Rachael Maskell
MP for York Central · Labour (Co-op) · United Kingdom
“I welcome today’s statement and I welcome the Secretary of State to her place. York hospital was heralded as a cheap build, but we are paying a heavy price today. We know that heat in that hospital will have an impact on clinical outcomes as well as on staffing.”
“The conflict is moving beyond traditional warfare; we are now seeing extensive drone use, mercenaries being brought from Colombia, and the exchange of money too. We also know that Russia has its own interests in weapons and gold. We must look at the minimal interest in Sudan and the developments in Port Sudan at this time.”
“When we think about the fact that 33.7 million of the Sudanese population are in need of humanitarian assistance, 13 million have been displaced, 19.5 million are at levels of food insecurity and need urgent attention, and there are 8 million children who are not in the safety of school every day, getting their education, which will fuel…”
“Will the Minister tell us what progress has been made in that area, how that money has been spent and its impact to date? As we see increasing brutalisation in war, we have to focus even more on how we use international law to hold actors to account, and on the pace of that process, because it takes forever and a day to bring people to ac…”
“In the assault on El Fasher in particular, we saw the systematic raping of women, the burning of people and places, and the escalation in the next chapter of the civil war that has raged since April 2023.”
“It is a pleasure to see you in the Chair, Dr Allin-Khan. I congratulate my hon. Friend the Member for Gillingham and Rainham (Naushabah Khan) on securing such an important debate.”
The complete record
Every one of 5,723 lines we hold for Rachael Maskell, in date order, each linked to its source. Free to read, in full, without an account. Page 1 of 115.
“I welcome today’s statement and I welcome the Secretary of State to her place. York hospital was heralded as a cheap build, but we are paying a heavy price today. We know that heat in that hospital will have an impact on clinical outcomes as well as on staffing. Will she look at York’s desire to have a new hospital, co-located with the university, that is fit for modern healthcare? Will she recognise the work being done in York to prevent frail and elderly people from entering hospital through the incredible primary care work that is leading the way?”
“Up to 2023, civil society played a major role in maintaining stability in Sudan. Being able to work with local leaders is crucial to increasing their opportunity to build the bridges that are necessary to de-escalate the risks we see. How are we not only investing but inspiring community organisations and actors to use their accountability and creative diplomacy, and how are we providing the necessary support that they need to build for the future?”
“Will the Minister tell us what progress has been made in that area, how that money has been spent and its impact to date? As we see increasing brutalisation in war, we have to focus even more on how we use international law to hold actors to account, and on the pace of that process, because it takes forever and a day to bring people to account. We also need a different vision for how we build diplomacy, whether that is a focus on the post-conflict opportunity of trade, on reciprocity in co-operation, on security and stability, or on where we can use pragmatism and protection to build rules and rights. We must take the seeds of London and the shoots of Berlin so that they grow into a settlement that works for people on the ground in Sudan. Will the Minister also look at the role of civil society?”
“In the assault on El Fasher in particular, we saw the systematic raping of women, the burning of people and places, and the escalation in the next chapter of the civil war that has raged since April 2023. Last year in London, and this year in Berlin, the UK and other actors brought people together to break the deadlock, yet the fruit of those efforts has been so small. We need to look more widely at our infrastructure for addressing conflict. I welcome steps taken by the former Foreign Secretary, my right hon. Friend the Member for Pontefract, Castleford and Knottingley (Yvette Cooper), to address the issue of women in conflict, and particularly the investment for those who have experienced sexual harm as a result of the conflict.”
“The conflict is moving beyond traditional warfare; we are now seeing extensive drone use, mercenaries being brought from Colombia, and the exchange of money too. We also know that Russia has its own interests in weapons and gold. We must look at the minimal interest in Sudan and the developments in Port Sudan at this time. In fighting this proxy war, we need to ensure there is proper global accountability, which seems so lacking from our systems. In our tinderbox of geopolitical fragility, where domestic politics sucks our attention, we need to find the capacity in Government to provide the leadership that is necessary and the resolutions that are so urgent. We must match those with commitments to provide aid at scale and to use the political capital that we can bring. In recent years, we have witnessed new approaches.”
“When we think about the fact that 33.7 million of the Sudanese population are in need of humanitarian assistance, 13 million have been displaced, 19.5 million are at levels of food insecurity and need urgent attention, and there are 8 million children who are not in the safety of school every day, getting their education, which will fuel challenges for the future too, it is so urgent that we find a path to move beyond these atrocities. Yet it feels like actors cannot see beyond the desire to gain ground, destroy lives and property, and kill any hope. The Sudan war is a proxy for external actors, and that is what demands our urgent attention. We must use all the leverage we have to stop fuelling the conflict, not least by addressing the behaviours of countries such as the UAE and, at times, Egypt too.”
“It is a pleasure to see you in the Chair, Dr Allin-Khan. I congratulate my hon. Friend the Member for Gillingham and Rainham (Naushabah Khan) on securing such an important debate. As we think about the displacement and destitution, the hunger, the rape and the violence in everyday stories of this forgotten war in Sudan, which is destroying a nation, ripping it apart and fuelling the greatest humanitarian disaster on our planet, we know we have to step up our focus and our action in this place. Although I welcome all the contributions of hon. Members to this debate, the amount of attention that the House gives to this disaster is still insufficient.”
“Will the Minister meet me and the leader of City of York council? The fair funding formula is not working for our city because it does not use the lower-tier data with regard to the indices of deprivation, meaning that we are the worst-funded local authority. Can we have that meeting?”
“Since 2020, Governments, Prime Ministers, Ministers, UK Research and Innovation and businesses have all supported the BioYorkshire project, which will address issues to do with the environment and the climate crisis, as well as providing good-quality jobs and a return for the Treasury. However, the Government have not been able to get money out of the door, so can the Minister say more about how she will invest and spend that money?”
“I have listened carefully to the debate. May I refer to my new clause 57? The challenge of the NHS is that so much significant, unaccountable power is being held that we, as Members of Parliament, cannot even deliver for our constituents. Will my hon. Friend look at her my new clause, and work with me to ensure that we get the Bill in the right place with regard to accountability before it goes to the Lords?”
“Many Members were unable to contribute to today’s debate but have much to say, so will the Minister meet those Members to discuss further issues that were not raised during the debate?”
“We know that a small number of children, parents, carers and adults are hesitant about taking up vaccines. Sometimes that is about information, but sometimes it is simply a fear of needles. Can we look at different delivery mechanisms for vaccines so that people and communities are protected?”
“Vaccine delivery mechanisms also need to be expanded—we have heard many examples today, such as health visitors visiting family hubs for the early years, the schools programme, and the places where people connect, including workplaces and elsewhere. We need to ensure that we have a comprehensive system. I call on the Minister to look at the technology available to her to identify areas of low take-up. We know it is low in areas of deprivation and where ethnic minority groups, who are more hesitant to take up the vaccine, are concentrated. I ask that we have a proper, comprehensive vaccine passport that can be used by all clinicians who deliver the vaccine programme. I also ask the Minister to look at the issue of hesitancy in the round.”
“York’s uptake is 86.2% against Yorkshire’s 85% and England’s average of 83.8%, but the World Health Organisation sets the ambition at 95% because that is the level for herd immunity, which will keep our communities safe. When will that target be reintroduced? It must be reintroduced, because we know that it is effective. There are lessons we can learn about how to deliver vaccinations more effectively. If we think back to covid, many people—communities, schools and faith and community groups—were involved in getting the message out. We need to be able to communicate better to our communities, in this day of information overload, the importance of vaccines.”
“It is a pleasure to serve under your chairship, Mrs Barker, and I thank the Health and Social Care Committee for its work. It is a real privilege to be able to access vaccine programmes. They are the most effective public health interventions, and there are 15 vaccine-preventable infections against which we can be inoculated. Just this week, the winter flu vaccination programme started; I urge all those watching to take up the opportunity to protect themselves and their community. In York, take-up is relatively high; however, we are not complacent. A particular challenge for us is the uptake of the second MMR vaccine. I would like to know what the Government are doing to support initiatives to improve that.”
“We all live on this fragile planet, which is disintegrating before our eyes. This is an opportunity to reset the clock and get global and environmental stability. All nations much work together to save planet Earth. We are already seeing how intolerable it is, not least in the global south. It is coming our way too, so we cannot prevaricate, as we have over decades in the political space. We must now convene and act to stop the multifaceted risks we are seeing before our eyes, ensure that we stick to the Paris climate commitments and move faster. The disintegration and collapse of this planet is getting out of control. Will the Minister convene her colleagues for a new opportunity for geopolitical stability and, hopefully, save our planet?”
“It is a pleasure to serve under your chairship, Sir Desmond. The national emergency, coupled with the national security assessment, makes it absolutely clear that the political landscape has to change locally, nationally and internationally. We need to change the geopolitical processes and fora through which these issues are discussed and acted on. Their insufficiency in the face of the emergency of our time dictates that we do that. Every conversation, policy and action must be oriented towards saving our planet. The scale and pace of collapse mean that we have no choice, but we do have an opportunity if we can pull our country and our communities together and focus on our consumption—we consume the equivalent of 1.6 planets. We must also pull the nations together.”
“Can we have a statement on the closure of post offices? When York’s Crown post office was closed after 138 years and moved into WH Smith, we were given assurances that it was a long-term solution. Now we have Modella Capital private equity buying out WH Smith, we have seen the closure of our WH Smith branch on the high street and of 150 branches across the country, meaning that we will lose our post office once again. Can we have a statement to ensure that we secure the jobs, but also the services for my residents and businesses? [Hon. Members: “Hear, hear!”]”
“As the Minister enters the fray of negotiations, I ask him to look at rebuilding an economic union with Europe that will be of value to our constituents by ensuring that trade brings good-quality jobs and powers the research that drives our economy forward. On immigration, I ask him to consider the asylum and migration management strategy that Europe has adopted and look at a risk-sharing approach so that we can rebuild balance in our system to ensure that we are supporting vulnerable people in the right way instead of pointing the finger at them. That will help our communities and our country. And ultimately, our leadership will help our world.”
“Locally, we know that the consequences are significant. Our constituents are £3,000 poorer as a result, and they are now faced with the cost of living challenge. We have to dig deep on where we go next and ask the questions that should have been asked in 2016. How can we have a stronger and safer economy? How do we have good trade? How do we best control migration, collaborate on a destabilised planet and ensure that our interactions abroad bring people here at home better job security, financial security and, of course, hope for the future? As we move forward, yes, we need pragmatism, but we need boldness too.”
“Thank you for chairing the debate, Ms Butler, and I thank the hon. Member for Perth and Kinross-shire (Pete Wishart) for securing it. If you ask the wrong questions, do not be surprised by the consequences. Brexit was about the politics of the time in the Conservative party, not about the economic future of our country. Let us remember the history and the poor deal that Lord Cameron tried to secure ahead of going to the country with this referendum. Our country is now poorer and more fractious. Trade is more challenged, and we see queues at the border, horizons closing to our young people and increased migration levels. We have to ask the value of the deal that was struck after 2016. As a country, we are now significantly weaker on the global stage in a more unstable world where we should be taking the lead as we did in Europe.”
“I am grateful to my hon. Friend for her incredibly powerful speech. She is right that this is not a necessity; it can be addressed. Does she agree that the Department for Work and Pensions needs to ensure that parents get support from day one so that they can address the increased financial costs that they face from the beginning of a diagnosis, and the real need for parents to be present to support their child?”
“In the light of the fact that we are moving into a new era of a can-do Government, will the Minister look, together with clinicians, at the opportunity and benefit of delivering DLA from day one, and then bring the evidence back to the House?”
“I welcome my right hon. Friend to his role. Ten months ago, my constituents were promised a public inquiry into our mental health trust, after 10 years of campaigning for it. People have died in the interim, and it is simply unacceptable. In writing about unaccountable power over the summer, I have seen the weaknesses not only in the decision-making processes, but in the lines of scrutiny to ensure that we can deliver for our constituents. Will my right hon. Friend work with me and join me in the work I have been doing to ensure that we are talking about the devolution not just of power, but of scrutiny to hold such bodies to account?”
“It is crucial that conditions are followed on release. However, automatic recall often means that people who miss a probation appointment end up in prison, often for months on end. Will the Secretary of State look at the recall process and ensure that it is fair and equitable and that if people do err on their conditions, there is work to support that person outside prison rather than their being brought back into custody?”
“Q11. Before coming to this House, the Prime Minister and I attended the launch of my uncle’s book. It was entitled “Fine Lines and Distinctions”. Clearly, sometimes we have had those differences, but I genuinely wish him and his family well for the future. But before he places his pen down, I understand that there is a tradition of leaving a note for your successor. In wishing all hon. Members the very best of summers, I ask that he asks his successor, my right hon. Friend the Member for Makerfield (Andy Burnham), to enact my legislation to license short-term holiday lets and ensure that we can protect our communities from family houses turning into party houses in residential areas and ensure that we keep housing costs down?”
“How are we ensuring that the people working in those facilities have the support they need to say, “Tools down, we can’t work any more”? Of course, that is very difficult when we are talking about health facilities—we think back to covid and the conditions in which people were working in extreme heat there—but we need plans to support workers who are at risk of many of the same health challenges. What I am really asking from the Minister is this. What are the resources and how will we ensure that devolution is part of that? How will we institute comprehensive planning, so that we do not continue to face the risks, the closures, the real discomfort and, tragically, the deaths that we have seen this year?”
“Anyone struggling to breathe will find it massively challenging in those environments. Therefore, the urgency with which we need to make our public buildings resilient cannot be overstated. I therefore call on the Minister—I appreciate that this goes way beyond her brief, but it is a cross-Government function—to look at how we build resilience across the board. What resources are we going to invest in our climate resilience? Will we have a single Minister, leading cross-departmentally, to ensure resilience? How will we ensure that we are not just looking in Westminster? We know that real change and impact happen on the ground in localities, so how are we empowering our local authorities with the resources and the plans to make a difference now, not just in the future?”
“Many people can go out and buy an air-con unit or a fan to keep themselves cool, but those without resources clearly do not have that advantage and their health is placed at even greater risk. We know about not only the distress that this causes—respiratory or cardiovascular distress—but the serious risk of kidney dysfunction and so much more we could name. We have heard about the pharma impact and the impact of exhaustion cramps—and then there are the risks of cancer; we have not heard about that in this debate, but greater UV exposure will increase those risks, too. We also have to think about the environments that people then go into. Our hospitals are just not equipped for this heat. York hospital, built in 1977, is just not heat resilient—it is a greenhouse, as has been highlighted.”
“I want to focus on a few points around health, that being my speciality, and to look at the scale of what we are talking about. We have heard already about the 2,700 deaths so far this year from the climate emergency due to heat alone. We think particularly of the most vulnerable—babies, children under the age of four and older people, whose bodies find it harder to regulate—and those who have cognitive dysfunction, who will find it difficult to make the necessary adaptations to keep themselves safe. Of course, we also know that the challenges bear down hardest on those in lower socioeconomic circumstances. As a result, we need to look at this in a way that ensures justice, equality and real fairness.”
“The city has done well by focusing on flooding, but heat resilience is a new area to which we must now pay all our attention. Over the last month, schools have had to close, and many of the hospital’s wards have overheated. Across our city, we have felt a real and massively challenging swathe of heatwaves. We recognise that, if we are going to address the issue of flooding in our city, we have to get the hydrology right in the upper catchment area. That means that we have to make certain decisions: can we afford grouse moor shooting any longer, since it drains the land and as a result makes it more prone to catching light? There is much thought that needs to be given to the infrastructure needed, both in agriculture and across our buildings, our public services and so much more.”
“It is always a pleasure to see you in the Chair, Sir Christopher. It was the 1976 New Forest fire in your own constituency that woke me up to the dangers of climate destruction. Just last weekend, on Sunday night, I heard about a fire raging in the area of Acomb, on the edge of my own constituency. A field of wheat had caught ablaze, causing fear to residents; I really thank the police and fire service for their rapid response, but the fire obviously came at great cost to not only the farmer, but the community, and it makes us all so alert to the challenges we face in our time. From discussions about the challenges that our city faces, it is clear that we are not climate resilient. We do not have the necessary strategies and plans to address the urgent needs of our time.”
“Research shows that specialist palliative care can deliver palliative care in the community, saving the NHS 1.5 million bed days, as well as £817 million. It is important that funding accompanies the modern service framework, so that we have an invest-to-save model moving forward. Will the Minister meet me and Baroness Finlay, to consider the work we have been doing in this area, and see what more the Government can do to enable that?”
“I congratulate my hon. Friend, but I want to ask about pharma in the light of the US-UK pharma deal. When I met academics yesterday, they expressed a concern that if we were to change the terms of the deal with the US, because of mounting costs and the cost to lives which are foreseen under that deal, it could have an impact on the deal that he has now signed. Can he give this House an assurance that we would not have to go back and renegotiate the deal with Switzerland, if we were to renegotiate the deal with the US?”
“I welcome the 30 by 30 nature and climate plan, which responds to the crisis that we face and builds resilience and restoration. Following my youth environment conference in York, “Our Planet, Our Future”, it is clear that young people want to get involved, so in addition to setting up the youth climate and nature panel, will the Minister ensure greater accountability to young people across the country, through local panels that will hold local authorities to account for their actions?”
“Last Ukraine day, an event was held in my constituency where I heard from a Ukrainian woman and saw a film about the sexual violence being perpetrated against women in Ukraine, and the horrors and the scars that it has left them with. They did not speak, because of the shame it brought them and the trauma that they were going through, but, when they started to share their stories, it brought healing between them. Without the proper support and psychological care wrapped around individuals, that healing does not come. That is why I am so proud that our Foreign Secretary has recognised that and has put resources into it, particularly in the Sudan region. We need to make sure that women there access the support.”
“When infrastructure breaks down, resilience plummets and that is particularly stark among older people. The Government must be mindful of that when appraising their priorities. Without financial resilience, even the basics become barriers, especially for women in conflict zones. Aid must ensure provision of food, care, medicines and support. It needs to be a lifeline. This is not just about the physical impact of destitution and the health consequences. The psychological trauma must be recognised, too. Elders play such a pivotal role in communities and families. If their resilience is broken, so is that of their societies. In many societies to this day, women are at particular risk of violence and abuse, including sexual violence. It has been a taboo subject, not least among the older generation, yet it is so traumatic.”
“It is about social care and the social infrastructure when family is no longer available to provide support. State provision can be disrupted, and pensions no longer available. Food supplies are diverted into emergency and humanitarian aid. It is so important that we put older people at the front of all agendas. I say that as chair of the all-party parliamentary group for ageing and older people; I take this matter very seriously. Now, with severe cuts to international aid, a humanitarian response is more challenging. I urge the Government to return to 0.7% as a matter of urgency and to provide leadership once again, to ensure that we can provide aid. Not everyone will be able to receive that, but we should provide it to as many people as possible. Older lives matter, too.”
“Our hearts beat when we know that a child has been rescued or a life has been saved, but although the life of an older person is of equal value, often the resources are not there to save or sustain that life. As the hon. Member for Strangford said, it is often the elderly who stay behind in conflict zones because they cannot move—they cannot be displaced, and they stay in those areas. We have seen that in Ukraine and in many other areas. Our research shows that moving an elderly person has other impacts; it can cause much confusion and have a real impact on mental wellbeing. We need to take on board why so many older people die in conflict; it is because they are in the direct firing line, or because the facilities and infrastructure that keep them going are removed. This is not just about healthcare.”
“That breaks the rules of just wars, but these wars, of course, are never just. We have also seen the shrinking capacity of healthcare against the increased demand, whether from the wounds of war or the poor mental health sustained from the sharp rise of sexual violence against women. As a result, the ability to access healthcare is reduced, and that, of course, will always impact older people the most. Often in war, we look at the wounds and we understand why, but it is the chronic conditions—the cancers, the diabetes and other illnesses—that often get forgotten; it is the drugs not getting through, the treatments not available, the clinicians simply diverted to acute care.”
“Those figures show that conflict shortens lives by decades through poor access to healthcare and pharmaceuticals; disability, disruption and displacement; prevalence of disease and hastened frailty; and an environment of climate change, floods and famine. Gender-based violence scars the lives of its survivors. I am so proud that our Foreign Secretary has rightly placed tackling the prevalence of the use of gender-based violence as a weapon of war at the heart of her work. Access to healthcare, an issue that I particularly look at in my work in the House, is significantly reduced, with the targeting of health facilities and health professionals now central in many conflicts. We have seen that in Gaza and in Sudan. Health professionals working there run these risks in the work that they do and because they are targeted by weapons.”
“It is a pleasure to serve under your chairship, Mr Betts. I congratulate the hon. Member for Strangford (Jim Shannon) on securing this debate. I also wish his mother a very happy birthday for next Tuesday. In many areas of deep conflict, the population rarely reaches our definition of older people. In Gaza, life expectancy has plummeted from 73 years to just 40.5 years. In Sudan, life expectancy is 66 years, and in Nigeria and Chad, it is 55 years. Compare those numbers with the UK life expectancy of 81.3 years or the life expectancy in Japan of 84.7 years. It is a privilege that our nation is safe, secure and conflict-free.”
“I trust that we can rebuild our humanitarian response with good data, programmes and rights to support older people in conflict zones.”
“Will the Government ensure that they crunch the numbers for conflict areas and use the data to design humanitarian responses, recognising the prevalence of older people and the focus that they need? Finally, I again make the point that the pivotal game changer for the issue is to have a UN convention on the rights of older people. That is about giving agency to older people in conflict zones, to better facilitate their participation in humanitarian planning, peace building, monitoring and decision taking. I look forward to hearing the Minister’s response, and to contributions from the shadow Minister, the hon. Member for Fylde (Mr Snowden), and the Lib Dem spokesperson, the hon. Member for Horsham (John Milne).”
“Will the Government ensure that their humanitarian response is always age-inclusive, with an understanding of the risks that older people face when social infrastructure is destroyed by conflict? Will they also ensure that distribution is targeted to reach elderly people who have both chronic and acute health needs, wherever that focus is required? Will the Government promote opportunities for social protections, such as social security and pensions, among older people in conflict zones to ensure that they can access the resources that they need? Of course, it is important in many countries, as it is in this one, that people can use more traditional ways to access those services.”
“Having a rights-based framework will move the agenda; it will enable us to focus on that protected characteristic—for example, age-inclusive specialists can help to reprioritise the humanitarian response, particularly in health or care. We must also ensure that we have good data to accompany that work, so that we know exactly how to focus our humanitarian response. Of course, when it comes to healthcare insurance, we can then ensure that pharmaceuticals and equipment are available in conflict areas to meet the needs of the demographic that we are debating today. When only 0.1% of humanitarian funding databases mention older people, we know we have a problem. Can the Minister assure me that the Foreign Office will write older people into all its work, and will spread that good practice to agencies and other nations?”
“The work of the UN convention on the rights of older people has been inspiring, and it very much follows the lines along which other rights have been established, including the rights of the child or disabled people, to ensure that the protected characteristic of older people is upheld. Of course, it falls on the Foreign Office to advance that work and ensure that the UK plays a full role. We must bring our experience into that space so that older people’s identity can be seen, and so that their needs, in particular, can be supported. I ask the minister: what exactly are we doing to lead that work? Will the UK adopt the UN convention, once it has been established, to ensure that women, men and older people across the piece have their value recognised and their rights upheld?”
“It is often the older women who can use their wisdom to bring co-ordination and build a way to the future. Indeed, I have been inspired by many older women leaders who have led the charge out of conflict, into a more resilient future. However, we must also recognise that there are significant challenges. First, what are the Government doing to provide better protections for older people and their rights? We in the all-party parliamentary group undertook an inquiry into the human rights of older people, which looked at the frameworks and mechanisms that we can deploy to enhance and protect those rights, and to ensure that people can uphold them.”
“It is not only about ensuring that people have the ability to reach that food; it must also be prepared for them in the right way. We have been talking about some of the challenges that we have seen in Sudan as of late. It is a horrendous and complex war, so I am glad that it was discussed at the NATO summit recently and remains at the forefront of our Government’s mind. It is very much a forgotten war in so many respects. Evidence has also shown that the elderly in Sudan have been in the direct line of violence. It is important that we do not forget that either. Older people—not least women—play a crucial role in the home and in the community, which often ripples out far beyond. Often, they are the ones who build the bridges, build the civil society, create the pathways to peace and organise communities at their most challenged.”
“I am really grateful to my hon. Friend for raising that point, as it is so important to make a catalogue of war crimes. Whether they are committed against the elderly, or they consist of any other form of violence, including sexual violence, it is crucial that we keep good records so that we can hold perpetrators to account when the opportunity arises. We know that if older people do not get the right nutrition, it has a massive impact on their ability to function. They can have greater episodes of confusion, making life much more challenging; they can become frailer; and they can rapidly lose their mobility, meaning that they have more complex needs. Good distribution of humanitarian aid is vital for the vulnerable, and we must always ensure that we factor in access to targeted support.”