Health and Care Bill

Baroness Merron Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Mackay of Clashfern (Con)]

My Lords, I support these amendments, subject to the economic difficulties. As I listened to the local Baroness, Lady Brinton, I wondered whether the amendments might be strengthened by some reference to the timescale in which they must be implemented. That might have some beneficial effect for many people who are waiting.

[Baroness Merron (Lab)]

My Lords, I welcome these amendments, which relate to the National Institute for Clinical Excellence—NICE. I thank all noble Lords for tabling these amendments and for their contributions today, which certainly expanded my knowledge of the subject, as I am sure they did across the Committee. The debate has shown that there is a need for change, as I am sure the Minister has heard, to better equip the National Health Service to provide the patient what they need when they need it.

The noble Baroness, Lady McIntosh, spoke clearly about hurdles that must be overcome, whether they are bureaucratic, process, budgetary or administrative. All these hurdles get in the way of the end result: meeting the needs of patients. That, I believe, is what this debate is focused on.

NICE is well recognised as a partner to our NHS. Its objective approach and evidence-based analysis rightly gain respect. However, as my noble friend Lord Hunt said—he can now be called the first Minister for NICE—although the National Health Service is full of innovation, it is also slow to pick up on it; that point was emphasised by the noble Lord, Lord Warner. That begs the question: what kind of partner should NICE be to the NHS? Is it going to be an enabling partner, or will it frustrate at times? Of course, we all want to see NICE in that fully enabling capacity.

However, beyond what NICE approves in terms of treatments, pathways or otherwise, there must be procedures for it to implement and connect effectively to patients’ needs. We know that no system or set of procedures will ever be perfect; we have heard that today. Understandably, therefore, as the Minister has heard, pressure and a will for change—in a positive sense—is contained in these amendments. The noble Baroness, Lady Finlay, spoke about how important it is to have evidence-based healthcare and to have known guidelines and see them complied with, as is right and proper.

There are cautionary considerations to note in this debate; we have heard some of them. One is whether it is wise to put what in some cases appear to be operational requirements in the Bill. I am sure the Minister will address this. The new world is certainly paying a lot of attention to flexibilities. We want to make sure that anything contained in the Bill does not inadvertently work in another direction.

My understanding is that NICE guidance is mandated, in effect, with the guidelines somewhat less so. Amendment 54 contains a proposal to reinforce the intention that, once a treatment has been properly assessed and recommended, all patients should be able to gain the benefit. We know, and we have heard in this debate, that this does not always happen, and that clinical commissioning groups follow different policies. However, in considering the amendment at face value, it is important that we consider what impact this latitude might have. I am sure we are all keen not to accidentally invoke some kind of fallout, such as taking away all leeway from commissioners. At present, they can depart if they can set out an objective case for doing so; for example, with requests for certain drugs and therapies through individual funding requests.

Similarly, it would be unfair if a patient could cross an integrated care board border and receive a treatment that was not available in another ICB area. That would seem inadvertently to achieve what we do not want to achieve: the worst of a postcode lottery. Equally, if we have locally based approaches, the reality is that some localities will differ in their priorities and services. I know that we will return to this topic many times in our consideration of the Bill because the care that patients receive should certainly be equitable and fair and not based on where they live.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 3 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I feel honoured to be a fellow Member of this House with the noble Baroness, Lady Finlay, because of her professional and political work in raising this issue before your Lordships.

I want to use a word that has not been used yet in this debate, and that word is “fear”. The noble Baroness, Lady Fraser, nearly used it when she said that people are scared. Anybody who has read the reports that say that only 50% of people who need palliative care receive it will feel fear: “Is it going to be painful?”, “Am I going to be able to bear it?” and, on the part of the carer and family members, “Is it going to be terrible for my loved one?”, “Am I going to be able to help them?”, “Am I going to be able to cope?” The physical pain is part of it, but, as the noble Baroness, Lady Hollins, said, the fear and the psychological distress make things a great deal worse. At a time when it is in our power to give people a good death, we are not doing it; that is a disgrace.

[Baroness Merron (Lab)]

My Lords, I think it is fair to say that the debate today across your Lordships’ House has shown that it is impossible to understand how specialist palliative care can be regarded in any logical, practical or humane sense as something so different. I am sure that the Minister will do his very best to address that in his consideration of these important amendments.

I am grateful to noble Lords for making this debate possible by bringing forward these amendments and making sensitive, informed and often personal contributions to underline the need to ensure that specialist palliative care features in the Bill. I am particularly grateful to the noble Baroness, Lady Finlay, for setting out the fact that if we are to say that the NHS is cradle-to-grave, that must absolutely shape how we approach such services. The noble Baroness and others, including the right reverend Prelate, talked about inequality and the fact that, when we speak of specialist palliative care, inequalities are not just in the course of someone’s life but actually to the very moment they leave this world. That really had an impact on me, because that surely is an unfairness too far for us to just stand by.

Taking action could not be more pressing a need. We know that the UK’s population is ageing rapidly. The Office for National Statistics predicts that, in 20 years’ time, there will be twice as many people over the age of 85, while Marie Curie’s analysis for Cardiff University has concluded that the number of people needing palliative care will rise by 42% by 2040. This is a challenge to our society which will not go away. As the noble Lord, Lord Patel, said, we should be able to live our lives in anticipation of a good death. The right reverend Prelate spoke of the difference of witnessing a good death, as opposed to a death that is less than what it should be.

It is important to say that, even before the pandemic, experts at the Royal College of Physicians, the Care Quality Commission, the health service ombudsman and Compassion in Dying were all sounding the alarm on how those approaching the end of their life, and their loved ones, did not, in so many circumstances, feel supported to make the decisions that faced them and that it was impossible to turn away from. They did not know what choices were available, and, sadly, were not given an honest prognosis.

The amendments in this group offer dignity to the greatly increasing numbers who will need this care, and would bring in moral and well-evidenced measures essential to providing the tailored care that is needed in the final stages of one’s life. This includes sharing information about a person’s care across the different professionals and organisations involved in that care, and providing patients and their loved ones with specialist advice, 24 hours a day, every day of the week—which expert practitioners, including those at Cicely Saunders International, have been crying out for.

My noble friends Lord Hunt and Lord Howarth, the noble Baroness, Lady Finlay, the noble Lord, Lord Patel, and others underlined the work, role and contribution of the hospice movement, and also spoke about their incredulity at the reliance on charitable funding. Who in this Committee can be surprised at that feeling? I hope the Minister will be able to speak to that absolutely crucial point because, even before the pandemic, many hospices were suffering from poor decisions from clinical commissioning groups, poor practice, and a lack of support and recognition of the vital role that they play. That impacts on the individuals who so sorely need their services.

Marie Curie reported that 76% of carers who lost a loved one during the pandemic felt that they did not get the appropriate care that they needed. This is an opportunity to fix the problem. Every day, pandemic or none, the quality and personalisation of specialist palliative care will dictate how dignified and comfortable —or not—the end of a life will be, and how much of a burden will be borne by the carers and loved ones: whether, as the noble Baroness, Lady Hollins, reminded us, those left behind are adults or children. These amendments seek to get it right, and the feeling of this Committee could not be clearer. I look forward to the Minister’s response.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)]

My Lords, as we reach the closing minutes of today’s debate and reflect on the wonderful contributions from across the Committee, perhaps it is fitting that we also talk about the final chapter of life, as the right reverend Prelate the Bishop of Carlisle said.

I thank all noble Lords who spoke very movingly today, particularly the noble Baronesses, Lady Meacher, Lady Hollins and Lady Walmsley, the noble Lord, Lord Patel, and my noble friends Lady Hodgson and Lady Fraser, who spoke about their own experiences. I also thank the noble Baroness, Lady Merron, for pointing out the 42% figure, which is very important to recognise. I thank the noble Baroness, Lady Finlay, for the engagement we had prior to this debate and for her helpful engagement with our officials and the Bill team. I hope that will continue.

What is interesting about this is that when I was younger, we as a society found it very difficult to talk about death. I was once told by my parents that the British find it very difficult to talk about death, except in faith groups. It is interesting that, over time, as we have become an ageing society, we are talking, as a matter of fact, about death. We talk about our wills, financial planning, and planning for care at the end of our life. It is appropriate that we recognise this. The fact is that, nowadays, when we look at the hospice movement, we do not think of it as a quaint little service or a charity; we think that it provides an essential service to help someone at the end of their life, and we recognise the difference between palliative care and end-of-life care.

I hope that I can reassure the Committee that the Government are committed to ensuring that people of all ages have the opportunity to benefit from high-quality, personalised palliative and end-of-life care, if and when they need it. I also pay tribute to the noble Lords, Lord Howarth and Lord Scriven, for their contributions. The noble Lord, Lord Howarth, talked about the role that the arts play in helping those at the end of their life, which he has talked about in a number of discussions we have had on this issue. Like the noble Lord, Lord Scriven, he made the point that while you want to see the state do more, you do not want to push or squeeze out the hospice movement, as we need the right balance.

Eating Disorders

Baroness Merron Excerpts

Monday 17th January 2022 Lords Chamber

[Lord Kamall (Con)]

The issue of poor body image that my noble friend raises is very important. The Government are addressing known risk factors through both universal and targeted interventions. At the top level, that means looking at the Better Health and Every Mind Matters content, which focuses on support for mental health and well-being. Poor body image and low self-esteem are topics addressed there. It is also about looking at what pupils expect and at the prevention concordat for better mental health programmes, as well as working as part of the anti-obesity strategy to make sure that we get the right balance. Sometimes when you focus on information on packets, for example, it can have unintended consequences for those with eating disorders. Every time we look at labelling, we have to make sure that we have addressed those unintended consequences on people with eating disorders, so that they do not react negatively to it and perhaps indulge in behaviour that we do not want to see them indulging in.

[Baroness Merron (Lab)]

My Lords, the Royal College of Psychiatrists has warned that the hidden epidemic of eating disorders has surged during the pandemic, with many community services overstretched and unable to treat the number of people who need help. Will the Minister publish data about the number of people waiting for eating disorder treatment better to understand and meet the scale of the demand? Will he deliver a workforce plan to tackle staff shortages in eating disorder services so that it may be possible to treat everyone who desperately needs this help?

[Lord Kamall (Con)]

I thank the noble Baroness for raising the issue of the backlog as a result of the pandemic. We have seen eating disorder services continue to face increasing demand, especially as a result of lockdown and its mental health impact. The number of young people entering urgent treatment has increased by 73% between 2019-20 and 2021, and the numbers waiting for treatment have also increased from 561 to 2,083. To make sure that we meet the standard and get those waiting times down, we have invested an extra £79 million this financial year, and we are working with systems across the country to see how we can make sure that we address young people and adults who need access to this treatment.

Vaccination Strategy

Baroness Merron Excerpts

Thursday 13th January 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I pay tribute to the staff of the NHS, volunteers and others, who have made extraordinary efforts during the vaccine rollout to save lives and build a world beyond Covid, while a particular debt of gratitude is owed to the Deputy Chief Medical Officer, Jonathan Van-Tam, who is standing down from his role.

To drive up vaccination rates, there is a growing need to tackle anti-vax propaganda and stop intimidation and abuse. Will the Minister commit to a communications campaign to tackle misinformation, particularly focusing on places and people with lower rates of take-up? Following the Labour amendment to the policing Bill that was agreed last night in your Lordships’ House, will the Government now take the opportunity to fast-track buffer zones around schools and vaccination centres?

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)]

I thank the noble Baroness for raising these issues. The first issue, that of anti-vaxxers, is really important. In a free society we always have to get the balance right between freedom of speech, making sure that people are free to go about their daily work, and making sure that those who want the vaccine get it as soon as possible. The Government are aware of this and are looking at it, but it is really important that we get the right balance. Whatever we think of the anti-vaxxers’ message, they have a right to say it, but we have to make sure that it does not impinge on the liberty of others to get their vaccine, especially since we are encouraging as many people as possible to get vaccinated.

I join the noble Baroness in paying tribute to the Chief Medical Officer, Jonathan Van-Tam. He appears on our daily omicron calls and I have had a number of conversations with him, and I know that there is incredible respect for JVT across the country. Indeed, I know that a number of people tuned in to his Christmas lectures on the virus; as the noble Baroness says, they were an excellent explanation of the virus and how to tackle it.

As for how we reach local communities, particularly those communities that have not come forward, I have had a number of conversations with noble Lords and Baronesses with their own experience of working with local communities in a bottom-up way. We have seen a number of local activities; indeed, my local masjid, or mosque, has a walk-in vaccination centre, and we have seen that in other faith places. A number of faith-based and interfaith networks have worked closely with the local community, because often some communities do not have the trust in authority that they have in priests, vicars, bishops—if I may say so—imams, et cetera. That is really important. We have also recorded promotional films in a number of languages, including Punjabi and Urdu in Birmingham, and got some celebrities to come up. I know I have gone on too long but I am very excited about what we are doing.

Health and Care Bill

Baroness Merron Excerpts

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

Moved by

[Baroness Merron]

2: Clause 1, page 1, line 5, at end insert—
“(1A) The Board of NHS England must be made up of—(a) a Chair appointed by the Secretary of State;(b) five other members so appointed of whom—(i) one must be appointed to represent Directors of Public Health;(ii) one must be appointed to represent the Local Government Association;(iii) one must be appointed to represent the interest of patients;(iv) one must be appointed to represent the staff employed in the NHS; (v) one must be appointed to represent the integrated care partnerships;(c) one further member appointed by the Secretary of State after being recommended by the Health Committee of the House of Commons as a person with appropriate knowledge and experience;(d) executive members as set out in Schedule 1 to the Health and Social Care Act 2012.(1B) In making the appointments in subsection (1A)(a) and (b) the Secretary of State must have due regard to—(a) the need to ensure diversity and equality of opportunity; and(b) the need to ensure that no person who could be perceived to have a conflict of interest by virtue of their current or recent employment or investment holding in any organisation with any role in the delivery of services to the NHS may be considered for appointment.”Member’s explanatory statement
This amendment requires changes to the membership and composition of the Board of NHS England to reflect its new role under the Bill.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, for their support.

This amendment seeks to define the composition of the board of NHS England to better align it to the new requirements set out elsewhere in the Bill. There must not be any doubt as to why board members have been appointed. In other words, their appointment must be made on their ability to contribute and add strength to the board, rather than—perhaps—because of those whom they already know. Key factors in the appointment of board members need to be an independent assessment of their value and meeting a fit and proper test of freedom from conflict of interests—things that I hope we would all agree on in your Lordships’ House.

Beyond that, we must also look at what the new NHS England board will be required to do. Other parts of this Bill deal with the powers and duties of this new version of NHS England, originally the NHS Commissioning Board. This is the clearest demonstration of the reversal of the 2012 Act, as the new NHS England bears no resemblance to its original predecessor—and that is a good start. The new NHS England will of course be an amalgamation of the old NHS England, Monitor and the NHS Trust Development Authority. It will commission some specialist services. It will be the regulator of a market that no longer exists. It will performance manage both commissioning for integrated care boards and provision of services by trusts and foundation trusts.

This is indeed a wide range of responsibilities, and how it sits with roles within the department unfortunately remains as vague as ever, with the ability of Ministers to micromanage depending on other parts of this Bill. However, the most crucial policy change is that the new NHS England will sit at the top of a system based on the integrated care boards being the major commissioners of services. The Explanatory Notes and the government pronouncements about these new integration bodies strongly assert their role as driving the reintegration of the NHS, repairing the worst of the fragmentation caused by the 2012 Act and dealing with aspects of previous legislation which had a somewhat market-centric view of our NHS.

This purpose drives what we now need from the new board members of NHS England. Those new board members must chime with this new philosophy of partnership and collaboration rather than markets and competition. In the new world, the NHS will still be bound, as it always has been, by its core principles: comprehensive, universal, free, and funded from general taxation. Board members need a demonstrable record of commitment to these principles. They should also have a commitment to the new values, which favour a stronger role for patients and the public to have influence, a view of the NHS as contributing to reducing inequalities and improving well-being, not simply being a sickness service, and greater alignment of NHS services provided through local government. The current make-up of the board is a chair and five other non-executives, all appointed by the Secretary of State and then the appropriate executive directors. Given the huge importance of the NHS, it is appropriate of course that the chair and at least some of the non-executives are appointed by the Secretary of State. This amendment deals only with the remaining non-exec members.

--- Later in debate ---

Amendment 3 (to Amendment 2) withdrawn.

[Baroness Merron (Lab)]

My Lords, the noble Earl, Lord Howe, hoped that his comments would be helpful and I reassure him that he is always helpful in the comments that he offers. Today, of course, is no exception.

As my noble friend Lord Howarth said, this has been a very interesting debate and it has certainly stimulated many angles of consideration. At a minimum, that has been extremely useful because what binds us all together in this debate, whether or not we agree with the amendment, is the wish to see the new NHS England perform to the highest order in terms of not only confidence but effectiveness. I know that we all want to move in the same direction.

Clearly, we have heard differences of opinion. I am grateful to the noble Baroness, Lady Walmsley, for speaking further to the point about representation. I say to my noble friend Lord Howarth that I did not interpret her as having reservations; her concerns were more about clarification, and I share them. The intent of the amendment was not that people should be consulting back and be a straightforward linear representative, but that they should represent and come from the area which we were discussing. The noble Lord, Lord Patel, made a particularly strong case for the importance of influence in public health; that was echoed by my noble friend Lord Brooke. We are all keen, I am sure, to see the ability to promote good health and well-being such that the NHS, as I said in my opening remarks, should not be focused entirely on dealing with ill health, important though that obviously is.

It is important that we get the right people in place to build the right team. It is crucial that they work together. I am sure that many noble Lords who are non-executives on boards know that a successful board is one that invites challenge, dissent and the widest range of voices. I certainly hope the new NHS England board will do this.

As the right reverend Prelate the Bishop of London so clearly put it, it is too easy for patients’ voices to be forgotten—this must not be the case. I know the noble Earl, Lord Howe, will do his best to ensure that those voices are well heard. Certainly, we in this House will continue to pursue that.

The areas outlined in the amendment from which we had hoped to seek representation remain as important as ever after this debate. I am sure that the noble Earl, Lord Howe, and the Minister will reflect on them in the context of the debate. I thank the noble Lord, Lord Mawson, and the noble Baroness, Lady Harding, for providing challenge, as is quite right and proper. I look forward to the new board of NHS England doing the job we all want it to do. In view of our debate, I beg leave to withdraw my amendment.

Amendment 2 withdrawn.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I feel that today’s debate on this important group of amendments should carry much weight because, at its core, this is about treating people as whole people and seeing them as physical, mental and social beings. Our welfare on each of those fronts is absolutely key to the others. It is not possible simply to treat one without regard to the others, and it is crucial that we enhance people’s well-being across our whole complexity as human beings.

I am glad to speak to this group of amendments because, as we have heard across all sides of the Committee throughout today’s debate, the reality is that, despite the best efforts encapsulated in the mandate, and many times in policy, we find that competing priorities, an avalanche of guidance and instructions, and events—the pandemic has been referred to several times, of course—mean that mental health services can be, and indeed have been, relatively left behind. As the Centre for Mental Health reports:

“Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”


In the debate today we have also asked ourselves: where is the accountability? For example, we know that in many clinical commissioning groups the actual spend on mental health was below what it was supposed to be, yet there have been no consequences. We need to address not just the finances but the mechanisms around it and the impact on individuals.

The founding National Health Service Act 1946 rightly spoke of a comprehensive health service that secured the improvement of both physical and mental health, and subsequent Acts, quite rightly, have confirmed this. In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through this NHS mandate, but we know, and have heard again today, that this requirement falls down when we go to a local level.

One way or another, we will all be familiar with a whole range of stories of people who have not been able to access treatment in a timely manner or who find that they are pushed around a system with very little effect and discharged from care before it is appropriate, with consequences that are all too clear to see. It is difficult to overestimate just how challenging this is, not just for the individuals but for local commissioners, because they face competing pressures in trying to deal with this.

As has been emphasised, this group of amendments is about not just getting on the road to financial parity, important though that is, but changing the culture and the whole means of monitoring and implementation, so that disparities can be addressed—indeed, if possible, so that difficulties can be headed off at the pass. It is a well-worn phrase, but it sometimes seems that mental health is a Cinderella service—the one that can be cut first, to the benefit of the more visible services. Some of the recent statistics show that one in four mental health beds has been cut in the last decade, while just last year 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic that we need to move away from.

I thank noble Lords for promoting these amendments and for their contributions illustrating what they mean and the reason we need them today. The noble Lords, Lord Stevens and Lord Patel, made timely points about the impact of the pandemic. If this is not a moment for focusing more on mental health, I do not know what is. The challenge we have and the difficulty presented by the pandemic is that while there is a focus on cutting waits for operations—and we know that is important—this could be a reason for mental health services to get somewhat lost, when in fact the pandemic reminds us of the importance of mental health and the need for the NHS to meet the needs that there now are.

The amendment by the noble Lord, Lord Stevens, encourages and directs the actions necessary for transparency on expenditure. I recall that they were referred to in the debate as legislative levers, and that is indeed what they can be. For me, they encourage not just accountability and transparency but actual action and change—the change we need to see.

The noble Baroness, Lady Hollins, referred to parity of esteem having to be applied locally, not just at a higher level. That is the only way we will see a difference in mental health services and improve the mental health of people in this country.

The noble Lord, Lord Crisp, made reference to the fact that legislation is trying to catch up with where we are as a society, and the noble Lord, Lord Warner, referring back to the meeting he attended, said that the public are well ahead of the game. I believe that is true. Indeed, as the noble Baroness, Lady Watkins, said, we have to prepare for tomorrow. It is not satisfactory that we stay stuck in today, or indeed in the past.

In my view, these amendments move us on. They bring mental health services into real parity with physical health services, but they also connect mental and physical together. I hope they will find favour from the Minister.

[Lord Kamall (Con)]

I begin by thanking all your Lordships for the wide-ranging debate. I want to say how much more I learn, listening to the contributions in each of these debates, before I stand up to speak. I thank all noble Lords for their contributions. As the noble Baroness, Lady Merron, says, this debate carries some weight for our understanding that social, mental and physical well-being are equally important. We should not seek to suggest that one takes precedence over another. I also thank the noble Lord, Lord Stevens, for kicking off this debate with his encouraging and not critical amendments; I take them in that spirit.

Following on from that, and before I go to some of the specific amendments, I will just reflect on some of the contributions made thus far. I first thank the noble Lord, Lord Howarth, for raising social prescribing. I know we have discussed this a number of times since I became the Minister, with particular contributions from the noble Baroness, Lady Greengross, on the importance of art and music in helping to unlock the mind and touch the soul.

As has been made clear, social prescribing is a key component of the NHS’s universal personalised care, and I know that, crucially, this can work well for those who are socially isolated or whose well-being is impacted by non-medical issues. The NHS has mechanisms to ensure that social prescribing is embedded across England: for example, the primary care network directed at enhanced services specification outlines that all PCNs must provide access to a social prescribing service.

I also thank the noble Lord, Lord Patel, for raising the importance of the mental health of children and for making sure that we do not forget, even within mental health, that many sections of our society can quite easily be forgotten.

I agree with the right reverend Prelate the Bishop of London: we have come a long way. I remember as a child in the 1970s going to visit my uncle who was a psychiatric nurse at Claybury Hospital and looking at the patients, with the innocence of a child, and thinking, “These people don’t look ill to me.” We have come far since then. I remember the Rampton hospital scandal in the late 1970s, where the patients were treated appallingly, almost not as humans, and with a lack of dignity. The fact that today we are discussing the parity of mental with physical health shows how far we have come as a society.

We also spoke about loneliness and isolation. The noble Baroness, Lady Watkins, and I have had conversations about loneliness and some of the civil society projects that, for example, bring together lonely older people with children from broken homes so that both can benefit and learn from each other. I remember a story that I have mentioned in the past: in one of the projects I visited, a rather old man said, “I lost my wife five years ago and I had almost given up on life. The fact that I am now working with children from broken families and am almost being a mentor to them gives me a purpose to live—a reason to get up in the morning. I have no longer given up on life.” There are so many of these civil society projects, and no matter how we legislate, sometimes those local projects get to the nub of the problem in their local communities.

I have to pay attention when not only two former NHS chief executive officers but the former Chief Nursing Officer speak in the debate. The noble Lord, Lord Crisp, talked about the focus on outcomes, not inputs and how it is important to make sure that we are not gaming the system, mentioning mental illness and mental health but not doing anything effective about it.

Autism was mentioned by the noble Lord, Lord Warner, a former Health Minister. We are fully committed to improving access to and provision of health and care services for autistic people and people with a learning disability. I know that we have had at least one debate on the treatment of patients with autism and sometimes the terrible conditions they experience. That just shows how important this is.

I am trying to say that in many ways that the Government are absolutely committed to supporting everyone’s mental health and well-being and to ensuring that the right support is in place for all who need it. I therefore welcome the amendments which look to ensure parity of esteem across physical and mental health. I assure noble Lords that we support the sentiments behind these amendments and take mental health seriously.

Indeed, one of the considerations in weighing up the many arguments for further measures in response to Covid—from those who were asking for lockdown, for example—is that we also had to recognise that there was a mental health impact to lockdown. As a Government, we had to look not only at the societal and economic impacts but the mental health impacts within health considerations.

On the amendments, I will first address those tabled by the noble Baroness, Lady Hollins—I add my voice to those of the many noble Lords who have paid tribute to her work over many years in promoting this issue and ensuring that we take it seriously. I also pay tribute to the noble Baroness, Lady Walmsley, for making sure that we are informed about this. These amendments would explicitly reference both mental and physical health and illness in certain provisions of the Bill. I understand that the intention is to ensure that due attention is given to both “mental and physical health” and “mental and physical illness”. Indeed, you cannot separate mental and physical illness, as the noble Baroness, Lady Jones, said. We have moved way beyond “Pull yourself together, man” or a stiff upper lip attitude. We see how mental health plays a role, for example, in terrorism, with those who are recruited to be terrorists, or in those with eating disorders, or the number of people in prison who suffer from mental health issues. It is important that we fully recognise that.

Public Health: Night-time Working

Baroness Merron Excerpts

Thursday 6th January 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, night working can place a strain on people’s health through increased incidents of depression, diabetes and cardiovascular disease. Can the Minister tell the House what work the Government are doing with unions and employers to reduce this link between night working and ill health, and what account they are taking of the TUC report which calls for greater attention to the pressure of night working on home life and relationships?

[Lord Kamall (Con)]

A number of noble Lords have made the very important point that there is clearly an impact on individuals of working at night, including fatigue, wider pressures and disruption to family life. The sleep review has looked at this and reported just before Christmas, after consulting a wide range of stakeholders. The Office for Health Improvement and Disparities will publish its report in the summer of 2022, I hope.

Medical Schools: Training Places

Baroness Merron Excerpts

Monday 13th December 2021 Lords Chamber

[Lord Kamall (Con)]

There has rightly been much discussion of workforce planning for the NHS and adult social care, and the Bill will build on this. Clause 35 will bring greater clarity and accountability in this area, requiring the Secretary of State and the NHS to produce a workforce plan.

[Baroness Merron (Lab)]

My Lords, with the intensification of the Covid booster programme, more doctors will, of course, be diverted from their usual roles, making it even harder for people to get an appointment at their local surgery, and record waiting lists will continue to increase. What revisions will the Minister make to existing plans for numbers of training places to meet the need for more trained staff, including doctors, nurses, lab technicians and auxiliaries? How will the Minister respond to the report from the Royal College of Surgeons that 13,000 planned operations have been cancelled in the last two months alone?

[Lord Kamall (Con)]

The focus and priority for the next three weeks is on omicron and making sure that people get their boosters as quickly as possible. It is not only doctors who are involved: nurses, pharmacists and, incredibly, a number of civil servants are now taking part in that programme. For the next three weeks, the focus is on getting more jabs into arms.

Health and Care Bill

Baroness Merron Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am glad to speak in this Second Reading debate on a Bill that has generated much anticipation and interest; the Minister’s comments today have also created much anticipation and interest. I am grateful to the many parliamentary colleagues, organisations, charities and representative bodies that have given their time to give their invaluable views and expertise to many of us in your Lordships’ House. I also thank the Minister and his team for making themselves available, and for the extensive work that they have already undertaken and will continue to undertake. I look forward to the maiden speech of the noble Lord, Lord Stevens of Birmingham; I wonder how he decided to choose this particular Second Reading in which to make it.

However, I am sorry to say that this is the wrong Bill at the wrong time, as it fails to deal with the real and immediate issues in the health and care system: scandalous social care provision; no workforce planning; no strategy for integration between health and social care; weak and underfunded public health services; and inadequate levels of funding. Regrettably, the Bill does nothing to resolve the democratic deficit around accountability in the NHS, and fails to put patients, their carers and the workforce at the heart of building back a better NHS. It is not about improving well-being or addressing the social determinants of poor health. Nothing in this Bill will make much difference to the long waits for people in pain and distress, or those who experience delays in waiting for an ambulance. As for it being the wrong time, we know that the pandemic is far from over. We still await proposals for social care integration, and the most vital issue—responding to the workforce crisis in the NHS and social care—is not even at the planning stage.

Let us remind ourselves that this Bill began as a legislative response to desperate pleas from the NHS to reverse some of the provisions in the Health and Social Care Act 2012, which made it impossible to develop the NHS Long Term Plan. There were demands to end compulsory competitive tendering for health care services and allow much greater co-operation and joint working between various bodies. Also, it was clear that the informal organisational arrangements that the NHS had developed in the sustainability and transformation partnerships needed to be put on to a statutory basis. These have become the proposed 42 integrated care partnerships.

So, a Bill that was expected in 2017 is now with us in 2021 with the addition of extensive new powers for the Secretary of State, which give rise to deep concern. These extend to direct involvement in service reconfigurations, which could be as purely operational as moving a clinic a few yards down the road. They refer to the transfer and delegation of various functions in relation to arm’s-length bodies, the regulation of healthcare and associated professions, and reporting on workforce needs. After Committee in the other place, out of the blue, the Government added a highly contentious new clause concerning the social care costs cap, which will doubtlessly stimulate many hours of debate in your Lordships’ House.

We acknowledge the proposals around information standards and information sharing; setting up, at long last, the Health Services Safety Investigations Body; the introduction of Care Quality Commission powers to investigate adult social care; the reference to medical examiners; food advertising to combat obesity; fluoridation; and the banning of virginity testing.

From these Benches, we broadly support those parts of the Bill that remove the worst of the 2012 Act, but will look to add key safeguards to ensure proper governance and accountability and prevent new arrangements being open to abuse around contracting, particularly with the private sector. However, as I mentioned earlier, we do not support most of the proposed new powers for the Secretary of State in the absence of a proper case being made for them. Of course, the Delegated Powers and Regulatory Reform Committee has reported on these issues; we will be looking very closely at its report.

It is a matter for regret, as I have said, that the Government did not bring forward legislation in 2017 to solve these problems with a far simpler Bill. Having missed the opportunity to act decisively at the right time, we now have to rush through a far more complicated Bill at a more complex time.

Part 1 mostly sets out yet another NHS reorganisation of commissioning on the back of many previous attempts to do likewise. Commissioning will still be conducted on many levels and be difficult to understand and manage. What the public will make of all this is unknown—but then, perhaps nobody actually asked them.

We know that, in Committee in the other place, the Government made a virtue of the flexibility of the Bill. This extends to changes to procurement and pricing, although no details are available. There is a similar lack of detail about what will happen at place, or indeed how “place” is to be defined, or how the two headed integrated care systems will function and how the money will flow.

The Part 1 new powers of the Secretary of State that are spread through the Bill were not what the NHS asked for. Ironically, one relative success from 2012 was the separation of NHS operational accountability from Ministers; the reasons for reversing this are hard to fathom. As any former Minister, including myself, will understand, it is mystifying as to why Ministers should seek such powers.

We will seek to include amendments that will strengthen the governance of integrated care systems by requiring stronger public, patient, carer and staff involvement as a right. We will seek to ensure that the best people are elected or appointed into key roles with due regard to diversity, fairness and transparency. We will seek to prevent the potentially undue influence of private sector organisations in commissioning, and ensure that contracts are awarded with a proper and transparent process that is as good as the Public Contracts Regulations that will be disapplied. Moreover, the Part 1 clause about discharging patients before they have had their social care needs assessed needs fundamental safeguards to ensure that we do not hear once again of an elderly person being returned in the early hours to a cold and empty home. This has to stop.

Let me turn to what is perhaps the most challenging clause, the one relating to workplace planning. If there is one thing about which there is universal agreement, it is the inadequacy of this clause. Having the right workforce across the health and social care sector is the issue of the day, and the response thus far is wanting. We need to see a more resolute approach that properly plans ahead across the NHS, social care and public health. This is not just about doctors and nurses but about the entire team, including cleaners, care assistants, lab technicians and catering staff. Last but not least, there is the last-minute new clause on the rules for calculating the cap on care costs, which will be robustly scrutinised and opposed by these Benches and by many others.

Of particular interest to me as a former Health Minister are a range of other welcome provisions dealing with virginity testing, fluoridation and hospital food, to name but three of the public health measures on which I used to work. However, it is disappointing to see a dearth of proposals on dealing with the increasing and unacceptable level of health inequalities that have been exacerbated by the pandemic and well highlighted by Professor Marmot over many years.

As was experienced in the other place, we know that there will be many more proposals for new clauses to cover other matters. This is surely a Christmas tree Bill, and decorations will surely abound. We will be glad to support the three new clauses proposed in the other place dealing with duties on reducing inequality, attention to waiting times and restricting the use of the term “nurse”.

Before I conclude, I wish to come back to the important matter of patient safety and the health services safety investigations body. We strongly supported the original Bill and were very disappointed when it suddenly fell off the Government’s radar. Despite efforts from across the House, Ministers were unable to explain where it had gone and why it was not being vigorously pursued in the light of the urgent imperative to embed the “lessons learned” culture into the NHS.

The aim of this body is of course to improve the quality of locally conducted investigations and to reduce the incidence of future harm to patients. The benefits cannot be quantified, but the expectation and the hope are that they will far outweigh the costs incurred by the investigations, avoid costs associated with correcting or compensating for harmful incidents, and encourage health improvement. I hope this will be a major contribution to patient safety.

In conclusion, I regret to say that, however this Bill is presented, it is in effect yet another NHS reorganisation. In the last 30 years, we have seen around 20 reorganisations of the NHS, and the British Medical Journal has observed that

“Past reorganisations have delivered little benefit.”


So the questions for the Minister are many. Why will this Bill be any different? How will the 85-year-old with multiple needs get better care based on them perhaps being treated as a whole person as a result of this restructuring? How will waiting times for elective surgery for cancer and mental health support be improved by this reorganisation? How will health inequalities, which have widened, and life expectancy advances, which have stalled, be corrected by this Bill? A real test for this Bill is: will it makes things better and, if so, for whom?

This Bill can do some good, but its timing is unfortunate at best and an opportunity missed at worst. The question remains as to whether this is the right Bill or the right time. However, if the Bill is to be implemented from 1 April, it has to be the best that we can collectively craft. We look forward to making a positive contribution to making it so.

Cigarette Stick Health Warnings Bill [HL]

Baroness Merron Excerpts

2nd reading
Friday 3rd December 2021 Lords Chamber

[Baroness Merron (Lab)]

My Lords, it is a pleasure to speak in this Second Reading debate on a Bill on which varying views have been expressed. I fear that the noble Lords, Lord Moylan and Lord Naseby, will be somewhat disappointed in me, but it is a risk I am prepared to take because I congratulate the noble Lord, Lord Young, on bringing the Bill forward today. He rightly commands much respect across the House and is a doughty and informed campaigner on this issue.

I am pleased to say that this measure, which was proposed in the other place as an amendment to the Health and Care Bill, has the support of these Benches. It is important to remember why we are talking about it today. We are not talking about it as a measure for a measure’s sake, but as a major contribution to the improvement of people’s health, the reduction of inequalities and people living longer and healthier lives. That is the reason we are discussing it today.

We welcome the Government’s ambition to be smoke-free by 2030, and I hope the Minister will be able to welcome the measures outlined in the Bill. If we look at the 2019 prevention Green Paper, the Government committed to making smoking obsolete, but regrettably there is still no sign of the proposed and promised bold action that they agreed was essential to achieve that extremely challenging shift. There have been great strides in reducing smoking rates and improving people’s health and life expectancy over the past 20 years, but we must acknowledge that a continuing decline in smoking rates is not guaranteed and needs further work. As we have heard, evidence shows that we must constantly renew and refresh our tobacco control strategy to avoid stagnation in smoking rates and a widening of the already significant inequalities in rates between those who are richer and those who are poorer. With only nine years left to end smoking, Cancer Research UK analysis shows that the 2030 target will be missed by seven years and that it will be doubled for the most disadvantaged. I hope that is of concern to this House.

I am pleased to observe that tackling smoking is not a party-political issue. Governments of all stripes have implemented a comprehensive approach to tobacco control, starting at the beginning of this century with banning smoking in public places and in cars carrying children, then the point-of-sale display ban, which I saw through as Minister of Public Health at the time, through to standardised tobacco packaging. They have all helped to drive down smoking rates and have discouraged people, particularly the young, from starting smoking in the first place.

Nowhere is this consensus more evident than in the cross-party support for the Government’s smoke-free 2030 ambition, which if delivered would represent one of the most transformative public health statements and achievements in modern history. It is supported by more than three-quarters of the public, with majority support from voters of all political parties. This suggests a mandate to demand bolder action from the Government to end smoking by 2030.

Ending smoking will improve the quality of people’s health and save millions of lives in decades to come. It will also help to dramatically reduce health inequalities and lift thousands of households out of poverty, making it absolutely central to the levelling-up agenda. Tobacco is the leading cause of health inequalities in our society and is responsible for half the 10-year difference in life expectancy between the richest and the poorest. For every smoker who dies, another 30 are suffering from serious smoking-related diseases that affect not just the smoker but all those around them. This burden is dis- proportionately concentrated in our poorest communities; the Covid pandemic has really laid this bare for all to see. Consequently, people in these communities would accrue the greatest benefit from policies to deter people from smoking and make it easier to quit. Ending smoking for all would lift 500,000 households out of poverty. That includes 740,000 working-age adults, 180,000 pensioners and 330,000 children concentrated in the north and Midlands.

Ending smoking in these communities would not just benefit the health and well-being of individuals but inject into local economies money previously and literally going up in smoke. This would show just how serious the Government are when they talk about levelling up, but disappointingly they have thus far opted not to support the amendments proposed to the Health and Care Bill to get us on track to meet the smoke-free 2030 ambition. This includes the measure we are discussing today. These amendments form a key part of the comprehensive package of messages and measures needed to drive down overall smoking rates while also tackling the disproportionately high rates of smoking among poorer and more vulnerable groups.

To their credit, Ministers in the other place expressed support for the principle behind the amendments, but said they needed more time to consider the proposals. My point to the Minister today is that it has been more than two years since the Government announced the 2030 ambition. With that in mind, when will action be under way to deliver this important commitment?

Ministers have also stated that the Health and Care Bill is not the right place for measures to tackle smoking, which will instead be announced and introduced in the forthcoming tobacco control plan. However, this plan has already been delayed twice and seems unlikely to be published this year as proposed, meaning that we might not see concrete action to deliver the smoke-free 2030 ambition until 2023. When can we expect to see the plan?

We cannot afford to wait this long. The Government have the opportunity to adopt this Bill or accept the tobacco amendments to the Health and Care Bill. We have an opportunity now to move this agenda forward and start building back the nation’s health as we emerge from the worst of the pandemic. I urge the Government not to waste this chance. The Bill would play a contributory and important role in helping us reach the smoke-free 2030 ambition. I hope the Government feel able to support it.

Coronavirus Act 2020 (Early Expiry) (No. 2) Regulations 2021

Baroness Merron Excerpts

Tuesday 30th November 2021 Grand Committee

[Baroness Brinton (LD) [V]]

My Lords, this is beginning to have the feeling of “Star Trek”, which is certainly not my intention. Thank you, Deputy Chairman. I declare my interest as a vice-president of the Local Government Association.

From these Benches, we will not oppose the expiry of these 12 provisions, although we have some comments on them. It was really good to hear the Minister outline the “hands, face, space” guidance, readopted in the past couple of days. Will there be a public communications campaign to reinforce it because, sadly, I suspect that not many people will have heard it in Grand Committee today in Parliament, let alone in the outside world?

Yesterday, in the Statement repeat, we debated masks and self-isolation; we will do so again tomorrow when we look at the SIs. On vaccination, it was good to hear the Prime Minister and the Secretary of State refer to the clinically extremely vulnerable in this afternoon’s press conference. I promise the Minister that I will not repeat all the questions I asked him yesterday, but not one of them has yet been answered. Delivering either the fourth, or a booster, jab for 3.7 million clinically extremely vulnerable people will not work effectively without clearer information systems on exactly who the CEV are and which jab they should get; there is still a lot of uncertainty there. I thank the Minister for his offer of a meeting during yesterday’s Statement. With today’s announcement, vaccination is becoming urgent; I look forward to hearing from him shortly about when it can happen.

From these Benches, we want to make a brief comment on the assessments for local authority care and support. I note that the Explanatory Memorandum says that only

“eight local authorities used these powers between April 2020 and June 2020. No local authorities in England have used them after 29 June 2020.”

That is good to hear, but it is evident that assessments are still happening very slowly. It is one of the problems that hospital trusts across the country are facing, with people in beds awaiting an assessment. Some of that is much more about workforce availability, both in the NHS and in the local authority system, than about the arrangements to reduce these assessments.

Reference has already been made to local authorities having virtual meetings. Members from these Benches and others objected when the Secretary of State decided that all local authority meetings had to cease being virtual in January this year. It has meant that a number of councillors have been unable to attend their council meetings through no fault of their own. If the Lords can have a handful of people contributing virtually, and with cases going up and certain areas having problems, is it possible to return to virtual meetings and leave the matter as a choice for the local authority concerned?

I note that the Explanatory Memorandum says:

“This instrument does not relate to withdrawal from the European Union/trigger the statement requirements under the European Union (Withdrawal) Act 2018.”


However, it is only fair to point out that Section 25 gives early expiration to the power to require information relating to food supply chains to avoid serious disruption. In principle, we do not have a problem with that as a provision during the pandemic, but I say to the Minister: that statement may be true in treaty and UK legislation terms but, as we face this Christmas, there are increasing concerns about disruption to food supply chains, for three reasons.

One is a direct consequence of Brexit. European providers of food and many other products have significantly reduced or stopped exporting to the UK because of the complex, slow and, for both exporter and importer, expensive costs now that we are outside the European Union. Since Brexit, the reduction in the number of EU abattoir workers—as they leave the UK—has meant, this week and for the past month, thousands of pigs and other livestock being culled but not brought into the food chain. Worse, the increase in avian flu cases and the restrictions placed on all poultry farms mean that there are concerns about the supply of birds for the Christmas dinner table. Thirdly, there is a delay in foods and other goods coming in from around the world as a result of the pandemic. This is what one might describe as a perfect storm. Is the Minister confident that, given all these factors as well as trying to manage omicron in its early stages, it is appropriate to expire this particular provision?

We accept the expiry of emergency volunteering leave and compensation for emergency volunteers, although I do want to comment on the problems with the Bring Back Staff scheme, especially for doctors and some nurses. It was absolutely fine in principle, until it hit human resources in trusts. I know of two doctors who had recently retired and were kept hanging around for five months. One was a doctor teaching trainee doctors; however, she was unable to be used because the system just made it impossible for her. If there is any cause to reintroduce this particular provision, will the Minister ensure that we do not gold-plate the complex HR arrangements, making it impossible for staff, former staff or those who might come back on a temporary basis to do so?

We do not believe that the extension of time limits for retention of fingerprints and DNA should remain. We objected to that a year ago, when it was brought in.

Finally, I wrote to the Minister earlier today with real concerns about the problems that some returning international travellers are facing, following the new regulations that came into force at 4 am today, arising from concern over omicron. This is a logistical problem with the change from lateral flow to PCR tests and the passenger locator form. As of this morning, it was still possible to put only the details of your lateral flow test on to the passenger locator form, not the arrangements for the PCR test. One cruise company has 700 people coming into a UK port tomorrow and, despite talking to officials, it cannot get a sense of how the passengers will be able to get off if their details are not on the passenger locator form. I hope another method has been found, otherwise this may be a bit of a problem.

It is right that the Government made the provisions we face today, even if we do not agree with all of them. But I say to the Minister that, as with other statutory instruments, holding on to some of these provisions for a little longer, even if unused, might be useful in case the pandemic takes us down a course that not one of us wants, as the Government and other public services might need to call on them at short notice.

[Baroness Merron (Lab)]

My Lords, I thank the Minister for his most helpful introduction to these regulations, which we will not be opposing. As he acknowledged, when the original Act came into force, we were in extraordinary times and they required unprecedented legislation. However, as time moves on and experience and circumstances change, it is right that we seek to remove powers that are no longer needed. The move to do so today is welcome because, in those circumstances, such provisions should not remain in statute.

Examples of those include Section 56 and Schedule 26 powers relating to magistrates’ courts; Part 1 of Schedule 16, which provides for the temporary closure of education and childcare settings, and was not used; and Section 78 powers around local authority meetings, which need to go because the provisions are simply out of date. On this, I add my voice to a point I made previously in Grand Committee: as the Minister has heard from noble Lords today, surely how a local authority meeting is conducted must be the responsibility of the local authority itself. In the case of these regulations, I accept that the provision is out of date, but perhaps the Minister will apply his consideration to that more general point. The provision of powers to detain infectious people was particularly controversial and it is right that it is removed, having been used only 10 times, the last being October last year.

I will raise a few points with the Minister and I first emphasise the need for clarity of communication from the Government. With that in mind, I refer to the comments of Dr Jenny Harries, the head of the UK Health Security Agency, which she made on BBC Radio 4’s “Today” programme. She said:

“If we all decrease our social contacts a little bit, actually that helps to keep the variant at bay”.


However, a spokesperson for Prime Minister Boris Johnson said that he does not share her view. I understand that the Government have sought to reassure the public that they have no plans to tell people to limit their social contacts with others, which is in direct contrast to the view of this leading medical expert. I would be extremely grateful if the Minister could clear this up for us today.

--- Later in debate ---

[Baroness Merron (Lab)]

That was an invitation I could not refuse to assist the Minister.

[Lord Kamall (Con)]

Thank you. I appreciate it.

[Baroness Merron (Lab)]

Before we go off the issue of face masks, I appreciate the explanation about restaurants, but my question was about large gatherings—for example, cinemas, theatres and conferences, to name but a few. The explanation about restaurants does not apply there. I hope the Minister will take this back as it is simply a question of where is the logic regarding the venue. It seems to make no difference; it is about the fact of there being a number of people.

The real point I would re-put to the Minister, which links with that, is my question about the comments of Dr Jenny Harries on Radio 4. She said that we should decrease our social contacts, whereas the spokesperson for the Prime Minister says that we will not be doing that. I am very concerned about mixed messaging, as I am sure the Minister is—I know he is from what he has said. It would be extremely helpful to put on the record where we are on whether decreasing social contact makes a difference.

[Lord Kamall (Con)]

I apologise if I was not clearer before. I thank the noble Baroness for taking advantage of the opportunity to ask that question and finding the urge to do so irresistible. On theatres and cinemas, one of the things that was put to us was that in a restaurant, you are constantly taking a mask on and off, whereas in a cinema or theatre you are not really eating that much. Okay, you might well go to buy your ice cream—I do not know whether they still sell ice cream and jelly babies in theatres, or whatever it used to be; this will look very odd in Hansard when someone reads it—but you are not constantly doing and you are more or less constantly wearing your mask. However, I will take that back. It is a fair point, and one thing that I do when I am being briefed is to challenge because I know that noble Lords will rightly challenge me on this issue.

In response to the comments by Jenny Harries, I hope I have been clear that we take advice from a range of advisers and there is not yet consensus, but we have been relying not just on making mask mandatory when necessary as a precaution, but at the same time on people’s individual behaviour and them acting responsibly. It is about getting that balance right. We listen to Dr Jenny Harries, but she is one of a number of experts whom we listen to. We weigh up the different views; it is as simple as that. As we have been clear, there is no one trigger for any of these measures. We always consider a range of measures, including capacity in the NHS, the trends et cetera. I have listed them in previous debates. It is not one person whom we listen to. We listen to a range of experts.