Tobacco Packaging

John Baron Excerpts

Thursday 28th November 2013 Commons Chamber

[Jane Ellison]

The hon. Gentleman refers to another Bill, rather than the issue we are discussing now. I have heard none of those concerns from the charities he mentioned, which I understand have warmly welcomed today’s announcement.

[Mr John Baron (Basildon and Billericay) (Con)]

I, for one, very much congratulate the Minister on this welcome news. As she well knows, the all-party group on cancer has been one of many that have argued for added urgency on this issue. The Government have listened and responded, which is a sign of strength, not weakness. To follow up a previous question, will the Minister give an assurance that the regulations will be in place before the end of this Parliament, because if the recommendations are in favour of introducing standardised packaging, they will need to be implemented quickly?

[Jane Ellison]

That is certainly the objective of the timetable that has been drafted, once the Government have received the review and made a decision. I see no reason why what my hon. Friend suggests could not be the case.

Oral Answers to Questions

John Baron Excerpts

Tuesday 26th November 2013 Commons Chamber

[Dr Poulter]

That is a question that the hon. Gentleman had much better address to his own Front Bench, who made the decisions to devolve these responsibilities locally. When it comes to commissioning health services, we believe it is down to doctors and nurses, who are now leading clinical commissioning on the front line, to determine which services are appropriate in local areas. There were clearly concerns about the way that urgent care centres had previously been commissioned. That is why so many of them are now being relocated and co-located in accident and emergency departments.

[Mr John Baron (Basildon and Billericay) (Con)]

T8. The Secretary of State is well aware that the all-party group on cancer has campaigned long and hard for the monitoring of one and five-year survival rates as a means of promoting earlier diagnosis, cancer’s magic key. Is he confident, though, that the mechanisms are sufficient to ensure that those clinical commissioning groups that are underperforming in relation to their one and five-year survival rates will face concrete action to improve earlier diagnosis, given the recent OECD report suggesting that 10,000 lives a year could be saved in this country if we matched European average survival rates?

[Jane Ellison]

My hon. Friend is right to champion early diagnosis and he has raised these issues in the House on many occasions and with me. Improving cancer survival is a key priority for this Government. We aim to save an additional 5,000 lives each year by 2014-15. Clinical commissioning groups have a duty on early diagnosis. It is part of their crucial outcomes indicators set, and they will be held to account for that because we cannot deliver those improvements in cancer outcomes without early diagnosis.

Tobacco Packaging

John Baron Excerpts

Thursday 7th November 2013 Commons Chamber

[Jane Ellison]

We are aware of that, but smoking in this country has dipped below 20% for the first time ever. I am aware of the hon. Lady’s concerns and I shall talk a bit about some of the public health campaigns and the new opportunities, not just for the Government but for local government and individual Members, on tobacco control policy.

As our plan makes clear, effective tobacco control needs comprehensive action on many fronts. The Government are taking action nationally. We are committed to completing the implementation of legislation to end the display of tobacco in shops. Since 2012, supermarkets can no longer openly display tobacco. In 2015 all shops will need to take tobacco off view. Tobacco can no longer be sold from vending machines, which has stopped many young people under 18 accessing smoking.

I do not want to downplay the importance of this policy—we are conscious that it could make an important contribution—but we can do many other things. The reasons why children, in particular, take up smoking are very complex, and are to do with family and social circumstances. One policy alone will not address that. Local authorities have a vital role to play, which is why we have given local government responsibility for public health backed by large ring-fenced budgets—more than £5.4 billion in the next two years. I encourage all hon. Members who have participated in today’s debate to ask tough questions of people locally. I hope that they are talking to their public health directors, health and wellbeing boards and clinical commissioning groups about where tobacco control sits in the armoury of local government. That is why this power has been devolved. The local insight and innovation made possible by that policy will help us to tackle tobacco use at a local level as well as through policies that the Government can put in place.

[Mr John Baron (Basildon and Billericay) (Con)]

I congratulate the Minister on her obvious grasp of the subject. She is right to say that this will be a continuing debate beyond the issue of standardised packaging. Does she agree, however, that an increasing welter of evidence suggests that standardised packaging would help in the fight against smoking, particularly among the young? Will she give an assurance that the Government will increase the urgency of their review of the situation, and especially of the growing evidence in favour of standardised packaging?

[Jane Ellison]

I can give my hon. Friend that commitment and I am giving this my urgent consideration. It is impossible to sit through a debate such as today’s, and hear the passion expressed by many hon. Members on both sides of the House, without going away, as the public health Minister, to give it one’s serious, urgent and active consideration.

I have laid out a little challenge to hon. Members to take this issue up at the local level. I appreciate that it is right that I should be held to account on this issue, but in the new world of devolved public health powers, I urge hon. Members to have those conversations with their health and wellbeing boards and with public health directors. In areas of the country where smoking prevalence among children is a difficult issue—some examples have been cited in the debate—our belief is that by devolving some of the power and, importantly, the ring-fenced budget to local authorities who know their communities best, they can begin to tackle the problem with great urgency and added innovation in a way that central Government cannot.

Public Health England has an important part to play. As a new, dedicated, professional public health service, it will be available to advise on local action to promote public health and encourage behaviour change to help people live healthier lives. It will put expert advice at the disposal of local authorities.

Cancer Patient Experience

John Baron Excerpts

Wednesday 30th October 2013 Westminster Hall

[Mr Clappison]

I am grateful to the hon. Gentleman for that intervention. I agree that communication skills are important; the important factor is that kindness should be received by the patient.

I put a point to the Minister on behalf of Macmillan Cancer Support: I hope that the Government will deal with the matters we have discussed and put patient experience at the heart of the inspection process being put in place for our health service. One way of doing that is to use the results of the cancer patient experience survey to inform ratings at a cancer team and service level and to monitor and assess providers of care—for example, as part of the foundation trust assessment process.

In the light of all that, I have four specific questions for the Minister, on behalf of Macmillan Cancer Support and other charities. First, will the Government consider making relational care a priority area in the refreshed 2014-15 mandate to NHS England? Secondly, will the Government support the use of cancer patient experience data in the inspection regime of the Care Quality Commission, which is led by the chief inspector of hospitals?

Thirdly, will the Government work with commissioners and providers to ensure that the results of the national cancer experience survey continue to drive improvements in cancer care? Fourthly, and specifically on breast cancer, can the national cancer patient experience survey include a question asking whether the respondent has secondary breast cancer? The Breast Cancer Campaign specifically asks to have that included.

More generally, I welcome the Government’s ambitious plans to improve cancer care in the United Kingdom, including those they set out in January 2011 in “Improving Outcomes: A Strategy for Cancer”, which promised action on a number of important fronts, such as diagnosing symptomatic cancer earlier; helping people live healthier lives to reduce the incidence of preventable cancers; screening more people; introducing new screening programmes, as recommended by the National Screening Committee; and ensuring that all patients have access to the best possible treatment, care and support.

Those measures should save at least an additional 50,000 lives every year by 2014-15. Many of us will be aware of the efforts being put into those different fields, to encourage people to come forward for screening, to make screening available, to make members of the public more aware of symptoms and to encourage people to lead healthier lives. That has been much more evident than it had been hitherto. In the light of all that, it would be good to hear from the Minister what progress has been made on the ambitions that the Government set out in January 2011.

Furthermore, what progress has been made in tackling inappropriate regional variations in cancer outcomes? Many advances have been made in cancer treatment in the UK, of course, but historically there has been a disparity on cancer survival rates between the UK and other comparable western nations. That has been the case for many years, under Governments of all parties, but it was underlined most recently by a 2009 Eurocare study, which revealed a disparity between UK cancer survival rates and those achieved in countries with the best outcomes.

England rated 16th in the survey for both men and women. Wales was ranked just in front, and Scotland and Northern Ireland were just behind. Apart from Ireland, every other major western European nation performed better than the UK, and some of them much better. Sweden was the best performing country.

The 2009 analysis was a little old, because it was based on patients diagnosed between 1995 and 1999, although that had to be the case to detect survival rates. More recent surveys have also seen the same pattern, such as one comparing the USA with the United Kingdom. With older patients, there is an even more marked gap between the UK and other comparable nations and economies. I have seen figures from the British Journal of Cancer that show that for women over 70 with breast cancer, the three-year survival rate in the UK is 79%, but in Sweden, it is 91%.

[Mr John Baron (Basildon and Billericay) (Con)]

I congratulate my hon. Friend on securing the debate. Although comparisons are always dangerous, a further acknowledgement of how far we remain behind our European partners is that even if we met the Government’s laudable target of saving an extra 5,000 cancer lives over the next couple of years, that would still only bring us up to the European average on survival rates.

[Mr Clappison]

My hon. Friend makes an excellent point. I am sure he would agree that there is a lot of ground to make up. The important point is that we should not only take encouragement from the improvement of survival rates as a result of advances in medical science; we should judge ourselves by how well we use those advances compared with other countries. We should set ourselves the more ambitious target of not just improving survival rates, but improving them so much that we close the gap on other countries.

Members of the British public who fall ill with cancer and their families expect cancer treatment to be on a level with that of comparable countries, our neighbours and other western developed economies. Sadly, it is not at that level, although I hope the Minister will tell us that we have made some progress.

Yesterday, some encouraging statistics were released that showed a trend of increasing survival for patients diagnosed between 2007 and 2011. The Minister will agree that that is good news, but I look forward to hearing from her that the Government’s ambition is to close the performance gap between ourselves and other countries and that the gap is being closed.

In closing, I should like to pay the utmost respect to doctors, nurses and all clinicians working in the field. We owe them a great debt of gratitude and my comments are no reflection on them. We are all hugely indebted to their work and I am sure that many of our constituents would echo that sentiment. I am just drawing attention to how the system has operated in this country over a number of years, and the experience of the patients within it. I hope that the Minister can tell me that the Government have ambitious plans for improving the cancer patient experience and that there is evidence that those plans are on the road to fulfilment.

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[Mr John Baron (Basildon and Billericay) (Con)]

I congratulate my hon. Friend the Member for Hertsmere (Mr Clappison) on securing this important debate. I apologise to him that I will have to leave slightly early to meet, coincidentally, the new cancer tsar, Mr Sean Duffy. That appointment has been in the diary for some time. I echo my hon. Friend’s warm words of praise for all those charities and individuals who work towards combating this disease. They do excellent work, which I know all of us across the House very much support and praise.

As chairman of the all-party group on cancer, I congratulate the Government on their excellent work on cancer in recent years. Focusing on outcomes as a driver of change within the NHS has been crucial in not only driving up outcomes, but ensuring that changes in the NHS take place for the benefit of patients.

I will not speak for long, because I am conscious that there will be other speakers after me, but to give a little bit of the history, the all-party group produced a report in 2009 on cancer inequalities across the UK. We tried to analyse why patients who reach the one-year point in this country stood as much chance of getting to the five-year point as in any other health system in Europe, while we fell down on getting patients to the one-year point. That result tends to suggest that the NHS is as good as, if not better, at treating patients once cancer has been diagnosed, but is very poor at diagnosing cancer in the first place.

We tried to come up with a solution for how to drive forward earlier diagnosis. I suggest that that is the magic key for cancer. There are very few magic keys in life that will unlock the door to a panoply of unexpected treasures, but one exists for cancer—earlier diagnosis. With the wider cancer community, the all-party group—it sees itself as representing that community in Parliament—proposed putting up in lights the one-year and five-year survival indicators.

Instead of bombarding local primary care trusts, as they then were, with lots of targets and bureaucracy, we decided to put up those indicators in lights, with the emphasis on the one-year point, as a driver of change. PCTs—now clinical commissioning groups—that were towards the bottom of the table would, if their managers were worth their salt and their large salaries, introduce local initiatives, peculiar to their population: for example, whether theirs was an ageing population, whether an adaptation was needed for an industrial illness, such as mesothelioma, or whether there were black and minority ethnic communities. Those local initiatives would drive up earlier diagnosis to combat those poor one-year survival figures, because we all know that late diagnosis makes for poor one-year survival figures and, in turn, poor five-year figures.

The Government listened not only to us, but to the cancer community that also came up with the idea, and to Members from both sides of the House who came in behind it. We campaigned together, and we are delighted that the Government have now put in place one-year and five-year survival figures both nationally and locally through the CCG outcomes indicator set—brilliant news.

There has to be a bit of tweaking, for the simple reason that we were previously dealing with PCT populations that were larger than those of CCGs, so the issue of statistical significance comes into play. I was not wholeheartedly behind—in fact, if anything, I was quite sceptical—about the structural changes to the NHS, but that is now history and we have to deal with the future. Given that the populations are smaller, we are now arguing for the introduction of proxy measures locally to supplement, although not to replace, the one-year figures. Measures focusing on accident and emergency and on staging would be two ways to supplement the one-year figure. That is an ongoing conversation, and the Government and NHS England are in constructive dialogue with us about it.

I mentioned the focus on outcomes because, to achieve improved cancer outcomes, it is essential to put up in lights the patient experience and to prioritise it nationally and locally. If I have one concern about the present direction of Government policy, it is that patient experience is built in at national level, through the outcomes framework, but as yet, it is not built in at the local or outcomes indicator set level. I am not alone in worrying that there will be a disconnect. Setting the bigger picture strategy is well intentioned and essential, but if we are really to improve patient experience, we need to ensure that that national policy is followed through locally. At the moment, that is not taking place, and if we do not put that right pretty quickly, we risk not meeting the Government’s laudable target of an extra 5,000 lives saved by 2015, which is something that we all very much want.

The Minister, to whom I wish the very best in her new post—I did not get the opportunity to say that in Health questions—will know from her civil servants that the cancer community and the APPG on cancer participated in the public consultation on the 2013-14 clinical commissioning group outcomes indicator set. Held by the National Institute for Health and Care Excellence, it listed patient experience of cancer services as a potential indicator for future development. The NICE CCG OIS advisory committee agreed that such experience would be useful, yet it is not included in the 2014-15 CCG outcomes indicator set. I ask the Minister in all earnestness to look at that again. We are talking about NHS England to a very large extent, but I would be very surprised if there were not conversations with it about such issues. Will the Minister use her influence and best offices to try to influence the debate?

There is no shortage of reasons why cancer patient experience is important and why it should be included locally. I will bombard the Minister with one or two facts. We know, for example, that there is vast variation of cancer care across the country. There are unacceptable geographical variations, and we need to iron them out. There have been some particularly bad examples recently in London, and we need to look at them.

Within cancer itself and the condition of cancer, there are huge variations. For example, people with rarer cancers report a worse experience. People in the most deprived areas report less favourably on their care. Those are reasons why the monitoring of cancer patient experience locally is important.

Furthermore, the cancer patient experience survey is effective at driving improvements locally, and that must not be overlooked. By contrast to the current CCG OIS indicators under domain 4, the cancer patient experience survey captures detailed service specific data about trusts’ performance across a range of aspects of cancer patient experience. For example, all London trusts put action plans in place, following the 2010 cancer patient experience survey, so we know that that is effective. We do not need to reinvent the wheel on that one; we have something within our possession that is effective in driving forward improvements. The idea of monitoring cancer patient experience locally is feasible.

As my hon. Friend the Member for Hertsmere mentioned, more than 2 million people are living with and beyond cancer. That will rise to 4 million by 2030. Cancer is a unique and complex medical condition, and as we well know, certain aspects of patient experience have a particular emphasis for people living with cancer.

The CPES has a high sample size and response rate. Data from the 2010, 2011 and 2012 surveys are already easily accessible for CCGs to analyse. They are useful and user friendly. Furthermore, the CPES is regarded as an example of best practice in measuring holistic patient experience of care—looking at the complete pathway—which is something that we do not talk enough about in the NHS. It is particularly important, as the Minister fully understands, when it comes to cancer patients.

In conclusion, lots of good work is being undertaken by the Government on cancer. The Minister will know that I am not afraid to come forward and say otherwise if I think that that is the case. None the less, I urge her to look again at what appears to be a disconnect between a national priority and implementation locally. The cancer patient experience survey is terribly useful, helpful and effective. We need to get it into the CCG OIS. I hope the Minister will respond to that point when she sums up, but I apologise that I will not be here to listen to her.

Oral Answers to Questions

John Baron Excerpts

Tuesday 22nd October 2013 Commons Chamber

[Mr Hunt]

As I said in response to an earlier question, the responsibility to be transparent about care should apply equally in the public and the private sector. Obviously, in the public sector we have more levers, because we are purchasing care and we can impose more conditions than it is possible to do in the private sector. The most important thing is to have a culture in which such problems come to light quickly when they happen, so that they are dealt with and not repeated.

[Mr John Baron (Basildon and Billericay) (Con)]

15. For what reasons the publication of data on one-year and five-year survival rates for all cancers within the Clinical Commissioning Group Outcomes Indicator Set has been deferred until March 2014.

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

I am aware of delays in the availability of source data at a local level. For that reason, it is not possible to publish data on one-year and five-year survival rates for all cancers before March 2014. I know that my hon. Friend is frustrated by this and that he has done a lot of work on this issue as the chair of the all-party group, but I am sure he will agree that it is better to have accurate information to make these vital clinical judgments.

[Mr Baron]

The Minister will be aware that the all-party group on cancer has campaigned long and hard for the monitoring of the one-year and five-year survival rates as a driver for earlier diagnosis—cancer’s magic key. What assurances can she give that the March 2014 deadline will be met and that appropriate action will be taken against those CCGs that underperform?

[Jane Ellison]

We have spoken to NHS England, which has advised me that it is not aware of any reason to think that the March 2014 will not be met. As my hon. Friend knows, however, the day-to-day management of CCGs is a matter for NHS England, and I am sure he would not approve of Ministers trying to micro-manage CCGs from Whitehall. His strength of feeling is clear, and I am happy to have an ongoing dialogue with him and the all-party group on this matter.

Hospital Mortality Rates

John Baron Excerpts

Tuesday 16th July 2013 Commons Chamber

[Mr Hunt]

Staffing levels are indeed one of the issues that contribute to poor care, if we get them wrong. That is why we are committed to implementing the Francis recommendations on safe staffing levels, and why, having protected and increased the NHS budget—contrary to what the shadow Secretary of State wanted—we now have 6,000 additional doctors working in the NHS. [Interruption.] In these individual cases, if staffing levels are the issue, they will be addressed.

[Mr John Baron (Basildon and Billericay) (Con)]

The Secretary of State has been absolutely right to highlight and pursue past failures for the benefit of future patients. That includes investigating why the regulatory system seems to have failed in these cases. Does he agree, however, that we must not allow the report to overshadow much of the good work that is being done in our hospitals, including Basildon hospital which now has new management and is instigating changes?

[Mr Hunt]

I agree with that. One reason why it is so important to reform the regulatory structures that we inherited is that they tried to identify only poor care—not terribly successfully—when we need a system that identifies outstanding care as well. We need such a system for the benefit of the general reputation of the NHS and the morale of the service. We also need one so that a failing hospital can have an organisation on which it can model itself, just as a failing school can model itself on a school that has received an outstanding Ofsted report. That provides a solution to the problem: we identify a problem transparently and we sort it out.

Oral Answers to Questions

John Baron Excerpts

Tuesday 16th April 2013 Commons Chamber

[Norman Lamb]

My ambition is that the UK have a global reputation for the best possible care at the end of life. Whether we are talking about the Liverpool care pathway and concerns that have been raised about some care in hospital or care in the community and caring for people at home at the end of life, it is essential that people have a dignified death and the best possible care. Everything we are doing is aimed at achieving that. Where there are specific cases such as the one the hon. Lady raises, the relatives have the right to pursue a complaint, and ought to do so if care has fallen below an acceptable standard.

[Mr John Baron (Basildon and Billericay) (Con)]

14. How the NHS will be held to account on the experiences of cancer patients using the NHS.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

The Secretary of State made it very clear to NHS England in his mandate that we expect to see an improvement in patient experience.

[Mr Baron]

The Francis report recommended that the NHS be held to account on patient experiences. Given that the national cancer patient experience survey is a proven tool in driving up the quality of care, will the Minister endorse calls for the survey to be carried out annually, and support the development of a clinical commissioning group outcomes indicator set indicator based on the results in order to incentivise CCGs to improve cancer patient experience?

[Anna Soubry]

I am grateful to my hon. Friend for those comments; as he knows, these are now matters for NHS England. I will make sure it is aware of what he has said and his urging it to do both those things for the obvious benefits they would have for a cancer patient’s experience.

Oral Answers to Questions

John Baron Excerpts

Tuesday 26th February 2013 Commons Chamber

[Mr Hunt]

We are investing £34 million in cardiovascular research. Much excellent work is being done at, in particular, the Oxford Biomedical Research Centre, which will help us to make great strides.

[Mr John Baron (Basildon and Billericay) (Con)]

19. It is widely accepted that late diagnosis of cancer makes for premature mortality. Will the Government recommend the inclusion of proxy measures such as staging and accident and emergency admissions in the outcomes indicator set, as a way of complementing the one and five-year survival measures? That would give us a more complete picture of how CCGs are performing in encouraging earlier diagnosis.

[Mr Hunt]

I congratulate my hon. Friend on his campaigning. No sooner do we agree to the inclusion of one indicator in relation to early cancer diagnosis than he finds another that should also be included.

I will certainly consider the issue that my hon. Friend has raised, but I think that there is a broader question about the role of GPs. They should see themselves as being in the front line when it comes to early diagnosis of not just people who walk through the doors of their surgeries, but people in their communities who are at high risk. That is a much more fundamental change that we need to think about.

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[Mr Jeremy Hunt]

I am aware how concerned people are throughout north-west London about the proposals. If the matter is referred to me by Ealing council, I will indeed ask the independent reconfiguration panel for its independent view on the proposals.

[Mr John Baron (Basildon and Billericay) (Con)]

T9. The cancer drugs fund has been a huge success and has helped up to 25,000 patients, but the negotiations between the Government and the pharmaceutical companies on its replacement—value-based pricing—is causing real uncertainty for cancer patients and clinicians alike. For example, will new medicines be available to new patients under the new system and what guidance is being given to local cancer drugs funds as they wind down? Can we please have clarity urgently?

[Mr Speaker]

I think the hon. Gentleman was seeking an Adjournment debate and is disguising his request as a question, for which we are grateful.

Oral Answers to Questions

John Baron Excerpts

Tuesday 15th January 2013 Commons Chamber

[Mr Hunt]

I know that the hon. Lady spoke very movingly in the debate on dementia last week and I wholeheartedly agree with her. The medicines available for people with dementia do not help everyone, but we do not know that until we try them. By diagnosing only 42% of people with dementia, as is currently the case, we are denying nearly two thirds of dementia sufferers the chance to see whether they could benefit from those medicines and, as she rightly says, the chance to plan their care, which could mean that they could live at home for much longer.

[Mr John Baron (Basildon and Billericay) (Con)]

The all-party group on cancer is delighted that the one and five-year cancer survival indicators have been included in the CCG outcome indicator set. We have campaigned for that in the belief that it will drive forward earlier diagnosis, as the Secretary of State knows. Can he clarify how CCGs will be held to account through that indicator set? For example, what action will be taken on underperforming CCGs?

[Mr Hunt]

I congratulate my hon. Friend on his campaigning on cancer issues through the all-party group. The NHS Commissioning Board is held to account through the mandate, which clearly states that we must make tangible progress towards having the lowest mortality rates in Europe for cancer and a number of other major diseases. I will expect the board to clamp down hard on CCGs who fail to deliver on what needs to happen for them to deliver on that promise.

NHS Commissioning Board (Mandate)

John Baron Excerpts

Tuesday 13th November 2012 Commons Chamber

[Mr Hunt]

Any such examples are totally unacceptable. The rights that people have to the treatment they need clinically are enshrined in the NHS constitution. There will always be a need for MPs and other campaigners to highlight problems in the system, but we hope to make it much easier by exposing unacceptably low levels of clinical care much earlier than happens currently. As a result of the changes in the next two years we will see the NHS becoming the most transparent health care system of any in the world, which we hope will enable us to identify failures before they lead to the kind of tragedy the right hon. Gentleman mentions.

[Mr John Baron (Basildon and Billericay) (Con)]

I understand that the Government are adding the one and five-year indicators for all cancers to existing indicators in the NHS outcomes framework. That is very welcome. It will particularly help those with rarer cancers, and the all-party group on cancer has long lobbied for it. Will the Government work towards ensuring that the commissioning outcomes framework, which measures clinical commissioning groups, mirrors those one and five-year indicators, which are terribly important in encouraging earlier diagnosis so that we have coherent policies at the national and local level?

[Mr Hunt]

May I thank my hon. Friend for his work campaigning on cancer? He is absolutely right. We want to make sure that we pick up rarer cancers, so we are moving towards a composite indicator for cancers with the one and five-year measures. He is absolutely right that, properly to drive improvement, we need to compare not just hospital and consultant-led teams, but local GP-led commissioning groups, so that where there are successful outcomes everyone knows that. To get that comparison to work, we have to ensure that we compare the demographics. Part of the work we are doing is to understand how we can meaningfully compare CCGs, so that the public can truly understand who is doing best and who needs to do better.