Health: Hormone Pregnancy Tests

Baroness Walmsley Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, this issue goes back to the 1950s, so trawling back over that period may not be that helpful. What is helpful is that we learn lessons from the past so that the existing regulatory system can learn from those errors. I am, however, very happy to meet the noble Lord and others who are interested to discuss this further, if they wish to do so.

[Baroness Walmsley (LD)]

My Lords, given that many of the survivors of Primodos, the drug in question here, were not told that they were taking part in a clinical trial, will the noble Lord assure us that today nobody would take part in a clinical trial without their knowledge?

[Lord Prior of Brampton]

My Lords, I understand that to be the case but I will double-check and, if it is not, I will of course write to the noble Baroness.

Health and Social Care: State Pension

Baroness Walmsley Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

The right reverend Prelate is right to remind the House of the report by the Commonwealth Fund which indicated that the National Health Service is the most efficient and overall the best healthcare system in the world. He also referred to prevention. The childhood obesity prevention strategy is due to be announced by the Government in the next couple of months. We have made huge progress on reducing smoking and in other areas of prevention, but I agree with the right reverend Prelate that prevention is a critical part of our long-term approach to healthcare.

[Baroness Walmsley (LD)]

My Lords, the Minister talks about the support for the five-year forward view, but is he aware that more than 80% of finance leads within the health service do not believe that the five-year forward view can achieve the savings that it says it can? It just cannot be done without extra resources. Surely, particularly with the state of affairs in social care, where the Government’s extra money is being back-loaded, not front-loaded, we need to take an overall holistic look at health and social care and how much we should be spending as a country and how we are prepared to raise that money fairly.

[Lord Prior of Brampton]

My Lords, I think that the same question is being asked in slightly different terms by many different noble Lords. I cannot really add to what I said before. We are supporting the NHS’s plan. By the end of this Parliament we will be putting another £3.5 billion into social care through the social care precept and an extra £1.5 billion into the better care fund. We believe that we have a plan for social care and healthcare over the course of this Parliament.

Health: Cancer

Baroness Walmsley Excerpts

Wednesday 20th January 2016 Lords Chamber

Asked by

[Baroness Walmsley]

To ask Her Majesty’s Government what assessment they have made of the factors contributing to cancer survival rates in the United Kingdom.

[Baroness Walmsley (LD)]

My Lords, my reason for asking for this debate is to highlight the fact that, despite much good work, cancer patients in the UK have poorer survival chances than those in comparable countries. We rank 20th out of 24 developed countries for cancer survival in breast, cervical and colorectal cancers. For a Government that seek a world-class health service, this is not good enough. I want to look at the reasons and ask what the Government plan to do about it, in particular the implementation of the five-year cancer strategy.

Anyone who has had a diagnosis of cancer will know the naked fear that the news generates. At that moment, it is hard to remember the great strides we have made in cancer survival, with half of all cancer patients now surviving for 10 years or more compared with a quarter 40 years ago. Some cancers such as breast cancer have seen remarkable improvements in survival rates, particularly because of the excellent screening programme, for which I am most grateful. But others such as pancreatic cancer have seen very little improvement. Some cancers related to lifestyle or environmental factors, such as skin cancers or the various bowel cancers, have become more common. But many more people are living with cancer for a long time and we need to consider how we look after their needs.

So what needs to change? We need to invest in prevention through information and help for people to reduce their risk and earlier, more accurate diagnosis. We need better training and resources to enable GPs to refer quickly and a realistic approach to consultant utilisation and shortages, along with that of specialist nurses. We need better data collection and transparency and earlier access to innovative treatments. To show public support, I hope that all noble Lords will celebrate World Cancer Day on 4 February by sporting a unity band to celebrate survival, show solidarity with those in treatment and remember loved ones.

Let us look at some figures. According to Public Health England, four in 10 cancers are preventable. Cancer cases are increasing, partly it is believed because we are living longer and partly due to lifestyle, so more people are living with cancer. One in two people will develop cancer at some point in their lives. But according to Eurocare-5, the UK’s survival performance rates are below the European average. According to the Lancet in 2011, Norway, Canada, Sweden and Australia do a lot better than us, while recent studies have shown that the gap is not being closed. As we do better, other countries are doing even better. That is why we need excellent data and accountability. Experts tell us that the one-year survival rate is a very good indicator of success or failure, so it is important that this information is collected efficiently and made available transparently.

This week, we have had some very worrying headlines. Cancer services have missed key targets. The six-week target for diagnostic tests to be done was missed and it is now two years since it was last met. One of the key cancer targets, the 62-day target for treatment to start from urgent GP referral, was missed. Those missed targets mean that nearly 2,000 people—not targets—had to wait longer than they should have. Wales was the worst, with only 71.9% of patients starting treatment within that time in Swansea and 62.9% in Cardiff and Vale. In Wales overall, the target has not been met since 2008. In England, just under 8,000 people with suspected cancer did not see a consultant within two weeks of an urgent referral by their GP and 536 patients had to wait more than a month to have their first treatment for cancer. We need to be cautious about targets. There is no point in setting higher and tighter targets for tests if hospitals do not have enough consultants to deal with the patients diagnosed as positive.

What is the Government’s answer? The independent cancer strategy, which reported last July, made six key recommendations: a radical upgrade in prevention and public health, including national plans on reducing smoking and obesity; earlier diagnosis with 95% of patients referred by a GP being diagnosed or given the all-clear within four weeks; patient experience on a par with clinical effectiveness and safety through access to test results and a clinical nurse specialist or other key worker; transformation in support for people living with and beyond cancer, and appropriate end-of-life care; investment to deliver a modern high-quality service, including upgrading radiotherapy machines, reviewing the Cancer Drugs Fund and better molecular diagnostics for more personal treatment; and a big effort to address the shortage in the cancer workforce. It also called for overhauled processes for commissioning, accountability and provision with a regional network of care alliances and a national cancer team to oversee delivery of the strategy.

The Government have accepted the recommendations and the latest NHS five-year mandate asks for: early diagnosis to be a priority; more work to tackle smoking, alcohol and physical inactivity; reduced impact of ill-health and disability; and support for research and innovation to enable new treatments to reach patients more quickly. So there was a recognition of the role of speedy diagnosis in improving cancer survival rates, but nothing about better training or diagnostic tools for GPs. Molecular diagnostics have made enormous strides in recent years for monitoring the effectiveness of treatments as well as diagnosing the disease and enabling more effective personalised treatments. The strategy asks for a national commissioning framework for this. Will the Minister ensure that that happens? It is vital for equal access for patients, particularly for rare cancers.

The mandate recognised the need for prevention, but then we had cuts in public health budgets. When will the Government accept the common sense and economic benefit of prevention and put their money where their mouth is, and save money and lives at the same time? The mandate mentions support for research and innovative new treatments, but many in the service are not convinced that appropriate pathways exist. The mere existence of the accelerated access review recognises that the UK is very poor at getting innovative new treatments to patients, and that needs to change.

In the first year, among other things, the Government are reviewing the operating model of the Cancer Drugs Fund within its existing budget. This is currently being consulted on, but patients, clinicians and pharma companies have serious concerns that the outcome will not achieve what it should. Does the Minister agree that any new methodology should guarantee increased access to innovative medicines, as proposed in the cancer strategy? We do not want the UK to become a “late-launch market”, meaning that UK patients would have poor access to innovative drugs compared to others worldwide.

Nothing should be done to deter pharma companies from doing R&D and clinical trials in the UK, since this both adds to total UK life sciences and covers the costs of treating patients which would otherwise be borne by the NHS. Indeed, we need an about-turn in relation to research. Every patient, every doctor and every health worker could be involved in medical research, but there are currently threats to the collection of data. I would encourage all patients, with suitable assurances, to allow their anonymised data to be used for medical research to save future lives. Without complete data, the researchers are working blindfold and we cannot hold CCGs, hospitals and the Government to account.

NICE must look again at its methodology for evaluating cancer drugs, especially those focused on rare cancers. But there are no proposals for NICE to change the criteria or thresholds and no recognition of unmet need, such as for cancers with very poor prognoses, such as pancreatic cancer.

It is instructive to look at some specific cancers to see where the problems lie. Despite being the 10th most common cancer, pancreatic cancer is the fifth biggest killer. Yet it only gets a tiny research spend. Survival rates are shockingly low. Only 4% survive five years from diagnosis and this has not improved in 40 years, indicating a desperate need for earlier diagnosis and more research. Around four in five patients are diagnosed at a very advanced stage and may have made up to seven visits to their GP with symptoms. All that suggests a need for better GP training and better access to diagnostic tools so that patients can have surgery before it is no longer an option. Other specialties such as skin cancer have a shortage of consultants and the ones there are spend far too much of their time seeing patients whose GP could have diagnosed the lesion as benign if they had had better training. This is another area where public awareness of symptoms needs to improve.

I have not been able to cover all the ground in 10 minutes, but I hope that other speakers will. I thank all those who are about to take part in this debate and hope that the Minister can answer the many questions that will be raised.

Health: Red Cell Folate

Baroness Walmsley Excerpts

Tuesday 19th January 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that, as I was told this morning by three neural disease specialists, the danger of overmedication with folic acid by fortification is absolutely minuscule—you cannot measure it? In addition, they suggested to me that it is vital that we reduce the number of babies with neural tube defects because, due to our success in the past in reducing the numbers, the specialists and services for such babies are very thin on the ground. We really need to do something about this now.

[Lord Prior of Brampton]

My Lords, the danger of overmedication with folic acid is small, I accept that. It is not non-existent but it is small. Just so that the House knows the numbers, the number of babies aborted because of neural tube defects is about 400 a year; the number who are born with neural tube defects, alive or not alive, is about 60 a year. It is a very serious issue and one that the Government are taking extremely seriously, but we have to weigh that against the other issues of medicating the entire population.

National Health Service

Baroness Walmsley Excerpts

Thursday 14th January 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, we are on the last lap. I thank the noble Lord, Lord Turnberg, for telling us about the enlightened approach of Salford Royal Hospital. It has obviously made great progress since I worked in Manchester and it was known as the “No Hope Hospital”.

It is no coincidence that the London Olympics highlighted the NHS in its very creative opening ceremony. We are all very proud of it, particularly the staff, but it would be stating the obvious to say that it has numerous problems. At a time when it faces unprecedented increases in demand, the NHS has been given its most challenging funding envelope ever. The future of the health service is in jeopardy unless we do something radical. As the noble Lord, Lord Rea, said, it cannot get out of this hole by itself.

That is why my right honourable friend and former Health Minister Norman Lamb introduced a Private Member’s Bill in another place a week ago. He called for the establishment of an independent commission to examine the future of the NHS and social care system, to take evidence and to report its conclusions to Parliament. I pay tribute to those on the Conservative Benches who have called for something similar, but I think that a royal commission may take too long and that something quicker is required.

Norman Lamb was supported by two former Secretaries of State for Health, Members from all parties and the chief executives of more than 40 organisations in the sector. I join with his call today in this debate, along with many of your Lordships. When you get agreement from so many from all sides of health and social care, it is clear that you are reflecting a real need. The purpose of the commission would be to consult widely to find solutions to the massive challenges that face the health and care services, and to establish a sustainable—a crucial word—new settlement which takes into account present and future demands.

In order to calculate future demand, we need no crystal ball—we have a lot of evidence to help us. We know that since the Second World War demand has gone up by about 4% every year. For example, thanks to successful new diagnostics, treatments, drugs and surgical procedures, half of people diagnosed with cancer now survive the disease for 10 years or more compared with only a quarter 40 years ago. Other chronic conditions are also now managed better than ever. We should celebrate all this while being realistic about what it means.

We have heard about the predicted gap of £30 billion in NHS funding by 2020 unless something is done. The Government have committed to providing only £8 billion of this and expect the NHS to find the other £22 billion through efficiencies and new models of care. However, experts involved in the process are unconvinced that this can be done.

The King’s Fund’s Quarterly Monitoring Report, published in October 2015, included a survey of NHS finance directors’ views on their ability to achieve 2% to 3% productivity gains per year, which would be needed to achieve that saving. The vast majority were sceptical to say the least. Eighty-four per cent of NHS trust finance directors and 88% of CCG finance leads felt that there was a “high” or “very high” risk of failing to achieve the target. Here are a few respondent comments:

“I feel strongly that the low-hanging fruit has been taken. The modus operandi needs to change fundamentally”.

“When plans are not credible then it is impossible to enthuse people”.

“Increased national pressures/tying of hands … make it difficult to achieve big savings”.

“The £22 billion challenge requires productivity gains significantly over what has been achieved over the past few years”.

“Unless there is a national debate about what the NHS can provide then there is no way that the NHS can deliver within the financial envelope”.

Jim Mackey, chief executive of the hospital regulator, NHS Improvement, put it in colourful language—and I quote him verbatim—saying that the efficiency targets set by the Government are,

“unachievable and, frankly, bloody stupid”.

That is what he said, my Lords.

Given that the recently announced increases in funding will be swallowed up mostly by paying for the £2.2 billion of deficits in NHS and foundation trusts, increases in payments to pension funds, apprenticeship levies and the new minimum wage, it is pretty clear that this extra money will do nothing to address future increases in demand. Meanwhile, social care funding has been cut in real terms and faces a funding gap of £6 billion by 2020 according to the Health Foundation, but this does not take into account the effect of the new minimum wage in a sector where so many workers are on the minimum wage. The LGA estimates that this will add a further £1 billion to the gap. Now Ministers have decided to stop the £1 billion payment-for-performance element of the better care fund and, instead, have mandated local targets for the reduction of delayed transfers of care. So the Government give with one hand and take away with the other.

Did the Chancellor provide the answer to these problems in the autumn spending review? I think not. The new provision for councils to raise a 2% social care precept would provide only an extra £1.7 billion by 2020 if every single council did it. In poor areas the ability to raise significant extra funds in this way is in inverse proportion to the need—not a very clever solution.

The increase in the better care fund will not come until 2019. Sadly, this will mean that the better-off will be able to pay for good care and the poor will get either no care at all or a substandard package—the best their poor stretched local authority can manage—adding further to our appalling health inequalities. The inevitable pressure that these cuts to social care will put on the NHS is obvious and has been clearly outlined by Simon Stevens, the head of NHS England. So current and projected NHS funding does not allow the service any chance of fulfilling the mandate, mentioned by the noble Lord, Lord Lansley, put upon it for the next five years by the Government themselves. Beyond 2020, it will just get worse if nothing is done, and our precious NHS will no longer be the envy of the world. Mention of the mandate reminds me to endorse the call of my noble friend Lady Tyler and the noble Lord, Lord Bradley, on mental health. We need to find new answers.

All Governments pledge themselves to protect the NHS, yet our spending as a proportion of GDP is low, as we have heard, compared to that of other developed countries. According to the Office for Budget Responsibility, it will decline further by 2020. The position of social care is even more dramatic.

What is the point of growing our economy if we do not spend the money on the things that most of the population would like it spent on—and what they vote for? Given what we know about rising demand, it makes no sense at all. The consequences of the Government’s failure to address this are very serious and completely contrary to what they say they want according to the latest mandate. Standards will not rise, new technologies will be unaffordable and services will not be able to address our health inequalities—an absolutely top priority in my book.

The silly thing is that nobody really believes in the ability of the system to fill the gap through efficiency savings and new models of working, desirable though they may be. Money is so tight at the moment that many parts of the system are struggling with crisis management, let alone improvements. To make things worse, there are numerous financial disincentives. For example, where is the incentive for acute hospitals to work with local services to keep patients out of hospital when they rely on the payments for activity when they come in?

The social care system is living on borrowed time. Eligibility criteria are getting tighter every day. Will the Government face this crisis head-on, take politics out of it and support my right honourable friend’s call for a commission to bring together all the evidence, the brains and the expertise available?

I think it boils down to five simple questions. How much should we be spending as a country and how should it be raised? How can we spend it better and have all services reach the standard of the best? How can we end the artificial divide and conflicting incentives between health and social care? How can we minimise future demand by avoiding preventable diseases? How can we reduce health inequalities? It is time for a new Beveridge commission.

Sugar Tax

Baroness Walmsley Excerpts

Wednesday 13th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I think that the noble Lord is right; indeed, the Prime Minister has called this the new smoking. Obesity is as important to public health as smoking has been in the past. We have to build a much stronger case among the public at large before we can start to introduce the full range of tax and other measures that we have had for cigarettes and alcohol.

[Baroness Walmsley (LD)]

My Lords, has the Minister tried the Sugar Smart app on his mobile phone, which can be found on the Change4Life website? I tried the app this morning—it is very clever; it reads a barcode and tells you how much sugar is in a product. Unfortunately, however, I tried it on five sugary products and it did not have any of them in its database. Has this very good idea been under resourced?

[Lord Prior of Brampton]

My Lords, fortunately I, too, tried the Sugar Smart app this morning. Interestingly, 600,000 people have downloaded that app and the PHE Change4Life programme has had considerable success in raising awareness of the amount of sugar that you consume when you buy a product in the supermarket.

Children: Obesity

Baroness Walmsley Excerpts

Tuesday 12th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, my noble friend is right that we have to involve all departments. For example, she mentioned the environment. There is plenty of evidence to suggest that urban and educational environments can be designed so that children spend more time walking. The development of cycleways in London is another example of how we can design our environment to improve the level of physical exercise that we take.

[Baroness Walmsley (LD)]

My Lords—

[Baroness Finlay of Llandaff (CB)]

Can the Minister outline what is being done specifically in relation to women in pregnancy, given that excessive weight gained in pregnancy, which is often linked to the phrase “eating for two”, is very difficult to lose afterwards, particularly if women do not breastfeed? Moreover, postnatal depression can itself be a cause of excessive eating after delivery of the baby, causing the maintenance or even aggravation of obesity. That requires specific services to target these women.

[Lord Prior of Brampton]

The noble Baroness will know that the report of the Chief Medical Officer which came out two or three weeks ago laid particular stress on the importance of women who are pregnant because of the impact of obesity not just on themselves but on their children as well. Advice is available through NHS Choices, Start4Life and Healthy Start; we have various schemes that are focused on pregnant women. I am sure that we can do more, and perhaps when the government strategy on obesity is announced in the near future, it will address that issue as well.

[Baroness Walmsley]

My Lords—

[Lord Winston (Lab)]

My Lords, given that homo sapiens is a species that is programmed to eat carbohydrate and fat, what estimate have the Government made of how much childhood obesity is due to epigenetic factors rather than simply eating sugar and carbohydrate later on in life? Might this not be programming earlier in the generation perhaps as the result of previous generations’ environment? This is an essential point in understanding obesity.

Pregnancy: Neural Tube Defects

Baroness Walmsley Excerpts

Monday 21st December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I pay tribute to the noble Lord for the extraordinary work that he has done in this field and for giving this very important and tragic issue a greater degree of public awareness. My honourable friend in the other House, Jane Ellison, the Minister for Public Health, is considering her response to the report that the noble Lord referred to and to the report by the SACN, the committee on nutrition, published on 20 October. I expect that she will come to a decision early in the new year.

[Baroness Walmsley (LD)]

My Lords, given the importance for the health of the foetus of folic acid being taken by women before they are pregnant, will the Minister work with his colleagues in the Department for Education to ensure that all young women—and young men—know the importance of taking folic acid long before they even think of becoming pregnant?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. When you know you are pregnant, it is too late to start taking folic acid, and that is the fundamental reason why the noble Lord, Lord Rooker, is pushing for fortifying flour with folic acid. However, she is absolutely right that education is fundamental to this as well.

Down’s Syndrome: Do Not Resuscitate Orders

Baroness Walmsley Excerpts

Tuesday 15th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, perhaps I could address first the particular issue of Andrew Waters. The doctor who signed the DNR order was a junior doctor who made a mistake. It was a misjudgement, he apologised for that mistake, and he has learnt from it by using his experience to teach other doctors how to deal with similar issues. It is important to make that statement first—the reaction of that junior doctor was the right one, having made that mistake. The noble Lord mentioned the Blue Apple Theatre company. He was kind enough to send me a copy of some of the work that it does, which illustrates that people with Down’s syndrome can have a very full, useful, good and happy life, and their lives should be valued just as highly as the life of any other person.

[Baroness Walmsley (LD)]

My Lords, does the Minister know how widespread such discrimination is against people with learning difficulties? What reassurance can he give to parents such as those I met recently in the House of Commons Dining Room, who were terrified to allow their disabled son to go into hospital because they knew they were going to be put under pressure to sign a DNR notice? They were also afraid that, even if they refused but were not at his bedside 24 hours a day, it would happen anyway.

[Lord Prior of Brampton]

My Lords, the noble Baroness has just made a truly shocking statement. If indeed this practice was systemic and widespread, it would be a matter of huge concern and I think all of us in this House would be appalled by it. I have no evidence that this is a systemic problem, but it is absolutely the case that this group of very vulnerable people have been let down not just by doctors and clinicians but actually by all of us—the whole of society, for ever. The report produced three weeks ago called Building the Right Support recognised that we have let down this group for decades, and I hope that over the next five years we can start to make amends.

Southern Health NHS Foundation Trust

Baroness Walmsley Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, these are truly shocking revelations and reveal deep failures at the trust. I start by echoing his remarks about the families so grievously affected.

As the Minister said, only 195 of the 1,454 unexpected deaths were actually treated by the trust as serious incidents requiring investigation. Perhaps most worryingly, it appears that the likelihood of an unexpected death being investigated depends hugely on the patient. For those with a learning disability, just 1% of unexpected deaths were investigated. For older people with a mental health problem, just 0.3% of unexpected deaths were investigated.

Obviously, we will expect a full response from the Government when the report is published, but in the mean time, can the Minister say whether he judges services at the trust to be safe? What advice can he give patients currently in the care of this trust, and their families? He explained that NHS England first received the report in September. Can he say why it has not yet been published, and when a final report will be made available?

Finally, I want to raise an issue the Minister himself mentioned. I understand that the trust disputes the analysis by the audit company Mazars, which produced the report. NHS England needs to sort this out. When the report is published, it is clearly vital that there be no question about its methodology or the robustness of its conclusions. Is he absolutely confident that NHS England has got a grip of this?

[Baroness Walmsley (LD)]

My Lords, our hearts go out to the family of Connor Sparrowhawk and all the other families who have struggled so hard to get investigations of the unexpected deaths of their loved ones. On many occasions they have struggled to find the financial support required to make that investigation. That is quite wrong. In this particular hospital’s case, the percentage of unexpected deaths that was investigated is pretty scandalous. In fact, across the board, only 1% of unexpected deaths of those with learning disabilities are investigated.

I very much welcome the Minister’s saying that a light will be shone on this, but will the investigation bear in mind the possibility that it should not be the hospital trust itself that decides which of its unexpected deaths should be investigated? Police forces no longer investigate themselves—that is done by another police force. Should that not be the case with hospitals too? My second question is about timeliness. The report is not the first indication we have had of problems with this trust. The coroners have complained on numerous occasions, and over a long period, about the timeliness and quality of the reports received by them on cases that were investigated. Surely this indicates that there have been problems with the administration, the collection of evidence and the systems of this trust. Why was that not picked up earlier?

[Lord Prior of Brampton]

My Lords, the noble Lord, Lord Hunt, gave two very important figures: 1% of these incidents involving people with learning difficulties were investigated and 0.3% involved people with learning difficulties who are older. We have not got it right in this country when it comes to people with learning difficulties. We have not fully learnt the lessons of Winterbourne View. However, NHS England has now published this new strategy for people with learning difficulties and mental health problems. We will hold it to account for delivering that. I think that represents a step change in trying to get as many of these people out of hospital settings—“from hospital to home” is the line in the report—which is so important. That is the fundamental issue that we should not lose sight of.

NHS England received the report in September. It has not yet been published because it had to give the trust a chance to comment on it, and the methodology has to be fully sorted before it is published. However, Jane Cummings has given a commitment to the Secretary of State that the report will be published before Christmas. So does NHS England have a grip? I think it does.

On the question of an independent investigation, which the noble Baroness, Lady Walmsley, raised, the trust has to be the first line in this. It is up to the trust to have the right culture within it so that these incidents come to the surface. We now have a much more empowered CQC providing independent inspection, and of course the Secretary of State has agreed to set up an independent investigation branch, on the recommendation of the PASC, which will be operable from March.