Haemophilia

Paul Goggins Excerpts

Wednesday 8th February 2012 Westminster Hall

[Diana Johnson]

I am grateful for that intervention. I pay tribute to the hon. Gentleman for his involvement in and hard work on behalf of the all-party group. He makes an excellent point in asking the Minister whether she will find time. I know that she has a busy diary, but she has made time in the past to meet victims and Members of Parliament. I hope that that will happen in future as well.

On compensation for those infected by contaminated blood products, the Macfarlane Trust was set up in 1988 for people infected with HIV. In 2004, the previous Labour Government established the Skipton fund. In 2010, the incoming Government undertook to review the support available to individuals. Some progress was made, but unfortunately, there are still problems with the system.

In particular, I am concerned about the fact that the Government have introduced a two-stage payment for hepatitis C, but the criteria for determining the second stage are still fraught with difficulties for many. As I understand it, only about 20% of those people with hepatitis C are eligible for assistance via the second stage payment. That must be looked at. My constituent Glenn has produced evidence that removing the artificial distinction between stages 1 and 2 could be achieved and would cost about £22 million, which I am led to believe could be reallocated from the under-spend of other available compensatory pockets of money.

Welfare reform is an issue for the group of people we are discussing. We have had a lot of discussion in the House of Commons about the impact of welfare reform on cancer patients, but there is a special case to be made for people with hepatitis C.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

I join other hon. Members in congratulating my hon. Friend on obtaining the debate. She speaks powerfully for her constituents, as well as for my constituents, Fred Bates and Peter Mossman, who will be grateful.

The core theme of my hon. Friend’s powerful speech is trust. The trust of that community was shattered by their experience. This Minister is trying hard to restore that confidence, and her work is important, but is it not the case that the needs of our constituents with haemophilia who have been infected with hepatitis C and other infections should always come first now, not last, after the dreadful experience that they have had?

[Diana Johnson]

My right hon. Friend makes a powerful point about trust and the need for us all to work together to ensure that those people do not suffer further, and that they get the compensation and support they are clearly due.

I want to concentrate on hepatitis C sufferers for a minute. I believe that they will be unfairly penalised by the Government’s plans in the Welfare Reform Bill. In a debate in October 2010, I asked the Minister whether it would be possible for people with hepatitis C and HIV to be passported on to the new system. The Haemophilia Society has also asked about people with fluctuating medical conditions, such as bleeding disorders, particularly those with viral infections from contaminated blood products. People suffering from fluctuating medical conditions such as haemophilia, HIV and hepatitis C tend to have good days and bad days.

The Haemophilia Society recommends that the work capability assessment be suspended for people with fluctuating conditions until Professor Harrington has considered the representations of the Disability Benefits Consortium. Many people living with hepatitis C in particular have been placed in the work-related activity group of the new employment and support allowance, rather than in the support group, where benefits will continue indefinitely. That has two consequences: it means that sufferers will have to have annual assessments, and that, after 12 months, their benefits will become means-tested. That is effectively penalising people for prudent behaviour and hard work while they were well enough to be employed.

People diagnosed with hepatitis C know that they are unlikely to be able to continue working until normal retirement age. Furthermore, people must currently wait up to 11 months for a tribunal appeal. It is to be noted that appeals for hepatitis C sufferers have a particularly high success rate. Automatically moving contaminated blood product victims into the support group would save patients stress and the Government money.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to serve under you, Mr Weir. I thank the hon. Member for Kingston upon Hull North (Diana Johnson) for securing the debate. I am grateful for the opportunity to discuss the issue. I also thank her particularly for her comments about the contact that we have had. I will continue to keep in contact with her and many other Members who continue to highlight the specific issues suffered by their constituents. I know that Glenn Wilkinson and others, some of them not still with us, have worked tirelessly on the issue.

I was interested to hear about the new campaign. Of course I will meet its representatives, as I continue to do. This is an opportunity to say that Whitehall can be distant from the rest of the population. As a Minister, I will, as all Ministers should, use the opportunity that Back-Bench and Opposition Members have given us to ensure that we stay in touch and do not become insulated from what is happening in people’s lives.

I wish that I could make up for what happened. It is a very long and sad saga. I can do only what I can do starting from here. I am also aware of the fact that it will never really be enough, because I cannot turn back the clock, but what matters is that we keep contact going.

The hon. Lady asked specifically about future commissioning arrangements and specialised services for haemophilia and other related bleeding disorders. As she has rightly said, those services are currently commissioned at a regional level by specialist commissioning groups. We are working with the NHS to produce a list of specialised services to go in a new set of regulations for the NHS Commissioning Board. At the moment, we are not able to produce a final list, but a list of services currently set out in the Specialised Services National Definitions Set—the titles that the Department of Health and others come up with are extraordinary—will form a basis for the Commissioning Board’s final list. I expect that we will be in a position to announce that list of services in the coming months, at which point it will be subject to consultation.

The hon. Lady is right to say that that will be an opportunity to share best practice. I get frustrated when I hear that some areas do things well, while others do not or do not adopt the same sort of best practice. The hon. Lady has voiced her concerns and fears that this could lead to services being levelled down, but I think there will be an opportunity—I was born an optimist—to share best practice. The financial arrangements for this particular group of people affected by contaminated blood will remain an issue for the Department of Health. What matters on services, however, is that we ensure that best practice is shared.

The hon. Lady mentioned care plans. As somebody who trained as a nurse and who worked in the NHS for 25 years, I get frustrated about this issue, because everybody should have a care plan and everybody should be involved in it. The plan should involve all the different agencies, including the local authority on housing and social services on social care. It could also involve the voluntary sector for people who are isolated. A number of agencies can improve the quality of life and ensure that people’s lives are fulfilling and meaningful.

Today, treatment for haemophilia is much improved. On the issue of blood safety, which the hon. Lady raised, some haemophilia patients still need to be treated with products that have been manufactured from human plasma, but those products are manufactured under very strict safeguards. Many haemophilia patients are now treated with synthetic products, and both types of product are extremely safe. Lessons have been learned. The shadow of what happened all those years ago continues to hang over us and everybody involved with the safety of blood products.

Synthetic and plasma-derived clotting factors are procured nationally by the Department, with commissioners and clinical and patient representatives involved from an early stage. That means that the NHS buys products that are not only cost-effective, but reflect what patients and doctors actually need. In turn, manufacturers and suppliers can better understand what matters to the people who use those products. At the end of the day, that is what should matter to us.

To further improve patient involvement, the Department of Health has brought the Haemophilia Alliance into discussions on all the issues that affect haemophilia patients. The alliance is made up of patients, clinicians and other professionals involved in haemophilia care, and I am grateful to those who give up their time to involve themselves in it so positively.

A decontamination research funding initiative worth about £2.4 million over four years was announced in 2011. It will address the decontamination of surgical instruments, improving the effectiveness of washer disinfectors and exploring contamination and novel technological approaches to the decontamination of endoscopy scopes. These products will also have wider applicability to human prion diseases, such as CJD, and other health-care-associated infections. Some issues are unresolved, because the proven and effective technologies needed to address them do not yet exist. There will continue to be money in research until we are absolutely sure that we have done all we can.

When people were infected with hepatitis C and HIV, it also had a significant effect on their families. We often forget that such issues have a massive ripple effect, not just on immediate family but on distant family. In January 2011 the Secretary of State announced that we would provide additional support, not just for haemophilia patients, but for anyone infected with HIV or hepatitis C by NHS blood transfusion. That support includes ensuring that the annual payment for those infected with HIV is linked to inflation; introducing a similar payment for those most seriously affected by hepatitis C; and increasing the value of the lump sum. The support will also make £300,000 available over three years for counselling services. I find it interesting to look at the uptake for such things, because it lets us know when we have hit the target. It is so important that I continue to get that feedback. The combination of fixed and discretionary payments provides flexibility to enable them to be tailored to meet individual personal needs.

I know that there is concern that insufficient support is available for people who have developed hepatitis C, particularly the Skipton Fund stage 1 recipients. The scientific and clinical advice that we received during the review that we conducted in autumn 2010 did not support regular annual payments to everyone infected with hepatitis C, many of whom go on to clear the virus. I was delighted to hear from one such person, who has campaigned actively. New treatments are available, improving the prognosis for some infected patients, but I know—I think the hon. Lady was at the same meeting as me recently—that concern remains about the cut-off.

I know that one of the constituents of the hon. Member for Kingston upon Hull North has worked out the potential cost of removing the distinction between stage 1 and stage 2, but the current system of payments for hepatitis C is itself based on expert clinical and scientific review, which continues to support the two-tier system. Evidence, however, evolves and it would be arrogant of a Minister to say, “That’s it for ever.” It is terribly important, as I hear about the experiences of the constituents of individual Members, that I continue to receive advice, so that what we do is relative to the current expertise.

I apologise to the hon. Lady for not responding to her e-mail about my meeting with the expert group, but I was delaying my response while departmental officials worked out the details of the meeting. I am pleased to say that I will write to the relevant patient groups, asking them to nominate two people—I think that seems about right—to represent them at the meeting. I think that will be important.

The hon. Lady is probably aware of the Caxton Foundation, which provides support tailored to the needs of those affected. All payments made by the foundation are for the trustees to decide. I have met the trustees and their feedback is important in enabling us to see how the support works. The charity’s objectives are laid out in its trust deed, and it is accountable to the Charity Commission. I do not have any powers to direct it, but it has to be kept under review.

[Paul Goggins]

On the Caxton Foundation, in future will the Minister take particular notice of the needs of carers? It is important that that fund is in a position to support carers as well as those directly affected.

[Anne Milton]

Yes. I thank the right hon. Gentleman for that point. The discretionary ability to distribute funds is important. He is absolutely right to raise the issue of carers, who are all too often forgotten.

The hon. Member for Kingston upon Hull North mentioned the capability assessment. She might want to initiate a similar debate on that issue. Health conditions are not automatically a barrier to work, but we recognise that they are for some people. Indeed, some people will never work and we must make sure that we support them. It would probably not be right—this is certainly not in my gift—to give automatic exemptions, but I urge the hon. Lady to raise the issue with the Secretary of State and the Minister responsible.

Life Sciences

Paul Goggins Excerpts

Monday 5th December 2011 Commons Chamber

[Mr Lansley]

There is always that risk because, as my hon. Friend entirely knows, international competition is intense, particularly in the pharmaceutical sector. Following the measures that were announced alongside the Budget in the plan for growth, not least the availability of the patent box from April 2013, it is clear from discussions that my right hon. Friends and I have had with many of the boards of leading international pharmaceutical companies that the United Kingdom is now becoming a better location for investment in pharmaceutical activity than used to be the case. Those companies look very positively at the steps we have taken on regulatory activity and clinical trials, at the steps we are taking on promoting innovation through the value-based pricing system, and in particular, understandably, at the tax measures that my right hon. Friend the Chancellor announced, especially on the patent box.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

The Secretary of State’s statement raises a number of important ethical issues. Will he take a close look at the emerging proposals for a medipark that is close to Wythenshawe hospital and part of Greater Manchester’s airport city enterprise zone? This has tremendous potential to attract investment from global bioscience and pharmaceutical companies, which would make a massive difference in my constituency and way beyond that. Will he look to see what support can be offered?

[Mr Lansley]

I will gladly do so. As the right hon. Gentleman knows, the designation of an academic health science centre in Manchester has supported many developments. We want to go further. In today’s life sciences strategy, we are making it clear that not only do we want to maintain the academic health science centre designation as a world-class designation for comprehensive research centres, but we want to go further and ensure that such centres are used to diffuse and spread innovation across the NHS more effectively. Next spring, we will set out how we will enable academic health science networks to be designated. That will happen during 2012-13. I will happily look at the circumstances in south Manchester and at how this matter will apply there. I hope that partnerships will be forged between the NHS, universities and the private sector of the kind that he and I know will be successful.

Oral Answers to Questions

Paul Goggins Excerpts

Tuesday 22nd November 2011 Commons Chamber

[Mr Lansley]

Yes, of course I will join my hon. Friend in paying tribute to all the work that I know personally that the Stroke Association has done over a number of years in raising public awareness of the importance of developing stroke services, which has had an impact inside the NHS. We have improving figures in terms of reducing stroke mortality, and I now want to go further in ensuring that we enable people not only to survive stroke but to recover as many as possible of their abilities afterwards.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

T5. Will the Minister with responsibility for public health update the House on her plans to review the criteria whereby people with haemophilia who have been infected with hepatitis C can claim stage 2 payments from the Skipton fund? Specifically, will she tell us how she intends to involve patients and carers in that review?

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I know that the right hon. Gentleman has campaigned hard on this issue. I can assure him that I recently met a group of MPs, and constituents of theirs who are suffering from hepatitis. As he knows, there is a wide spectrum of illness associated with chronic hepatitis C infection. We are aware that people could be suffering financial hardship as a result, and I would urge them to apply to the Caxton Foundation. The Department’s expert advisory group on hepatitis C will continue to keep the evidence under review.

Oral Answers to Questions

Paul Goggins Excerpts

Tuesday 18th October 2011 Commons Chamber

[Anne Milton]

I would be very happy to meet that gentleman. There is no doubt that promoting this in schools has a profound impact and is an opportunity to change people’s attitudes to organ donation and, more importantly, makes families discuss it, which is critical. It is not just about signing on to the register.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

Last week I had the opportunity to meet members of the Ticker club, an organisation of former heart patients who continue to provide support to patients at Wythenshawe hospital, a specialist centre for cardiac and thoracic surgery, including heart and lung transplants. They have strong opinions on organ donation, so will the Minister agree to involve such groups in ongoing campaigns to raise awareness of the benefits?

[Anne Milton]

I thank the hon. Gentleman for raising that issue. My right hon. Friend the Secretary of State has visited that hospital, and I am happy to work with any group. I reiterate the fact that we particularly need to work with black and minority ethnic groups, in which the rates of donation are truly dreadful: 23% of people on waiting lists are from black and minority ethnic communities, but only 1.2% of those on the register are from that same group. We need to do everything we can to improve those rates.

Oral Answers to Questions

Paul Goggins Excerpts

Tuesday 7th June 2011 Commons Chamber

[Mr Burns]

I hope that I can reassure my hon. Friend by giving him a straightforward yes in answer to that question.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

Will the Minister look urgently at what is happening in Trafford? The Trafford Healthcare NHS Trust has decided not to seek foundation status and is looking to transfer its acute services to another local provider. One difficulty with that is the projected funding shortfall of £55 million. Will he take a close interest in that, and seek to resolve the current uncertainty?

[Mr Burns]

I am grateful to the right hon. Gentleman for that question. I am aware of that situation and of the problems at that hospital. My understanding is that the strategic health authority is working hard with the trust to seek a solution. That work will continue until a viable solution is found.

Oral Answers to Questions

Paul Goggins Excerpts

Tuesday 7th December 2010 Commons Chamber

[Paul Burstow]

I am grateful to the hon. Lady for her comments and will ensure that they are reported back to my hon. Friend the Under-Secretary for her consideration in the review.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

6. What steps he is taking to reduce energy consumption in hospitals.

[The Minister of State, Department of Health (Mr Simon Burns)]

The NHS continues to improve its energy efficiency. The Department provides guidance to the NHS and supports the NHS sustainable development unit, which promotes energy awareness and carbon management across health care providers. Hospitals are working with the Department for Business, Innovation and Skills to engage with suppliers who provide innovative solutions.

[Paul Goggins]

I thank the Minister for his answer and invite him to join me in congratulating all the staff at Wythenshawe hospital in my constituency, which was recently named overall winner this year in The Guardian public services award as the country’s greenest hospital and for reducing energy emissions by 26%. What further pressure is he putting on other hospitals and health service providers to ensure that they follow that fine example?

[Mr Burns]

I am happy to join the right hon. Gentleman in congratulating the university hospital of south Manchester on its fantastic achievement and the award that it has won. As he knows, his local hospital did that by reducing its energy consumption and carbon emissions by 26% over the past three years in ways such as the greater use of biomass fuels. It is a fantastic achievement and the staff should be justifiably proud of it. They are a beacon for other hospitals to follow to reach the same level of sustainability, and I am delighted that a number of hospitals throughout the country are striving to reach the position of the one in his area. I am confident that through greater sharing of information and work, more and more hospitals will make their contribution to reducing carbon levels.

--- Later in debate ---

[Mr Lansley]

I join my hon. Friend in paying tribute to the staff in ambulance service—in the current circumstances, with the winter pressures being what they are, we should especially do so. But those staff can come under particular threat from time to time and we have to prepare for all eventualities. For example, if an attack involving firearms takes place, as it did recently in Cumbria, it is possible that ambulance staff would be working alongside other emergency services in responding to it. It is only right, therefore, that they are offered as much training and equipment as possible to carry out that work.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

T2. This morning, the Justice Secretary said that he was working with the Health Secretary on plans to divert more mentally ill offenders away from prison. I broadly welcome that, but could the Health Secretary tell us how much new money will be made available for that initiative, especially given the comments made by my right hon. Friend the Member for Wentworth and Dearne (John Healey) about the cut in the real value of health spending?

[Mr Lansley]

The right hon. Gentleman is in no position to make that point, given that his party wanted to cut the NHS budget. What my right hon. and learned Friend said this morning about our working together is indeed true. However, this is not a case of our diverting patients; it is about ensuring that people who have mental health problems are dealt with appropriately rather than there being a failure to deal with them. That applies whether they are in prison or in hospital. We are working together on that, and I know that my right hon. and learned Friend will be making a statement shortly.

Contaminated Blood and Blood Products

Paul Goggins Excerpts

Thursday 14th October 2010 Commons Chamber

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

I pay tribute to the hon. Member for Cardiff Central (Jenny Willott), both for her work and for her speech, and I join my hon. Friend the Member for Coventry North West (Mr Robinson) in paying tribute to Lord Archer for his report—and also to Lord Morris of Manchester, who was my predecessor as Member of Parliament for Manchester, Wythenshawe, and has done so much work on this and many other issues.

Much of my understanding of this issue comes from the experience of three of my constituents: Peter Mossman, Fred Bates and Fred’s wife Eleanor. I pay tribute to their resilience and determination. Peter discovered that he was a mild haemophiliac in 1976. One day in 1985 he came home from work with bruising on his leg. He went to hospital, where he was treated with contaminated blood and infected with hepatitis C. What resulted immediately was a desperate illness followed by, in the longer term, worsening bleeds and severe liver damage.

Fred was also a mild haemophiliac, although his condition is now severe. He has never been able to identify precisely when he became infected with hepatitis C, although it is certain that, although tests were carried out throughout the 1980s that would have confirmed his condition, he was never told. Only after the chance reading of a leaflet in 1993 did he ask whether he was infected, and he was finally told the truth. He was then told to go home, and that there was nothing to worry about. Life for Fred means often feeling extremely cold. He suffers from severe bleeding, and now has cirrhosis of the liver. For Eleanor, life means not only supporting Fred and enduring severe financial hardship, but having to live for years unaware of the risks that she faced to her own health because Fred had never been told the truth about his condition.

What Peter, Fred and Eleanor find hardest to bear is covered in chapter 7 of Lord Archer’s report—namely that doctors knew about the risks involved in treating patients with blood products, but failed to inform them. There is no doubt that Fred and Peter, who were both mild haemophiliacs, would never have consented to treatment with contaminated blood products which carried a high risk of infection with HIV and hepatitis C. However, it is not only the doctors who failed to explain the dangers. It seems to me, and indeed to all of us, that the whole health system was caught up in what amounts to a conspiracy of silence.

I have a copy of a letter dated 31 July 1981 from a member of staff in the Department of Health and Social Security to an official in the Treasury. The letter is headed “Blood products laboratory—redevelopment”. It states, among other things, that

“health authorities are obliged to supplement supplies from BPL with expensive and, because of the hepatitis risk, less safe imported commercial blood products at a cost of up to £10m annually.”

People at the top of the DHSS knew the risks, but patients were not informed, and four years after that letter was written, my constituent Peter Mossman was infected with hepatitis C.

[Mr Wayne David (Caerphilly) (Lab)]

Is my right hon. Friend aware that it has been estimated that as many as 90% of haemophiliacs who were treated with blood in the 1970s and 1980s have at least one life-threatening disease?

[Paul Goggins]

I am aware of that. What I am trying to emphasise is that if my constituents, and indeed many others, had been given proper information, they would have been able to make a balanced decision about the risks that they faced.

We all have constituents who will have their own stories, and as a result of the Archer report we now have a definite analysis of what went wrong. The great thing about the report, however, is that it points the way forward. It is now a case of what we can do to support those who survive in the circumstances in which they find themselves, and I believe that we need to do at least four things.

First, there needs to be an apology. I know that some people feel that an apology is just words and is therefore meaningless, but in June this year the Prime Minister proved from the Dispatch Box that that is not the case when he gave an unequivocal apology to the families of Derry for what had occurred on 30 January 1972. That apology means a lot to those families, and it is enabling them to move forward. I believe that haemophiliacs infected with hepatitis C and HIV deserve no less.

Secondly, there must be proper financial recompense. There is a debate about that. Archer recommends equivalence with the Irish scheme, but the Government ruled that out today, and are to institute a review instead. Whatever the outcome of that review, it must be demonstrably fair to those who have been affected. There must be a level playing field between those infected with, respectively, hepatitis C and HIV. Thirdly, there must be no impact on benefit entitlement: any recompense must be over and above the benefit payments that people receive.

[Charlotte Leslie]

I want to pay tribute to my constituent Bob Purnell, who died, his son Edward, and his wife Gill. I also want to dispel any misunderstanding that there may have been about the debate’s being partisan. I welcome it very much.

I think we all appreciate that the Government are in a difficult position because of the financial situation. Does the right hon. Gentleman agree that if we cannot make the payments that I think we would all like to make to victims who have suffered greatly, it might be possible to increase payments in future as the economic situation becomes more viable?

[Paul Goggins]

I am pleased that the hon. Lady has had an opportunity to mention and pay tribute to her constituent. There may be an argument for staging payments over time, but the Government must be clear about the award and the level of compensation at the outset.

Finally, the whole social care and health system must become much more sensitive to the needs of those who were caught up in this tragedy. There must be more sympathetic treatment for those who have been infected and their carers.

I regret the fact that we were not able to do more over the past 13 years to support and assist this particular group. I want to compliment the Minister, because I know from conversations that I have had and from things that I have read that she has gained a fair amount of confidence from those who were caught up in the tragedy, and from members of the haemophiliac community. My guess is that her experience of the health service, along with her own personal qualities, has led her to want to deal with the situation and, in her own words, to get closure before the end of the year. Let me say to her that having come so far so quickly, she now carries a huge burden of responsibility to ensure that the solution that she comes up with retains that confidence, and does not further dash the hopes of a community who have been so badly let down in the past.

Oral Answers to Questions

Paul Goggins Excerpts

Tuesday 29th June 2010 Commons Chamber

[Mr Lansley]

Yes, we will consider that.

[Paul Goggins (Wythenshawe and Sale East) (Lab)]

12. What his policy is on maximum waiting times in accident and emergency departments; and if he will make a statement.

[The Secretary of State for Health (Mr Andrew Lansley)]

From April 2011, the accident and emergency four-hour waiting time standard will be replaced by a set of clinical quality standards, developed with clinicians, which will support quality care without the damaging distortion of the four-hour tick-box target. On the basis of clinical advice, I have immediately reduced the threshold for meeting the four-hour standard from 98% to 95%.

[Paul Goggins]

I am sure that the Secretary of State will want to join me in congratulating the staff at Wythenshawe hospital in my constituency. Last year 85,000 patients were seen in the accident and emergency department, 98% of them within four hours. Can the Secretary of State explain to my constituents why he has decided that this year 4,500 of those patients will not need to be seen within that time?

[Mr Lansley]

As I told the right hon. Gentleman, I made that decision on the basis of clinical advice. It was clear that the 98% standard was distorting clinical care for patients. There is no benefit for patients if, for the purpose of meeting a four-hour target, they are discharged inappropriately, transferred to wards when they have not been thoroughly looked after in the accident and emergency department, or indeed put in an observation ward for 48 hours, which is under the scrutiny of the accident and emergency department but ticks the box. None of that helps patients. I will focus on what is actually in the best interests of patients, and delivers the right outcomes for them.