescriptions to those who suffer from sickle cell disease and beyond. Sickle cell disease usually requires lifelong treatment, and a medicine called hydroxycarbamide—I probably spell it worse than I pronounce it—may be prescribed by a patient’s doctor to manage episodes of pain. Patients are usually told to take it as a capsule once a day.

In Scotland, we abolished prescription charges in 2011, but in England the current charge is £9.35 per item. There is a live petition—e-petition 588355—to encourage the UK Government to add sickle cell to the prescription charge exemption list. They responded on 6 August that they have

“no plans to make changes to the list of medical conditions exempting patients from prescription charges”.

That petition has a few days left for people to sign it. I encourage the Minister to reconsider the position on prescription charges and to support the recommendations detailed in the excellent all-party parliamentary group report.

Covid-19 Update

Martyn Day Excerpts

Monday 6th December 2021 Commons Chamber

[Sajid Javid]

Let us see what next week brings.

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

Several of my constituents have met difficulties in booking hotel quarantine for their return from South Africa due to problems with Corporate Travel Management being unable to verify certain card payments or with getting bookings, despite the website showing availability. As a result, they have missed flights and had to book others in their stead, which have had to be paid for. Will the Minister therefore commit to reimbursing such constituents for the failures of the system?

[Sajid Javid]

I am not aware of the details of the individual cases that the hon. Gentleman mentions, but a variety of credit cards and payment systems can be used. If he believes there has been a failure of the system, I would be happy to take a closer look at that.

Alcohol Harm

Martyn Day Excerpts

Thursday 25th November 2021 Commons Chamber

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

I am grateful to the hon. Members for Liverpool, Walton (Dan Carden) and for St Ives (Derek Thomas) for securing this debate through the Backbench Business Committee. I would like to take this opportunity to praise the opening speech by the hon. Member for St Ives, who I think covered the points very well and summed up the position. I find myself in agreement with many of the points that have been made, and I am grateful to hon. Members for their personal testimonies, which have added very strongly to what we are considering today.

In Scotland, on average, alcohol causes about 688 hospital admissions and 23 deaths per week. That is a lot of misery for a lot of families, and it comes at a vast cost and disruption to the health service—a similar problem to what has been seen in England. Fighting alcohol abuse must therefore be a priority for us all, because all our families and communities must get the support they need. Alcohol is everywhere in our society, and in many ways it is hardwired into our cultural DNA. It features in countless songs, poems, stories and humour—from the works of our national bards, Burns and MacDiarmid, through to popular culture.

I remember hearing the late Hamish Imlach in concert, and he had quite a few songs about booze and drink in his repertoire, but he also used to crack jokes. He said that he had an allergy to leather because he realised that every time he fell asleep with his shoes on, he woke up with a blinding headache. I tell that anecdote not to be flippant, but in an attempt to illustrate how ingrained the problem with our culture actually is.

It will therefore 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 the wider community and public safety. Hearing figures that suggest one in five people have been harmed by other people’s drinking in the last year alone is frightening. Then we have the financial burden on the economy through costs to the NHS, police and emergency services, and in lost productivity to businesses.

In 2020, adults in Scotland drank an average of 9.4 litres of alcohol per head, which is 18 units per adult per week, or almost 30% more than the low risk guidelines. That is an improvement from 2015, when the average was 10.8 litres. It is moving in the right direction, but not fast enough, and of course an average hides a wide variation in consumption rates between different individuals. Notwithstanding this trend of reduced consumption, the sad reality is that the pandemic has driven up alcohol-related deaths. Evidence from various surveys shows that those who were drinking heavily before the pandemic were more likely to increase their drinking during lockdown, thereby increasing their risk of harm.

Reducing harm from alcohol is an issue devolved to the Scottish Parliament. As we have heard, Scotland is leading the world on alcohol pricing, being the first country to implement a minimum price of 50p per unit, which aims to reduce the harms, save lives, reduce hospital admissions and, ultimately, have positive impacts across the whole health system and for our wider society. The early indications are very encouraging. Before minimum unit pricing was introduced in May 2018, the weekly lower-risk drinking guideline amount of 14 units could be bought for £2.52, which is as little as 18p per unit.

The ability of the Scottish Government to tackle health issues such as alcohol harm is now, I fear, at risk from the UK Government’s plan to grab devolved powers back under the new internal market legislation. I hope that the Minister can give us a guarantee that under no circumstances will they use the United Kingdom Internal Market Act 2020 to undermine the Scottish Government’s ability to set minimum unit pricing, because it really is making a difference.

We must recognise that tackling alcohol harms does not simply mean addressing alcohol use. Mental health, trauma, isolation, housing and employment are just a few of the issues that can either lead to or contribute to problematic substance abuse. The Scottish Government’s alcohol framework sets out our priorities for preventing alcohol-related harm, and includes consulting on potential restrictions on alcohol advertising and improving health information on product labels, although some aspects, such as TV advertising, are currently reserved to the UK Government.

The framework contains some 20 actions building on existing measures to change Scotland’s relationship with alcohol, and there is a strong focus on reducing health inequalities and doing more to protect children and young people from alcohol-related harm, including through education. Key actions include consulting on options for mandatory restrictions on alcohol marketing in Scotland, and pressing the UK Government for a 9 pm watershed on alcohol TV adverts—as they have consulted on for high fat, sugar and salt in foods—and under-18 films at cinemas, or else they could perhaps devolve the broadcast advertising powers and we can do that ourselves. They also include giving consumers useful health information on product labels and continuing our “Count 14” campaign work to raise awareness of the UK chief medical officer’s lower-risk drinking guideline of 14 units per week; I expect many people still remember the previous higher limits. I could say much more about the work done in Scotland but it is important to recognise that, whatever we are doing in any part of the UK, more can still be done to make sure people get into appropriate treatment quicker in order to reduce harms and help with treatment and recovery.

As I said earlier, while alcohol harm is a devolved matter, several of the levers that can influence the issue remain here at Westminster, and I therefore wholeheartedly support the call in the motion for the Government to commission an independent review of alcohol harm.

Oral Answers to Questions

Martyn Day Excerpts

Tuesday 23rd November 2021 Commons Chamber

[Sajid Javid]

I am very happy to do so. My hon. Friend will know that the system that we set out back in September for social care will mean that no one loses out. In fact, when it comes to receiving social care in the future, the vast, vast majority of people across the country will be better off, including his constituents.

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

While the Scottish Government are taking action to establish a national care service in Scotland, the UK Government’s plans allocate the bulk of the money raised over the first three years of the national insurance rise to the NHS backlog. Does the Secretary of State agree that A&E functioning is greatly impacted by the lack of beds due to delayed discharges to social care? Will his Department provide urgent funding for the critical support for social care?

[Sajid Javid]

The Government have provided urgent funding, especially because of the impact of the pandemic. We have put more than £34 billion extra into health and social care, with the relevant Barnett consequentials, from which Scotland will of course have benefited. The issue of delayed discharges is an important one to continue working on and addressing, which is exactly why NHS England has a delayed discharge fund of almost £500 million for this winter.

--- Later in debate ---

[Maggie Throup]

In late September, the Leicestershire Partnership NHS Trust school age immunisation service devised an updated schedule for covid-19 and flu vaccinations comprising the remaining schools to be visited. This was to address some operational challenges, reduce the need to postpone sessions at short notice and offer the best experience to the young people receiving vaccinations. All affected schools were notified as soon as possible. As my hon. Friend said, the service will be attending Humphrey Perkins on 30 November, when eligible students with consent will be offered both the flu and the covid-19 vaccines. West Leicestershire clinical commissioning group has confirmed to me that this date will not be moved.

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

Wales has now joined Scotland in having vaccinated more than half of all 12 to 15-year-olds, Scotland’s figure being 57.7% in comparison with England’s 36.3% of eligible pupils. Given that 10 to 19-year-olds have maintained the highest rate of infections in recent months, what steps are the UK Government going to take to follow Scotland’s lead and improve vaccination further in this age group?

Covid-19 Update

Martyn Day Excerpts

Monday 15th November 2021 Commons Chamber

[Mr Speaker]

I call the SNP spokesperson.

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

I thank the Secretary of State for his statement and for advance sight of it. He said much today that I can agree with.

Vaccines certainly remain key to our coming out of the pandemic. Research from Scotland shows that vaccines are 90% effective in preventing delta variant deaths and that boosters are 93% effective in reducing the risk of infection, so I am delighted that the Scottish Government will also be following the advice of the Joint Committee on Vaccination and Immunisation to offer booster jabs to the over-40s and second doses to 16 and 17-year-olds.

Excellent though the efficacy of boosters is, however, we must remember that there are many who remain unvaccinated, both at home and abroad. We run the risk of allowing this to become a pandemic of the unvaccinated. What measures are Ministers taking to maximise the uptake of second and first doses for those who have not yet had theirs? What more can be done to further share vaccines globally?

Finally, in the light of the compulsion to have NHS staff in England double-vaccinated, I am concerned that mandating vaccination may increase distrust and harden views, potentially turning those who are vaccine hesitant into vaccine refuseniks. What assessment has the Secretary of State made of that issue? What does he plan to do to overcome it?

[Sajid Javid]

First, may I say to the hon. Gentleman that one of the biggest successes of our national vaccination programme is the UK-wide approach, which has really helped to build confidence? The way that Scotland, England and other parts of the UK have moved together to accept advice is really important. I hope it stays that way.

The hon. Gentleman rightly asked about the unvaccinated and what is being done. I know that Scotland will have an approach as well, but certainly in England it has been very much about making sure that access is as easy as possible, with multiple sources, from vaccination centres to grab-a-jab offers and walk-in centres. It is also about communications to remind people not only of the vaccine’s importance, but of its safety and effectiveness.

I think that in his question about mandating, the hon. Gentleman was referring to the requirement in England for NHS and social care workers to be vaccinated. That whole issue was looked into very carefully. There was a consultation, which received more than 30,000 responses, and I have explained in detail how the Government reached the decision. I think it is vital for patient safety, and I hope that Scotland is able to take a similar approach and protect its patients in hospitals and care homes in the same way as England has.

GP Appointment Availability

Martyn Day Excerpts

Tuesday 26th October 2021 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Robertson, and I am grateful to the hon. Member for Beaconsfield (Joy Morrissey) for securing this debate. She gave a good summary of the issue and I am grateful for her personal testimony. I think all our communities have experienced different levels of satisfaction or otherwise with GP services.

Let me start by paying tribute to the work done by GPs and primary care staff, who, along with their colleagues throughout the NHS, have performed admirably and heroically throughout the pandemic. It would be completely wrong for anyone to claim otherwise. Incidents of harassment of GPs and medical staff—such as the Watford incident, where staff were locked into a consulting room until they agreed to carry out a face-to-face consultation, and an attack in Manchester that left a GP with a fractured skull and other staff with deep lacerations—are unacceptable and should be condemned. I trust that the Minister and every MP will join me in that condemnation.

I cannot help but fear, however, that the UK Government’s harmful rhetoric, including their threat to shame GPs for not returning to face-to-face appointments, may have played a part in such shameful behaviour. The Government must support GPs and not threaten and shame them. While the pandemic remains, it is safer for medical staff and patients to continue hybrid screening and appointments—I stress hybrid. Forcing face-to-face appointments too soon is unsafe and may harm patient care.

For many patients, the choice of using e-health and telehealth solutions to contact their GPs initially has been convenient, but clearly it is not appropriate for all. Some individuals and certain conditions would benefit from a face-to-face appointment and it is important that we get that balance right. However, forcing an immediate return to face-to-face appointments will not necessarily benefit the patients and it may harm efficiency of care.

GPs in England have overwhelmingly rejected the DHSC England plan for forced face-to-face appointments, with more than 90% saying they would increase workload and therefore decrease the amount of time caring for patients. The Royal College of GPs in Scotland said last month:

“We believe that there is a key role in modern general practice for remote consultations and would oppose any moves to deny patients this option of accessing care by reinstating pre-pandemic ways of working”.

It went on to say:

“Instead of arbitrary targets which we feel would not benefit either patients or the wider health service, we need to see concerted and urgent action in a range of areas that would improve general practice and ultimately the standards of care that patients that receive … Key to this is the need for credible workforce planning to ensure that we have an appropriately staffed service”.

That is an absolutely fundamental point. It may be worth mentioning that GP training recruitment in Scotland this year has been the most successful year of any of the last five, with 99% of GP training posts filled so far and with one recruitment round remaining. Already Scotland has a record number of GPs, with more per 100,000 of the population than the rest of the UK. We are on track to increase that number by a further 800 posts by the end of 2027. For comparative purposes, that is currently 94 for every 100,000 people, compared with 76 in England, 75 in Wales and 72 in Northern Ireland.

The BMA said on 15 September:

“Any arbitrary timetables or targets for face-to-face patient consultations would be both unrealistic, demoralising and potentially counterproductive, leaving those desperately in need of appointments waiting even longer”.

I am pleased that the Scottish Government will not be pressuring GPs into unsafe early reopening, just because some politicians and some sections of the press want to insist on it.

In conclusion, the UK Government should match the Scottish Government’s stance and insist on a safety and efficiency-first position, not bow to demands of the right-wing press, which will sacrifice patient and staff safety without providing any benefits to our patients. The key to this issue is getting the balance right in terms of the hybrid approach, which of course requires adequate recruitment levels, which are absolutely fundamental.

NHS England Funding: Announcement to Media

Martyn Day Excerpts

Monday 25th October 2021 Commons Chamber

[Edward Argar]

My right hon. Friend will know that by far and away the overwhelming majority of that money was one-off spending to tackle the pandemic in its most acute phase. We will need to continue to spend some of that on therapeutics, vaccinations and similar. On other things, such as the significant increase in infrastructure and understanding that we have built in test and trace and in testing and diagnostic capacity, I am looking at how a long-term legacy can be born of that and how we can transition the learnings and infrastructure from that to continue to deliver for patients in more normal times.

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

This announcement goes to the very heart of what is wrong with the Union. Ministers make decisions from here in real time for England based on their perception of needs, while the devolved nations get the consequentials. The Health Secretary’s announcement mentioned that consequentials would be coming. Can the Minister tell us today exactly how much money is coming to Scotland and when the Treasury will send it?

[Edward Argar]

The hon. Gentleman is absolutely right that the Secretary of State said that there would be Barnett consequentials. The details of those will be set out on Wednesday.

Covid-19: Government Response

Martyn Day Excerpts

Thursday 21st October 2021 Commons Chamber

[Maggie Throup]

I thank my right hon. Friend for his questions. I would like to reassure him that I have regular meetings with the Prime Minister and that the Prime Minister takes the vaccine roll-out extremely seriously, as does the Secretary of State. Regarding the timescale for the eligibility for boosters, the Joint Committee on Vaccination and Immunisation has provided advice that there should be a minimum of six months after the second jab, but I would like to reassure the House that the immunity does not fall off a cliff edge. It has waned slightly but not sufficiently, so there is still time for people to come forward. Obviously, we are encouraging them to come forward as soon as they are eligible, but they still have a huge amount of immunity over and above those who have yet to get their first jab.

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

With infection levels worryingly at previous lockdown levels, with the Government being accused of having taken their foot off the brake by the British Medical Association, and with NHS leaders calling for the reintroduction of restrictions, the Secretary of State’s stance of not implementing plan B at this point does not look credible. It looks like a repeat of the previous mistakes of acting too late. If the Government will not now follow Scotland’s lead and bring in measures such as mask wearing to reduce infection, how much worse must things get before they implement a plan B?

[Maggie Throup]

Our vaccines programme has really created a wall of defence. We are in plan A, and there is still more that can be done as part of plan A. That is why I am calling on the 4.7 million people who have yet to come forward for their first jab and on others to have their booster jab as soon as they are eligible, as well as encouraging 12 to 15-year-olds to get their jab as soon as they have the opportunity.

Covid-19 Update

Martyn Day Excerpts

Thursday 21st October 2021 Commons Chamber

[Maggie Throup]

It is good to be asked a further question by my right hon. Friend. I would like to reassure the House that vaccines continue to be effective in preventing serious illness. Current evidence suggests that the AstraZeneca vaccine is at just under 80% effectiveness at five months, and that is brilliant. Even though effectiveness is waning, it is not dropping off a cliff. That is why, before levels get lower, we are encouraging people to come forward for their boosters. He asks what more we are doing to get more people to do that. For 12 to 15-year-olds, until now they have been able to claim their first jab through the School Age Immunisation Service. We are now opening up the national booking service for 12 to 15-year-olds so that they can go along with their parents and get their jabs at the centres throughout England. I am sure that my right hon. Friend is pleased that we are providing more choice.

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

I thank the Minister for her statement. I do, however, fear that the Government are being too reliant on their plan A and not sufficiently heeding the warnings from the health community over the pressures faced or the urgency to act. However, we rehearsed those arguments earlier. On the issue of getting the unvaccinated vaccinated, the Government have my full support. It is incumbent on every one of us, as MPs, to show leadership in encouraging our constituents to take up their vaccinations.

Scotland leads the UK both in first and second dose vaccination rates, with 90% of those aged 12 and over vaccinated with at least one dose, while England sits at 85%. For second doses, this amounts to 81% versus 79%, with booster roll-outs now taking place across these lands as we speak. How do the UK Government plan to match Scotland and encourage greater uptake of vaccinations among those who are so far unvaccinated? Vaccinations among 12 to 15-year-olds are 3:1 times higher in Scotland than in England, with more than 46.5% of eligible Scottish students having got the vaccination compared with just some 15% of eligible English students. English headteachers have called for the Government to follow the lead of the Scottish Government and have drop-in vaccination centres at GP clinics, pharmacies and community centres. Will the Minister listen to English headteachers and seek to follow the Scottish Government’s lead with vaccination drop-in centres?

[Maggie Throup]

I would like to reiterate the data I gave earlier that across the UK 86% of people have taken up the opportunity of a first dose and 78.9% their second dose. That is a really great achievement. To me, it is inappropriate to try to draw divisions between our Union; we need to work together on this. As I mentioned to my right hon. Friend the Member for South West Surrey (Jeremy Hunt), we are opening up more opportunities for 12 to 15-year-olds to take their vaccines, and that is only right. However, we have to be really aware of safeguarding issues when it comes to 12 to 15-year olds getting their jabs and the importance of having their parents with them at that time.

Oral Answers to Questions

Martyn Day Excerpts

Tuesday 19th October 2021 Commons Chamber

[Gillian Keegan]

This is absolutely vital. The recent announcement of £500 million over three years to fund social care professionalisation is very warmly welcomed by the sector. It is a sector that employs 1.54 million people. It is larger than the NHS, construction, transport or food and drink. I am of course happy to meet my hon. Friend and other Gloucestershire MPs. I know this issue is a challenge. We have some short-term actions, and it is a key pillar of our long-term reform.

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

With the Government introducing a health and social care levy, will the Minister ensure that social care is not at the back of the queue for spending? Can she provide clarity about every penny of Barnett consequentials that will be given to the devolved nations?

[Gillian Keegan]

I am sure that the Chancellor will be setting out what will happen with the Barnett consequentials. Yes, this issue is important. The most important thing to say is that this is the start—we have £5.4 billion over the next three years for us to embed some of the changes we need in the system, but this levy will continue, and social care will be a big part of and a big beneficiary from that levy in the future.

--- Later in debate ---

[Maria Caulfield]

I thank the hon. Lady for her question. I reassure her that around 90% of prescription items in the community are provided free of charge. Those who are vulnerable and on low incomes, such as those on universal credit, income support and jobseeker’s allowance, already qualify for free prescriptions. It is really important that those over the threshold can also apply for the prescription prepayment certificate, where all their items will cost just about £2 a week. We are making sure that costs are low for those on low incomes.

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

Record levels of funding by the Scottish Government for primary care will protect free eye examinations and free prescriptions for people in Scotland and will also enable the abolition of all NHS dentistry charges. Will the Minister follow Scotland’s lead and commit to a similar policy for England?

[Maria Caulfield]

I thank the hon. Gentleman for his question. Although the Scottish Government provide free prescriptions, the money comes out of existing budgets, which means it is taken from elsewhere in the health service. That may be why, at the moment, three health boards in Scotland need the armed forces’ support to deal with their winter crisis.