Public Petitions Committee, 17 Nov 2009

Meeting date: Tuesday, November 17, 2009

Official Report 345KB pdf

---

Current Petitions

---

Cancer Treatment (Cetuximab) (PE1108)

Item 2 is consideration of a current petition with which we are familiar. PE1108, which was lodged by Tina McGeever on behalf of her late husband, Mike Gray, calls on the Scottish Parliament to urge the Scottish Government to consider the provision of cancer treatment drugs, in particular cetuximab, on the national health service to ensure equity across NHS boards in determining the appropriateness, effectiveness and availability of such treatments.

We have considered the petition in substantial detail. At our meeting on 6 October, we agreed to invite the Cabinet Secretary for Health and Wellbeing to attend a meeting to detail the progress that has been made, and today I welcome Nicola Sturgeon to the committee. We have provided her with information that relates to the petition, which will, I hope, facilitate discussion.

I also welcome the Scottish woman of the year, Tina McGeever, who was the major contributor to the petition. She should feel free to sit at the table if she wishes to do so—in quickly scanning around, I see that she has already done so. I congratulate her on her award and achievement, which I know she recognises as an achievement for compelling emotional reasons.

I invite the cabinet secretary to make some opening remarks.

Thank you very much, convener. I welcome the opportunity to update members on the progress that we have made so far in addressing the recommendations in your inquiry report.

There can be no doubt in anybody's mind that consideration of the important issues that the petition raised identified necessary and significant improvements that had to be made to the availability of and access to innovative treatments for NHS patients. I am pleased to report that substantial progress has been made in a number of areas and that work is on-going in other areas. With the committee's indulgence, I will take a few moments to run through some of that progress. I, too, welcome Tina McGeever to the meeting and pay tribute to her for lodging the petition and for driving some of the changes that we will discuss today.

From the outset, our intention has been to achieve a strategic approach to change and improvement. We do not want to make changes only at the margin. Our intention has been to focus on clinical effectiveness, patient safety and person centredness.

The Government's responses under each of the headings of the committee's recommendations have been addressed in previous correspondence with the committee, most notably the response that was provided on 3 September 2008, and in the statement that I made to the Scottish Parliament on 25 March 2009.

In summary, each of the key themes of the committee's recommendations, which spanned clarity about roles, provision of guidance, gathering of data, the role of quality-adjusted life years and the availability of new medicines, including exceptional prescribing and funding arrangements, is being addressed in detail by several strands of work. Taken together, those strands, which we will no doubt discuss in more detail today, are intended to provide a strategic framework that for the first time in Scotland sets out the arrangements for the introduction and availability of new medicines, with the express aim of achieving greater clarity and consistency of approach across the country.

The strands of work were set out in my response of 3 September 2008, which addressed each of the recommendations. My statement in Parliament on 25 March 2009 set out a range of additional development areas, as well as other areas of progress, such as the publication of the revised guidance on arrangements for NHS patients receiving health care services through private health care arrangements.

I will give a brief update on progress on other points that I covered in the statement. The first related to the development of extensive new guidance for NHS boards on the introduction and availability of new medicines. Guidance has been developed and is intended to provide a framework to which NHS boards must align local policies on access to new medicines. The draft guidance contains specific advice on what we now term individual patient treatment requests, which were previously known as exceptional prescribing requests, and has been circulated to NHS boards and a wide range of stakeholders and patient groups for comment. I would be pleased to give the committee the opportunity to influence the guidance prior to publication.

Comments on the draft guidance are expected by 20 November, which is the end of this week. Work will continue thereafter, so that we can finalise and issue the guidance as soon as possible. The user-friendly patient information leaflet that is being developed by health rights information Scotland and is intended to describe the end-to-end process, from licensing through to individual patient treatment requests, is currently being tested in a variety of groups involving health care professionals, patients and the wider public.

In my statement in March, I announced that the Scottish Medicines Consortium would shortly publish on its website modifiers to be used when appraising new medicines for which the cost per QALY is in excess of the normal parameters. Those modifiers have been published and have been on the SMC website for some time. They give the SMC increased flexibility that can be applied to any new medicine that it is appraising, not just cancer medicines and end-of-life medicines. I understand that so far the SMC has approved three new drugs under the new arrangements.

I also said in my statement that I had accepted the recommendation that a national framework for assessing proposed patient access schemes at national level be established as a way of potentially reducing the overall cost of new medicines. A patient access schemes assessment group has been established. It will function separately from the SMC and provide an independent and objective evaluation of access schemes across Scotland. The group is currently operating in a transitional phase, but to date three schemes have been appraised under the arrangements; that has resulted in the acceptance by the SMC of two cancer medicines as part of patient access schemes.

I hope that all the developments that I have described will improve access to new medicines in the NHS for patients throughout Scotland. The committee made recommendations on the need for national data gathering, which are being progressed via on-going work at national level to develop information technology and data analysis systems to provide information on medicines uptake and how medicines are being used. That is work in progress. I am happy to update the committee on it further today, but I am sure that the committee will request on-going updates. A key message in the draft guidance is that NHS boards need to identify and share good practice in planning and introducing new medicines.

That was a relatively brief update. Like the committee, I remain committed to ensuring that people have the best health care possible. In addressing the committee's recommendations—we have tried and continue to try to address them all, one by one—we are intent on improving access to new medicines. The issues are complex and at times difficult, but we are committed to continuing to work with the committee to do what we can to improve the systems that are in place. I am pleased to say that there is clear momentum throughout the NHS in Scotland to achieve greater access and greater consistency.

I am happy to answer questions.

We have questions about data gathering and quality-adjusted life years that we will submit for written responses rather than ask today.

You have highlighted several issues. The committee has played a role—in partnership, I hope, with you—through the parliamentary debate and the subsequent responses in finding better ways of operating in the health service. We have made progress since the petition was lodged.

Members will explore with you the issues that you have identified.

Good afternoon, cabinet secretary and colleagues. You wrote to NHS boards on 29 January. Were their responses positive? Do they accept the need for change? What is the position on achieving a coherent picture throughout the country? You talked about clear momentum. How much more has to be done?

We have done much, but there is more to do—this is work in progress. As you said, I wrote to all NHS boards on 29 January. We received responses from all 14 territorial NHS boards. Although the evidence is anecdotal and the proof of the pudding will be in the eating, I detect a strong momentum and a clear determination in the NHS to improve the arrangements that are in place.

The responses from all the NHS boards were fully assessed, distilled and fed into the preparation of the draft guidance that I mentioned in my introduction. The process was inevitably quite long, because it was important to get that right and to consult not just NHS boards but other stakeholders. That guidance is almost in its final form and is with NHS boards and other stakeholders, as I said. The deadline for comments is 20 November, which is this Friday. Thereafter, we will aim to finalise the guidance as quickly as possible. In the period between the deadline for comments and publication, I will give the committee the chance to see and comment on the guidance.

The process of formulating and finalising the guidance has been lengthy, but NHS boards have not been at a standstill while that has happened. The process of drawing up the guidance required us to consider best practice around the country, so that we could spread that best practice through the guidance. Boards have already examined their policies and processes and thought about what they need to do. I hope that, by the time the guidance is published, most if not all boards will be able to say that they have policies in place that comply with the guidance.

The committee looks forward to having input into finalising the guidance. As part of that necessarily complex process, have boards been encouraged to talk to one another?

Yes. As I said in my opening remarks, the Government's intention has been to set the strategic framework. Part of that is about ensuring that existing best practice is shared among boards so that those that do not comply with best practice are pulled up to scratch. Where, frankly, things might be done better than was the case in any NHS board in the past, we want all boards to improve on their position. Therefore, a lot of discussion has been involved. I say again that, in my experience, boards have been very up for that. Certainly, that has been the tenor of the feedback from them.

Obviously, once the guidance has been operational for a reasonable period, the situation will be reviewed. All boards will be expected to demonstrate that their policies are aligned with the guidance and that the board is doing what is required of it, so the publication of the guidance will not be the end of the story. We will monitor the impact of the guidance to ensure that it is having the desired effect.

Obviously, policies should be under constant review, especially for such serious matters.

I have one more question. When the cabinet secretary mentioned the new modifiers that the Scottish Medicines Consortium has published, she mentioned that three new drugs are now available. What are those drugs? Are there any other practical examples of how things are now better as a result of the publication of the SMC's new modifiers?

I knew that I would be asked what the drugs are called, but they are all unpronounceable—

I will not push it, then.

The three drugs are sunitinib, romiplostim and mecasermin—

That is exactly what we were thinking.

I am sure that my pronunciation is way off mark, but we can provide further details about those drugs. Sorry, what was the second part of the question?

Basically, are there any other practical examples of how things have improved because of the new modifiers that the SMC has published?

It is important to see the modifiers almost as a stand-alone. They are designed to give the SMC more flexibility than it had in situations where the standard QALY methodology—which I know all members are now well versed in—would not, in the normal course of events, lead to the approval of a drug. The modifiers apply to drugs that might, for example, deliver a significant extension to a patient's life, improve a patient's quality of life but not prolong that life or provide some other benefit for which no other therapies are available. Those are some examples of the modifiers. The three drugs that I mentioned are the only drugs that have been approved under the modified approach since that came into place in May this year. Therefore, it is reasonable to say that, in all likelihood, those three drugs would not have been approved but for the modifiers.

Separate from the SMC modifiers is the patient access scheme. I mentioned two cancer drugs that have been approved under the patient access scheme. That is another example of a practical difference that has been made. Over and above all that, as I said earlier, the process of preparing and consulting on the new guidance is already leading NHS boards to make improvements in their local processes. Obviously, that is a practical benefit of the committee's work.

Absolutely. I will not ask the cabinet secretary to pronounce these if they are difficult, but could she perhaps have a go at telling us which two new cancer drugs have been approved under the patient access scheme? Is cetuximab one of those, or is it being considered?

Cetuximab is not one of the two drugs that I mentioned, but cetuximab is due to be considered under a patient access scheme proposal in the fairly near future. The two drugs—I will not pronounce them, but I will say what they do—are for the treatment of multiple myeloma and for the treatment of gastrointestinal tumours.

I understand that other drugs are currently available under the patient access scheme in England. What are those drugs? Will they become available to patients in Scotland and, if so, when will that happen?

I can provide that information to the committee, but I do not have it with me today. The arrangement that we have put in place for the consideration at a national level of patient access requests involves an assessment group that will consider applications that are made for the approval of drugs. The assessment group examines patient access scheme proposals and, if it considers them worth going ahead with, the information goes to the SMC for it to make its recommendation in the light of that. Applications that are made under patient access schemes are considered in that way. I know that applications for some of the drugs that are available in England have not yet been made in Scotland. However, that is in the hands of the drug companies and I dare say that the picture will be fast changing.

One of the issues that arose in our inquiry, which led to the progress that is being made, was regional variation in prescribing, which we are trying to overcome. Will the new guidance reduce the risk of postcode prescribing and ensure more consistency? I hope that it will. Will the decision-making process become more transparent?

The answer to both those questions is yes, I hope so. National consistency is important. The patient access scheme system and SMC modifiers operate at the national level and ensure consistency at that level. The guidance to NHS boards on the processes and systems that they should have in place for the introduction of new drugs and for exceptional prescribing—or individual patient treatment requests, as we are now calling them—will ensure much greater consistency throughout the country. I expect that there will be greater transparency as well, as the guidance to boards includes guidance on the need to put their policies in writing, to have them on their websites, to have clear arrangements for communicating decisions to patients and to have patient involvement in some of the decisions. All those things will improve the transparency.

We are trying to establish systems that encourage and facilitate consistency throughout the country. I agree that that is very important. Nevertheless, some of the decisions—especially on individual patient treatment requests—will, of necessity, deal with individual patients' circumstances, so there will continue to be instances of an individual in one part of the country getting a decision on a particular drug that an individual in another part of the country might not get. That will not be a sign of inconsistency; in most cases, it will be a sign that there are different circumstances at play in the two cases. We must be open eyed about that.

We are determined to establish systems that facilitate the consistency that the committee has requested in the past.

Hopefully, the greater transparency of the system will make it obvious why certain patients do not get the decisions that they want.

My final question is on the status of SMC guidance and the account that clinicians must take of it. You have said before that NHS boards are expected to take SMC advice into account. When medicines have been approved by the SMC, will there be a timescale in which boards will have to make those medicines available to patients? If a board decides not to add an approved medicine to its formulary, what will be the basis of the decision-making process? Will the guidance ensure that that process is robust and consistent?

The guidance will lay out the steps that the boards must take through their area drug and therapeutic committees to implement the SMC's recommendations, and it will include timescales in which those decisions must be made.

I have made it clear before and I will continue to make it clear—not just to the committee, but to all NHS boards—that SMC recommendations are not optional. When the SMC recommends a drug, a board has an obligation to make that drug or its equivalent, if it is not a unique drug, available. There is no dubiety about that. If, at any time, there is any evidence or suggestion that a board is not acting in that way, the issue will be taken up vigorously with the board in question.

Thank you for that. There is a feeling that barriers are sometimes put in the way of patients getting SMC-approved treatments.

You referred to individual patient treatment requests. Is that the new name for them?

Yes. It is the new name for exceptional prescribing.

I thought so. I asked just for clarification.

Poor communication was one of the issues that Tina McGeever's petition highlighted. In paragraph 85, our report suggests that health boards should appoint local liaison officers, whose role would be to encourage better liaison between the clinician, the health board and the patient. Will you ask health boards to appoint local liaison officers? If not, what practical steps should they take to address such problems?

Yes. That was an important recommendation, and the guidance will direct NHS boards to put in place and to identify the staff members who have the responsibility of being liaison officers. As well as having to identify an appropriate person who is well placed to perform that role, they will have to signpost patients and the public to that person through their written policies and their website, so that it is well known who that person is and they can be easily identified by patients who require help and information.

Is local liaison better now than it was a year ago?

Yes, I think that that is the case. Is it where we want it to be in all NHS boards? Not necessarily. Many of the changes that will bring that about will follow from the guidance. As I said, boards are already working on bringing their policies and procedures into line with what they expect the guidance to say. I would not say that it is job done on that aspect or on any other aspect of the issue. We have made great progress, but some of this is work in progress, which we need to continue.

I welcome the input of health rights information Scotland to the guidance on exceptional prescribing, or individual patient treatment requests, as the issue is now referred to, but were any other bodies, such as patient bodies, involved in drawing up the guidance? We all welcome the fact that you said that you would seek comments from the committee on the draft guidance when it comes out. Will any of the patient bodies be asked to comment on the draft guidance?

The draft guidance is currently with NHS boards and other stakeholders, including patient groups. The leaflet has been sent for comment to a total of 36 stakeholders, 22 of which are cancer-related organisations. They include Breakthrough Breast Cancer, the rarer cancers forum, Macmillan Cancer Support, Bowel Cancer UK and the Scottish cancer coalition. The Scottish long-term conditions alliance, which covers a range of long-term conditions, has also been consulted on the leaflet, because it is important that we get it right.

Are there any other questions on the broad area of availability?

You talked about the desire and the need to ensure uniformity of process for patients across boards. Will there be uniformity of process for patients who wish to appeal against the decision of a board not to fund a treatment?

The guidance will make it clear to boards that they require to have in place clear and understandable arrangements for patients who want to appeal. The processes will not necessarily be identical in every part of the country, although because, as Nanette Milne said, all the policies and procedures in different board areas will be highly transparent, my view is that they will end up being very similar. The appeals system is an important part of the process, and it is just as important that that part of the process is understood as it is that earlier parts of the process are understood.

That part of the process will be as transparent as other parts of the process.

Yes.

I am grateful for that.

Good afternoon. In the context of leaflets or information generally, to what extent will boards be required to take on the fact that not everyone reads English? Not everyone's first language is English and some people simply cannot read for a variety of reasons.

It is our normal practice to make leaflets available in a range of languages and formats. I am looking for a nod to tell me that that will be the case with the leaflet that we are discussing.

Absolutely.

Thank you for that confirmation.

One of the reasons for choosing to involve health rights information Scotland was to ensure that the equality proofing was done and that the information that was produced was as widely accessible as possible. Equally, with information that is made available through NHS boards, we expect existing arrangements for engaging the public to take account of the point that you make.

I am just very glad that the issue has been taken on board at the beginning of the process, because too often it is done too late.

Do members have any more questions about availability?

On the exceptional prescribing process—that process has a new name—does every board now give each patient and clinician the opportunity to attend its meetings together when individual cases are being discussed?

Several boards already do that, but the guidance will make it clear that where that is appropriate and desirable from the patient's point of view—I will not go into all the circumstances in which it might not be appropriate or desirable—they should have the opportunity to be present.

I want to ask about the swiftness of response, never mind the disappointment of it. I refer to the petitioner's experience. How quickly would you expect people at the health board level to respond under the new criteria and guidance?

To exceptional prescribing requests?

Yes.

It is quite difficult to set absolute rules and guidance on that. The guidance that we will publish will say that the timescales that are followed must be sensitive and responsive to the patient's clinical condition. I will not spell out different circumstances, but there will be many circumstances in which quick consideration of the request and a quick decision are essential. In other cases, things may not require to be as quick. We would always want speed to be balanced with proper and full consideration of the request in all cases.

Regardless of the speed that might be dictated by clinical circumstances, it is crucial that the patient or their family is kept fully informed at all steps of the process and that the process is fully explained to them. I have spoken to patients who have experience of the system, and I am sure that Tina McGeever can speak about it as well. Often, the problem is that people do not really understand the process that will lead to a monumental decision for them. To a large extent, the speed of the process will be dictated by clinical circumstances, but regardless of that speed the patient must be involved and the process must be explained to them every step of the way.

We understand that. Obviously, we wanted the timescales to be a bit firmer, but we understand the complexities that are involved.

If you find that health boards do not respond in any real sense to the broad criteria, how can you deal with that? How would you deal with a situation in which there had clearly not been enough attention to detail, if one arose again?

Any failure of a board in the area that we are discussing—or in any other for that matter—to comply with guidance and meet the standards that it is expected to meet would be taken up directly with it either by me or by my officials through the normal accountability and performance arrangements that are in place for boards. The guidance is not yet in place, but it will be shortly. We intend to give it a reasonable period of operation and then review its impact by asking boards to demonstrate what it has meant to their policies and patients' experiences.

Next, we want to explore funding, which is always the more challenging area for us all. We want to explore how individuals can economically deal with demands for access to drugs.

I have just joined the committee, but I understand from my reading that revised guidelines on co-funding have been issued to NHS boards. I want to ask about those guidelines, as co-funding is obviously a major issue. What response has there been to them? Are you monitoring whether they are being applied uniformly throughout Scotland?

That is an important question. The co-funding guidance that we published back in March will be evaluated in the fullness of time in the same way that the guidance that I have mentioned will be once it has had a reasonable period of operation.

The thrust of everything that we and, I think, the Public Petitions Committee are trying to do is to improve access to and the availability of drugs on the NHS. The success of the work that we are jointly pursuing will be judged on the extent to which patients are more able to access drugs on the NHS without any consideration of co-payment or co-funding. That is the guiding principle for me.

My view is that, if we are successful, a patient will have to consider co-funding only if in all honesty a drug cannot deliver the benefit for them that they perhaps think it can. That would be based on the opinion of the clinicians who have been involved in their care. However, clearly, there is patient choice. Patients should still be able to pay for treatment privately should they choose. The guidance has tried to put in place a framework and principles that say that, assuming that certain tests and conditions are met, a patient who chooses to fund a part of their treatment privately would not lose the entitlement to other aspects of NHS care that they would otherwise have. It is about fairness. That is the approach that we are trying to take.

Rhona Brankin asked how the guidance has been received. It is early days. It has been fairly well received so far by organisations such as the British Medical Association. We know that some patients have already taken advantage of it—it is already in operation—but we require to give it a bit more time before we can evaluate it. In the fullness of time, we will be able to draw firmer conclusions.

I am confident that the approach is right, but the more important focus is on all the other work that we are doing so that the instances in which people find themselves relying on the guidance are as few as possible.

Are you effectively saying that the scenario that Tina McGeever faced cannot happen again?

I do not want to go into all the particular circumstances of Tina's case, so I will generalise rather than talk about that particular case. I might be wrong about some of this but, as I understand it, in the past, some people who have opted to pay privately for a drug have found that the other aspects of their care also have to be funded privately. The guidance seeks to ensure that, assuming that important tests can be met, the patient does not lose entitlement to other aspects of NHS care just because they choose to pay for a particular portion of it privately. That is the important difference between the new guidance and what existed previously.

If the other changes that we are making, the effect of which is to improve the availability of drugs on the NHS, are successful, I hope that fewer people—not nobody, because we cannot say that—will have to make such decisions.

Apparently, the committee suggested in its report that some form of trial could be introduced whereby a board would agree to fund an initial trial of a drug to see whether it was clinically effective for the patient. Are such trials going on?

We have not introduced trials of that nature at individual board level; we have introduced a patient access scheme at national level, which I think is more equitable and will help ensure consistency, the lack of which the committee has rightly criticised in the past with regard to other aspects of this issue. The patient access scheme means that drugs that otherwise might not be approved because of a lack of assurance about their effectiveness are given a chance, through whatever the detail of the scheme is. We are doing that at national level rather than at board level.

So you would not see any opportunity for or advantage in doing that at board level?

My preference is for what we are doing through the patient access scheme but, on an issue as emotive and important as this, I will not close my mind to anything that can help improve the situation. We will keep all this under review, but my strong feeling is that it is more equitable to have these kinds of schemes introduced nationally rather than locally. When you do these things at local level, you are more likely to end up with the postcode prescribing scenario that the committee has rightly criticised in relation to other aspects of this issue.

One issue that came up in the evidence that we received and in our discussions was about collection of data from boards. Some practitioners felt that there is little or no data collection from the boards. Has there been any improvement in the information that comes from boards and which is gathered by the Scottish Government? In relation to cancer care or any other medical care that health boards deliver, the issues that we are discussing are predicated on gathering the information that is necessary to make correct assessments of how the care is delivered. I seek assurances from the Scottish Government that the data that were referred to in our report are being collated by health boards and passed to the Scottish Government to allow it to make correct assumptions about the delivery mechanisms.

That is a fairly big question. I will do my best to cover as much of the issue as I can verbally, but the committee might want to receive further information in writing. As I said, SMC recommendations are in effect binding on boards. We have no evidence that boards do not make available drugs that are recommended by the SMC, or the equivalent. We will always act on information that that is not happening. The committee has previously raised the issue of gathering information on exceptional prescribing. We are considering how we might do that in future when the new guidance is in place and boards have had an opportunity to implement it.

A range of work is under way on medicines utilisation, to use a shorthand name. The committee will be familiar with CEPAS, the chemotherapy prescribing and administration system, and C-PORT, the chemotherapy planning online resource tool. CEPAS networks all chemotherapy prescribing in Scotland and will in effect allow much greater information on what is being prescribed and to whom. That will go a long way to providing the information to which John Wilson refers. The hospital medicines utilisation database will provide an overview of prescribing activity across Scotland. Through those IT programmes, we are gathering more information than ever before, which will help to inform the picture of how well the measures that we are talking about today feed through to the patient. There is a range of information, and I am more than happy to provide it to the committee in writing.

I want to pull together some of the core questions, although I know that you will give us fuller responses in writing. The rarer cancers forum's report on exceptional prescribing was produced after some of the committee's discussions. Do you have any views on the funding issues that are raised in that report? Are any of its recommendations at all relevant to our discussions on the petition?

I assume that you are referring to funding in the more general sense, rather than co-funding. Funding will always be a challenging issue in the NHS. I say that in the context of NHS budgets that are rising. Next year's budget will be higher than this year's and this year's is higher than last year's. The nature of health care, particularly in relation to new drugs, means that NHS boards will always have to make difficult decisions. It is important that they have robust and transparent procedures in place for implementing SMC decisions so that they can take decisions and finance them in a managed way. I do not imagine that there is a health care system anywhere in the world in which the difficult issues of how to fund new technologies and drugs in a sustainable way are not a challenge. We are no different in that respect.

I think that you said that the deadline for comments on the draft guidance is the end of this week. I might have missed this earlier so, for my benefit, will you say when the committee will have a chance to look at the guidance?

We have asked for comments by Friday. If it is okay with the committee, we will take some time to distil the comments and to revise the draft guidance in line with them. I ask Colin Brown what a reasonable time would be. Would it be a couple of weeks?

Perhaps a bit longer.

In the near future.

Yes, in the near future. We will discuss the matter privately and come back to the committee with a more definitive timeline.

The timescale is not really the issue; it is good to have established the principle.

Before we conclude our discussion, I would just like to say that the partnership that the committee has developed with the Government, which we have seen not only in the debate in Parliament but in ministers' willingness to come before the committee and, I hope, respond with other specific details, has been very helpful. As the cabinet secretary made clear in her response to the rather deep questions arising from Tina McGeever's situation, the fundamental principle is to try to ensure that this situation is better for the couples or individuals involved than it was a year or a year and a half ago.

I am sure that you will put me back in order if what I suggest strays out of it, but would it, exceptionally, be in order for Tina McGeever to make one or two points to the cabinet secretary about what she has heard this afternoon?

This is where the committee clerk comes in.

According to standing orders, Tina McGeever cannot ask any questions. However, if it helps, she can make some general comments. To be fair, we have had very useful and constructive discussions previously and again today about what has been a very difficult case.

What I have heard today has been extremely positive and I look forward to seeing everything being put into place. I feel that we are beginning to get somewhere and that real, practical solutions are being found to many of the problems that are faced by people who are going through the same process that Michael went through. Thank you for that.

Tina has been fantastic in her ability to come forward even in the most difficult of circumstances. I should add that, on Saturday, she will participate in a major conference on understanding and influencing your Parliament. She has certainly been very positive about the relationship that we have had with her over this petition.

On behalf of the committee, I thank Tina McGeever for attending the meeting and the Deputy First Minister and Cabinet Secretary for Health and Wellbeing for the response that we have had. We will continue the partnership approach that we have developed, certainly with regard to this petition if not on the more contentious issues that lie ahead of us. It is a good example of the committee and ministers working together to find solutions to the problems that people have experienced.

I thank everyone for their time this afternoon.