Lung Disease
The final item of business today is a debate on motion S1M-1740, in the name of Michael Matheson, on lung disease in Scotland. It would be helpful if those members who wish to take part in the debate would indicate that now.
Motion debated,
That the Parliament notes the increased incidence of lung disease, in particular the rising number of women suffering from lung cancer; further notes the inconsistent way in which services are provided within the NHSiS for those who suffer from lung disease; recognises the need for greater research into lung disease in Scotland, much of which is presently funded by the British Lung Foundation; congratulates the British Lung Foundation on the work of its Breatheasy groups in providing support to those in local communities who suffer from lung disease, and acknowledges the need to give consideration to the formation of a national strategy to tackle lung disease in Scotland.
I begin by thanking the 36 or so members from all the main parties in the Parliament who took the time to support my motion. I also welcome representatives of the British Lung Foundation and of the Forth Valley Breathe Easy group, who have come to hear the debate and who have been instrumental in introducing the issue to the Parliament. They hope that the Parliament will address it.
When the late Princess of Wales was patron of the British Lung Foundation, she stated that breathing should be a pleasure, not a fight for life. However, 500,000 Scots are affected by lung disease. It touches all parts of society, from premature babies and children with asthma to employees with work-related lung disease and elderly people who suffer from emphysema and bronchitis. Every day, thousands of people in Scotland struggle with lung disease; it affects every aspect of their daily lives. Many members take for granted activities such as walking to the shop or car, or climbing the stairs in their home, but such so-called normal activities can leave thousands of Scots who have lung disease breathless and struggling to draw their next breath. The effect that lung disease can have upon an individual's quality of life is dramatic.
We have all experienced some type of breathing difficulty in our lives. Perhaps we have had a lung infection or an injury, or perhaps the wind has caught us and made our breathing difficult. It is only at such moments that we appreciate how much we value being able to breathe without great difficulty.
Although lung disease is predominantly a physical condition, we should in no way underestimate the psychological effect that it can have upon a sufferer. Alongside the physical limitations that I mentioned, loss of confidence and a feeling of isolation are common.
Scotland has a poor record on lung disease in comparison with many other European nations. If we include lung cancer in our definition of lung disease, Scotland's record is appalling. In some areas of Scotland, lung disease now kills more people than heart disease does.
In essence, lung cancer is an extreme form of lung disease and it is on the increase. Annually, about 4,500 people in Scotland are diagnosed with lung cancer. Of those diagnosed, fewer than 5 per cent will live longer than five years. Survival rates have shown little improvement in the past 20 or so years. If we compare the figures with those of other European countries, we see that the equivalent survival rate in other countries is in the region of 14 per cent.
Although I am sure that most of us would recognise that people survive longer in different countries for a variety of reasons, one of the most important factors is the ability to get access to the right treatment at the right time. One consultant from Falkirk royal infirmary highlighted to me the advances that have been made in the treatment of people who have lung cancer. Continuous hyperfractionated accelerated radiotherapy treatment—CHART—has been shown to improve considerably the survival rate among lung cancer sufferers. To date, the treatment is not available in Scotland, although it is readily available in many European and non-European countries.
I am sure that the minister will say that CHART can be considered within the Executive's proposed cancer plan, but given that the incidence of lung cancer in Scotland is so high and that it is coupled with a poor survival rate, why do we continually find ourselves trying to catch up with other European nations? Given our record, Scotland should, if anything, be at the forefront of developing new treatments and ensuring that they are implemented for those who suffer from lung cancer and other lung diseases in Scotland.
If we are to shake off our sick-man-of-Europe tag, we must recognise that lung cancer remains one of the most frequently diagnosed cancers among men in Scotland and that the rate of diagnosis among women is steadily increasing. Even the most recent statistics from the World Health Organisation show that our record is extremely poor in comparison with that of other countries. The latest figures show that the death rate for males per 100,000 is in the region of 94. In Ireland, the equivalent figure is about 53; in Finland, it is around 60; in England and Wales, it is around 74.
The number of women in Scotland who die from lung cancer is even more concerning. The figure has tripled over the past 20 years alone. In Scotland, in the region of 63 women per 100,000 head of population die from lung cancer. In France, the figure is as low as 13; in Ireland, it is 28; in England and Wales, it is 41. I hope that the minister will take on board how poor Scotland's record on tackling lung cancer is. We need to be at the forefront of eradicating it.
We should also recognise that there are considerable inequalities in the service that is provided across the country. For example, the provision of oxygen to people who suffer from a lung disease can vary from one pharmacist to the next. The deposit that needs to be put down for the cylinder can vary. Service can also vary from one health board area to the next.
General practitioners prescribe only a standard size for the gas bottles that are used for oxygen because the Government's drug tariff only allows them to do that. However, patients who are dependent on oxygen often find that they run short of oxygen early on. If they go on a day trip or on holiday, they need to take a large supply of oxygen with them. One solution suggested by the Forth Valley Breathe Easy group is the provision of liquid oxygen, which lasts much longer and allows patients to have a better quality of life. I hope that the minister will consider drug tariffs, to allow general practitioners to prescribe liquid oxygen, especially for patients who are heavily dependent on oxygen as a result of their condition.
From one hospital trust to the next, there are variations in the provision of nebulisers: some will provide them, some will not; some will charge, some will not. In addition, few trusts in Scotland provide respiratory nurses. Those nurses can often add significantly to the quality of life of someone with lung disease, bridging the gap between GPs, the hospital and the patient. Respiratory nurses can play an important role, not only in improving patients' quality of life but—through early intervention in the home—in reducing admissions to hospital. To its credit, Forth Valley Primary Care NHS Trust has been one of the leading trusts in achieving that. It employs several respiratory nurses. The resultant improvement in the health of the local community has been significant. It is disappointing that many other trusts across Scotland have failed to follow suit.
Given the extent of lung disease in Scotland and the considerable variation in the quality of care and service, I believe that we require a national respiratory disease strategy. That would assist in ensuring that respiratory medicine is given sufficient priority and would allow for a better quality of service across the country. If we are to tackle lung disease, a national strategy is required to ensure that we do so in a focused, determined, serious and concerted manner.
I congratulate my colleague Michael Matheson on securing a debate on lung disease in Scotland. As an asthma sufferer, I have a particular interest in this area of health. That interest has led to my becoming convener of the cross-party group on asthma and a member of the National Asthma Campaign advisory committee.
Asthma is one of a number of respiratory conditions that, taken together, account for a large proportion of illness and of health service activity. Besides asthma and other allergies, many people suffer from bronchitis, emphysema and work-related diseases. The global resurgence of tuberculosis is also worrying.
Half a million Scots, from babies to pensioners, are affected by lung disease. To put it another way, on average, one member of every family has a lung condition. A total of 300,000 Scots have asthma—19 per cent of boys and 16 per cent of girls. GP consultations for asthma among young people between the ages of five and 14 are second only to consultations for sore throats and colds—which are more correctly called upper respiratory tract infections. More than 100 people every year die of asthma. Studies have found that, of every 1,000 children, 133 are on bronchodilators, 47 are on inhaled steroids, and three are admitted to hospital each year.
Although different respiratory conditions have their own particular needs, many people face problems that are common to a variety of conditions. Treatments can overlap. There is much to be gained from the development of a health service strategy to address the treatment of respiratory conditions, both collectively and individually. We need to ensure that health professionals work together to avoid duplication of effort or facilities, thereby ensuring the greatest possible benefits for patients.
Among the shared problems that affect patients are the limited availability of nebulisers—already mentioned by Michael Matheson—and the limited capacity for assessment and training in their use. It is not just a question of delivering nebulisers; people need to understand how to use them and they need support in using them. Nebulisers can make a huge difference to patients' quality of life.
There are other areas where there is common ground. Those include the provision of outreach workers, respiratory nurses and asthma nurses, who can help families to self-manage asthma and who can help children to identify when an asthma attack might come on. They also include other aspects of community care, such as self-help initiatives and training for patients and relatives, to help them to understand the drugs and other treatment.
I am pleased to note that several organisations, including the National Asthma Campaign, the British Lung Foundation and Chest, Heart and Stroke Scotland, are working together to create a respiratory alliance to bring together major organisations that are active in the field. I ask the Deputy Minister for Health and Community Care to ensure that the Scottish health service matches that initiative by producing its own comprehensive strategy to guide the approach to respiratory conditions.
I congratulate Michael Matheson on bringing an important subject to the attention of members this evening. In addition to the welcomes that he extended, I point out that there are officers from the National Asthma Campaign in the gallery. I will focus on asthma partly because, like Cathy Peattie, I have an interest in the subject because I am a minor sufferer myself and one of my children is ill with it on occasion. Asthma strikes regardless of age or activity.
I agree whole-heartedly with my colleagues about the need for a national strategy. One of the early questions that I asked when I was elected to the Parliament was about information on asthma trends that is held centrally, because the incidence of the condition is increasing. I was shocked to hear from the Minister for Health and Community Care that no statistics are held centrally. How can policy be developed if the centre has no idea about the developing problem? I have since been assured by the Minister for Health and Community Care that steps are being taken, but I do not know what they are. Perhaps the Deputy Minister for Health and Community Care will tell us tonight. We must have a national strategy. It must not be over-burdening and bureaucratic; it must have focus, because of the number of people who are involved, their misery and the cost to them.
Cathy Peattie, who is the joint convener of the cross-party group in the Scottish Parliament on asthma, of which I am a vice-convener, highlighted a number of serious issues. I welcome the formation of the respiratory alliance, and the fact that it has supported a member of staff to work with the National Asthma Campaign to research variations in care in Scotland, which I am concerned about.
I used to be an oxygen supplier when I worked in community pharmacy. Michael Matheson highlighted the problems with the oxygen service, which is expensive and difficult to manage, but vital.
I am also concerned that the Arbuthnott changes to funding in the health service will deprive certain health boards—for example, my local one in Grampian—of the ability to develop services. The National Asthma Campaign is producing a report, which I gather will be published over the summer. It is vital that we take it on board, because it is a valuable piece of work.
Another subject that I have raised in the past is guidance for school staff on how to manage medicines of all varieties, but particularly medicines for asthmatic children. I conducted a survey of the education authorities in the north-east, and found that there was no common line. In some areas the guidance was good and in others it was patchy. Staff have said that it is vital that they are given adequate training so that they can act as a parent—that is what they are during the school day—and look after children and know their individual cases and requirements. I look forward to the Deputy Minister for Health and Community Care telling us how guidance for schools will be rolled out, because I am worried about the lack of attention that that has been given.
I appreciate that other members wish to speak, so I will conclude. From my former life as a community pharmacist, I know that asthma is a badly understood difficulty. Most families come across it only when somebody is in deep trouble, perhaps because of another condition. Asthma is misunderstood in many ways. It is vital, if we are talking about inclusion, to give children the proper control that will allow them to participate in the things that young people want to do—for example, sport—and to ensure that they are screened early. In Scotland, not enough screening for respiratory conditions is done at an early age.
I, too, congratulate Michael Matheson on giving us the opportunity to debate this important subject. I fully support his motion and I pay tribute to the excellent work of the British Lung Foundation and its local organisation, Breathe Easy Forth Valley, which covers my constituency. Mr Henry McPake, chairperson of Breathe Easy Forth Valley, wrote to me earlier this year to request more Government or Executive funding for research into lung disease and for treatment of those who are affected by lung disease. Lung disease is the second biggest killer in this country and it affects the whole age range of the population, from childhood asthma to many lung diseases of later life, some of which are occupational.
Today, I received a message from the National Asthma Campaign Scotland, asking for support for a national strategy to tackle respiratory disease and for more research and higher standards of care throughout the country. Asthma affects more than 300,000 people in Scotland and was responsible for more than 120 deaths in 1998. About one in six Scottish children aged from two to 15 has asthma, and a recent international study of 12 countries showed that Scotland has the highest prevalence of children reporting asthma symptoms in the past 12 months. The Scottish Executive must take action to ensure that more research takes place and that better standards of care are provided for people who suffer from asthma and other lung problems.
We are relatively fortunate in the Falkirk area, because Falkirk royal infirmary has a pulmonary rehabilitation course for people who have lung disease. Three whole-time equivalent nursing posts were attached to the respiratory services and associated outreach services at Falkirk royal infirmary, but one post was recently withdrawn. Following complaints, I wrote to the Deputy Minister for Health and Community Care, and I was pleased to hear from him in a recent letter—which, coincidentally or otherwise, I received only today—that funding for another permanent full-time outreach nurse will be secured by the end of this month. I thank the deputy minister for that.
In an earlier reply to me, the deputy minister referred to a detailed change programme that would be announced later this year. Will he give details of that in his summing-up? I would also be grateful to hear what further funding will be available for research and treatment. In the long term, that could save money, because it would mean less hospitalisation. That makes good economic sense as well as good health sense.
Some lung diseases—I emphasise not all—are smoking-related. The UK Government has not yet named a date for introducing a bill to ban tobacco advertising. Will the Scottish Executive therefore set a good example by introducing now a bill to ban tobacco advertising? I have no doubt that such a ban would help to reduce the incidence of some forms of lung disease, including lung cancer. It would therefore help to save lives. The Scottish Executive must face up to its responsibilities.
I, too, warmly welcome the debate and I congratulate my colleague Michael Matheson on securing it.
Lung disorders are a major cause of suffering, pain and death in Scotland and around the world. However, the scale of the problem is grossly under-recognised. Lung disease affects people of all ages, but lung damage in the very young might have long-term consequences and lead to serious lung disease in later life.
Many diseases can affect the lungs, such as asthma, bronchitis and emphysema. They are collectively known as chronic obstructive pulmonary disease—COPD. As the research paper that was provided by the Scottish Parliament information centre shows, mortality from COPD has increased in Scotland from 2,381 in 1981 to an alarming 9,581 in 1999. In the past 19 years, 120,248 people have died from such diseases—three quarters of which deaths were caused by tobacco use.
Those diseases share common symptoms such as coughs, wheezing and breathlessness. For people who suffer from lung disorders, a major issue is access to smoke-free air and smoke-free public areas. Experts agree that the main indoor air pollutant is cigarette smoke. According to the UK's independent Scientific Committee on Tobacco and Health, environmental tobacco smoke—also known as passive smoking—is a cause of lung cancer and childhood respiratory disease. It makes respiratory conditions much worse. Indeed, the impact of other people's cigarette smoke on people who have asthma is immediate. Cigarette smoke is a highly common trigger of asthma attacks and it causes difficulties for up to 80 per cent of people who have asthma.
Young children are particularly at risk from tobacco smoke. Exposure to passive smoking increases dramatically the risk of cot death, acute and chronic middle-ear disease, asthma and impairment of lung function. Up to 50 children a day, or over 17,000 each year, are admitted to UK hospitals because of the effects of other people's cigarette smoke. In Scotland, the figure is five children a day or almost 2,000 children each year.
In 1999, the World Health Organisation stated that passive smoking was a real and substantial threat to child health. The Froggart report, published in 1998, attributed 300 lung cancer deaths each year to passive smoking. The death rate for Scottish women from lung cancer is five times the rate in France, partly because of passive smoking. The General Register Officer for Scotland, in evidence that was published in the British Medical Journal in 1997, estimated that passive smoking leads to a 26 per cent greater risk of contracting lung cancer.
What is the Executive doing to help and support people who have lung disorders in their daily lives, or to prevent young people from being exposed to passive smoking from an early age? I regret to say that it is doing very little. Vulnerable groups of people who suffer from lung conditions are discriminated against. A lack of smoke-free public places means that they do not have smoke-free access to shops, restaurants or cafes. That restricts their basic freedom of movement.
A national survey that was undertaken last year by Action on Smoking and Health (Scotland) and the Health Education Board for Scotland exposed the lack of policies on smoking throughout the leisure industry. It was revealed that more than half of the establishments that were surveyed, including shops, cafes and community centres, did not have any form of smoking policy in place. A shocking 58 per cent of businesses allowed members of their staff and the public to smoke on their premises.
In areas of deprivation the figures were far worse, with 92 per cent of pubs and bars allowing the public to smoke throughout their premises. The Executive's failure to implement policies to restrict smoking means that the general public and, in particular, vulnerable groups such as children are not adequately protected from the health risks of passive smoking. Since the survey was undertaken, the Scottish Executive has introduced a voluntary charter on smoking in public places, which is welcome. A year on, however—albeit that it was a step in the right direction—the voluntary approach is proving to be woefully inadequate, because it is failing to protect public health.
We must introduce, as a matter of urgency, legislation to restrict smoking in public places. Passive smoking is a major public health risk, especially for vulnerable groups such as lung-disease patients and children. We need a national public information campaign on the risks of passive smoking to educate and inform the public and to support those in our society who are discriminated against and who suffer the burden of respiratory disease.
I commend Michael Matheson's motion and the work of the British Lung Foundation's Breathe Easy clubs, ASH Scotland and the other groups in the Scottish cancer coalition on tobacco. I also commend all those who are fighting for clean air and an effective national strategy on lung disease.
I declare that I undertake occasional work with Astra-Zeneca, a company that has some interests in respiratory health.
I join others in congratulating Michael Matheson for securing the debate. There are about 4,600 new lung cancer registrations every year. As Michael Matheson said, it is poor indeed that the five-year survival rate continues to represent about 6 per cent of cases. In addition to concerns about the numbers that are diagnosed and the five-year survival rate, the other concern is that the median survival rate is only three months. Those figures show the poor outcome from lung cancer disease.
In the past 20 years, the incidence of women who are diagnosed as having cancer has doubled. The rising trend of smoking, especially in young women, is storing up problems for the future. The tobacco industry is more than happy to replace women who die from lung cancer with new recruits. I hope that ministers will continue to press their UK counterparts to reintroduce the bill to ban tobacco advertising. If that happens, I also hope that it will not be blocked by the Conservative Opposition or by the House of Lords.
We need an effective care pathway that is based on grade A evidence, because that would more than double the five-year survival rates to around 14 per cent. It is suggested that if that happened, at least 300 lives would be saved each year. That would involve 100 additional, timely operations, 600 additional courses of radiotherapy, the introduction of CHART—the particularly intensive form of radiotherapy that produces the best results, to which Michael Matheson referred earlier—and 400 additional chemotherapy courses. To achieve that, the Clinical Standards Board for Scotland must not only comment on the standards, but report on the specific resources that are needed, so that those needs can be addressed.
It is a matter of concern that the Health and Community Care Committee, in consideration of the budget for last year and on examination of the health improvement plans, found that only £1 million of new money could be identified as going into cancer. At that rate, and unless the new cancer plan is costed quickly and implemented, it is unlikely that we will make improvements. We need earlier presentation and we need to deal with the bottlenecks—especially in radiology—and ensure that the managed clinical networks that are beginning to be set up are properly implemented, with good care pathways. In other words, we need an improved cancer journey.
On asthma, passive smoking—as one of the main triggers of asthma—must be tackled. Although there is no doubt that there has been a substantial improvement in asthma care over the past 10 years, many people still die of asthma. Best practice must be implemented in all areas. That can best be done through the local health care co-operatives which, through their programme of clinical governance, must ensure that the primary care teams throughout the country respond by improving practice.
I commend the fast access respiratory clinic that was set up in Falkirk, in the Forth Valley area that covers my constituency. That was based, entirely appropriately, on previous research that demonstrated that such a facility would reduce emergency admissions by some 18 per cent. That is the sort of one-stop clinic that the Executive has been promoting. However, I wonder why it is taking so long to introduce such measures. Surely such best practice should be rolled out more quickly throughout the country.
Finally, the role of occupational health must be examined closely. Scotland's Health at Work, under the chairmanship of Andrew Cubie, is beginning to make an impact on what is done in employment situations. However, when we hear that 58 per cent of employers still do not have a no-smoking policy in place, we realise that we still have a long way to go. We must start getting there.
I congratulate Michael Matheson on securing a debate on this important subject. Lung disease represents one of the major elements of the care that is provided by the NHS in Scotland. For example, worsening of chronic obstructive pulmonary disease—COPD—as we now call what used to be known as chronic bronchitis and emphysema, is the commonest cause of admission to hospital. A quarter of all medical emergency admissions are because of respiratory diseases.
The Executive greatly appreciates the work of the British Lung Foundation in Scotland. The foundation's 16 Breathe Easy groups across Scotland do excellent work in offering information and support to those who suffer from lung conditions, as well as to their families, friends and carers. They also help health professionals. The groups' involvement with health boards has encouraged initiatives such as the introduction of respiratory nurses in GPs' surgeries.
The motion mentions in particular lung cancer in women, as did Richard Simpson. That is an issue of serious concern. About 1,900 cases in women are diagnosed every year. Unfortunately, the incidence of lung cancer in women looks set to go on rising over the next 10 years.
"Scotland's Cancer Strategy", which is due to be published soon, sets out the Executive's key messages for improving cancer prevention and for the detection and treatment of cancer. Lung cancer will feature prominently in that national strategy. The Clinical Standards Board is developing standards for lung cancer, based on the relevant guideline produced by the Scottish intercollegiate guidelines network—SIGN.
The gloomy outlook for women and lung cancer is due in large measure to smoking patterns. Smoking is the greatest single cause of preventable disease and ill health in Scotland. It is responsible for about 84 per cent of lung cancer deaths; in some areas, the figure is as high as 90 per cent. We shall do everything we can to reduce the toll smoking takes on the nation's health. That applies to all respiratory diseases and lung conditions, not just lung cancer.
The Executive is already introducing a comprehensive range of measures to reduce smoking levels. I assure Richard Simpson that we have made the strongest possible representations to the UK Government about introducing the tobacco advertising ban that the Health and Community Care Committee recently agreed could be imposed most effectively on a UK basis.
Michael Matheson referred specifically to CHART. I tell him that £13 million has already been made available for linear accelerators. That will mean that, in time, treatments such as CHART can be planned for. More will be said about that in the cancer strategy.
The motion also refers to research. The Executive fully appreciates the valuable contribution that charitable bodies such as the British Lung Foundation make towards funding research. I am happy to endorse what the motion says on that score. The chief scientist's office, which is the body within the health department that is responsible for sponsoring research, has funded 36 research projects related to lung disease. Its total investment in that work is £3.5 million.
There is some good news in relation to specific lung diseases. On flu and pneumonia, we are encouraging vaccination for older people, with considerable success. On cystic fibrosis, the high quality of services that are provided for both children and adults has been recognised by the Cystic Fibrosis Trust. On chronic obstructive pulmonary disease, clinicians in Scotland have promoted a successful initiative, called the acute respiratory assessment services, which helps people with severe exacerbations of COPD. Michael Matheson, who referred to specialist nurses, will note that that initiative is a nurse-led, hospital-at-home service. Last year, it helped to avoid 120 hospital admissions to Edinburgh royal infirmary alone.
Cathy Peattie, David Davidson, Dennis Canavan and Richard Simpson referred to asthma. It is encouraging that the use of anti-asthma drugs has been rising. At least some of the credit for that must lie with the SIGN guideline on the management of asthma in primary care. All the guidelines are produced nationally, but they are intended to be implemented locally. I agree that we want uniformly high services across the country. "Our National Health: A plan for action, a plan for change" has as its fundamental aim the delivery of health service that is truly national, with consistent standards across the country as a whole. The SIGN guidelines are an integral part of that process.
The Clinical Standards Board for Scotland, too, can help. If the clinicians who are responsible for the management of lung disease could produce a set of core standards, which should apply no matter where in the country the treatment is delivered, the Clinical Standards Board could consider them. The board would want to ensure that the standards were in line with its ethos, which is about fully involving the public in the process. I remind members that the Clinical Standards Board is already working on cancer treatments.
David Davidson asked about guidance on the management of asthma in schools. The intention is that such guidance should be issued by the middle of August, in time for the start of the autumn term. It will have recommendations on raising the awareness of school staff about common conditions such as asthma. It will also provide guidance on more specific training for school staff who volunteer to administer medication to children, including children with asthma.
Does the minister agree that it is important that children are allowed to carry their own inhalers and take responsibility for self-management of their asthma? For too long, inhalers have been held by nurses, but a young asthmatic child in the middle of a playing field may be scared to run if they do not have their inhaler with them.
I bow to Cathy Peattie's superior knowledge in that regard.
For several years, the health department has given grant support to the National Asthma Campaign Scotland towards its work in supporting and promoting the interests of people with asthma. In the current financial year, the campaign has been awarded a grant of £57,000.
On chronic diseases generally, "Our National Health: A plan for action, a plan for change" commits the Executive to work with NHS Scotland and voluntary bodies, such as the British Lung Foundation, to improve services for people with chronic conditions such as asthma and bronchitis. That will provide an opportunity to examine the assertion in the motion that services are provided inconsistently across Scotland. I understand why there is a wish to raise the profile of those conditions through the development of a national strategy. I agree that we must all work together to tackle lung disease and reduce the suffering and misery that such conditions cause to all too many people in Scotland. As the action and investment outlined earlier testify, the Executive is committed to making a difference, but it is not a question just of money and organisation—it is also about the choices that people make about how to live their lives and the support that we give them in making those choices.
Meeting closed at 17:40.