NHS: Charitable Donations

Lord Brooke of Alverthorpe Excerpts

Thursday 22nd February 2018 Lords Chamber

Asked by

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government, further to the Written Answer by Lord O’Shaughnessy on 20 December 2017 (HL4078), why they have no plans to provide patients with the costs of their treatment in order to encourage charitable donations to the National Health Service.

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

My Lords, the NHS is based on the principle of access to treatment regardless of your means and according to clinical need. As a consequence, it is important that patients should not be exposed to the costs of care as it might deter them from seeking treatment. Where costs have been provided, such as the cost of missing GP appointments, this has been in an attempt to prevent waste.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister agree that we have a great gift in the NHS and that great gifts become even greater if one can make a return contribution to the giver? Why will the Government not reveal the cost of treatment to people—after they have had it, not before, and only to those people who request it—so that in turn they may make a voluntary contribution, either in full or in part, towards the cost of that treatment? Why is there such difficulty in encouraging people to play a greater part, to give more and to get more involved with the NHS in a way that the Government are refusing to do at the moment?

[Lord O'Shaughnessy]

I agree with the noble Lord that it is a gift. I also absolutely understand the sentiment behind what he is saying, which is a desire for people to contribute back to the NHS not just through the tax system. It is important to point out that there are more than 250 NHS charities, with an annual income of £400 million. One of the other great gifts we have in this country is people’s willingness to donate time and money not just to the NHS but to a range of health causes. So we do provide an opportunity for that and those gifts are supported by gift aid. With regard to itemising the bill, we worry about deterrence. Many users of the most expensive health services are older people. Itemising a bill could put some of them off and that would be the wrong thing to do.

NHS and Social Care: Winter Service Delivery

Lord Brooke of Alverthorpe Excerpts

Thursday 25th January 2018 Lords Chamber

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I too am grateful to the noble Baroness, Lady Wheeler, for initiating this debate and to everyone who has participated in producing a set of solutions which, if they were brought together, would solve the problem. I feel sorry for the Minister, who has had little support from any quarter today for his problem.

Everyone knows that much more money is needed. There is a 2% gap that needs to be filled and one way or another we have to find measures—basically through taxation—to meet that need. We also need to look for other ways in which funds can be raised in which we might involve the wider public so that, in turn, we get a greater recognition—to pick up the point of the right reverend Prelate the Bishop of Carlisle—that there has to be more responsibility for the NHS across a broader front. It is not only an issue of the Government providing the money but of how we care for ourselves and each other, of how families care—or do not care—for the elderly, and of how families pay for the elderly or refuse to do so because they want to keep the house for themselves in due course. When these issues are raised, there is a row and people run for cover because they are far too difficult to address.

As the noble Lord, Lord Smith, said, I hope we can spend some time addressing the winter problems, but we see these problems all year round. I bore the House to death when I go on about alcohol and A&E and the costs involved. When the Minister took his job, he said that he was going to stamp down on drunkenness in A&Es. I would like to see some evidence of that because the papers were full of such issues over the Christmas period.

Substantial numbers of people go to hospitals and A&E when they should not be there. I am probably the only Peer here today who was in an A&E department on Christmas day, when we had a family incident. I was there at 10 o’clock through until three o’clock in the morning before the family member was moved into an acute assessment ward and kept in for five days. We were not overrun, to my surprise, by the number of people I had anticipated being in A&E. However, given the relatively small number of patients there, we were, to a degree, overrun by the number of friends and relatives who went along with them. There were four or five people with each patient, creating noise on mobiles, causing confusion and making it much more difficult to manage the A&E. Some simple things need to be addressed. Why do we need so many people going into A&E when it causes a delay in patients being dealt with?

Similarly, when we got to the ward there was very little management and it was difficult to determine who was in charge. People were coming in, shouting and screaming down their mobile phones, and patients were surrounded by four, five or six people spending three, four or five hours in there. If people wanted to make a complaint about it, there was nobody around who was able to address the issue and slow it down. Hospitals used to be about patients, peace, calm, serenity and recovery. During that week, I was in that hospital every day—my Christmas was lost—and my experience, in many respects, was that I was in a place of riot and chaos. It should not be like that in a hospital. It would cost very little money to put this right, but it needs addressing. I know it is a minor issue compared with what we have debated today.

I return to the topic of alcohol. Cheap booze is a source of many of the problems within A&E—not only at Christmas but throughout the year, from Thursday evenings through to Sunday—and that has to be addressed. It is amazing that the Chancellor is struggling to find money for the NHS and yet, on the other hand, he is freezing the regulator in terms of increasing the cost of alcohol duties. He is making alcohol cheaper on the one hand and on the other is struggling to find the cash to keep people well. We now have more people drinking less but certain categories of people drinking more. More people are now going into hospital with less alcohol being drunk, and the price of alcohol, in the main, is going down rather than up. Fairly simple action could be taken on that by adjusting taxes. This would put it right and we would have a good response all the way round. We should apply it across the board—for example, with sugar and a range of other issues. We should look at the polluters who cause the problem to see whether they could make a greater contribution.

At the end of the day, much of this comes back to public health campaigning and how we look after ourselves and each other. Regrettably, the amount of money which has been spent on public health has been cut over recent years. We need to review that and start looking at ways in which we can help people to look after themselves better in the future, live longer and lead better and happier lives than they are doing at the moment. That requires bold decisions, frankness and honesty, which, regrettably, so far the Government have not been prepared to engage in.

Nurses: Tuition Fees

Lord Brooke of Alverthorpe Excerpts

Wednesday 29th November 2017 Lords Chamber

[Lord O'Shaughnessy]

It is important to point out that there are 10,000 more nurses on wards than there were seven years ago. One of the things that we are trying to do is encourage nurses to return to practice—3,000 of those nurses have been on the return to practice programme. In regard to attracting them to hospitals, the main thing is that we need to train more nurses to fill those places so that we fill the demand that we know that we have from a growing and ageing population. That is why there are going to be 5,000 more funded nursing training places from 2018 onwards.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is it not necessary to offer the most attractive terms to get more nurses into training? Will the Minister reflect on the very helpful suggestion made by the noble Lord, Lord Forsyth, that there is a possibility that a fair number of these people will never repay the full amount? Will he tell the House what the estimated write-off is of the repayments that will apply to nurses? If it is a high figure, will he reflect on the answer that he gave to the noble Lord?

[Lord O'Shaughnessy]

I shall certainly write to my noble friend, and indeed all noble Lords, about the proportion of the write-off. Let us remember, however, why the student loans system exists. It exists because those people who earn enough over the course of their working lives end up paying more than those who do not. Therefore, if somebody has gone into nursing but has then gone on to work in another profession, earning more money and being able to pay it off, it is equitable that they pay it off. That was the policy of the Labour Government, and it has been adopted by the Conservative Government precisely on the point of equity. It is only right that the loan is written off for those who have not earned enough but, for those who have earned enough, that they pay it off.

Brexit: Mental Health Research Funding

Lord Brooke of Alverthorpe Excerpts

Thursday 23rd November 2017 Lords Chamber

Asked by

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government whether they intend to match the current European Union contribution towards United Kingdom mental health research funding after the United Kingdom leaves the European Union.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, the Government have made clear that UK businesses and universities should continue to bid for competitive EU funds while we remain a member of the European Union and that we will work with the Commission to ensure payment when funds are awarded. The Government will underwrite the payment of such awards, even when specific projects continue beyond the UK’s departure from the European Union. This will include mental health research funded by the Horizon 2020 programme.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, does the Minister recall the Government’s promise in the May manifesto:

“We will make the UK the leading research and technology economy in the world for mental health”?


I am reassured by some of the Answer he gave, but he has not given a firm commitment that this will continue after Brexit. Will he give such a commitment; and given the promise that was made in the manifesto, will he outline how the Government intend to increase the amount of research that will be undertaken in mental health in the future?

[Lord O'Shaughnessy]

In our future partnership paper we have set out that we want an ambitious agreement on science and innovation and that we will continue, albeit in a new form, to collaborate with the European Union on health research, including mental health research. On honouring the bids that were underwritten, I should point out that that applies not just to bids or projects that are taking place but to bids that have been submitted up until exit day, so there is a long lead time. It is also important to point out what the Government have been doing domestically. For example, the National Institute for Health Research has increased by over 50% the amount of funding that it puts into mental health research, so the Government have been going a long way in increasing the amount of funding in this area.

Young Women: Self-Harm

Lord Brooke of Alverthorpe Excerpts

Thursday 16th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I congratulate the centre the noble Earl works for on its anniversary. He is absolutely right about the pressures of adolescence. Unfortunately, the causes of self-harm are not well understood. One of the hypotheses is that the motivation appears to be stress relief, which is an incredibly disturbing idea. I am aware of Lucy Crehan’s work from my previous work in schools. I do not think you can link school accountability with the kind of pressures we are describing today and how they manifest in self-harm. We want schools to be successful. It is vital that children are well educated. It is also true that that can be done in a number of ways. The best schools, including ones that I have been involved with in the past, practise something called positive education which emphasises not only the academic aspect but also character and well-being. I think that is the approach that we need to follow.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, if I may bring the Minister back to his area of responsibility, is he aware of recent research indicating that at primary level, references by doctors to mental health services are least in the deprived areas in the country and those are the areas where the self-harming is rising most of all? Can he tell the House what steps he is taking to halt that and move it in the other direction?

[Lord O'Shaughnessy]

I would be interested to see that evidence. It is not something that I have seen. All I can say is that mental health funding has increased by more than 8% in the last couple of years so there is more money going into it but clearly it is vital that it is properly spread.

Child and Adolescent Mental Health Services

Lord Brooke of Alverthorpe Excerpts

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

That is an incredibly important point because good relationships are very influential on young people’s mental health, and the Green Paper will look at the role of family conflicts. My noble friend will be pleased to know that the Department for Work and Pensions is launching a programme to reduce parental conflict in conjunction with the Early Intervention Foundation. I hope that it will have some positive benefit in reducing parental conflict, which is, of course, one of the causes of mental illness.

[Lord Brooke of Alverthorpe (Lab)]

Does the Minister accept that there is a wide variation in the offering of services between one geographical location and another? Will the Green Paper which is being prepared address this, and how quickly will it be resolved?

[Lord O'Shaughnessy]

The noble Lord is right about variation, sadly. We had the CQC thematic review on mental health provision at the end of last week, which showed that 80% of specialist in-patient care is good or outstanding but that that is true of only two-thirds of community care provision, with around a third either requiring improvement or inadequate. That is clearly not good enough. Patchy provision is absolutely one of the things that we need to deal with. The best way of doing that is by expanding both the number of children being treated and the size and quality of the workforce, to help us to meet our targets.

Alcohol: Children’s Health

Lord Brooke of Alverthorpe Excerpts

Monday 3rd April 2017 Lords Chamber

Asked by

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what assessment they have made of whether the way in which supermarkets and convenience stores display and promote alcohol can endanger the well-being and health of children.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)]

My Lords, Public Health England’s evidence review identified the negative impact that the advertising and marketing of alcohol can have on children and young adults. The Government are committed to working with industry to address concerns over any irresponsible alcohol promotions, advertising or marketing to make sure that children and young people are protected.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I take it from that reply that no research has been undertaken on this. In those circumstances, I wonder whether the Minister is prepared to commit himself to the Government undertaking such research. If they are not willing to do so on their own, will they enter into discussions with the drinks industry—probably the Portman Group, which represents the drinks industry—to see whether such research can be undertaken jointly?

[Lord O’Shaughnessy]

The noble Lord is not quite right on that. Public Health England’s evidence review identified a negative impact, and that constitutes research. It looked at the evidence, which is that advertising and marketing to young people has a negative impact on their drinking behaviours. There are stringent rules, particularly around advertising, which is policed by the Advertising Standards Authority, to make sure that that does not happen.

--- Later in debate ---

[Lord O’Shaughnessy]

The noble Baroness highlights a difficult and, indeed, tragic area. The other day, my honourable friend the Public Health Minister met the APPG on Children of Alcoholics. In preparing for a debate last week organised by the noble Lord, Lord Brooke, I discovered that Alcohol Concern estimates that there are 95,000 children under the age of one who live in a family where the parent has an alcohol problem. That is a rather horrifying statistic. One way we are dealing with that is through the family nurse partnerships; indeed, more than 16,000 places are now available and one of the capacities they have is to provide help for families struggling with addiction, whether it is to alcohol, drugs or other things.

[Lord Brooke of Alverthorpe]

My Lords, I want to come back to the Public Health England report that the Minister mentioned, of which I am aware. Would he concede that many issues are raised in that report? For example, it recommends that minimum unit pricing should be introduced, but it is not being introduced. When I am in my local Co-op, I am surrounded by alcohol as I queue for the checkout. I am also surrounded by children. Why are the Government not taking action to stop that?

Alcohol Abuse

Lord Brooke of Alverthorpe Excerpts

Thursday 30th March 2017 Grand Committee

Asked by

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what is their most recent estimate of the cost of alcohol abuse to the National Health Service; and what steps they are taking to reduce those costs.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful to the Chief Whip for finding a slot for this debate, even though it is the last business. I am grateful that I have so many speakers—I am surprised—and equally surprised by the number of people who have written to me in advance of the debate, which seems to indicate that we should look for a longer debate at some later stage.

After welfare, the cost of health is the biggest charge the Chancellor of the Exchequer has to deal with, yet if one examines Budget speeches one sees that it rarely gets a mention. In fairness to Philip Hammond, it did this year, because of the crisis in care, which is of course directly linked to health. Health costs continue to grow at around 4%, but the economy is down around 2%. With an ageing population, the health service, as one ex-Health Minister in the Lords recently said to me, is a car crash waiting to happen. So every action must be taken or at least explored to avoid further injury to or collapse of the health service.

Like the Queen, the NHS is one of the few remaining pieces of glue that keeps us together as a United Kingdom. People everywhere are increasingly fearful of what the future holds but, happily for the UK, at least for the moment, people do not have the fear that illness brings to many people overseas—the fear of how to pay for their treatment. That burden is lifted by the NHS, and it helps faster recovery, but it is at even greater risk if politicians are reluctant or unprepared to engage in an open and honest debate about the problems we have funding the health service. That is at the heart of my debate today—seeking changes that will reduce the burgeoning public health costs but also changes that lead to healthier, happier and longer lives. As part of that, the Government must confront the stark challenge that alcohol abuse presents for the NHS in terms of the financial costs, resources and the impact on staff time and welfare.

Alcohol is estimated to cost the NHS around £3.5 billion per year, which amounts to £120 for every taxpayer. If I have got the figure wrong, I am sure that the Minister will correct me. Even though drinking has declined marginally in recent years, there is a growing burden of alcohol-related admission problems for the health service. As our NHS tries to deal with these difficulties, there is the difference between costs rising at 4% per annum and growth in the economy at only 2%. The consequences of harmful drinking are a factor that we must address—and that is not surprising, given that Public Health England has recently reported that alcohol is the leading cause of death among 15 to 49 year-olds. There are now more than 1 million alcohol-related hospital admissions a year. Alcohol has caused more years of life lost to the workforce than have the 10 most serious cancers, and in England more than 10 million people are drinking at levels that increase the risk of harming their health. There are 23,000 alcohol-related deaths in England each year, which means that alcohol accounts for 10% of the UK burden of diseases and death, and is one of the three biggest avoidable risk factors.

Evidence indicates that ease of access and persistently cheap alcohol perpetuates these problems, with deprivation and health inequalities particularly prevalent among men from the lower socio-economic groups. Alcohol is 60% more affordable than it was in 1980, and affordability is one of the key drivers of consumption and harm. Cheaper alcohol invariably leads to high rates of death and disease. David Cameron and the coalition Government recognised this back in 2012 when they produced what I would describe as a progressive alcohol strategy. In its foreword, he talked about,

“a real effort to get to grips with the root cause of the problem. And that means coming down hard on cheap alcohol”.

Regrettably, that just has not happened. Other aspects of the strategy have disappeared, too. There seems to be a vacuum with no discernible sense of direction. I hope that today’s debate might start to move us towards a more positive approach than we have had for the past two or three years.

I will not spend much time on minimum unit pricing. I am sure the Minister’s reply will be quite predictable: we are awaiting the outcome of the Supreme Court’s decision on the Scotch Whisky Association appeal. If we did have that, I am sure the Minister would argue that we need to see whether minimum unit pricing is working in Scotland before taking any decision to bring it south of the border. If I am wrong on that, I would be very grateful if he could correct me.

What I would like to hear is whether the Secretary of State is willing to initiate talks with the Chancellor about revamping VAT and excise duties on alcohol so that low-alcohol drinks would not contribute anything, or very little indeed, in the future but we would start to tax at a much higher rate the stronger alcohol, which is particularly damaging to people’s health and which at present does not attract particularly high taxes. I am looking to see whether the Government are prepared to investigate a more differential approach to taxing alcohol.

Wine consumption has increased, particularly in recent years, and, as many people know, wine has got stronger and stronger. At one time it was 11% or 11.5%. Now it is in the order of 13%, 14% or even 14.5%. This is especially true of the red wines from the New World.

Happily, one of the positive sides of Brexit—this freedom we have—is that it will provide greater freedom for adjusting taxation. Such a change could not only raise income for the Exchequer; higher taxes on stronger alcohol could be an inducement for people to drink lower-strength alcohol, which would be better for them.

Is the Minister aware that the Institute for Fiscal Studies has recently done some research on this? Indeed, in February it produced a report which indicates that moving towards the differential taxes I have been describing could meet half the cost of the welfare bill, which of course is a major account the Exchequer has to deal with annually. Whether or not that is a starter remains to be seen, but I would be grateful if the Minister had a look at that report and let the Committee know whether he thinks the idea is worth pursuing, as well as raising the issue with his Secretary of State.

This week I have been to two parliamentary health meetings, one on gout. “Gout is not a laughing matter” was the title of the gathering. It was interesting to learn that one in 40 people in the UK now has gout, and its prevalence is rising. It rocketed between 1997 and 2012 by an astonishing 64%. Again, much of this is linked to the increased consumption of stronger red wines, and to obesity.

Alcohol is a major contributor to obesity, although many people are not aware of this. The drinks industry has managed to evade the usual labelling requirements for calories and sugar content in products. The Government have failed to effect changes here because they have prayed in aid existing EU regulations on labelling, which they say have prevented them moving in this direction. Showing calories and sugar content in alcohol is not required in Europe. There was an attempt to introduce such a requirement in Europe but it was overturned, so we must stick by existing EU regulations. Again, Brexit means we will have a freedom here we did not have previously. I have been campaigning for a long time to have calories shown on alcohol labels. People should know what they are consuming, just as they do with most other products. Why is it not happening?

In fairness, some producers, such as Sainsbury’s, which has its own brands, have shown calories. Sainsbury’s did that because research indicated that drinkers wanted to know about what they were drinking. Why should it not apply elsewhere? I would like to know what the Government are doing on this, given that they now have a strategy on obesity.

Alcohol also contributes to type 2 diabetes, which is reaching epidemic proportions. There is a direct link there. About 10% of alcohol contributes to diabetes and we need to get some movement on that.

This week I also went to a meeting of the All-Party Group on Liver Health—I declare my interest as patron of the British Liver Trust. Liver disease is now costing £2.1 billion a year, up 400% since 1970, and the upward curve continues in the UK while in Europe the cost is declining. There must be a reason for this, and we should be looking at what it is. This is a great problem for A&E departments, as mentioned in previous exchanges with the Minister. Alcohol is a contributory factor in 70% of A&E cases at the weekends, and I would like to know what the Government intend to do about that.

We need to start examining a whole range of other options, particularly given that this week, the Government are taking steps to withdraw certain free prescriptions. We need to look at the 9 million people with hypertension who are getting NHS medication for it. We need to look at the millions of people—and the number is increasing—who are on tablets for depression. Will the Minister say whether people who are on medication for depression should not be drinking alcohol, and whether it is permissible? If in fact, as I know, many people are taking tablets but still drinking, is it not time to look at that in the context of developments this week? People should have a choice: either they take the tablets for depression and stop drinking; or, if they want to continue drinking, they should pay for their tablets over the counter.

I saw the figures in a recent Written Answer from the Minister on how much is being spent on medication—it has rocketed since 2010. We have to start looking for a different approach. We need the Government to accept responsibility for the policy areas they can control. We need the industry to accept greater responsibility—I will not go on about the industry in great detail today; I will leave that for a separate debate—and we need people to take more individual responsibility, given this new world in which the NHS is under great financial pressure. I hope I will get a positive response on many of these points from the Minister, and maybe we can look forward to a wider debate on drawing up a real strategy in the future.

Mental Health and NHS Performance Update

Lord Brooke of Alverthorpe Excerpts

Monday 9th January 2017 Lords Chamber

[Lord O'Shaughnessy]

Mental health is an issue that spans education and health. I recognise the problems that the noble Baroness is describing. I do not know the specific details about the performance of referrals but I will write to her with that information. One of the purposes of the strategy, and the adoption of all the recommendations of this review, is to make sure that we make the system work better so that what the noble Baroness describes—which is not what we want to happen—happens less frequently.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I too welcome the noble Lord to his new appointment and wish him well. I place on record my gratitude to his predecessor, the noble Lord, Lord Prior, who was always open and honest in his dealings with us and straightforward in answering our questions. I hope we are going to have an open and honest discussion about the role of A&Es in the future and whether there is any likelihood that we are going to lose the four-hour limit. Over the holiday period, Sir Simon Stevens commented that A&E is not to be used as a “national hangover service”. Is there a possibility that we are to lose some of the terms we have had in the past because of the number of drunks who are being treated on Fridays, Saturdays and Sundays throughout the year—not just over bank holidays? This is creating immense problems within A&E, yet the Government refuse to do anything about the fundamental cause of that: to use Mr Cameron’s phrase, “cheap booze”. Back in 2012 he was advocating a change to try to stop this. Unless that is addressed, there will be a scandalised outcry about changes in the fundamental terms relating to A&E.

[Lord O'Shaughnessy]

I thank the noble Lord for his welcome. On A&E, the Statement is very clear that the Government are,

“committed to maintaining and delivering that vital four-hour commitment to patients”.

As the noble Lord described, there has been a change in the case load going into A&E. You only need to spend a bit of time in an A&E to know that alcohol is a factor. I do not know whether this is increasing, but I shall endeavour to find out. I absolutely agree that any proper strategy for relieving pressure on A&E must include cracking down on problem drinking.

Public Health England: Alcohol

Lord Brooke of Alverthorpe Excerpts

Tuesday 5th July 2016 Lords Chamber

Asked by

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government when they expect Public Health England to publish its independent evidence-based report on alcohol.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, the evidence review is currently being peer reviewed and PHE will publish it later this year.

[Lord Brooke of Alverthorpe (Lab)]

I am grateful to the Minister for that response and I look forward to the report. Is he aware that the latest statistics from the Health and Social Care Information Centre show that hospital admissions due to alcohol-related illnesses are continuing to rise and are now more than 1 million, that the number of deaths arising from alcohol continues to go up, and that the cost to the NHS of alcohol-related problems is more than £2.5 billion? Given the difficulties that the NHS faces in funding itself at the moment, given that the economy may slow down as a result of Brexit so that less funding is available and given that we heard today about the prospect of another doctors’ strike, are the Government prepared to review the plan for the NHS to which the noble Lord so frequently refers? It may need to be changed completely, so what is plan B?

[Lord Prior of Brampton]

My Lords, that goes slightly beyond the Question on the Order Paper. The Government are committed between now and 2020 to putting £10 billion of new money in real terms into the NHS and we have a plan to deliver on that. Clearly, if the economy changes to a great extent, we will have to keep that in mind.