Meeting date: Tuesday, February 21, 2017
Meeting of the Parliament 21 February 2017
Agenda: Time for Reflection, Business Motion, National Review of Maternity and Neonatal Services, Business and the Economy (Support), Scottish Rate Resolution, Scottish Fiscal Commission (Appointments), Business Motion, Decision Time, LGBT History Month Scotland 2017
- Time for Reflection
- Business Motion
- National Review of Maternity and Neonatal Services
- Business and the Economy (Support)
- Scottish Rate Resolution
- Scottish Fiscal Commission (Appointments)
- Business Motion
- Decision Time
- LGBT History Month Scotland 2017
National Review of Maternity and Neonatal Services
The next item of business is a statement by Aileen Campbell on the national review of maternity and neonatal services. The minister will take questions at the end of her statement, so there should be no interruptions.14:05
I am pleased to update Parliament on our response to the publication of the report of our review of maternity and neonatal services.
Every day, our maternity services deliver an excellent service to families across Scotland. In our maternity care experience survey, women reported over 90 per cent satisfaction with the care that they had received. We also continue to reduce rates of maternal mortality, stillbirth and neonatal mortality in Scotland to record low levels. The number of neonatal deaths has reduced by 40 per cent since 2007, which means that, in 2015, 76 more babies’ lives were saved by the high-quality care that was provided by staff in neonatal units across Scotland. It also means that there were 76 fewer bereaved families. That improvement is a testament to the hard work of the staff who look after sick babies in Scotland.
Our maternity system secures high satisfaction ratings among women and continues to improve care and outcomes for the sickest babies. We are in a position of strength, but we are not complacent and know that there is much that we can do to make further improvements. That desire to improve and transform in part inspired the review. The report is a landmark publication that represents a major opportunity to improve services even further, and its recommendations will transform service delivery in Scotland.
For example, some women currently experience no continuity of maternity care and can see numerous different midwives and obstetricians throughout their care journey. That is not what women or staff want, and evidence tells us that it is not good for care. To give women and staff what they tell us they want—which the report describes as family-centred care—will require a radical shift in how we deliver care. There is no doubt that such change will be challenging to deliver and, for many of our midwives and obstetricians, will represent a significant change in ways of working, but it will ensure better care.
This important review, with its far-reaching and considered recommendations, is down to the leadership of the chair, Jane Grant, and the work of the members of the review group, and I place on record my thanks to them for carrying out the commission. Their hard work and commitment have produced a report that is based on evidence and grounded in the views of the families who use the services and the staff who deliver them. The breadth of engagement that was undertaken by the review team, which was supported by the Scottish health council, was truly impressive and I welcome a report that is so strongly anchored in the views of the hundreds of service users and staff across Scotland who contributed.
I will outline the next steps on implementation and highlight some of the key principles and recommendations in the report.
It is my pleasure to announce that Jane Grant has agreed to chair the implementation of the review’s recommendations. It was Jane’s drive, commitment and inclusive approach that produced such a well-researched and thorough report. As an experienced national health service chief executive, she is the right person to chair the major programme of implementation that we will now embark on. Over the coming weeks, Jane will appoint the implementation group to drive forward delivery of the recommendations. Chaired by Jane, the group will be tasked with progressing quickly with the priority recommendations and providing a detailed plan and timetable for implementation over the five-year delivery period that is envisaged. I will ask the group to get under way quickly and to report back to me at regular intervals on its progress.
It will take time to implement all 76 recommendations, but they are important. I will highlight a few of them. First, there is a need for continuity of care. The report highlights at length the importance that women and families attach to forming a relationship with the professionals who care for them and having continuity. As the report acknowledges, the recommendation challenges traditional NHS approaches. It recommends identifying a number of early adopter boards to lead the change in practice, which are to be supported by proper training and development for staff who require it. I am pleased that a number of boards have already volunteered to do that. We will announce shortly which boards will lead the first phase of implementation, and we will work carefully with boards to scope out the scale of the task and ensure that the early adopter boards can properly test the challenges of implementation.
Secondly, I want to move quickly with the proposals to implement the range of recommendations on person-centred maternity and neonatal care that are aimed at keeping families together. Those include recommendations to keep mothers and babies together, to involve parents more in the delivery of care and to provide accommodation and a national approach to expenses for families with babies in neonatal care. I underline how important it is that families stay together. No mother wants to be separated from her new baby even for a very short time, and we should never underestimate the importance of the early days of life for family bonding, breastfeeding and attachment. I want that to be a core feature of our services in the future. I will ask the implementation group to prioritise those recommendations.
Thirdly, there is the redesign of maternity services with a focus on local care and multidisciplinary community hubs. We all know that women want care to be delivered as close to home as possible. Again, I would like boards to move quickly on the assessment of the potential for hubs in their local areas to allow local delivery of the majority of maternity care as soon as possible.
Finally, there is the model of neonatal care. The model that is described in the report aims to reduce the number of babies who need to spend time in neonatal units by keeping mothers and babies together in postnatal wards with in-reach support from neonatal staff and by putting in place wraparound community support to allow babies to be cared for at home by their parents sooner than they can be currently.
All 15 neonatal units will remain and continue to care for babies in their areas. The clinical evidence shows that the outcomes for the very smallest and the very sickest babies will be better if they are cared for in up to five enhanced neonatal units delivering highly specialist care, moving to three such units in the longer term if possible, based on the experience of operating in up to five.
The new model is based on evidence and emerging good practice from Scotland and the rest of the world, and I want the implementation group to outline clear plans to allow the neonatal community to make progress quickly with the implementation of those recommendations. Again, that will be a priority for the implementation group.
I have already outlined the strength of the engagement with women, families and staff in NHS boards that underpins the report. I want that partnership and co-production for delivery to be a core feature of implementation. I am sure that we all agree that solutions that are developed in partnership will have far more chance of success and sustainability. They will also require time and space to ensure that the beginnings of the transformational shift are right. That is why I will continue to keep Parliament and spokespeople informed of progress, particularly on neonatal units and pathfinders.
Proceeding on the basis of co-production and partnership will take care and time. Although the report has been warmly received across Scotland and discussions are already under way with the NHS community about the recommendations, implementation will be challenging and complex. I will request the chair of the implementation group to build partnership into delivery from the start and I am prepared to give the implementation group the time to do that properly. Similarly, I am keen to work in partnership across the chamber on this.
Although much of what is in the report is about the redeployment of existing resource, it is also clear that some of the recommendations will need investment to deliver. All boards are at different starting points in terms of delivery, and we will work closely with them, learning lessons from early adopters and existing good practice to quantify what additional resource will be required. In many cases, it is hoped that this investment will realise savings over time, although improved outcomes for women and babies is ultimately the real prize.
Finally, I will ask the implementation group to instigate a detailed piece of work on staffing. The review was firmly grounded in the views of staff, and the review report describes some of the challenges that they face. Those have also been reflected in recent reports by Bliss Scotland and the Royal College of Midwives. I will ask the implementation group to undertake some early modelling work with NHS boards so that we can get a better understanding of the workforce changes that are required to take forward the package of recommendations. That work will align with the workforce strategy.
The shift in care that the report describes sits within the overarching strategic context of our reform agenda for health and care services, as outlined in the national clinical strategy and “Realistic Medicine”, the chief medical officer’s annual report for 2014-15, and tackling inequalities.
The Royal College of Midwives described the report as having
“the potential to revolutionise maternity care, to delivery safer and better services for women, babies and their families”,
and Bliss Scotland described it as
“an ambitious and progressive vision for family-centred care and good news for the future of Scottish neonatal services”.
The report makes a clear case for change in our maternity and neonatal services and its recommendations and aims are supported by professionals, practitioners and, importantly, parents. Our aim is to make Scotland the best place to grow up, and that journey starts with excellent maternity care and giving all babies the very best start in life. Our job now is to implement the recommendations strategically and to take the time needed to ensure that this unique opportunity to transform the way that services are delivered makes good on our ambitions and visions.
I welcome questions on this statement.
Thank you, minister. I urge members who wish to ask questions and have not pressed their request-to-speak buttons to do so.
I thank the minister for early sight of her statement. Conservative members welcome the report and the general principles and recommendations that it contains, and the consensual approach that the minister has professed.
We agree that mothers who are having a normal delivery should, where possible, have access to local or community-based maternity services. However, it is clear that there are still issues that the statement did not address. Let me name two. First, we are concerned about the reduction in intensive care units, with the current eight units being reduced to between three and five, and ultimately to three by the end of the current session of Parliament.
Secondly, there are still major issues with staffing, which the minister brushed over in her statement. When the Royal College of Midwives commented after the report was published, it outlined its concerns about retirement, saying that heads of midwifery are getting nearly double the number of retirements that they used to get. It also spoke of general recruitment issues, particularly in the Highlands and Grampian.
The report states:
“All women should have an appropriate level of choice in relation to place of birth and there are a number of choices that should be available to all women in Scotland including birth at home, birth in an alongside or freestanding midwifery unit, and hospital birth.”
To that end, what action will the minister take to ensure that all women in Scotland have that choice? Will the Government support provision of such services in rural and remote areas?
I thank Donald Cameron for his series of questions, and for what he said about being eager and keen to work consensually to deliver on the report’s recommendations.
On Donald Cameron’s point about neonatal provision and his concerns about what he described as a “reduction”, there will always continue to be 15 neonatal units across the country. We are talking in the report about ensuring that we have the clinically specialised care that will allow us to deliver better outcomes for the sickest babies. That is where careful planning will be required, with progression to enhance care for those babies. I am talking about only a small proportion of the babies that are born in Scotland, but that is why it is important that we deliver that specialised care. As we do that, we will take care to work with clinicians, parents and professionals, and we will ensure that co-production and collaboration allow us to proceed based on consensus. As I said in my statement, I will continue to ensure that, as that develops, we keep Parliament informed of any moves.
On the workforce, there is no doubt that what is suggested represents a fundamental shift in the way in which people will be required to work, but it is also important to recognise that that was a key message about what professionals want in engagement with them. That is how they want to deliver maternity services across the country. It is important that we recognise that we have in place a workforce strategy and good numbers of midwives in our NHS. We will continue to work with professionals to ensure that we can develop and improve on the current situation, which is based on a position of strength, and we will work with staff as best we can in delivering on the recommendations.
On the need to ensure that we deliver for women in rural areas—I think that that was the last point that Donald Cameron raised—we want, of course, to ensure that women have appropriate choice, which is part and parcel of the report’s recommendations. We must remodel existing care structures to deliver for women and give them appropriate choice, but we must also recognise that, in some cases, more specialism will be required, and that a bit more will be required to be done in order to work out where those specialisms will be delivered. That is the basis on which the neonatal recommendations are being taken forward.
Much of the work will be delivered by the implementation group. It will be done at an appropriate pace so that we can deliver good outcomes for women and babies.
I thank the minister for prior sight of the statement. It is important to look at the report alongside “Bliss Scotland baby report 2017”, because it is clear that the Government’s failure to do workforce planning has left our maternity and neonatal units understaffed, and existing staff overworked. The Bliss Scotland report found that three quarters of units do not have enough nurses, that two thirds do not have enough medical staff to meet minimum standards of care, and that more than half do not have enough overnight accommodation for parents of critically ill babies. When will the Government publish a detailed workforce plan? How many additional staff will be provided and by when? When will all the units meet national standards for high-quality care?
The report recommends the removal of intensive care cots from 10 units over the next five years. Which 10 units will lose their intensive care cots and what impact will that have on travel times and on keeping families together? The report also makes clear the desire to keep mothers and babies together. What additional capacity will be created for free accommodation for parents of critically ill babies?
Lastly, the report says that
“All women should have an appropriate level of choice”
on where to deliver. Does the minister accept that the proposals to close the maternity units at the Vale of Leven hospital and at Inverclyde royal hospital are ill thought through? Will she call in the proposals and reject them?
Anas Sarwar fails to recognise that we in Scotland have a good record on delivering maternity services. Although there are challenges, as outlined in the report, there are things of which we should be proud. We have an innovative midwifery workload and workforce planning tool, which is a first in the United Kingdom. That has helped to ensure that the NHS in Scotland continues to meet the RCM recommended midwife to birth ratio—unlike other parts of the UK, about which the RCM makes it clear that there is a shortage of midwives. In Scotland, we are leading in delivering for women around the country.
Keeping babies and parents together is why we want to transform delivery of maternity services. We want to ensure that women are kept alongside their babies, because we know how important that is for bonding, for attachment, for breastfeeding and for a host of positive outcomes for the sickest babies.
The recommendations for reducing the number of specialist neonatal care services around the country from five to three is based on clinical evidence about what works for a very small proportion of babies. We are doing all that we can to ensure that we have good outcomes for those sick babies, and we are taking the recommendations forward at comfortable pace and scale in order to ensure that we transform how care is given and improve outcomes for babies. We need to unite behind that. What we do has to be based on clinical evidence that tells us what is best for the babies around our country.
As I said in my statement, we will look at accommodation and transport to ensure that people who live in rural areas are able to access specialist care in a way that is comfortable for them and which does not cause unnecessary stresses and strains. We know that stresses and strains have happened in the past and we want to eliminate that to ensure that every mother gets the very best care and that every child gets the best start in life.
I remind members that I am the parliamentary liaison officer to the Cabinet Secretary for Health and Sport. Can the minister outline what the expected patient-care benefits are for the recommendation that every woman who uses maternity services should have a primary midwife?
The recommendation aims to ensure that there is continuity of care for women during their maternity journey. People want to develop relationships, they want familiarity and they want to be informed. The process has been developed through deep engagement with mothers, mothers-to-be and professionals, and there has been a meeting of minds. The people who deliver maternity services want to create the service in that way; they want to ensure that they build relationships with mothers who are in their care.
The potential to transform how maternity services are delivered in Scotland is great, and we have a unique opportunity to build on the recommendations in the report, to transform the way in which maternity services are delivered and to ensure that we embed co-production, partnership and empowering of women and deliver what they want.
I welcome the fact that the review calls on all NHS boards to review their current access to perinatal mental health services to ensure that early and equitable access to high-quality services is available with a clear referral pathway. NHS boards have difficulties in recruiting trained psychological staff, so what more can the Scottish Government do to ensure that perinatal mental health services are appropriately staffed so that mothers who need the services and who would benefit from early intervention are not kept waiting for months for that support?
I acknowledge Miles Briggs’s real and long-lasting interest in that issue and more generally in mental health. I know that he hosted a conference yesterday. I would be very pleased to hear some of the outcomes from that conference, if he wishes to share them.
The Minister for Mental Health, Maureen Watt, has announced a managed clinical network that will focus on perinatal mental health. We are, of course, also taking forward the mental health strategy, which will dovetail into the work on improvements for maternity and neonatal services. We have a host of other ways in which we provide support for more vulnerable people, including the family nurse partnership programme, which engages deeply with potentially vulnerable young first-time mothers, and teenage mothers. We are rolling that out across the country.
There is currently a range of services, but we accept, of course, that challenges exist. That is why the Minister for Mental Health made the MCN announcement and why we are taking forward the mental health strategy. Together, we will make improvements for mothers’ mental health issues because of the recognition in the report that we have to make vast improvements in that area.
I refer members to my register of interests. I am a registered mental health nurse and am currently registered with the Nursing and Midwifery Council.
It is important to thank all those who work in our NHS. They do a fantastic job and provide an excellent maternal and neonatal service.
I welcome the minister’s update, but will she expand further on any development and training opportunities as a result of the review? Can she confirm that she will work with NHS boards to examine staffing implications?
Yes—absolutely. That reflects that a shift in the traditional norms of delivering maternity services throughout the country will be required. There has been engagement with NHS staff, and that responds to what they told those who were involved in the review. There will be implications for the workforce. Remodelling will be required and training will also be required to ensure that we have the correct and appropriate services in place to deliver for mothers who are about to use maternity services throughout the country.
Clare Haughey is absolutely correct to recognise the hard work and endeavour of staff throughout our country. We are in a position of strength in how we deliver maternity services in Scotland, but we want to build on that and improve those services further.
At this time last year, before the Scottish Parliament election, the Scottish National Party accused me of scaremongering when I spoke about the closure of the Vale of Leven maternity unit. Immediately after the election, the proposals, which had been denied, were published.
I very much welcome the minister’s commitment to delivering maternity services closer to home, but is she aware that NHS Greater Glasgow and Clyde has kicked the formal consultation into the long grass and—surprise, surprise—will not consider it until after the election? I am sure that the minister will view that as a deeply cynical move. Therefore, will she today put an end to that nonsense and commit to the continuation of the full maternity unit at the Vale of Leven hospital for the remainder of the session?
The member mentioned the Vale of Leven hospital. As yet, there are no firm proposals from NHS Greater Glasgow and Clyde on the future of the units at the Vale of Leven hospital. I understand that boards are currently considering the recommendations in light of the review as published.
The report suggests that it is important to maximise the potential of community maternity units, that boards should undertake an assessment of their viability
“against an agreed national framework to ensure consistency”
and that that should involve local service users so that their needs can be balanced with the need to maximise the use of resources. We expect boards to take cognisance of the report.
I gently point out to Jackie Baillie that the Vale of Leven hospital is there because of the Government’s work to ensure its future. The uncomfortable truth for Jackie Baillie is that her Administration was prepared to close it. [Interruption.] Jackie Baillie might say that that is boring. She and her colleagues are shouting at us about 10 years. It is a fact that the Vale of Leven hospital would have been shut for 10 years if her party had been brought back to power. The Government took decisive action and gave the Vale of Leven hospital a bright future.
Many aspirations in the report deserve support, especially the emphasis on local care. On delivering local care, will the minister commit to supporting our more rural neonatal units and maternity services, such as the excellent service at Dr Gray’s hospital in Elgin?
Will the minister acknowledge that, in order to maintain those services, the current pressures have to be addressed by health boards in terms of workforce planning and resources? That is particularly so, given that, in more rural units, a vacancy for a consultant or a midwife can have a disproportionate impact, and that it is not always in the interests of mums and babies to have to travel long distances for clinical and practical resource reasons.
Richard Lochhead is correct to point out the importance of workforce planning. That is why we will enshrine safe staffing in law by putting our workforce planning tools on a statutory footing. He is also correct to point out the importance of rural services, which are covered in another key element of the report in which mothers and families have told us how important they feel it is to have services delivered as close to home as they possibly can be.
Of course, that raises challenges where there is a requirement for specialist interventions. I reiterate that the review attaches great importance to rural services across our country. It signifies a transformation in the way that services will be delivered, and we will continue to work with health boards, patients, mothers and maternity services users across the country to make sure that the key principle of ensuring that those services can be delivered close to home is the way in which we proceed as we implement the recommendations.
I thank the minister for advance sight of her statement. The statement says that the outcomes for
“the very sickest babies will be better if they are cared for in up to five enhanced neonatal units delivering highly specialist care, moving to three such units in the longer term if possible”.
What would trigger such a move? If there are fewer units, that will necessitate more transport. To what extent has the ScotSTAR paediatric retrieval service been involved in the review process, and what work is planned to ensure that we have sufficient capacity in our neonatal transport services?
ScotSTAR will absolutely be involved in the process of recognising the greater requirements that we have made of transportation services as we work through the recommendations around neonatal units. As I said in my statement, I will keep Parliament abreast of progress around the neonatal recommendations. We have to do that in a managed way, as is recognised in the report. The first step is to make the move up to five units, which will require careful planning and capacity building in some units. The move to three units will be considered over a much longer timescale and will be informed by the experience of moving to those initial five units. Of course, that will also be influenced by the recommendations and aspirations that are set out in our national care standards.
I thank the minister for advance sight of her statement. Given that one in five new mothers experiences mental health difficulties as a result of pregnancy and childbirth, I very much welcome the minister’s comments in response to Miles Briggs earlier.
In Scotland today, only five health boards have specialist community perinatal mental health teams. Will the minister outline practical steps that her Government will take to expand that provision across other health boards and to equip maternity ward staff and neonatal staff with the tools to identify early-onset mental health issues when they first appear?
The importance of good maternal mental health is a main feature of the report as published. Again, that recognition was a motivator in the Minister for Mental Health publishing a strategy for developing an MCN and committing to rolling out best practice across the country. We recognise that challenges persist around mental health for mothers, and mental health more generally, which is why the Minister for Mental Health will publish her strategy very soon. However, again, the point that Alex Cole-Hamilton makes is a good one, and we will take cognisance of his keen interest in ensuring that we can do better by mothers, around their mental health, as we implement the recommendations. We will ensure that the implementation group, and Jane Grant who leads it, will prioritise that work.
The RCM Scotland Director, Mary Ross-Davie, said earlier this month that, in terms of midwife numbers, in Scotland, we are doing well. We have known for a long time that, in England, there is a significant shortage of midwives. Will the RCM be engaged in national and regional workforce planning to ensure that we have the right mix and numbers of staff in the future, and also to avoid the shortages that are being experienced in England?
As I said, we have a commitment to ensure that we have the right complement of staff, and our innovative midwifery workload and workforce planning tools, which are a UK first, have helped to ensure that in Scotland the NHS continues to meet the RCM recommendation on the midwife to birth ratio—unlike the situation in England, where the RCM is clear that there is a shortage of midwives.
We are not complacent in Scotland. We know that we must do more. It is also about redeployment of existing maternity staff and midwives, to ensure that we can transform the delivery of maternity services in Scotland, challenging existing norms in the NHS in that regard and ensuring that there is continuity of care and a person-centred approach.
We will continue to engage with staff, as will the implementation group, as we move forward with implementation of the recommendations.
I declare an interest: one of my daughters is a midwife. About 500 midwives are in training, and their training will be spread over the next three years. The Royal College of Midwives reports that 41 per cent of our current midwives—about 1,200 of them—are over 50 and are eligible to retire at 55. NHS Greater Glasgow and Clyde reports that it is losing midwives at double the rate at which it used to lose them.
Given the inevitable and chronic loss of experience, which cannot be replaced by newly qualified staff, how does the Scottish Government propose to correct the lack of foresight of the then health secretary, Nicola Sturgeon, who cut maternity training places in 2011, and ensure not only that staffing numbers are raised to an appropriate level but that crucial experience in maternity services is not lost, so that the strategy can be delivered?
In a number of responses to members who asked about midwife numbers, I said that Scotland’s ratio continues to be better than that of many other areas of the UK. I make it clear to Brian Whittle that we have increased the student midwife intake for five years in a row, including a 4.9 per cent increase for 2017-18, which equates to 191 midwifery training places in that year, compared with an intake of 172 students in 2006-07.
We must also deal with the context of Brexit, which the member’s party has imposed on us. We rely on European Union nationals to deliver many NHS services. [Interruption.] I hear members asking us to change the record, but the reality is that we have to deal with that as part of our workforce planning. I hope that Mr Whittle has been as robust with his colleagues down south as he was in questioning me, to protect Scotland’s position.
What is motivating me to move forward with implementing the recommendations is the desire to transform the delivery of maternity services in our country and build on the position of strength that we have, in which mothers report a high degree of satisfaction and there are improved outcomes for our babies.
I can take two more brief questions, if the minister is also brief.
Do ministers plan to reduce intensive care provision at neonatal units across Scotland? Today, NHS Greater Glasgow and Clyde agreed to submit its plan to close the children’s ward at the Royal Alexandra hospital, after months of denials from the Scottish National Party that such a proposal even existed. The final decision will rest with the SNP Government; the proposal must be rejected. Can the minister say whether the neonatal unit at the RAH is one of the units that are to be downgraded further, through the removal of intensive care cots?
The review talked about the need for choice in local maternity provision. Will the minister ensure that the Government keeps its promise to protect services in Inverclyde and rejects plans to close the Inverclyde birthing unit?
The recommendations include a move to up to five neonatal intensive care units, which will provide specialist care for the sickest babies, in the knowledge that that is driven by clinical evidence on the delivery of good outcomes for those babies. As I said in my statement, I will keep the Parliament informed of progress and ensure that the pace and scale of change are comfortable and as smooth as possible.
NHS Greater Glasgow and Clyde continues to work through its proposals. I know that the member has an interest in the services that are delivered close to his home. I expect our NHS boards to take cognisance of the recommendations in the report and proceed on that basis.
I welcome the statement and the minister’s commitment to accept all 76 recommendations that are in the report. Work to continue to reduce stillbirths and neonatal deaths must be the Government’s priority, but what steps will be taken to ensure that families who have suffered such a tragedy are treated with empathy and accorded dignity and respect by the NHS, rather than confronted with inertia, suspicion and hostility when they try to find out how and why their babies died?
I thank Kenneth Gibson for raising the question. I cannot imagine the pain and suffering that any parent goes through when they have lost a child; he is right to make sure that, when we improve maternity services, parents are treated with respect, dignity and empathy after having to cope with such a dramatic loss.
There are reasons to be hopeful about the improvements in maternity services, because the services are safer than they have ever been, but that does not take away from the pain of a family who are enduring such a loss. We will continue to support parents through bereavement and to make sure that we understand better what that will require. Bereavement support is very much a part of the recommendations in the report and we will take cognisance of members’ experience of personal suffering and any improvements that they think we should take forward under the review.