Dementia Services (South-West)

Alison Seabeck Excerpts

Monday 11th June 2012 Commons Chamber

[Mr Ben Bradshaw (Exeter) (Lab)]

Thank you very much, Mr Speaker—and thank you very much for granting a debate on a subject that is of great concern to my constituents in Exeter, to people throughout the south-west, and, indeed, to people throughout the country. My own mother suffered from dementia, and died very young when I was just 18. That was in the days when Alzheimer’s and other dementias were only just beginning to be recognised. Since then we have made great strides in terms of our knowledge and understanding, and the treatment that is available to sufferers and their families. I pay particular tribute to the Alzheimer’s Society for its campaigning work and the support that it provides for people.

There are currently 800,000 people with dementia in the United Kingdom, and one in three of us will have it by the end of our lives, so this is an issue that touches, or will touch, virtually every household and every family in our country. Although progress has been made, there are still big gaps and unacceptable variations in levels of service and support, and I shall focus on three issues that cause particular concern: the rates of diagnosis; the availability of drugs for sufferers; and the overall resilience of the care system, on which many dementia sufferers and their families depend.

Everybody—including, I am pleased to say, the Government—accepts that early diagnosis is absolutely vital in ensuring that people with dementia and their families receive the information, treatment and support they need. At present, however, fewer than half—43%—of dementia sufferers have a formal diagnosis, and in the south-west that rate is even lower; in fact, my region has the lowest diagnosis rate of anywhere in England at just 35.4%, with my own county, Devon, having barely a third of sufferers diagnosed and Dorset having the lowest rate in the country at just 27%. As the south-west of England has a higher than average proportion of elderly people, and therefore more dementia sufferers, that is extremely worrying. Indeed, according to the Minister’s own figures, in Devon alone there are almost 9,000 people with dementia who have not been diagnosed. In contrast, average diagnosis rates across Northern Ireland are above 60%, and in Belfast the rate is almost 70%. What is the Minister’s explanation for this huge variation in diagnosis rates across the country, and what are his Government doing to address that?

Many fear that the Government’s upheaval of the NHS might make this situation even worse, not better. Putting GPs in the driving seat means that the level of awareness and understanding of the problem among GPs will be more important than ever. GP training is therefore vital, and I welcome the progress that is being made, such as in Devon, where an education programme for GPs has reached 374 practices across our county, and there are already signs of increased diagnosis rates. But education alone is not enough. GPs need to have access to help and support, but the key to improving diagnosis rates in the south-west will be to ensure that GPs can refer patients to memory services for diagnosis. I have heard reports of people waiting over a year for an appointment at a memory clinic, however.

As the Minister will be aware, the Alzheimer’s Society recently wrote to all MPs asking us to write to our local primary care trusts in order to establish waiting times at memory services in their areas. I commend this initiative. Will the Minister say whether the Department of Health collects data on waiting times at memory services in the south-west—as well as in other regions? If not, will he arrange for NHS South of England to provide Members with this information?

The Royal College of Psychiatrists has established the memory services national accreditation programme, to ensure that services at memory clinics meet national standards. Does the Minister agree that all memory services should seek such national accreditation and that that should be a priority for local NHS managers?

As the Minister will also be aware, next month the all-party group on dementia will report on its inquiry into improving diagnosis rates. I understand that he has been invited to the launch of the report, and I hope he can confirm tonight that he will be able to attend.

The second issue I want to highlight is the variation in the availability of medicines for dementia sufferers. These medicines can make an enormous difference both to the progression of the illness and the quality of life enjoyed by the sufferer and their carers. The Minister will be aware of the massive—some reports have suggested as much as 50-fold—variation in the level of drug prescribing among PCTs in England. Again, the south-west does very poorly. We are not the lowest region in England in respect of prescribing, but we rank as the second lowest region after the west midlands. It is very worrying that our region, with its high proportion of elderly people and therefore of dementia sufferers, has the second lowest level of availability of medicines that could help them. Will the Minister explain the reasons for that, what the Government are doing about it, and how he can guarantee that this problem will not get worse under the Government’s reorganisation of the health service?

The third and final concern I wish to raise tonight is the financial hardship faced by dementia sufferers and their families because of the cost of long-term care. We know that, in some cases, that can run into hundreds of thousands of pounds; it can lead to families losing their homes or their inheritance because of the lottery of getting dementia. Many people rightly feel that that is deeply unfair. In my view, the long-awaited report by Andrew Dilnot on the future of long-term care provides a sustainable and equitable solution to that deep unfairness that some families face and to the general challenge of providing long-term care.

[Alison Seabeck (Plymouth, Moor View) (Lab)]

This is an incredibly important debate and my right hon. Friend has touched on a number of issues that affect my constituents. In a recent case, the mother of Lee Finn was in Derriford hospital with dementia; the family came in and read her chart—they had power of attorney— and saw that it said “Do not resuscitate”. The family had not been asked or consulted in any way. Does my right hon. Friend share my concern that, although there is some fantastic work going on in the field of dementia, crass errors continue to be made that cause families deep unhappiness? It is clearly not good for the dementia sufferers if the whole family is destabilised because of poor decision making.

[Mr Bradshaw]

I agree absolutely. As I said, and as I hope the Minister will endorse, training and awareness of dementia are vital not only in primary care settings but in secondary care settings, as in the case my hon. Friend raises. Some people who may seem to be extremely ill with dementia and who are in the situation she describes may in fact be physically perfectly fit and able to carry on living for some time. I hope that her local hospital will take up the case and provide a satisfactory response.

As I was saying, there is a strong feeling on both sides of the House that we need a sustainable and fair solution to the challenge of long-term care. That challenge particularly, but not solely, affects families with members who suffer from dementia because of the enormous costs imposed on them by having to pay for long-term care. I do not think it an exaggeration to say that there was great disappointment when the Queen’s Speech again failed to include a Bill to implement the Dilnot proposals. As far as it goes, the Government’s commitment to a draft Bill was welcome, but it would be helpful if the Minister told us when that draft is likely to be published and guaranteed that a Bill will be passed in this Parliament. May I boldly suggest that that would be a real legacy and worth working for?

--- Later in debate ---

[The Minister of State, Department of Health (Paul Burstow)]

I congratulate the right hon. Member for Exeter (Mr Bradshaw) on securing this debate. He is absolutely right to highlight the importance of the issue of dementia. It is, without doubt, one of the biggest health and personal issues affecting our society today, and it will touch the lives of many families in this country. He rightly rehearses the statistics, and dementia is a priority for this Government. We know that in England there are 670,000 people living with dementia, that the figure is set to double over the next 30 years and that in England the cost of dementia to society as a whole is about £19 billion. However, the true costs of dementia are incalculable. I am talking about the cost in terms of the impact on people’s lives, the lost opportunities and the consequences of taking on a caring responsibility within the family, and the costs and consequences for the individual. As has been said in this debate, we know that cancer has been replaced by dementia as the disease that people in their 50s now fear the most, and the right hon. Gentleman has highlighted a number of reasons for that.

That is why, on 26 March, the Prime Minister, on behalf of this coalition Government, set out this Government’s dementia challenge: to go further and faster in implementing the previous Government’s dementia strategy; to focus, in particular, on the issue of diagnosis rates; to raise awareness and ensure that we prepare our society to be adapted and adaptable to the needs of people with dementia; and to double the research funding available in the area of neurosciences and dementia by 2015.

The dementia challenge builds on the previous Government’s work on the national dementia strategy. We kept and built on that strategy, rather than losing any of the momentum that it put in place. I pay tribute to the Alzheimer’s Society for the work it does, and we are working closely with it. We have brought together three champion groups that are taking forward the work on raising the need to improve diagnosis and the treatment and care of people so diagnosed. We are also focusing on issues associated with how we raise awareness, both within the social care and health care work forces and in wider public services. Finally, we are working with the research community to improve capacity significantly and make sure that we have more good quality bids for funding for dementia research in this country.

On the recognition of dementia, we need to ensure that the challenge is not just for the national health service or social services departments, but for our whole society. Work is being led by the Alzheimer’s Society and one of its key champions and ambassadors, Angela Rippon, on how we create dementia-friendly cities, towns and villages. The county of Devon is taking a lead working with schools so that young people better understand dementia and get involved in services supporting people with dementia in the community.

The Government have laid the foundations for dementia research, investing heavily in biomedical research centres and seeding the necessary interest among the research community through themed calls. Something in the region of £17 million of new money is now going into research.

The right hon. Gentleman is right on diagnosis: there is still inexplicable and unacceptable variation within his own region, let alone across the whole of England. In 2011, 30,000 people had been diagnosed and were living with dementia in the south-west, which is among the lowest rates in England. However, we know from the figures that the movement is in the right direction. It is not as fast as he would like, nor as fast as I want it to be in future, but in 2010, the diagnosis rate was 35.4%; by 2011, it had risen to 37.3%.

The Government are ensuring through our dementia challenge that general practitioners and other health professionals are referring more people for assessment. We are making people aware of the availability of memory services and targeting hospitals to ensure that they receive extra resources to undertake dementia risk assessments of people over the age of 75. There will be additional resources to support that activity. We are confident that it will lead to a significant increase in the numbers of people being both diagnosed and referred for diagnosis.

The right hon. Gentleman referred to the Royal College of Psychiatrists accreditation programme. I endorse what he said. It is important that more memory services seek that accreditation, and many in his region are doing just that.

I can tell the right hon. Gentleman that there has been a further acceleration in progress on diagnosis. Devon commissioners tell me that, in the past year, Exeter has been among the strongest performers in Devon in improving its rate of diagnosis. Indeed, there was an 11.6% increase in the number of people receiving a diagnosis in the county. The local NHS is building into its commissioning plans for the coming year an improving diagnosis trajectory. I hope that he and other hon. Members continue to hold local commissioners to account for their commissioning decisions on dementia.

The right hon. Gentleman referred to Northern Ireland and the reasons for its success. One reason Northern Ireland has been successful is that it has invested heavily in its community and voluntary sector services, which has played a part in raising community awareness. More people have in turn asked whether they need to be referred to a memory service. That is one reason why the Government have sponsored an advertising campaign. We want to raise awareness and get families to talk about dementia, and not to put it off or believe that it is just a consequence of ageing.

[Alison Seabeck]

What the Minister says about Northern Ireland and the figures for Devon is interesting. Does he believe there is a connection between dementia diagnosis and support and the relative stability of a population, such as that of Belfast? Devon has a more transient population, and people move there to see out their old age, perhaps away from their families. How important is proximity to family and close friends in terms of diagnosis and support?

[Paul Burstow]

That is part of the Government’s approach to raising awareness. We recognise that getting families to have conversations when they see the first signs of memory loss, or other behaviours that might indicate dementia, is an essential part of getting people to have a conversation with their GP about referral to a memory service. Whether that is to do with more stable communities is an interesting question to consider further. We are working with the research community because we want to encourage more applications for social research as well as research into the underlying causes of the disease.

The right hon. Member for Exeter asked about waiting times. Although there have not historically been routine central collections of waiting times, we will have to consider the matter closely. The Government are keen to drive improvements, and it is no good somebody getting a referral if they and their family are then left hanging for too long. He made an important challenge on that matter.

The right hon. Gentleman rightly talked about support for families. In the operating framework for the NHS, which we published last December and which covers this year, we were absolutely explicit that NHS organisations must work with local authorities and carers’ organisations to get their sign-off for their plans for carers. We stated that they must be explicit about the number of carers’ breaks they will provide and the budget that they allocate for carers in their area. We need to ensure that carers get vital breaks, rather than having to have a breakdown before the NHS picks up the pieces.

From next year, we will also expect NHS organisations to demonstrate that they are supporting carers of people with dementia in line with the guidance that the National Institute for Health and Clinical Excellence issues. Early diagnosis is important because families and the individual themselves need to be able to plan, but also because NICE’s guidance on medication states that people need access to drugs at an early stage. I will write to the right hon. Gentleman about the variations that exist.

Health and Social Care (Re-committed) Bill

Alison Seabeck Excerpts

Wednesday 7th September 2011 Commons Chamber

[Owen Smith]

I entirely agree, and my faith is diminishing by the minute. I do not understand why the Government cannot simply concede that they have signally failed to deal with this crucial aspect of the Bill. It took them months to produce the revised failure regime. They managed to drag that out in time for Report, but they have not produced the impact assessment, they have not produced any figures showing how much this will cost the public purse, although we know that the amount is rising—I should love the Minister to tell us by how much—and they have not produced a solution to the crucial problem of staff training and work force planning. That is a disgrace. They could have and should have done it by now.

New clause 13 would place a further duty on providers, related to what is in the earlier new clause. It would oblige them to make provision for training and work force planning for their own staff, thus filling another gaping hole in the Bill. As the Minister might say if he intervened on me, Monitor may well have powers, under the pricing clauses, to pay less under the tariff to providers who do not engage in training, but nothing in the Bill compels new entrants—especially private providers—to give their staff any training, or to deal with any costs that the NHS has traditionally had to bear for the education of the work force.

We all know that in the incredibly fast-moving and innovative world of health care, keeping staff up to date is absolutely crucial. That is why—I hate to say it—despite the news that we are to have an amendment ín the Lords, we will attempt to press amendment 7 to a vote. It proposes the retention of SHAs until and unless we know precisely what the Government will put in their place in respect of training and administration.

NHS staff is another group that is profoundly concerned by the shambles, chaos and confusion that Ministers have overseen. Under the Bill, they are described as assets and will be transferred lock, stock and barrel between new providers. The new providers may be a private company—such as Helios, Bupa, UnitedHealth, or whoever else decides it is interested in running the NHS in future—and the staff may be transferred to the new providers. The Minister shrugs, suggesting that that is a misrepresentation, so I challenge him to intervene on me and state what he seemed to imply earlier: that what I have just said is not the case.

Schedule 23 makes that explicit, however. It provides for the transfer of NHS staff and other assets. It allows such so-called assets to be passed in future from NHS entities to the new CCGs. That can happen to any

“person who provides services as part of the health service in England and consents to the transfer”.

Under schedule 23, any NHS member of staff—or a building or intellectual property—can, so long as they agree, be transferred to anybody else who is licensed to provide services to the NHS. I find that extraordinary, but not quite as extraordinary as the next provision, which refers to NHS bodies being able to transfer all such assets—what a delightful way to refer to people—to a “qualifying company”, whatever that means. I will be delighted if the Minister tells us what the term “qualifying company” in schedule 23 means.

[Alison Seabeck (Plymouth, Moor View) (Lab)]

Does my hon. Friend join me in sharing the concerns of many public health consultants in this regard? They sometimes cover three areas of work, so in one area they could go to the commissioning board, in another they could go to children’s health commissioning, and in another area of their job they could go to the local authority. What are those people supposed to do? I suspect some of them will leave the service.

--- Later in debate ---

[Margot James]

I would love to but I am aware that others are waiting and I am trying to curtail my comments. [Hon. Members: “Hear, hear!] I will take that as a prompt to get a move on.

I want to address a point that was made earlier about where the director of public health should sit in a local authority. I think it is important that the public health director should report to the chief executive because the public health function will cover so much that is part of children’s services, adult and social care and housing that it is hard to see how they will fit in unless they report at the top level.

In conclusion, I believe that the elevation of public health will enable public health to be placed at the centre of commissioning and that the link between the wellbeing boards and the primary care commissioning groups will enable public health to be instrumental within commissioning. That is where we will see the long-term benefits outrunning the short-term imperatives.

[Alison Seabeck]

I shall cut to the chase because other Members want to speak and many colleagues have spoken powerfully about the benefits of the NHS. I have two very specific questions regarding concerns that people in the south-west have raised with me. These issues relate to part 1 of the Bill, the role of the director of public health, and the making of complaints, as covered by new clause 1. I want to link these issues to the duty of the Secretary of State to ensure that the basis on which actions are taken—indeed, the information that is used—is in the hands of and is accessible to people in the new set-ups who need that information and can use it.

The concerns that have been raised with me relate to the movement of national health service public health staff into local authority control and the fact that the Office for National Statistics currently has a duty to release certain data only to directors of public health, who are part of the NHS. I gather that the ONS has had concerns about this and I am interested to know whether it has waived the requirement for directors of public health to sign a confidentiality and proper use statement every year, or whether it has agreed to the passing of this role into local authorities. I cannot find that in the Bill, although I must admit that I am coming to this a little late—my apologies to colleagues about that—and I would be very grateful if the Minister could tell me whether that issue has been resolved.

Secondly, the Minister will know that we carry out nuclear decommissioning in Plymouth. Is he confident that public health can be fully protected in the way that it has been in the past? I note clause 54 on radiation, but will the Minister look at how H1N1 was dealt with? The first confirmed case of swine flu was in Paignton and the response was carried out by PCT public health staff in Plymouth and Torbay. They worked together rapidly to administer antiviral drugs to nearly 500 pupils and they provided reassurance and support to extremely anxious children and parents. That response was set up within 45 minutes of the initial phone call, despite the fact that it had not been done before, and it was done without any practical help from the Health Protection Agency, which was swamped with other work. The PCT public health staff just got on with it and they did a fantastic job—no other child was infected. Indeed, they compiled a guide on how to do it all, which was passed on and was commended by the Prime Minister. There is a view that such a response will not be possible in a few years’ time, so complaints from the public—this takes us back to new clause 1—will inevitably follow. Clearly, if we get health protection wrong, we can kill people.

In order to avoid complaints on new clause 1, will the Minister say what power the director of public health, sitting within the local authority, will have to galvanise staff across organisations? Will they be the appropriate authority, or will responsibility sit elsewhere? Will they have to go through another senior officer? Who is ultimately responsible if they get it badly wrong—the local authority, the director of public health or the Secretary of State? Or is it another instance when the Government are saying, “Not me, guv” and passing the buck to the local council and the political leadership of that council? If there was a viral outbreak in various parts of the country, widely spread, would the individual local authorities be held responsible for dealing with it, coming up with solutions and coping with the outcomes, or is this a case in which the Secretary of State actually has a clear duty to take the lead?

[Martin Horwood]

I am extremely grateful to you for calling me, Madam Deputy Speaker, as you have a tough job this afternoon. I have to declare an interest. I rarely speak in the House on NHS organisation, particularly public health, because my wife is employed as a director of public health. Obviously, the Bill and the public health section of clause 27 will affect her significantly, and by extension those of us in her family, but I make it clear to the House that although my knowledge of her role and profession has informed amendments 1255 to 1260, which stand in my name, she had no knowledge of them or their contents before I tabled them. However, I am grateful to the Faculty of Public Health and others who have given me advice.

Public health is pretty poorly understood, not least in this Chamber at times. There is a constant tendency to confuse it with the traditional, established local authority function of environmental health, and although I have great respect for the hon. Member for Stoke-on-Trent North (Joan Walley) in many respects, I think the risk of her new clause 23 is that it extends that confusion between environmental health and public health. There are many key functions to public health, not just the vital five-a-day style health promotion and health improvement work, but a critical role in health protection, including the management of outbreaks of communicable diseases—serious diseases such as meningitis and influenza—and a key role in influencing, at the moment, NHS commissioning at local level, using population-wide data and medical analysis. That, at the moment, happens very simply and straightforwardly within the primary care trust. Under the Bill at the moment, there is no role for the director of public health within the new clinical commissioning groups, and they have to exercise that kind of influence at several removes. That point was well made by the hon. Member for Plymouth, Moor View (Alison Seabeck).

It was suggested to me at one stage by some civil servants working on the Bill that in order to make up for the gap left by the director of public health in the new clinical commissioning groups—then called consortia—they might actually want to employ someone with public health expertise to make up for the reorganisation. That does not seem to me a very good use of public money.

Some of the things that Ministers have announced are to be welcomed. I will have to skip over them briefly, but principal among them is the very good decision to make Public Health England a separate Executive agency and not part of the Department of Health. That was a key request of the faculty, and I think it is very important that it retain that status and objectivity.

I pay tribute to the Minister of State, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), for taking a great deal of time and care over the concerns that I had in this whole area, but questions remain to be addressed and my six amendments are an attempt to address three main areas.

The first area is, as the hon. Member for Plymouth, Moor View pointed out, that under this scheme directors of public health will be removed from the NHS, as will their staff. One of my amendments suggests, therefore, that they should continue to be employed by Public Health England and retain that integration within a wider public health profession. At the moment directors of public health sit within primary care trusts and it is reasonably straightforward, but within the spaghetti-like structures created by the Bill, public health responsibilities and leadership are now to be split among Public Health England, the Secretary of State, the local authorities, the national commissioning board, the health and wellbeing boards and clinical commissioning groups. The threat is not just confusion and the unclear fragmentation of public health functions, but the fragmentation of the profession itself and of the career paths, whereby people might move from one bit to another and have to leave and rejoin the NHS, and so on. That is one of the issues addressed.

The second issue is that people should be suitably qualified. The responsibility for their professional qualification and professional development should lie in the hands of Public Health England, not local authority managers, who might have no medical or professional public health training. It is an important function, so they should be senior officers. Several members of the Health Committee, including its Chair, made the important point that they should report directly to the chief executive. It has been suggested in some parts of the country that the post of director of public health could be combined with or report to other directorates in the principal local authority—for instance, the director of housing.

I wrote to the Deputy Prime Minister on the issues, and he replied:

“given the importance of these new local authority public health functions, the leadership position of the DPH in the local community and the critical health protection functions to be carried out by the DPH on behalf of the local authority, we would expect the DPH to be of chief officer status”.

I do not think that an expectation is strong enough. I have great regard for many directors of housing, but if my child had meningitis, I would not want the director of housing to be on the other end of the phone line at a critical moment.

As it is still possible for the Government to address these issues through the consultation exercise on public health that is being planned, I will not press my amendments to a vote today, but I was rather disappointed with the Minister’s response to them. Should any noble Friends be listening from the Gallery, I hope they might take up the theme of public health in another place. Public health is poorly understood and has not grabbed the headlines in the way that the 38 Degrees campaign has, but over recent years it has been quietly becoming a more and more successful, professional and increasingly medically qualified discipline in the NHS. It saves lives, and we should protect it.

Oral Answers to Questions

Alison Seabeck Excerpts

Tuesday 8th March 2011 Commons Chamber

[Paul Burstow]

My hon. Friend is absolutely right to describe the contribution of Macmillan, other cancer charities and, indeed, charities in the health sector more generally as indispensable. I recently had the pleasure of visiting Macmillan’s headquarters, where I did an online chat with a number of cancer sufferers and their families and saw the helplines and other support services that it provides. In our cancer strategy, we are very clear that such charities have an invaluable role to play.

[Alison Seabeck (Plymouth, Moor View) (Lab)]

Plymouth and neighbouring Cornwall, a former objective 1 area, suffer from enormous deprivation. Will the Minister therefore do all he can to ensure that those communities benefit from Plymouth Hospitals NHS Trust’s much hoped-for CyberKnife technology, and that its benefits for cancer patients are felt not just in London, but more widely in other regions?

[Paul Burstow]

I am very grateful to the hon. Lady for her question, and she is absolutely right: that technology is invaluable. We want to ensure that it is available to the patients, and the tariff structures need to ensure that it is properly supported. She is right also that issues of equality in the service are key, and that is why we have maintained this Government’s commitment to supporting the NHS constitution and its commitment to promote equality in the system.

NHS White Paper

Alison Seabeck Excerpts

Monday 12th July 2010 Commons Chamber

[Mr Lansley]

It would be a good idea if Labour Members at least acknowledged that over the last 13 years health inequalities have widened in this country. We have not achieved health outcomes here that are at least as good as the European average, and in some respects regarding some diseases we are among the worst in Europe. We are going to turn this around. In order to do so, we are going to work not only with national strategies but with local strategies that are geared towards identifying those health inequalities and that expressly set out to reduce inequalities by looking beyond the NHS. Local authorities, the NHS, social care, the community and the voluntary sector will work together to make it happen.

[Alison Seabeck (Plymouth, Moor View) (Lab)]

The right hon. Gentleman talks about empowering GPs—some willingly and some unwillingly, I suspect. Some of them will need upskilling and training in order to understand the new process. What assessment has he made of the time GPs will need to devote to their training, and that of their staff, and of how much it will cost—or will GPs themselves be expected to pay for it?

[Mr Lansley]

I wonder whether the hon. Lady has met doctors in Devon. I have been to their local medical committee conference and discussed these issues with them. They are keen to go. If there was any difficulty, it was that at least one Plymouth GP had very high referral rates. I do not think he had ever checked those rates with his colleagues. It was interesting to hear them talk to one another. It became perfectly obvious that peer review—that sense of working collectively to manage services in an area—is going to hold GPs to account very effectively within consortiums as well. [Interruption.] The hon. Lady and all her colleagues completely underestimate the capacity of general practitioners, who are responsible for the overwhelming majority of patient contact in the NHS, not only to take on the responsibility of deciding whether they should incur the expenditure for the referrals they make but to have a say in designing those services.