Steve Barclay
MP for North East Cambridgeshire · Conservative · United Kingdom
“I speak to my brief exchange earlier with the Minister. As the previous speaker, the hon. Member for Harpenden and Berkhamsted, said, the draft regulations are fairly benign and very welcome to help people who are struggling with their bills.”
“The issue is not the lack of will; the issue is the alignment between procurement, regulation and clinical leadership, particularly in the colleges, as well as the ability to scale innovation—it is not about having more ministerial pilots.”
“Just to localise it to my own constituency, the Cambridgeshire and Peterborough ICB alone paid out £14 million in redundancies last year. It merged with a number of other ICBs to form the Central East ICB, yet we know hear from the Government that it should align with metro mayors, which means going back to exactly what it was before: the…”
“My right hon. Friend is absolutely right: the Government are spending millions of pounds and there is no plan. The measure was announced without working that out, it came as a surprise to many within the system, and it has had a chilling effect on many decisions. That is not isolated.”
“I rise to speak to clause 1 on the abolition of NHS England and clause 6 on promoting innovation. What characterises the first of those is an announcement without any clear plan. That is what has driven the cost and confusion that a number of Members across the House have spoken about.”
“All this is around 18 months on from the actual announcement. The confusion seems to extend to the Government themselves, because they seem unable to answer pretty straightforward written parliamentary questions. Given the time limit, I will give just a few examples.”
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“Friends the Members for Clacton (Giles Watling), for Brentwood and Ongar (Alex Burghart), for Castle Point (Rebecca Harris), and for Southend West (Anna Firth) for their determined campaigning on behalf of their constituents. Of course, we should all remember the important contribution of the former Member for Southend West, and a great friend to many across this house, the late Sir David Amess. He tabled a Westminster Hall debate on mental health services in Essex back in 2014, and he was a passionate campaigner for improving mental health care. I know he is very much in our thoughts. In 2021 we launched the independent inquiry to investigate the deaths of mental health in-patients across NHS trusts in Essex between 2000 and 2020.”
“Friend the Member for Chelmsford (Vicky Ford) for tabling a Westminster Hall debate on the Essex mental health inquiry earlier this year. She and colleagues, including our hon. Friend the Member for Rochford and Southend East (Sir James Duddridge) and our right hon. Friends the Members for Witham (Priti Patel) and for Maldon (Sir John Whittingdale), all spoke passionately about the need to get justice for patients and their families. I know that my hon. Friend the Member for South Suffolk (James Cartlidge) also tabled an Adjournment debate on mental health in-patient care in Essex before the independent inquiry was launched in 2021. I also pay tribute to my right hon. Friend the Member for Saffron Walden (Kemi Badenoch) and my hon.”
“With permission, Mr Speaker, I would like to make a statement on improving safety in mental health in-patient services across England. Before doing so, I want to thank all the right hon. and hon. Members from across the country who have campaigned tirelessly on behalf of their constituents to improve mental health care. Too many people have experienced care in mental health in-patient settings that has been well below the high standard that we all deserve when we are at our most vulnerable. I would also like to put on record my sincere condolences to the families and friends of those who have lost their lives. First, I will update the House on the independent inquiry into mental health in-patient care across NHS trusts in Essex between 2000 and 2020. I thank my right hon.”
“The measures that we are taking address the concerns of families who have suffered the most tragic loss. It is important that we learn the lessons, both in Essex and more widely. We have actively listened to the points raised by Dr Strathdee, who has done a fantastic job. It is right that the work moves on to a statutory footing, but it is also right that we look more widely at the lessons from other mental health in-patient facilities. That is exactly what we intend to do.”
“Of course, that sits alongside other mental health interventions, such as our programme to train more people to give mental health support in schools. The shadow Minister made an important point about working with families. I agree with her about that. HSIB will be meeting families—indeed, Ministers have been doing likewise—and we are keen that that should feed into the terms of reference, both for the statutory inquiry and for the HSIB review. We have touched on consultants, but let me make a final point on that. As far as I am aware, the Opposition do not support a 35% pay rise, whether for junior doctors or for consultants, but if that is their position, perhaps they will tell us whether this is yet another area that the stretchable non-dom contribution will reach to. Exactly how will it be funded? This is a serious issue.”
“That is why I will be placing in the Libraries of both Houses the outcome of the rapid review. That speaks to the importance of transparency as we learn the lessons of what went wrong in Essex and in other mental health in-patient facilities. The shadow Minister made a fair point about waiting times. We are committed to cutting waiting times, including in mental health. That is why we are spending £2.3 billion more on mental health this year than four years ago, we have commissioned 100 mental health ambulances, we have 160 different schemes looking at things such as crisis cafés to support people in A&E, and we have schemes such as the review through 111 and the funding the Chancellor announced in the Budget for mental health digital apps to give people early support.”
“There is often a balance to be struck between those inquiries, given the speed at which they can proceed, and a statutory inquiry, which has wider powers but often takes longer. It was because of our desire to move at pace to get answers to families that we initially commissioned a non-statutory inquiry, in common with Bill Kirkup’s inquiry into Morecambe Bay and inquiries into many other instances in the NHS. However, we have listened to families and to right hon. and hon. Members who have raised concerns about the process and, in particular, the engagement by staff, and decided to make it a statutory inquiry. The shadow Minister asked about our commitment to transparency. The very reason that we set up the rapid review in January was to bring greater transparency to the data.”
“Specific issues arose in respect of engagement by staff, and we have actively listened and responded to the concerns raised by families and by many Members of the House, particularly about the Essex inquiry. I will come on to those as I go through the wider issues. The shadow Minister mentioned speed. Of course, there is a balance to be struck between the completeness of a statutory inquiry and the greater speed that is often offered by other independent inquiries. Indeed, the Paterson inquiry was a non-statutory inquiry commissioned through the Department, and that is another vehicle that is often successfully used. There are also inquiries commissioned through NHS England, such as the Donna Ockenden review.”
“This debate is not about the issues normally raised during Prime Minister’s questions about the politics of the day; it is about the families who have tragically lost loved ones, about how we can learn the lessons from that, and about how we can ensure that we get the data right, get the support for staff right, and get the procedures right so that other families do not suffer loss. We have responded to the excellent points made by Dr Strathdee through her rapid review about data. There are two elements to that: there is data that is collected that does not add value, is often duplicative and takes staff away from giving care—that is somewhere that we can free up staff—but there is other data that is needed to better identify issues early, and we need to look at how we improve that data.”
“It is a shame that the hon. Lady chose to conclude her remarks in such a way. Let me address that head-on. It is bizarre to accuse a Minister who is literally at the Dispatch Box of being missing, particularly when the shadow Health Secretary, having managed to turn up for Prime Minister’s Question Time, has failed to turn up for this statement. It is even more bizarre that, although we are constantly told that the Labour party sees parity between mental health and physical health as a key priority, when it actually comes to debating the issue, the contrary is clearly on show.”
“I hope—I reinforce my right hon. Friend’s point—that families will take confidence from today’s announcement and that those families who have not come forward to date will be able to do so. I know that in my right hon. Friend they will have a resolute champion supporting them to do so.”
“In my discussions with my right hon. Friend and colleagues, I found the compassion that they showed and the way they championed the family voice compelling. I absolutely agree that it is important that families take confidence from the decision to move the inquiry on to a statutory footing and come forward with their evidence. I know that she plays an active part in that. Of course, we want families to be part of the discussion on the terms of reference. I know that, with her significant experience, my right hon. Friend is keen to be part of that too, and we are keen to engage with her on it. My right hon. Friend is right to highlight the evidence that has already been gathered through the excellent work of Dr Strathdee. I had a meeting with her yesterday to ensure that we capture that as part of the work that is moving forward.”
“The hon. Lady raises a very valid point. There are real concerns about Tees. We considered that when considering the scope of the statutory inquiry. Given that significant work had been done in Essex, we decided to strike the balance by putting that on a statutory footing but enabling work to proceed at pace through HSIB on Tees and some other areas. The hon. Lady will know that the Care Quality Commission prosecuted the trust in May for a regulation 12 breach, and that significant work has already gone in; the report of the system-wide independent investigation was published last March. They are very serious issues on which I think there is concern across the House, and we stand ready to work with her and other elected representatives from that area as part of the wider work.”
“I am therefore happy to give her an assurance that we will work closely with her on support for Essex as lessons are learned through the statutory inquiry and as services continue to be delivered. We are working closely on that with the chief executive.”
“Having discussed that harrowing evidence with my right hon. Friend, I do not think any Minister could either forget it or not be moved. I found it an extremely moving experience to hear her talk about the experiences of a number of her constituents. She is right to praise those who come forward, and to recognise that it is often a difficult ask to relive the most awful circumstances, but it is important that families come forward so that we learn lessons and ensure this is not repeated. My right hon. Friend is also right to highlight the two broad elements of learning the lessons of what happened in the past and maintaining services for the future.”
“Dr Strathdee did not particularly focus on staffing numbers, as far as I recall; she focused on some of the issues with care from staff. That was the nature of the concerns. On the ongoing risk, part of the reason why we commissioned the rapid review was to look, in particular, at the quality of data. There was a quantity of data that was not effective, and that often distracted staff from spending time with patients. There were also gaps in the quality of data that needed to be filled, and the document that will be placed in the Libraries of both Houses speaks to that point. That is why we are so keen to move at pace on learning lessons.”
“My hon. Friend is right to highlight the importance of pre-legislative scrutiny, into which he had a personal input. I am hugely grateful for his work and the work of Baroness Buscombe and others. I met Baroness Buscombe some months ago to discuss the outcome of that pre-legislative scrutiny. I do not have a date to share today, but I am happy to write to my hon. Friend with a further update.”
“We are investing more in mental health services as a whole, and that includes the important area of cleaning and catering services. Obviously, it would be inappropriate for me to comment on that specific contractual dispute, but industrial action, in its wider sense, is clearly disruptive and I am very keen for it to be resolved as quickly as possible, whether in the context of consultants or cleaning and catering services.”
“The chair is to be appointed, and given that statutory basis and the independence of the chair, it would be wrong for me to pre-empt the terms of reference. People can look to other statutory inquiries and come to a conclusion. The inquiry is not starting from scratch, and part of the reason we originally went with a non-statutory inquiry was because of the desire for speed. Of course, Dr Strathdee has done a huge amount of work and it will be available to the new chair of the statutory inquiry. One can look to other inquiries and draw conclusions, but I would expect it to move more quickly in this instance because a significant amount of work has already been done.”
“The reforms through integrating health and social care, having fewer targets from the centre and allowing more devolved decision making mean that those areas that want to put more money into in-patient mental health, for example, have greater flexibility to do so. The point the hon. Gentleman raises is extremely important and it is exactly what we are facilitating.”
“The hon. Gentleman raises an extremely important point, and he is right that a particular downside of out-of-area placements is often the distance from families. Indeed, one can see in the data that there is often a corresponding uptick in issues of harm. The crux of his point is very valid. That is why we are committed to building new facilities, with three new hospitals for mental health announced in the statement I gave on the new hospitals programme; that included three new mental health ambulances. This is also about preventing people from needing in-patient care through our crisis cafés, our earlier intervention in community services and the interplay with 111. More fundamentally, it is about giving greater power to commissioners on a place-based basis.”
“First, I do not want to wait for legislation before we make changes. Indeed, under the leadership of Paul Scott, who joined EPUT in 2020, investment has been made, with an extra £20 million being put into the in-patient wards and a further £20 million into community services. We are keen to make further progress on that. On the wider issue of legislation, I know that my hon. Friend, as a former Government Whip, is particularly acquainted with how the legislative process works, but the Government take her comments, and those of the House, on engaging staff in this process seriously, and we are working very actively on that.”
“I very much agree on that. The hon. Lady speaks powerfully of the importance of engaging with those with experience—the charity sector, the families and those directly impacted by the decisions taken in in-patient mental health facilities. She makes an extremely pertinent point and it is very much part of the approach we are taking.”
“I know that my right hon. Friend was particularly close to Sir David and is uniquely qualified to speak of his interest and involvement in these issues. I am happy to give him the reassurance that he seeks on working closely with the chief executive and the leadership team there. I know from my engagement with colleagues across the House that they will be closely involved in this in the weeks and months ahead.”
“The meaningfulness of those comments can be seen in the fact that we are putting this inquiry on a statutory basis; the £2.3 billion additional investment compared with what we had four years ago; the crisis cafés and the other schemes we have, as part of the 160 schemes we are bringing forward; and our willingness to innovate in mental health through the use of mental health digital apps. There is a whole range of initiatives because that is the right approach. Across the House, it has been recognised that in the past mental health did not get as much focus as physical health, which is why we are investing more. Again, the House recognises that covid has brought more focus to these issues, which is why this is a priority for the Government. Today’s statement is a further continuum in that effort.”
“My hon. Friend makes extremely important points, and I absolutely agree with him. Indeed, I will draw the inquiry’s attention to the points he raises. He is right about the trade-off between non-statutory inquiries giving speed and statutory inquiries having a wider range of powers. We have followed the evidence on that, which Dr Strathdee has shared. There is also a balance between the size of a facility and the quality of the care. Data is a key component within that and the rapid review was focused particularly on it. All of us are focused on, “How do we get the best patient outcomes? Where those have fallen short, how do we ensure the lessons of that?” That is what the statutory inquiry is absolutely focused on and it is important that families then engage with it.”
“The hon. Lady’s point is important, given that in the wake of the pandemic we have seen significant increases in demand, particularly for children’s and young people’s services. For example, in a year, the demand increased by 41%, so there is significant demand, which places pressure on the workforce. That is why the Prime Minister and the Chancellor have committed to the long-term workforce plan, which we will be bringing forward very shortly. We have been engaging with the sector, including the mental health sector, as part of that plan. NHS England has been doing significant work on that in recent months.”
“It is extremely important that we get support to young people, because many mental health cases start at a young age. Indeed, data suggests that as many as 50% of mental health cases crystalise by the age of 15, so it is important that intervention is made early. Our programme in schools, for example, is focused on that. It is also important for us to have better community support, which is why we are looking at what mental health support can be offered when people phone 111 and at how we can better scale up the use of digital apps that offer support, given that people often access information through their phones or digital channels in a way that they did not five or 10 years ago.”
“I am extremely keen to share our experience, so that we can learn from each other. As the hon. Gentleman knows, this is a shared challenge across our United Kingdom. The pandemic shone a spotlight on the mental health pressures that many people face, and I am extremely keen to work on a UK-wide basis with colleagues to ensure that we learn from each other as we take these measures forward.”
“That is an extremely good point. In fact, a key element of the primary care recovery plan looks at the handover points between secondary and primary care, which are often the cause of significant additional work within primary care. We are keen to see where we can ease those pressures, which in turn frees up our experienced GPs to do those tasks that require more time, so that is part of the primary care recovery plan. Through the rapid review and the focus on data, we are better able to identify where there are gaps or areas of duplication that take clinicians away from spending time with patients. That matters both in secondary and primary care, and it is something that the rapid review has been addressing.”
“It will be covered by the HSIB review. On how long that will take, investigations under the predecessor body typically took around a year, which is one of the advantages of the speed at which these things can be done. I hope my hon. Friend can see from the statement today that we will follow the evidence, given the decision we have taken to put the Essex inquiry on a statutory footing, but the HSIB approach has the benefit of speed. I hope that will benefit his constituents, as we learn the lessons. It is worth clarifying that the new body will have much greater teeth, as a result of the reforms that were passed by the House in 2022. While it is not on a statutory footing, it actually has more power than was the case in the past. That is why we think it is the right approach for learning the lessons in his constituency and more widely.”
“I commend my hon. Friend for the service he gives as a community first responder. Through that, I know he takes a huge interest in these matters. As with the point about data, I am extremely keen that where there is good practice, we are socialising that across the country as a whole, rather than having it in pockets. I would be extremely keen to work with him on the lessons coming out of north Lincolnshire and on how we scale that across the country, so that good practice can be adopted more widely. Indeed, the statement today is about how we will ensure that the lessons from Essex can be applied more widely, so that best practice is socialised across the country.”
“Together, this shows our direction of travel on prevention, which is focused on early detection of conditions through screening and better use of technology to speed up diagnosis and then treatment, because identifying and treating conditions early is best for patient outcomes and for ensuring a more sustainable NHS for the future, for the next 75 years. I commend this statement to the House.”
“That is why in April we announced a robust set of measures to help people ditch smoking for good, with 1 million smokers being encouraged to swap cigarettes for vapes in a world-first national scheme. All pregnant women will be offered financial incentives to stop smoking, and HMRC is cracking down on criminals who profit from selling counterfeit cigarettes on the black market. The lung cancer screening programme has been a game changer for many patients: delivering earlier diagnoses, tackling health inequalities and saving lives. We are taking a similar approach to tackle obesity, the second biggest cause of cancer across the UK. The pilot we announced earlier this month will ensure that patients in England are at the front of the queue for innovative treatments by delivering them away from hospital in community settings.”
“How will our lung cancer screening programme work? It will use GP records to identify current or ex-smokers between the ages of 55 and 74 at a high risk of developing lung cancer, assessed through telephone interviews. Anyone deemed high risk will be referred for a scan, and will be invited for further scans every two years until they are 75. Even if they are not deemed at high risk of lung cancer, every smoker who is assessed will be directed towards support for quitting because, despite smoking in England being at its lowest rate on record, tobacco remains the single largest cause of preventable death. By 2030, we want fewer than 5% of the population to smoke.”
“If results match our existing screening—there is no reason to think that they will not—when fully implemented the programme will catch 8,000 to 9,000 people’s lung cancer at an earlier stage each year. That means that each and every year around 16 people in every English constituency will be alive five years after their diagnosis who would not have been without the steps we are taking today. That means more Christmases or religious festivals with the whole family sitting around the table. Alongside screening to detect conditions earlier, we are investing in technology to speed up diagnosis. We are investing £123 million in artificial intelligence tools such as Veye Chest, which allows radiologists to review lung X-rays 40% faster. That means that suspicious X-rays are followed up sooner and patients begin treatment more quickly.”
“To put that in context, while a majority of patients diagnosed at stage one and two get to spend at least five more years with their children and grandchildren, less than one in 20 of those diagnosed at stage four are as fortunate. Thanks to our targeted programme, three quarters of lung cancer cases in those communities are now caught at stage one and two. Targeted lung cancer checks work. They provide a lifeline for thousands of families. We need to build on that progress, which is why we will expand the programme so that anyone in England between the ages of 55 and 74 who is at high risk of developing lung cancer will be eligible for free screening, following the UK National Screening Committee’s recommendation that it will save lives. It will be the UK’s first and Europe’s second national lung cancer screening programme.”
“That matters because NHS England states that when cancer is caught at an early stage, patients are nearly 20 times more likely to get at least five years to spend with their families. We all know that smoking is the leading cause of lung cancer. It is responsible for almost three quarters of cases, and in deprived areas people are four times more likely to have smoked. We have deployed mobile lung trucks equipped with scanners to busy car parks in 43 deprived areas across England. Before the pandemic, patients from those areas had poor early diagnosis rates, with only a third of cases caught at stage one or two.”
“1136.] Despite being a non-smoker, James knew that the biggest cause of lung cancer was smoking and that the most deprived communities had the highest number of smokers. That is why I am delighted that today the Prime Minister and I have announced a national lung cancer screening programme, building on our pilot programme, which will target those who smoke or have smoked in the past. Lung cancer takes almost 35,000 lives across the UK every year—more than any other cancer. Often, patients do not have any discernible symptoms of lung cancer until it is well advanced; in fact, 40% of cases present at A&E. Since its launch in 2019, and even with the pandemic making screening more difficult, our pilot programme has already given 2,000 lung cancer patients in deprived English areas an earlier diagnosis.”
“He campaigned tirelessly to promote lung cancer screening and was the first MP to raise a debate on that in Parliament. His wife Cathy is continuing the brilliant work that he started in partnership with the Roy Castle Lung Cancer Foundation. In 2018, after returning to work following his initial diagnosis and treatment, James told this House that the Government should commit to a national screening programme and use the pilot to support its implementation. I am sure many colleagues in the Chamber will recall him saying: “If we want to see a step change in survival rates—to see people living through rather than dying from lung cancer—now is the time to be bold.” —[ Official Report , 26 April 2018; Vol. 639, c.”
“Thank you, Madam Deputy Speaker. May I first address the remarks you made on behalf of Mr Speaker? Of course, any disappointment expressed by Mr Speaker is a matter of concern. No discourtesy was wished on the part of the Government. It may be helpful to clarify that no change of policy is being announced in the statement; it is an expansion of an existing policy, which I hope the House will regard as good news. However, we very much take on board any concerns that Mr Speaker has expressed. With permission, Madam Deputy Speaker, I would like to make a statement on our national lung cancer screening programme for England. About a quarter of patients who develop lung cancer are non-smokers. We all remember our much-missed friend and colleague, the former Member for Old Bexley and Sidcup, James Brokenshire.”
“It is part of our wider commitment, through our work with Genomics England and our work on the national screening programmes to screen 100,000 babies. The programmes cover not just lung cancer but, for instance, breast cancer. My hon. Friend the Member for Winchester (Steve Brine), the Chair of the Health and Social Care Committee, raised the issue of HIV screening with me last week. That is one of the areas in which early detection is having clear results. We are diagnosing more cases, which is why survival rates are improving in almost all types of cancer.”
“Gentleman raised the subject of research funding, and I was grateful to him for doing so, because the Government are spending more than £1 billion on research through the National Institute for Health and Care Research. I have met the president of Moderna, with which the Government have signed up to one of our landmark partnerships with the life sciences sector. There is huge potential for us to work with life science partners as part of our health commitment. It is clear that those within the industry see the Government’s commitment and are responding to it, even if Labour Members fail to do so. We are expanding our programme because it demonstrably works. It is tackling health inequalities and significantly increasing survival rates.”
“The NHS has seen and treated record numbers of cancer patients over the last two years, with cancer being diagnosed at an earlier stage more often and survival rates improving across almost all types of cancer. Indeed, the expansion of the screening programme is a good illustration of the clear progress that the Government are making. The hon. Gentleman raised the issue of junior doctors—an issue that we have debated a number of times across the House. He says that he does not support the junior doctors in their demand for a 35% pay rise. They have, of course, offered to spread it over an extra year to take 2024-25 into account, but for that they want a 49% pay rise. This is slightly esoteric: the hon. Gentleman says he does not support their demands, but he also criticises the Government for not meeting those demands. The hon.”
“The detection of stage 1 and stage 2 cancers, which has had such a remarkable impact on survival rates, has been targeted at the areas with the highest smoking rates and, therefore, the most deprived communities. I hope there will be a fairly wide consensus across the House that that is a real benefit of the programme. We aim to take the proportion of lung cancer survivors from 15% to 40% over the next 18 months, and to 100% in the years ahead, and we are talking today about a series of measures that have proved to be effective: there is remarkable evidence of the survival rates that they generate. The hon. Gentleman raised a number of wider issues related to the Government’s record on cancer.”
“On behalf of His Majesty’s Government, Madam Deputy Speaker, I echo your sentiments and those of the shadow Health Secretary in sending the House’s condolences to the hon. Member for Mitcham and Morden (Siobhain McDonagh), and also our fond remembrances of Margaret McDonagh. She played a pivotal role in the 1997 landmark election for the Labour party, and her loss will be keenly felt on the Labour Benches, but also much more widely across the political spectrum. The hon. Gentleman raised a number of issues relating to screening, on which there is much consensus in the House, but one issue that he did not particularly note is the importance of this programme in closing the health inequality gap.”
“I know that my hon. Friend was a Health Minister at the time that James was raising these points, and that he takes a close personal interest in the issue. He is right about the importance of the point at which people come forward. I was having a discussion this morning about the fact that when most patients come forward for screening, they will not be diagnosed with cancer, but it is still an opportunity for smoking cessation services, for example, to work with them on reducing the risk that continued smoking poses. My hon. Friend is right about using the opportunity of screening to pick up other conditions and to work constructively to better empower patients on the prevention agenda.”
“Clearly, the earlier we detect cancer, the less pressure it puts on the workforce. There is much more work involved in the treatment of a later cancer than of an earlier cancer. That is why we are investing in our community diagnostic programme, with 108 community diagnostic centres already open and delivering 4 million additional tests and scans. As part of the wider £8 billion investment in our electives recovery, over £5 billion is going into that capital programme. Yes, the workforce plan is a key part of that, but so is getting the CT scanners and the other equipment in place. That is exactly what our community diagnostic programme is doing, and it is being furthered by our screening programme through announcements such as this.”
“My hon. Friend is quite right to highlight the significance of smoking as a cause of cancer. We have a number of measures, including the programme to move 1 million smokers on to vaping, the financial incentives to encourage pregnant women not to smoke, the tougher enforcement and the consideration of inserts for packaging. The Government are taking a range of measures to address the very important issue that my hon. Friend rightly raises.”
“The hon. Gentleman raises a valid and important point on the targeting of mining communities. Of course, the roll-out will be shaped by clinical advice, but I will flag that point as we consider the targeting of the programme as it expands. On the hon. Gentleman’s first point, the major conditions paper will look at these issues in the round. That matters because one in four adults has two or more conditions, so it is important that we look at conditions. A moment ago, I touched on the fact that obesity is the second biggest cause of cancer after smoking, so it is right that we look at multiple conditions in the round. His point about targeting is well made, and I will make sure the clinical advisers respond.”