Organ Donation (Deemed Consent) Bill

Lord McColl of Dulwich Excerpts

2nd reading (Hansard): House of Lords
Friday 23rd November 2018 Lords Chamber

[Lord McColl of Dulwich (Con)]

I too congratulate the noble Lord, Lord Hunt, on bringing this Bill through. I should declare an interest as a former transplant surgeon. I found kidney transplantation the most exciting operation that I did in my 50 years of surgery. Kidneys would be flown in from all over the place in order to try to achieve a good match. One would connect up the vein and then the artery and to my surprise I found that some of the kidneys would start peeing on the table immediately, which was wonderful, but I noticed it was only the French kidneys that did this. I asked what it was about these French kidneys, and they said, “It’s the French wine, you know”. Well, in fact there were other factors involved.

At present, around 6,000 people are on the UK transplant waiting list, and last year over 400 people died waiting for a transplant. With so much at stake, it is not surprising that the question of how the donation system should operate is a source of strong emotion. The increased public awareness of the great benefits of donation is to be welcome, but—and there is a “but”—I have been rather taken aback by the way in which the evidence of what works, even the facts about the current law, has been manipulated and inflated by the media, in parliamentary debate and even in the consultation materials themselves. I do not think this is the way to support and maintain trust in our transplant system, nor to demonstrate commitment to evidence-based policy.

The 2011 Nuffield report, Human bodies: Donation for Medicine and Research, which has been mentioned quite frequently, strongly supported organ donation,

“where this is in accordance with the wishes of the donor”,

but it did not advocate a change in the current law to the opt-out system. Nuffield concluded that,

“such a system could be ethical, as long as a number of potentially onerous criteria were met. People need to be fully informed in order to be able to make an active choice about whether or not to donate, which implies a long term and expensive commitment to public information and education. Families need to be appropriately involved—recognising not only that they are likely to have the best knowledge of their loved one’s attitudes to organ donation, but also that they themselves, in their bereavement, have a stake in what happens to the deceased person’s body. Critically, the system must operate in a way that ensures that public trust in the donation and transplant system is not undermined, for example through perceptions that the state is intervening to ‘take’ organs against family wishes. We only have to look back two decades to the outcry caused by tissue retention in the NHS to be alert to the way in which trust can be undermined, not least by failing to take into account the complex family and personal meanings associated with the body in death”.

In considering these questions of trust, the report also assessed, in more general terms, whether such a change in the law would increase donation. As it said,

“the quick answer is that no one knows. In contrast with the claims (confidently asserted over past months) that opt-out will save ‘thousands of lives’, the Department of Health’s own Impact Assessment, published alongside the consultation document, described the evidence on the impact of opt-out on donation rates as ‘inconclusive’ … Despite all the emotional rhetoric, the jury is still out on whether changing the law in this way will make any difference at all to the numbers of organs available for transplant”.

In beginning to assess the efficacy of presuming consent, we have to confront a misunderstanding about how donation works in England today. All too often, the assumption is made that only those who have signed the organ donor register are potential donors. Given that just 37% of the population in England have signed the register, it is thought that a shift to presumed consent will increase the pool of potential donors dramatically. Even if 10% of the public opt out, one would still increase the total pool of donors from 37% of the population to 90%. The difficulty with this logic is that it fails to appreciate that, at present, it is not only those who have signed the organ donation register who can donate. As Answers to Parliamentary Questions I tabled in July demonstrate, most donations in England at the moment come from families of people who have not left instructions about what they want done with their organs. To put the same point another way, at the moment, most organs are donated by people who have not signed the register. Critically, this means that clinicians in England are not limited to a pool of the 37% of people who have signed the register—they can approach the families of 99.3% of people. The missing 0.7% relates to those who have signed the opt-out register in England, and cannot be approached.

Rather than increasing the pool of potential donors, moving to informed consent reduces it. Whenever consent is presumed, some people take offence and sign the opt-out register. In Wales, prior to the instruction of its deemed consent law in 2015, there was no opt-out register, so 100% of people were potential donors. As a consequence of introducing presumed consent, however, 180,000 people, or 6% of the population, have now opted out. It is no longer possible for clinicians to talk to families about donation, when previously they could all have been approached. The organs of those 180,000 people are simply lost to the system. Rather than increasing the pool of potential donors, the introduction of presumed consent in Wales has involved spending public money to reduce that pool from 100% to 94%.

The truth is that, regardless of what system is operated at the point of donation, the key player is the family. Not having signed the organ donor register does not prevent doctors talking to the family about donation. Presuming the consent of the donor does not enable doctors to avoid talking to the family about consent. It makes no difference whether the donor had signed the register or had his consent presumed. At the end of the day, they will be unconscious, and the key conversation must take place between the clinicians and the family. In this context, the focus of our attention should be, as many speakers have said, on the family.

We know from the detailed reports published each year by NHS Blood and Transplant that the key factors associated with high consent rates are support for families by specialist nurses, and families knowing what the deceased person wanted. Consent rates are as low as 27.5% when families are not supported by a specialist nurse. They increase to 68% when a specialist nurse is involved, and to more than 90% where families are confident of the deceased’s wishes, as the noble Lord, Lord Patel, the noble Baroness, Lady Finlay, and my noble friends Lord Lansley and Lord Ribeiro have already said.

This is consistent with the experience of Spain, which, as has been mentioned, has sustained the highest donation rate for more than 20 years. Rafael Matesanz, the leading light of the Spanish transplant system, ascribes the well-known successes of the Spanish system to its focus on efficient systems and excellent family support. He is on record as calling the opt-out system a “distraction”. Despite being classed wrongly by some as an opt-out country, Spain operates neither an opt-in nor an opt-out register, and relies entirely on family authorisation for the legal basis of donation.

The official evaluation of the Welsh law was published in November 2017, two years after it came into effect. It showed that if you compare the resident Welsh donor rate for the 21 months before the introduction of the new system with the 21 months since, far from increasing, the numbers fell slightly from 14.6 donation decisions per quarter to 13.4 donation decisions per quarter. This is less than encouraging. Admittedly things have since improved, but it will take at least five years to show any meaningful trend. In assessing that trend, it will be critical to allow for increased investment in specialist nurses in organ donation and critical care beds, which has nothing to do with presuming consent but will increase donation rates. The official evaluation concludes that longer period of time is needed to draw firmer conclusions about the impact of changing the law.

In the context of 400 people dying while waiting for a transplant, and when we do not have limitless public funds, I find the prospect of spending millions of pounds of public money on presumed consent rather concerning. Any money that we spend on presumed consent, for which we have no robust evidence of success, we cannot then spend on things that we know will increase donor donations. We should wait to see what happens in Wales and spend any additional monies on more specialist nurses in organ donation and more critical care beds. If the Government are determined to back this Bill, it will be imperative to limit the potential scale of withdrawal from donation by assuring people on the face of the Bill that their families will be properly consulted. This statutory guarantee of consultation must be genuine and not limited to simply giving the family a right to provide evidence that the family member did not want to donate, as in Wales.

Finally, I have another interest to declare. My daughter is a potential transplant recipient.

Obesity

Lord McColl of Dulwich Excerpts

Wednesday 18th July 2018 Lords Chamber

Asked by

[Lord McColl of Dulwich]

To ask Her Majesty’s Government what plans they have to address the incidence of obesity.

[Lord McColl of Dulwich (Con)]

My Lords, I say at the outset how much I am looking forward to the maiden speech of the noble Baroness, Lady Boycott, with all her expertise. We hope to hear a lot of her expertise in the years to come.

I start by recounting the story of Labour’s deputy leader Tom Watson, which he recently broadcast in the media. He explained that he was 51, very overweight and had tried many diets. When he started looking into the problem, he realised that all the advice given by the authorities was completely wrong. His research showed that he needed to cut down radically on sugar and starchy carbohydrates, and find ways of getting fat into his diet. Fat stops one feeling so hungry during the day. He also overcame his craving for sugar. This regime resulted in him losing seven stone, or 39 kilograms.

What Mr Watson rediscovered was what had been well known during the war. In 1939, one-third of the British people were either underfed or fed on the wrong food. Food rationing cured that rapidly. For the first time, people had the right quantity and right kind of food. There was no obesity then because they ate food that satisfied them: food they had to chew, including wholemeal bread with plenty of dripping on it—there is nothing wrong with fat, except saturated fats. Also, of course, there was very little sugar and less starchy food. I should explain that when we eat fat it leaves the stomach and goes into the duodenum, releasing a hormone which specifically delays the emptying of the stomach and makes one feel full. Hence, it limits the amount we eat. After the end of rationing in the 1950s, the food industry wished to increase its sales and profits. Realising that it was not selling a great deal of food and that fat was actually a brake on how much people ate, it decided to demonise fat and encourage carbo- hydrates. A low-fat, high-carbohydrate diet is pretty tasteless because it is fat that gives it the taste. The industry had to add large quantities of sugar so that people would eat it, and so began the obesity epidemic.

Another story I would like to tell is of a Member of your Lordships’ House who was paralysed and in a wheelchair. Being overweight, he decided to take three stone of weight off. He could not exercise and so decided on a really revolutionary way of losing weight. He lost three stone simply by eating less. Politicians and that organisation, NICE, have repeatedly stated that all the calories we eat are expended on exercise. This simply is not true. Only a fraction of the calories we eat are used up on exercise. Anyone who disputes this can go to the gym and exercise on one of the machines for half an hour. If they slave away and look at the dial to see how many calories have been used up, it will be about 300 calories in half an hour. That is what one gets from a small bar of chocolate.

The press and the media have been very helpful in the last year or two in drawing attention to the real cause of obesity, which is putting too many calories into one’s mouth. Many people find it difficult to eat less, so it is probably worthwhile looking at preventable problems that make obesity more likely. A lady of 42 with an eating disorder gathered together about 45 other ladies with a similar condition to see whether they could help one another with their problem. When they went round telling their stories, they had all been sexually abused as children. That is of course an anecdote—anecdote being Greek for “unpublished”, which is arguably what most anecdotes should remain—so let us look at science.

An excellent paper published by Danese and Tan in 2014 demonstrated without doubt that the maltreatment of children is associated with a substantial elevated risk of developing obesity. There is so much domestic violence and sexual abuse of children that a greater drive on reducing these risks might also help to solve the obesity epidemic. There has also been a suggestion that as mothers increasingly work outside the home, that may lead to families increasingly relying upon ready-made junk food, which never satisfies hunger and therefore leads to people eating far too much of it and hence obesity. This may be an important contributing factor.

Some elements of the food industry have made an effort to stem the obesity epidemic. The late Professor Terence Wilkin produced some very good scientific work, which clearly showed that obesity leads to inactivity but that inactivity does not lead to obesity—so do not call children couch potatoes. When one examines the genetics of all this, it is not a question of simple inheritance. It has been shown that the children of obese parents are six to 10 times more likely to be obese but, even then, it is not inevitable that they will become so. They will become obese only if they put too many calories in their mouth. There are some medical conditions which affect appetite but none that directly lead to obesity. The tendency towards obesity looks as though it is established early on in life, long before children go to school. As Professor Wilkin stated, this questions the rhetoric around school meals, computer screens, playing fields and of course physical activity, which is fairly unstructured in early childhood.

It is important to restate that physical activity is important for mental health, the heart and the body’s general well-being and functioning. But I hope the Minister will finally put to rest the repeated statements from the Department of Health and Social Care and elsewhere, saying that obesity can be solved by increasing activity and diet. They link those two but only a fraction of the calories we eat are used up in exercise. In their advice, exercise and diet should not be coupled together. They should be separated, not put in the same sentence.

The obesity epidemic is probably costing £30 billion a year. Saving on that would be a great help to the NHS. This whole subject has been bedevilled by, first, the food industry demonising fat and promoting sugar and carbohydrates—by the way, among five to eight year-olds tooth decay is far and away the leading cause of hospital admissions, which are mainly caused by excessive sugar consumption. Secondly, there is the false statement that all the calories we eat are expended in exercise, when only a small fraction are, as I said before. Thirdly, there is blaming and insulting other people, such as calling children couch potatoes when in fact inactivity does not lead to obesity.

Fourthly, there is the nonsense of skimming milk. Skimmed milk is so tasteless that sugar has to be added to get children to drink it. There is no need to skim milk. Eight thousand children in Canada were given whole milk from birth until the age of eight; their calcium metabolism was good and they were not fat but very healthy. Whole milk can actually reduce the incidence of stroke, as in the work published quite recently by Professor Otto in Texas. Human breast milk contains 3.5% fat, as does cows’ milk. I do not think they have started skimming human breast milk yet but you never know.

A fifth part of the department’s advice was to have only two eggs a week. There is no scientific basis for this at all. You can have an egg every day if you want. The sixth thing was that GPs were told not to call patients obese because it was judgmental. There is a difference between being judgmental and making accurate diagnoses. Seventhly, psychological reasons may have a role in obesity but we do not quite understand how.

What is the answer to all this? It is an all-out campaign involving every man, woman and child, every institution, school, university and government department to try and reduce the obesity epidemic.

I believe that the Department of Health and Social Care is moving in the right direction. The idea is not to tell people what to do but to tell them the truth—not in a patronising way, as in the old days, when at 7.50 every morning, at breakfast time, you turned on the radio and the radio doctor would say, “I’m the radio doctor and I’m going to talk about your bowels”. The answer to that was to switch the thing off, saying, “We’re not having bowels for breakfast”.

There have been some very good programmes such as “The Archers”, “Horizon” and many others, which have been very professional in promoting preventive medicine. In a recent campaign against AIDS—

[Baroness Manzoor (Con)]

May I remind the noble Lord that he needs to wind up, because this is a timed debate? I am so sorry.

[Lord McColl of Dulwich]

I was just going to say that there was a successful campaign against the AIDS epidemic, run by the present Lord Speaker when he was Secretary of State for Health. Why was it so successful? Because he was honest and straightforward, and did not beat about the bush. He said, “Don’t die of AIDS. AIDS is lethal”. That is how we need to fight the obesity epidemic, which is killing millions and costing billions. The cure is free. Eat less. Put fewer calories into your mouth. We must do this: we owe it to our children.

[Baroness Manzoor]

My Lords, to assist the House, before the next speaker starts may I remind all speakers that when the clock strikes five minutes, time is up?

NHS: Equitable Access

Lord McColl of Dulwich Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord O’Shaughnessy]

I thank the right reverend Prelate for asking two very good questions. We recently announced the first local health and care records, covering around 40% of the population. Sometimes, you can pitch up in one part of the NHS and they cannot access all your patient and care data; this measure will make sure that that does not happen. Patients want this; it is essential for good direct care.

The right reverend Prelate is quite right about the ethical considerations. We will publish a code of conduct on the proper use of AI in the NHS later this year. We are working with the new Centre for Data Ethics to make sure that this happens.

[Lord McColl of Dulwich (Con)]

My Lords, there are 4 million type 2 diabetics in this country. Does the Minister agree that they could be cured quite easily if they ate fewer calories?

[Lord O'Shaughnessy]

Changes in eating habits certainly help, as do changes in exercise. Our obesity strategy tries to make sure that those good habits are ingrained from an early age.

Childhood Obesity: Yoga

Lord McColl of Dulwich Excerpts

Thursday 21st June 2018 Lords Chamber

[Lord O’Shaughnessy]

I am not aware of the charity that the noble Lord mentioned, although after university I spent six months in India as a teacher. The school I taught in practised yoga with its children and it seemed to have a calming effect on them—which is just as well, because I am not sure my teaching skills had such an effect. I am sure many noble Lords know personally the benefits of yoga. It has not been proven to have any impact on obesity, although it has many other benefits, as the noble Lord pointed out. It is something that schools can and do use as part of their repertoire in the PE curriculum to provide exercise for children, although it does not count towards the moderate and higher levels of activity demanded by the PE curriculum.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that exercise does not deal with the obesity problem at all? There is only one way of dealing with obesity: eating less. Does he also agree that pregnant women who are obese transfer that tendency of obesity to their offspring by a mechanism, which we do not understand, called epigenetics? While we are on the subject, I congratulate the Minister on being a shining example of controlling his measurements. I have noticed that his waist measurement is less than half his height.

[Lord O’Shaughnessy]

I am wondering how my noble friend has made such an accurate assessment. He did not see my weight on the scales this morning. He is quite right. Of course, it is a combination of exercise and healthy eating, which is why there has been a push for both those things in our schools. There are great risks to pregnant women from being obese, not only to themselves with diabetes in pregnancy, which tends to reappear in later life, but in the impact on their children. That is why it is so important that pregnant women get good advice about healthy eating.

Long-term Plan for the NHS

Lord McColl of Dulwich Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

I would not agree with that because it is clearly the case that once we have left the European Union we will not be paying for membership of it—and it is those funds which will, in part, go towards helping us solve the funding challenge that we have set ourselves for the NHS.

[Lord McColl of Dulwich (Con)]

My Lords—

[Baroness Ludford (LD)]

My Lords—

--- Later in debate ---

[Lord O'Shaughnessy]

No.

[Lord McColl of Dulwich]

Does the Minister agree that the obesity epidemic is costing well over £25 billion a year? Would he consider having an all-out campaign— including every man, woman and child, every institution, school and government department—not to tell people what to do but to tell them the truth? For instance, there are 4 million people with type 2 diabetes due to overeating. If they ate less the savings would be terrific and most of them would be cured of their diabetes.

[Lord O'Shaughnessy]

My noble friend sets a tremendous personal example in this case. He is a fearless and tireless campaigner on the causes of obesity. He knows that it is our hope and intention that we will return to this topic so that we can start to reduce this plague on children and adults.

Children: Obesity

Lord McColl of Dulwich Excerpts

Thursday 19th April 2018 Lords Chamber

[Lord O'Shaughnessy]

One thing I noticed at Easter was that Easter eggs seem to have got bigger. I was counting the calories on the Easter egg that my children had. There is a serious point there. It is about reformulation, it is not just about reduced sugar, salt and so on; it is also about smaller portion sizes, and that is a measure that we are tracking as well.

[Lord McColl of Dulwich (Con)]

My Lords, it is really me. Is the Minister aware that a recent report from Canada showed that children who were fed on whole milk for the first eight years of their life were much healthier than those not, and they were not obese? Why on earth did we ever start skimming milk when human breast milk has the same amount of fat as cows’ milk? As far as I know, we have not started skimming human breast milk yet.

[Lord O'Shaughnessy]

I am trying to imagine how that might work. The noble Lord makes an important point which he also made in a debate the other day, that our understanding of dietary needs is changing. In some ways, we are rediscovering old truths about the importance of fat and reduction of sugar. That is part of the approach that Public Health England is promoting.

Children and Young People: Obesity

Lord McColl of Dulwich Excerpts

Tuesday 17th April 2018 Lords Chamber

[Lord McColl of Dulwich (Con)]

My Lords, I thank the noble Baroness, Lady Walmsley, for initiating this important debate. I do not need to repeat all the figures that she has so ably put forward. However, I shall ask a question: how on earth did we get into this mess in the first place? It is the worst epidemic for 100 years.

Now, many of us have managed to stay the same weight for 100 years—

[Baroness Jenkin of Kennington (Con)]

Not that many!

[Lord McColl of Dulwich]

I will not say “Speak for yourself”, but there are a lot of people who have managed to stay the same weight.

The question is: how did they do it? They simply respected the various mechanisms that exist in the body for keeping the weight constant. What are they? They are very intriguing. One is to eat food that you have to chew. When you chew, the chewing muscles produce impulses that go to the brain telling it that you have had enough to eat. If that does not work and there is fat in the meal, when the fat goes through the stomach into the duodenum it releases a hormone that stops the stomach moving any further. We get a feeling of being full, so we stop eating. It is a very nice mechanism. Then, when the fat has been emulsified by the bile, the whole thing moves on and the stomach starts to move again.

At the end of food rationing the food industry was presented with a problem. It wanted to increase the amount of food that people ate, because we were all eating just the right amount—food rationing had sorted that one out. How was it to persuade people to eat more? The simple solution is to sabotage these beautiful mechanisms for keeping the weight constant. How did the industry do that? It demonised fat and got some unscrupulous members of the academic world to produce research that just happened to confirm its view that fat was the wrong thing. Then President Eisenhower had a heart attack and they found that what blocked his arteries was atheroma. As noble Lords will know from their Greek studies, atheroma is a Greek word meaning porridge. It might be Greek porridge, but it is not Scottish porridge, that is for sure. In fact it is not porridge at all: it is a cholesterol, fatty material. So they blamed that. Fat was demonised, so we had a low-fat diet.

The problem then was where to get the calories from, so they filled the diet up with carbohydrates. A low-fat, high-carbohydrate diet is tasteless because fat gives us a nice flavour. The food industry then faced the problem of how to get people to eat this terrible stuff. The answer is to pour in sugar. That makes it palatable. So was born the obesity epidemic: a low-fat, high-carbohydrate, high-sugar diet.

Then, just to make things worse, NICE said that all the calories we eat are expended on exercise. That was not true either: only a fraction of the calories we eat go on exercise. In fact, it is about a quarter. This idea that exercise is the answer to obesity led to hundreds of thousands of people pounding the pavements and roads wearing out their joints, so you had more and more joint replacements for the hip and knee. So the nonsense continued. Of course exercise is very important to general well-being and health, but not in terms of controlling weight. Then we insulted the children by calling them couch potatoes. Inactivity does not lead to obesity. Obesity leads to inactivity, but that is a different matter.

What is the answer? It is that we need an all-out campaign involving every man, woman and child, every institution, school, university and government department to try to reduce the obesity epidemic. When we were taking evidence from the experts in a recent Select Committee, we were told that all-out campaigns do not work. I pointed out that the AIDS campaign did. One of these experts said, “No it didn’t”, which surprised the Lord Speaker, Norman Fowler, because it was his campaign. It worked because he was absolutely honest and did not bother with anything politically correct. He said it as it was: “Don’t die of AIDS”; AIDS is lethal. So the campaign was successful. That is what we now need, because we owe it to our children. The obesity epidemic is killing millions and costing billions. The cure is free: eat less.

Emergency Hospital Admissions

Lord McColl of Dulwich Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord O’Shaughnessy]

It is now the case that thousands of GPs and hospital staff have been trained to screen for the signs of alcohol abuse and to provide intervention. So not only are there dedicated staff and dedicated public health programmes, but hospital and primary care staff have now been specifically trained to look for the signs and to signpost people to care when they need it.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that one of the causes of the recent pressure on acute hospital beds is that young people and children who are waiting for scarce specialist mental health beds are frequently put into inappropriate adult wards because there is no room for them anywhere else? Would the Minister look into that again?

[Lord O’Shaughnessy]

I thank my noble friend for making that point. Unfortunately, we have a growing prevalence of the kind of mental illness he is describing. We are in the process of increasing the number of in-patient beds available for young people going through those kinds of episodes. That is the right thing to do. It means that they will not have to travel so far from their homes and has the benefit of relieving the impact on adult acute beds.

National Health Service

Lord McColl of Dulwich Excerpts

Tuesday 10th October 2017 Lords Chamber

[Lord McColl of Dulwich (Con)]

Does the Minister agree that the major problem in the NHS today is the enormous increase in demand? It is not old people getting older; it is not young people being couch potatoes, because inactivity does not cause obesity. The obesity epidemic is what is wrecking the NHS.

[Lord O'Shaughnessy]

The NHS is seeing more people than ever—I think that some 1,500 more people a day are being seen in A&E. A lot more people are going through the service. The truth is that there are a number of factors: there are factors around lifestyle and around ageing. The point is that we have to change. At the heart of this Question is the comment made by the chief inspector about our not having new models of care. We need to change the way in which we provide care. That means integrated care, with much more of it based in the community. That means us all taking difficult political decisions about how care is configured so that it meets changing needs related to obesity and ageing.

National Stroke Strategy

Lord McColl of Dulwich Excerpts

Wednesday 5th July 2017 Lords Chamber

[Lord O’Shaughnessy]

I know that the noble Baroness has a deep commitment to ensuring the best possible stroke care. She is quite right to highlight the economic and personal costs of stroke. There is a good picture in this country in so much as mortality from stroke and the incidence of stroke have halved over recent years—so the picture is improving. The stroke strategy the noble Baroness mentioned was superseded in 2013 by a cardiovascular disease outcome strategy that is obviously broader but includes stroke. That builds on the work that has already happened. I am realistic about the fact that there is obviously more to do, but we now have a number of hyperacute centres that are rolling out new treatments, such as thrombectomy, which will help treat stroke and make sure that we bring mortality down even further.

[Lord McColl of Dulwich (Con)]

My Lords, is the Minister aware that the incidence of stroke in the Scotland is 40% greater than in England? That is surprising in view of the fact that Scotland spends 25% more on its health service. Could this have something to do with the obesity epidemic?

[Lord O’Shaughnessy]

Well, in order not to fall out with Scottish noble Lords, I shall not comment on that. Under successive Governments there have been improvements in stroke outcomes, which have come about through the centralisation and specialisation of care. That is not always popular because of what it does with reorganisations, but it is definitely paying dividends in England.