Cerebral Palsy: Adult Care Transition

Paul Maynard Excerpts

Thursday 30th March 2023 Commons Chamber

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

It is a pleasure to have the chance to participate in a debate on cerebral palsy. I tend to be quite sparing in the opportunities I take to discuss this matter in this Chamber. I restrict myself to one opportunity per Parliament, so this is my effort for this particular part of the decade. So many and varied are the issues that could be covered that I could hold a debate on cerebral palsy every week of the year.

Cerebral palsy is one of the least well-understood conditions around—the incidence among the general population is the same as for Parkinson’s or motor neurone disease—and I think that it is partly because of that, and partly because of its broad spectrum of impairment, that it does not have the same profile in the public consciousness. Nor did it have, until recently, a condition-specific charity. Now, at least, I can thank Action Cerebral Palsy and the Adult Cerebral Palsy Hub for their actions and support for the all-party parliamentary group on cerebral palsy, which I chair, as well as the Cauldwell Children charity, which not only sponsors our APPG but, perhaps more importantly, supports tens of thousands of families up and down the country whose children often have quite complex special educational needs.

In this place, we often discuss issues around the transition from childhood into adulthood, so the Government recognise what a crucial stage that is in someone’s personal development. We consider it with regard to care leavers, for whom support has been extended to the age of 25, as well as to the introduction of education, health and care plans, which have also been extended to the age of 25. I think that we need to apply the same philosophy to cerebral palsy.

I mentioned earlier the broad spectrum of impairment, which is, I think, part of the problem in the way in which both Government and society as a whole deal with the condition. Eighty per cent. of those with cerebral palsy have some form of spastic motor impairment, but that is so broad that it ranges from the likes of me, who can function fine 98% or 99% of the time, to those with dyskinetic forms such as the twisting and repetitive movements known as dystonia, the slower movements known as athetosis, and irregular, unpredictable movements known as chorea, so planning for the inclusion of those with cerebral palsy in the adult world has to be, by definition, an individualised process.

The existing legislative framework is disconnected and fragmentary, and does not account for cerebral palsy as a condition in its own right. Indeed, all too often, I feel that it is bedevilled by ignorance on the part even of medical experts at times, and by a lack of common sense from providers. As those of us with cerebral palsy leave full-time education, we encounter a much less structured world where preconceptions about our abilities seem to be so much greater and, invariably, utterly misguided.

People watching the debate on their TVs will assume that I am drunk. That always happens; every time I stand up in this place and appear on TV, I get an email saying, “Why were you drunk when you appeared in the Chamber?” I personally find that quite ironic because I am actually allergic to alcohol as it is a trigger for my epilepsy. It is perhaps a good thing to have a Member of Parliament who is allergic to alcohol and can always speak and, indeed, vote with a clear mind—if only we could all manage that. Preconceptions about cerebral palsy are rife, day in, day out. I stress once again for the record that cerebral palsy is not an intellectual disability—it never has been; it never will be.

Help and advice for individuals during their transition into adulthood are all too scarce. During the course of the APPG’s inquiry into this issue, I have been consistently struck and, indeed, depressed by how policy and practice, as well as day-to-day experience, have not moved on since my own passage through education and early adult life. Indeed, the online community Cerebral Palsy Adult Advice UK made the following submission to the APPG’s inquiry:

“We have been totally overwhelmed by the number of adults joining our group looking for help because they have no idea where to start… we have been inundated by members seeking help—help that we are not equipped to direct them to, because it simply doesn’t exist.”

One young person with CP told us:

“I have to be the educator and adviser—there is still too much ignorance at every turn and an immediate assumption of my mental incapacity”.

This all leads to thwarted ambitions. The all-too-human desire to make the best of ourselves can be very hard to fulfil, given the hurdles that so many with CP face. People often ask me how I feel about what I must be missing out on in life. I get that question so often, and it really angers me. How could I have any conception of what I am missing out on? This is my lived reality day in, day out; I do not know any different. I do not feel I am missing out. I do not feel that there is any detriment to my life experience, but people always make that assumption.

There has to be a fundamental re-design of the services, rights and processes involved in the transition to adulthood. The consequence of not doing so is a failing at both an individual and systemic level of what is needed to support, equip and prepare young people with cerebral palsy as they move into adulthood and a lack of understanding of the day-to-day challenges that they will experience. Every young person with cerebral palsy must have in place a road map for their transition to adulthood that includes their education, health and care needs.

Like any good APPG report, mine has come up with a 10-point plan—I often wish we had 11 points or nine, just for a bit of variety, but there we are. As we have a Minister from the Department of Health and Social Care, my hon. Friend the Member for Faversham and Mid Kent (Helen Whately), here today, I will restrict myself to the health points. I recognise that a special educational needs and disabilities review is under way, which will consider the other points that I will not raise today.

The APPG recommends that each child and young person with cerebral palsy and their family must have a dedicated lead professional to act as an advocate, co-ordinator and support from the point of diagnosis through to the completion of their transition to adulthood. Each integrated care system must enhance the empowerment of young people living with CP by creating dedicated budgets for the individual to access the necessary resources and services from the public, independent and voluntary sectors to prevent the deterioration of their health and wellbeing in adulthood.

Every integrated care system in England should create new regional hubs of specialisms for those living with CP hosting multidisciplinary teams, bringing together experts from the public, independent and voluntary sectors. These hubs would have a specific focus on upskilling, training and recruiting specialist therapists and clinical practitioners.

The Government should make available investment in high-quality healthcare, therapy and education to unleash the potential of young people with CP, which, in turn, will reduce future costs in adulthood incurred by those living with the condition.

Dedicated healthcare transition care pathways for young people with cerebral palsy, alongside a dedicated adult service for the condition, should be in place in all nations of the UK. I have always been struck that I had no medical follow-up after the age of about 13, with no more physio and no intervention, yet that was the point at which my body was growing the fastest and my muscles and limbs were outgrowing the ability of my brain to develop them properly. Right when I needed it most, I had the least intervention of all. I only began returning to a proper form of physio three years ago, which has made an immense difference, not necessarily visibly but to my core body strength and my ability to do things that we need to do in daily life. That is why it is really important that we do a much better job at identifying people with CP, to monitor their development throughout their lives. I welcome the fact that the cerebral palsy integrated pathway is being upscaled to create cerebral palsy registers in every part of the UK. That has to be a good thing, but we must build on it and utilise that information now that it is being collected.

An estimated one in four children and young people with cerebral palsy will be non-verbal and require the use of assistive technology and alternative and augmentative communication strategies throughout their life. Preliminary research findings from Ireland have found that, while assistive technology—or ATech, as it is called—is valued, it also carries a “challenging and lengthy” funding process and high rates of abandonment without proper assessment or training. This is an issue that I have done a great deal of work on with Ministers during my time in this place, and I recognise that ATech is something that is now really embedded in the Government’s approach. I welcome the work done in the UK by bodies such as the Ace Centre to make us a world leader when it comes to ATech; I am pleased to also chair that APPG, but I will save that for what I suspect will be a future Adjournment debate. I am grateful to the disability Minister, my hon. Friend the Member for Corby (Tom Pursglove), for his engagement and support and for recognising the role ATech can play in the workplace.

All the strategies I have outlined are lifelines for young people with cerebral palsy who have challenges with motor function and verbal communication. Effective and timely access to appropriate equipment and training in the use of technology, which should start in infancy for all those who will require it, will enable the young person to engage fully within their social environment, home and school or further education community, and in the workplace. Families with young people with cerebral palsy have given testimonials to the APPG that they require expertise and support from professionals who understand how the interrelated comorbidities of cerebral palsy impact on each area of their son or daughter’s life. Parents have described the sense of exhaustion that they are driven to by having to explain their child’s condition to multiple agencies over and over again, and facing long delays for decisions to be taken and funding agreed on.

The most common proposed solution from parents and carers of young people with cerebral palsy is the creation of one-stop-shop regional centres, bringing together expert professionals: doctors, therapists, orthotists and dieticians, dentists, nurses, educationalists, and indeed anyone we can think of to collaborate and meet the holistic needs of the individual with cerebral palsy. For example, changes or deterioration in tone and postural stability related to growth may result in orthopaedic issues. Those may in turn lead to a need for changes in seating, wheelchairs and hoists, which may in turn affect access to augmentative and alternative communication or AT devices.

In its submission to the APPG, University College London Hospitals NHS Foundation Trust called for inequalities in health services for those living with cerebral palsy throughout the UK to be addressed by making it a statutory obligation for each integrated care board to provide a multidisciplinary service for people with cerebral palsy living in their area. I concur with that suggestion—indeed, I desperately await being drawn out of the hat for a private Member’s Bill one year, which I will use to put that suggestion forward as a Bill, because it sounds like just the sort of thing that would have a chance at going through. In the meantime, policymakers must put in place urgent and ongoing measurements of the capacity of local areas and integrated care boards to deliver the level of support that young people with complex cerebral palsy within their areas require, including appropriate access to doctors, healthcare and therapists.

I recognise that I have read out a very long shopping list today, but that is partly because we are starting from a much lower point than so many other conditions. Therefore, perhaps predictably in an Adjournment debate, I ask the Minister to please meet me and Action Cerebral Palsy to discuss all those issues—and more, I have no doubt. Cerebral palsy should not be seen as a condition where the prognosis is gloomy and the existence is depressing, but rather as a condition, however severe, where the individual living with it can, with help, live a productive and fulfilling life. That is what we anticipate and aim for for all our children; it should be no different for those children living with cerebral palsy. I thank the Minister for listening today, and look forward to hearing her response.

Oral Answers to Questions

Paul Maynard Excerpts

Tuesday 24th January 2023 Commons Chamber

[Steve Barclay]

First, that is exactly what the women’s health strategy is doing through designing women’s health hubs. It is exactly why we are appointing a wider portfolio of roles into primary care. The hon. Lady says that Labour has a plan, but Labour’s plan is to divert £7 billion out of primary care property, which will not improve services for women and will actually impede the ability to deliver exactly the sort of services she is calling for.

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

Thornton Cleveleys will see a 17% increase in new patients registering for primary care in the next five years, exceeding the physical capacity. Cost-effective solutions have been found, but the obstacle is the integrated care board, which keeps changing its mind as to whether money is or is not available. The clock is ticking on the need for this new capacity. Will the primary care Minister meet me to resolve this impasse and get the ICB to sort its act out?

[Steve Barclay]

My hon. Friend brings welcome transparency to the issue. The Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Harborough (Neil O’Brien) was listening intently, and is nodding his head about meeting him to discuss it.

Cystic Fibrosis: Prescription Charge Exemption

Paul Maynard Excerpts

Wednesday 2nd February 2022 Westminster Hall

[Mr Virendra Sharma (in the Chair)]

Before we begin, I remind Members to observe social distancing and wear masks.

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

I beg to move,

That this House has considered prescription charge exemption and cystic fibrosis.

It is a pleasure to serve under your chairmanship, Mr Sharma, and to open this debate on a matter that I know is of very great interest to a significant number of people in the country. I am very grateful to all those who have emailed me over the past few days since the debate was announced, not least those who contributed via the Chamber engagement programme that the House of Commons runs. Their comments and insights have certainly deepened my understanding, and I hope that their contributions will enrich the debate in particular. I am also grateful to the Cystic Fibrosis Trust for its members’ contributions, and for the support and briefings that it has given me.

I am sure that hon. Members here today are more than aware of cystic fibrosis. It is one of the few serious, life-threatening, chronic conditions for which people are still required to pay prescription charges. The Cystic Fibrosis Trust estimates that there are around 2,500 people in England who did not qualify for free prescriptions and are faced with a lifelong financial burden. Indeed, the Cystic Fibrosis Trust calculates that there are now more adults than children with cystic fibrosis.

This issue has concerned me not just over the past few weeks but for 25 years, since I was first diagnosed with epilepsy. The consultant told me, somewhat bizarrely, that one upside of the diagnosis was that at least I would now get free prescriptions. I said, “What?” That was news to me; I was not even aware such a thing existed. I had not required medication for my cerebral palsy, and had been a relatively healthy teenager. It had never occurred to me.

At the same time as I had the good fortune to be diagnosed with epilepsy, I had an even weightier burden to carry: I was the health policy officer for the Conservative party, as we languished in opposition. It was a slightly odd time, I have to say—perhaps that gives hope to those opposite that all things change in time. I not only had to deal with the somewhat bizarre queries of Ann Widdecombe at 6 am when I rang her up, but got to see all the briefings and lobbying that came across my desk. One of the early ones was from the Cystic Fibrosis Trust, telling me about the particular predicament that its members were in: not being entitled to free prescriptions. I thought to myself, “How perverse! They have a lifelong, life-limiting, chronic condition for which they cannot get prescriptions, yet, for my epilepsy, which is chronic and can have devastating consequences, I do get free prescriptions.”

It is not just a case, like mine, of taking some five tablets over the course of the day to manage epilepsy. As Gayle told me,

“My daughter takes more than 50 tablets a day to treat the condition. When you compare this to other serious lifelong conditions that are exempt from prescription charges it is impossible to understand why CF is not included and this outdated decision needs to be rectified”.

The lack of an exemption leads to some perverse situations. As Sarah told me,

“Thankfully I developed diabetes, which is a horrible thing to be grateful for. As a result of getting another health condition which comes with more challenges for my health, it meant I was exempt from paying all prescription charges”.

Go back to that first word that she used: “Thankfully”. What a bizarre thing to have to say with regard to diabetes.

At this point, I should pay tribute to someone who is not here today: Bob Russell, the former Member for Colchester, whom older Members here will know well. He campaigned non-stop on this issue. It is worth cycling back to what he said in 2013, the last time that we debated this issue in the House. He said:

“Those with long-term conditions do not choose to be ill. They face a daily routine of various types of medication and physiotherapy to maintain any quality of life.”—[Official Report, 10 July 2013; Vol. 566, c. 511.]

Those words are as true today as they were back in 2013—and back in 2003, 1993, 1983 and all the other many times that this issue has been discussed.

When I first researched this issue 25 years ago, I was even more surprised by the fact that the exemption list was based on a list of conditions that had not been reviewed since as far back as 1968—before man had made it to the moon—with the exception of the addition of cancer in 2008. My contention to the Minister today is a simple one. It is the one I urged my right hon. Friend the Member for North Somerset (Dr Fox), when he was shadow Health Secretary, to pose to the then Health Secretary Alan Milburn in 1999. Why has the list not been reviewed since 1968? People live with cystic fibrosis well into adulthood these days, which was not the case in 1968. Why can we not review matters and take modern medicine into account? In particular, why is it fair for me to get free prescriptions when they cannot?

As Anna told me:

“The exemption list was introduced in 1968 when children born CF were not expected to live to their teens. Now more than ever, with the life-changing personalised medicines that are available to the majority of CF patients, life expectancy will be massively increased. Therefore, CF should be reconsidered for exemption as most patients will now be living relatively normal lives.”

[Ruth Jones (Newport West) (Lab)]

I thank the hon. Member for giving way; he is making a powerful speech. As a former physiotherapist who used to treat children and young people with cystic fibrosis, I know exactly the point he is making. Living in to adulthood is fantastic and brilliant, but people are being penalised. Is it not right that those people should not have to worry about having to take medication? It should be a right.

[Paul Maynard]

The hon. Lady is exactly right, and I will demonstrate why with a few examples from people with CF. For those living with CF, medication, physio and general health all have to be considered when planning the simplest activity. Being unwell frequently interferes with work and education. As Sam says:

“Due to the nature of the illness I have been unable to work full time after previously trying. Prescriptions is another cost I have to pay despite barely getting any financial support from the government. To me it shows a lack of understanding the fact the medication ultimately contributes to us staying alive and gives us the best chance of trying to contribute to society.”

We could easily be having a debate about other long-term conditions, such as asthma, which are not included either. I could point to transplant patients, a category that would not have existed in 1968 but who rely on drugs to sustain their lives. If any Scottish National party or Plaid Cymru Members were present, they might have cited the example of prescription charge regimes in Wales and Scotland. Opposition Members might bring up the claims and calls of the wider Prescription Charges Coalition. I will leave it to them to make those points; those views are not necessarily shared by Government Members.

I want to focus, laser-like, on this single issue. We have seen in today’s newspapers the success that such an approach can have. The long campaign on hormone replacement therapy by the hon. Member for Swansea East (Carolyn Harris) finally got some good news. It is clear that we need to undertake a thoroughgoing review, setting out what conditions have been brought into scope since the Medicines Act 1968, through advances in medical science. Those might be conditions that did not, or could not, have existed in 1968, or conditions where life has now been further prolonged.

I am sure I can predict some elements in the Minister’s reply, because they were made by former Labour Ministers and in 2013. I am sure we will hear of the wonders of prescription prepayment certificates at just £2 a week—what could be better value? That is less than the price of a cup of coffee at Costa. But many living with a long-term medical condition such as CF can be economically disadvantaged by their condition, by prescription charges and by paying for the annual prepayment certificate, which costs £108. That adds to their financial burden.

According to the Cystic Fibrosis Trust, about one in 10 people with CF—just under 1,000 in the case of that survey—received emergency grants of about £150 from the trust in 2020-21. More than half of those grants were awarded for daily living costs, such as food. As Tracy told me:

“A few years ago I had to take redundancy due to ill health…I had previously paid for a prepaid prescription certificate but could not afford to renew it when it ran out. After 3 months without medication, I was in a poor state of health, constantly coughing, very weak, unable to lie down or even sleep sat up due to the accumulation of mucus in my lungs. After 4 nights without sleep I saw my GP who gave me a prescription for a strong course of antibiotics and steroid tablets. We had to miss a payment on a household bill so that I could pay for my prescription. The first course of antibiotics didn’t clear the infection, so I needed a further one. I had to borrow money from a family member to pay for it…Eventually, I was able to claim PIP which allowed me to pay for my own prescriptions again. I consider myself lucky to have someone who was able to help me out when they saw how ill I was.”

There is also a serious risk that those who incur prescription charges for their CF may not take their essential medicines, particularly if they are experiencing financial hardship, or in higher education on a limited income. Over a third of those who replied to the Cystic Fibrosis Trust survey said that they had not taken medication because of the cost of prescriptions. As Anna told me:

“During university I didn’t take my medication simply because I couldn’t afford the fees. The blunt fact here is that people with CF take anywhere from 10-30 different medications a month. People with CF have been charged an insane amount of money when there is a system in place meant to protect people with long-term health conditions from being financially penalised—however they are being kept from the exemption list.”

The cost to the Government of righting what I believe to be a moral wrong is £270,000. As a former Minister, I know that that sort of money can often be found with a good rootle down the back of the ministerial sofa—a bit of jingling of the coins. However, there must be darker, deeper and slightly odder reasons why successive Governments—of all colours, and I look across the Chamber as I say that—have refused to review the 1968 list, despite all the pressure and reasonable arguments to do so. I cannot begin to imagine why Ministers are saying no.

If anyone wonders what this change might mean for CF patients, they should listen to Mario:

“My partner would then feel supported by the government rather than left on her own. The relationship to her medicine would change from financial to purely medical. Support, hope and fairness is the minimum we ought to give to people with life-threatening long-term conditions such as cystic fibrosis.”

Or listen to Donna:

“CF patients have enough problems to face, we should do anything we can to help. CF drugs may be expensive, but lung transplants cost even more.”

I will leave the final words to Sharon, another survey contributor:

“I would have more money available to pay for life’s other essentials. It would be pleasing to see the end of an injustice as I have no choice but to take this life lengthening medication and shouldn’t be required to pay for it when if I had been born with another condition, I wouldn’t have to.”

I hope that the Minister listens to those pleas and reasonable questions, and sets out the Government’s agenda to right what I believe to be a wrong.

--- Later in debate ---

[Paul Maynard]

I thank all those who have participated, particularly my hon. Friend the Member for Ashfield (Lee Anderson). We are all grateful to him for not just speaking on a personal basis, but illuminating a debate far better than I could from my more dry, academic analysis. I thank him for his personal contribution, and I thank all hon. Members for a constructive debate. I recognise the point that the Minister made; making a commitment on the hoof at the Dispatch Box can be career-limiting. I know that myself, as I reflect on what I once said on rail and aviation, which I suspect led to my defenestration. Saving High Speed 2 can be terminal for a career, perhaps. None the less, I hope he will take the issue back to Lord Kamall, and that he might encourage him to meet me and other interested Members to hear what the Gentleman whose brief it is thinks of the matter.

[Edward Argar]

I am happy to reassure my hon. Friend that I will certainly convey his request for a meeting to my noble Friend.

[Paul Maynard]

We have something concrete on which to conclude the debate.

Question put and agreed to.

Resolved,

That this House has considered prescription charge exemption and cystic fibrosis.

Covid-19 Update

Paul Maynard Excerpts

Monday 13th December 2021 Commons Chamber

[Sajid Javid]

There will be two ways to access high-risk events, be it a nightclub or larger events. The main way will be to take a lateral flow test and get a negative result, which would need to be registered through the NHS website and the proof could be through the pass or a text message result, for example. There will be an exemption from that for someone who is double-vaccinated. The proof of vaccination can also be given through the letter process.

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

A constituent of mine has both anaphylaxis and urticaria. She has been told that she cannot be medically vaccinated. Amid all the talk about second doses and third doses, she cannot access even her first dose. What assurances can the Secretary of State give her regarding access to non-invasive forms of vaccination?

[Sajid Javid]

My hon. Friend asks a very important question. The rules around the need to be vaccinated, whether for passes or otherwise, do not apply to anyone who is medically exempt. Many people have received exemption certificates directly from their GP. That is the best route. Some individuals have called 111 and received advice. If I can be of direct assistance to my hon. Friend, then of course I will help.

Covid-19 Update

Paul Maynard Excerpts

Monday 6th December 2021 Commons Chamber

[Sajid Javid]

The rules apply equally to everyone.

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

For what reason is the Department of Health and Social Care making an announcement on extensions to the red list, rather than the Department for Transport, as has been the case previously?

[Sajid Javid]

Departments across Government work together on the pandemic, and that means that my Department works very closely with the Department for Transport.

Oral Answers to Questions

Paul Maynard Excerpts

Tuesday 8th June 2021 Commons Chamber

[Matt Hancock]

That is not something that has yet come across my desk, but I will make sure that the relevant Minister writes to the hon. Gentleman with as much detail as we know.

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

Community defibrillators are vital potential life savers, and many community groups fund investment in them. However, it is concerning to hear that members of the public are denied access to defibrillators when they are on private land. What can Ministers do to ensure that access is presumed rather than subject to permission?

[Matt Hancock]

What my hon. Friend says is absolutely right. Of course if someone puts a defibrillator on private land, access to it should naturally be open to anybody who needs it. I will look into the exact legal status, but let us set aside the legal status for a minute. If there is a defibrillator on private land that could save somebody’s life, the landowner should of course allow access to it for anybody who needs it.

Oral Answers to Questions

Paul Maynard Excerpts

Tuesday 23rd February 2021 Commons Chamber

[Jo Churchill]

I thank the hon. Lady for her question. I would also like to point out that, in her area, 93% of cases are being tracked and people are being spoken to, which highlights the great work that is being done on the ground locally in that area. We are providing support, and I would urge her constituent to reach out to the council, because it is important that we give people the support they need in order to isolate. As I say, she will be hearing more on that subject from the Chancellor during the Budget next week.

[Paul Maynard (Blackpool North and Cleveleys) (Con)]

What plans he has to reform the public health improvement functions of Public Health England.

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

We are currently considering the best future arrangements for Public Health England’s important health improvement functions. We have been engaging with key stakeholders throughout the process and will be setting out further details of our approach in due course. We are excited about creating the national institute for health protection to ensure additional capacity so that we have future capability and a laser-like focus on areas of health inequality.

[Paul Maynard [V]]

I very much welcome the plans to reform Public Health England’s health protection functions, and I note with interest the Secretary of State’s new powers of direction in some public areas, such as obesity. Blackpool has some of the most severe public health challenges in the country. Further discussions about the health promotion functions of Public Health England were promised when the NIHP was announced, so can the Minister say now how other areas of public health promotion that are not referred to in the White Paper will be addressed?

[Jo Churchill]

I thank my hon. Friend for his question, and I recognise the challenges that Blackpool faces. I read with interest the Blackpool town prospectus, which highlights the public health challenges, and I am looking forward to talking to the clinical commissioning group lead about them later this week. We remain convinced that place-based approaches will have the best results, where we can target interventions in the right way when they are needed. I think my hon. Friend is alluding to other areas such as work, housing and so on. Discussions are going on with other Departments, but those specific initiatives are for those Departments themselves. As the details of the national institute for health protection are outlined, these things will become clearer. I know my hon. Friend cares deeply about his constituents and their health, and I look forward to working with him and others in the future.