Webchat with health secretary Alan Johnson
This is an edited transcript of our webchat with Alan Johnson on April 16 2008
Breastfeeding questions | Miscarriage code of practice | MMR and single jabs | Midwife shortages | Health visitors' lack of training | NHS dentists | Doctors and flexible working | NHS Choices | Superbugs, hygiene and cleaning in NHS hospitals | Nurses' pay | Routine health checks | Nestle boycott and Breastfeeding Manifesto | Alan Johnson and leadership of the Labour Party | Alan Johnson's typing skills | Birth choices in the NHS | The NHS postcode lottery
Alan Johnson: Hello everyone, and thank you for inviting me to Mumsnet. Really pleased to be with you today even though it's meant me travelling to North London! As a South Londoner I'll go anywhere for Mumsnet! I probably won't have time to answer all of your questions, but I'll do my best to get through as many as I can.
TheDevilWearsPrimark: I love you for mentioning the North / South divide in your first post! Genius!
Q. Little Bella: So Alan, what are you going to do about the piss-poor support from the NHS for breastfeeding? One of the most shocking and dismaying things for a new mother is to find that having read a couple of books about breastfeeding, she actually knows more about the subject than most of the midwives and health visitors she comes across, because they are so badly trained and ill-informed. And yet the long-term benefits of breastfeeding are so well-established that we know it would save the NHS a fortune if our breastfeeding rates were as high as those of Norway, Sweden et al. How high is this on your priority list and what measures are you considering to ensure that BF rates are improved, if any?
A. Alan Johnson: Several of you asked about breastfeeding, and support for mothers who want to breastfeed. I agree that breastfeeding is best for babies, and the government recommends breastfeeding for the first six months of a baby's life. More mums do breastfeed now - more than three-quarters - but breastfeeding rates are lower among mothers under 20 and those from disadvantaged groups, and so apart from all the other benefits, increasing breastfeeding will help us tackle health inequalities - a key Labour government priority.
Our recent obesity strategy highlighted breastfeeding as a key way of reducing childhood obesity rates, and we're doing a number of things to promote breastfeeding as the norm for mothers. A lot of that is about education, with an information campaign along with continued support for National Breastfeeding Awareness Week, a National Helpline for breastfeeding mothers, and work to ensure that maternity units have an environment that supports breastfeeding. But we also want to do more to encourage employers and businesses to support employees and customers who breastfeed.
Q. cmotdibbler: From the latest infant feeding survey: 78% start breastfeeding; at one week this drops to 63%; at six weeks 48%; and six months 25%. At six months, less than 1% are exclusively breastfeeding. On the support boards here, we hear time and time again about the lack of community support to keep bfing exclusively, and about HCPs who give advice directly against the national and international recommendations to bf exclusively to 6 months, and to continue breastfeeding to two years or beyond. We also hear that HVs have no obligation to keep up to date with breastfeeding advice, and so continue to give information that they received 20 years or more ago.
Q. VeniVidiVickiQV: The Government recommends exclusive breastfeeding for the first six months of a baby's life - if it doesn't recommend breastfeeding beyond that, why is follow-on still allowed to be sold, since it's very clearly a breastmilk substitute.
The National Helpline is to be applauded, but the funding is lamentable compared with the number of women who start breastfeeding in this country - and I have had to dig to find information about it - it has not been advertised much. Smoking cessation gets FAR more support - the NHS has a dedicated helpline etc. We know women want to breastfeed, we know breastfeeding is best for babies AND for mothers - and, I believe, for society as a whole - why isn't there more funding being put into breastfeeding support across the country?
"The current UK position regarding baby milk legislation has been likened to the practice of securing your home by locking the front door and all the windows but failing to close the backdoor. It gives the baby feeding industry in the UK the key to the expansion of the baby milk market - the use of the health care system as a market place. The NHS is left to pick up the costs - estimated to be £35m for gastroenteritis alone." (http://www.babyfeedinglawgroup.org.uk/resources/whychangelaw.html)
£35m is a lot of money that, if a decent breastfeeding strategy existed in the UK, could be diverted into other areas of the NHS. It would only take one generation of properly trained healthcare workers to bring about a change in thinking - hospitals ought to be told they have to go Baby Friendly (NICE says the BF standards should be the MINIMUM), for instance. Or maybe, and this is a bit radical admittedly, make breastfeeding training and updates mandatory for all NHS staff - it currently isn't, which is outrageous.
Q. kiskideesameanoldmother: Are you interested in supporting women's choice to breastfeed for as long as they wish? Are you interested in addressing the problem of sophisticated marketing of formula to health care professionals? My consultant told me antenatally that he is all for 'choice' when it comes to infant feeding. I told him that so was I. And that 76% of women choose to initiate breastfeeding after giving birth. At six weeks half that number have given up and 90% of those who had given up wished to bf for longer. This info comes from the DH's own infant feeding survey for 2005. FYI, over 35m a year is spent every year on treating gastrointestinal infections alone in children under 12 months. So I asked my consultant what could our hospital do with an extra £35m. He had no answer to that but suggested I become a politician.
A. Alan Johnson: There have been many points being made here about breastfeeding, including a question as to whether this was a Government priority. It is and it's also something that I feel very strongly about. The issue emerges in various departments, for instance our move to increase maternity leave orginally to 26 weeks and soon to 52 weeks was in part driven by the fact that we've been signed up to the WHO policy of encouraging breastfeeding for the first six months for many years but our maternity provision didn't reflect this policy.
Many of the points that have been made here about the disparity between information and advice and poor training for some midwives and nurses about the importance of breastfeeding are ones that I will take away and talk to colleagues in the Department about.
We want to improve the situation particularly given that as some correspondents have said that many women give up having initially been persuaded to breastfeed and there is obviously more we could be doing in this area. As already mentioned, our policy on health inequalities will address breastfeeding because of the evidence that those from more deprived backgrounds are less likely to breastfeed and our policy on tackling obesity already has a major element relating to breastfeeding.
Finally, on the question on infant and follow-on formula we have recently implemented new regulations with the Food Standards Agency to more strictly control advertising of all types of formulae to ensure that breastfeeding is not undermined by the marketing of such products. I believe the FSA has finished consulting on draft guidance notes for the regulations and will publish them shortly. An independently chaired review will be formed to look at the arrangements - and I hope Mumsnet will be a crucial part of this review, which will begin next month.
Q. sfxmum: Miscarriage is a very troubling and upsetting event for most women and as someone who has had a few I am shocked at the variation in care women receive. Can we please make sure there are some clear standards of care and common procedures to follow. We need appropriate immediate and sympathetic care we adequate follow-up.
A. Alan Johnson: it seems to me from all your comments and from talking to the Mumsnet people here that we really should seek to ensure a common set of standards across the country. I think I'm in at the start of a new campaign and it's something I will talk to Ministers about when I return to the Department. Mumsnet has informed me that I will not be allowed to forget this issue!
Q. sfxmum: I gave my child the MMR vaccine but isn't it better to make the singles available rather than just leave it for those who can afford it and allow others to go without?
A.Alan Johnson: Why not make single vaccines available on the NHS? Well, the simple answer to that is that MMR is safe. There just isn't any credible evidence linking MMR to autism and bowel disease, and more and more evidence that there is no link. We have to base our policies on the evidence available, and the evidence says that MMR is the safest way to protect children against measles, mumps and rubella.
We don't offer single vaccines because this involves more appointments, and more chances that children will miss appointments or catch measles, mumps or rubella in the gaps between the vaccines - if we offered single vaccines, more children would get ill. About 85% of children have received their MMR vaccine by their 2nd birthday, and this figure is going up. That's good news. But obviously lots of parents are concerned: getting the facts on MMR is really important, and for more on this you should visit www.mmrthefacts.nhs.uk.
Q. With regard to maternity services, this Government should be hanging its head it shame. The midwives in my area, do homebirths in their OWN time - they are seriously overstretched but still give amazing care.
Q. Lulumama: So, we are around 10,000 midwives short, leaving women worried that they cannot have the birth they want as there are not enough staff...women are being told they cannot have a home birth as there are not enough staff...women and babies are being compromised, nationwide. Women are losing faith in the system...independent midwives are beyond the financial reach of the majority and due to lack of insurance now, people are put off..so when are women going to get the midwifery service they need? One woman, one midwife, a real choice of where to give birth, not just lip service and also, birth centres and MLUs are being closed, thus taking away real choice there is no choice if the staff are not there to ensure choices can be met.
A botched delivery or a woman traumatised by her birth experience due to lack of staffing will ultimately cost the NHS more in terms of repairing the woman physically and emotionally. How is this going to be addressed?
A. AlanJohnson: On maternity services and midwife shortages - the birth rate is rising, and we need to keep pace with that. We've recently announced £330m in extra funding for maternity services over the next three years, and that will pay for a substantial increase in the number of midwives - an extra 1000 by 2009, and an extra 4000 by 2012.
That includes encouraging former midwives back into the profession with a "golden hello" package with a grant, free training and help with childcare and travel costs - we want to bring back the expertise of good midwives who've left the NHS. This will help us with our commitment to deliver by 2009 choice for all women in where and how they have their baby and what pain relief to use, depending on their circumstances. We'll also give more choice in antenatal and postnatal care.
Q. VeniVidiVickiQV: What plans do you have for improving our (I use "our" in the loosest sense of the term) health visitor service. They appear to be shockingly understaffed, training, knowledge and clinics vary wildly, and a different system seems to be set in place from borough to borough. One of the biggest bugbears parents have on Mumsnet is due to incorrect information disseminated by health visitors. I note that another parenting website has teamed up with health visitors. I am concerned that a question be asked, and then the thread closed so that you cannot see what advice is being handed out to this person, which in my view, isn't a step forward.
A. Alan Johnson: The biggest complaint I hear is that there are not enough health visitors. I committed Government last year to increase the numbers and I'm working very closely with Ed Balls at DCSF to ensure that in Sure Start centres, for instance, we have the right level of cooperation with the health service, which usually involves health visitors.
The issue about quality of training hasn't come up as often but I will look into this particularly as it relates to the earlier point about breastfeeding in general and a feeling that perhaps very good professionals who have been in post for a long time are not being kept up to date with new developments.
Q. Sidge: Why is dental provision no longer available on the NHS?
Q. Hassled: Why aren't there enough NHS dentists to go around and why has NHS-funded paediatric orthodontistry been cut?
A. Alan Johnson: I know lots of people are concerned about access to NHS dentistry, and we do need to increase access. But we should acknowledge the wider context: children's oral health is better than it has ever been. We are making real improvements, and we're allocating more money to NHS dentistry, ring-fencing dental budgets until 2011, and demanding that Primary Care Trusts deliver year-on-year increases in the numbers of patients accessing dental services.
Also, local health services now have a duty to provide urgent dental treatment to those who need it, so you can get treatment if it's clinically necessary, even if you don't have a regular dentist. And we've simplified the system of charging for dental treatment, replacing the old system of almost 400 different charges with just three charge bands and cutting the maximum charge by 50%.
By the way, as you probably know, children under 18, pregnant women and women who've had a baby in the last 12 months are among the groups entitled to free NHS dental treatment.
Q. pyjamarama: I am a doctor, and have worked in the NHS for the past seven years. My first child is due in a few weeks, and after maternity leave I would like to work, and continue to train, part time. However, the government has withdrawn funding for flexible trainees, meaning I am forced to either return to work full time, or sacrifice the career I have spent the last 7 (12 if you count med school) years working towards. This penny pinching will result in the NHS losing many dedicated and experienced doctors it has spent hundreds of thousands of pounds training, and is further increasing the flood of hospital doctors into general practice. Your excuses please.
A. Alan Jonhson: Pyjamarama - your specific point is I think related to the attempts to ensure Government money for further and higher education is focused remorselessly on the millions of people who have no qualifications at all and where the Leitch Report predicted that we would have serious problems if it wasn't addressed.
However, having said that, I am concerned that one of the reasons why so few women end up in senior positions in the NHS is that although our medical schools have more and more women graduates, the system doesn't allow any flexibility at senior level. In one sense this is understandable, given that consultants have to be called back out to see patients when problems occur.
I am convinced that there is more we can do in relation to the kinds of opportunities we can offer to women coming back into the NHS after maternity leave or any other reason for a break in service. I have talked to our senior clinicians in the Department about this and we will be working on this over the coming period. I'll also look at the specific point you've raised in relation to funding because I can see how counter-productive it is to lose the investment that the taxpayer has put into putting the investment in providing you with the skills you have.
Q. RubySlippers: I don't want choice and control over services - I want to go to my local, clean hospital and not have to wait for months to see a consultant about an ongoing health problem I have.
Q. itscoldtoday: Perhaps you would like to explain your "personal NHS offering maximum choice" when surveys show that the majority of patients want to be treated at their local hospital and aren't much interested in the choice of further flung places? Isn't it the case that the NHS is a very expensive burden that the government has to shoulder, and that what you would really like is to start privatising it as much as possible? And isn't it also the case that the huge amounts of negative press you are giving to GPs is a part of trying to make primary care as unpopular as possible, easing the transition from free at the point of service care to pay as you go polyclinics? Can you admit that the government, when negotiating the new contract, were warned by GPs that if we were given targets to achieve, we would achieve them; so it is a bit unfair to whinge when we do in fact hit those targets and our pay goes up in accordance with you contract? Yes, we are expensive, but you made us that way. Shame you can't pay the nurses, porters, and so on a wage equal to their hard work too.
Is it possible to see that as much as the politicians want shot of the NHS, we'd be quite happy to see the end of the politicians making headline grabbing 'initiatives' instead of addressing problems that need solving.
You shut down two of our local Cottage Hospitals two years ago, and we have had an almost constant beds crisis at the local DGH ever since, with patient care suffering as a consequence. Today I had to argue with that same DGH to keep a patient in because the family could not cope with him at home; had my Cottage Hospital been open I would have kept him there. The hospital had no quarrel with the fact that the patient needed admission, they simply had no beds.
The NHS is a money pit, I agree, but the money thrown at it is often thrown in the wrong direction, from the ridiculously over-budget computer system to costly consultations with management directors over whether or not the Health Board will save a few quid shutting a Cottage Hospital.
Oh, and while you're here, perhaps you can help me: where am I going to find child care for my two children for me to work the extended opening hours that our patients have never asked for, for which there will be no lab back up, and potentially no out-of-hours coverage for either. The same goes for our receptionists who will be manning the desks - possibly on their own, late at night in an isolated rural practice. Thanks so much.
A. Alan Johnson: Choice is not an end in itself, it's a mean to an end, the end itself being better quality. It's not the only way of achieving better quality but it's an important facet of achieving better quality healthcare. I think that the view of the NHS was that people should be grateful for what they received whereas if you wanted things like choice and a more personalised service that was somehow the exclusive provision of the private sector.
Of course we want every hospital to be of the highest quality and most of them are. However, somebody going in for a hip replacement will want to know what the rate of healthcare acquired infections is; what the food is like; the visiting times etc and may want to have the operation in a hospital closer to where their family lives.
The vast majority of people will go to their local hospital but it seems to me to be an anomoly in the 21st century for us to insist that whereas citizens have choice in so many areas of their live now that it should somehow cease when they enter the portals of the NHS. Incidentally, now that we have established the single tarrif so that the NHS pays the same amount for eg a hip operation wherever it takes place, it means that we can utilise private hospitals to ensure that we have adequate capacity and that we don't go back to waiting times of two years and more as happened under the previous government.
There have been several questions on GP access. Let me first of all make it clear that we are not seeking to go back on the GP contract we negotiated in 2004. There is a loss of collective memory in some quarters. Prior to 2004 there was a real problem in recruiting people into general practice and a real fear that with so many GPs due to retire there would be a crisis in provision.
We were quite right to raise GPs' pay, which was very poor, and to reduce their hours while enabling them to spend more time with each patient. I find it incredible that GPs were expected to be bright and efficient at 9am, having been out half the night dealing with call-outs. It was a system that had to change and we changed it.
Access is not about out-of-hours. We do not intend to go back to the 24/7 coverage by each GP. What we do want is for patients and the public to have greater choice about when they see their GP. People now work in a completely different way than they did 50 years ago and in those practices where they do open in the evenings and on Saturday mornings they find not only blue-collar workers who have difficulty getting time off from employers during the week but also those mothers with children that some people told us were perfectly satisfied with the current arrangements.
We have put extra money into the system and we are not asking GPs to do this for nothing. 92% of BMA members voted for greater access and I think it's very much in tune with what the public expect from the health service that they fund.
Q. JT: Hello Alan, I've got a little tip for helping with the superbugs. When my sister did her nurse training in the late 60s, woebetide if they went home in their uniform, never mind pick the kids up, go for a Tesco shop, stuff their pockets with goodness knows what. Nurses are bloomin marvellous but they look like cleaners. Elderly patients, in particular, can't work out who is who. It interests me this cleaning bit. I mean WHY should it be any different to years gone by? Maybe the cleaners aren't being managed properly, paid enough, what? I mean, you've got managers coming out of your ears, but they just don't seem to be, er, managing.
Q. willow: I've got another tip re dealing with superbugs. How about making sure the cleaning staff actually clean? I was in hospital for ten days following the botched birth of my son - for the entire time a huge clot of blood, like a piece of liver, from another mum remained lodged in the plug hole of the bathroom I had to use. (Fortunately, I was only allowed showers at that point.) I was way, way too ill to deal with it - and, more to the point, why should I have had to? It was visible to anyone who used that bathroom - that it was never cleaned up (in what is considered a flagship hospital) gives a massive pointer as to one area that needs dealing with sharpish. So what steps are you taking to make sure hospitals are cleaned properly on a daily basis?
Q. Monkeybird: As I understand it, cleaning is contracted out in many NHS hospitals. Not surprisingly, it isn't done well. That is surely one thing that can be changed?
A. Alan Johnson: To be frank I don't think that the NHS treated this as the high priority issue that it is. There was a certain complacency in the system which is, thankfully, being eliminated. NHS frontline workers knew how important cleanliness was but it didn't figure large enough in the overall priorities. In terms of what we're doing now, it's not just deep clean - there is no single solution to the problem and deep clean was symbolic of the need to ensure the highest standards of cleanliness and hygeine.
The three crucial areas remain - handwashing, responsible prescribing of antibiotics and isolation facilities with cohort nursing. The latest stats show MRSA rates down by 18% on the previous quarter; C.Diff down by 21%. Across Europe most countries are seeing an increase. The question of nurses uniforms often comes up. There is actually no evidence that this is a major part of the problem. However, in many trusts nurses are not encouraged to wear uniforms outside of the hospital because if the public perceive this to be part of the problem it helps public confidence to ensure that it doesn't happen. We wouldn't dictate this kind of issue from Whitehall and it is a matter for local acute trusts.
Q. flossish: I would also like to know about nurses' pay. We are encouraged to no longer call the people we treat patients, instead clients or service users. Quite rightly we are constantly striving for a patient centered approach. We are criticised for not smiling enough, the state of our attire and for poor hand washing skills.
We are expected to take on extended roles and do more and more, paperwork and computer work levels constantly increase. And yet we are expected to do all this, smilingly when we are becoming worse and worse off due to below inflation pay rises. The recent changes to taxation means again that nurses working part time are even worse off. Unfortunately our main trade union has no backbone. I fail to see any other reason why we are valued less than teachers, say.
Also if I can raise the subject of budgets. As I understand it, the ward budget has to allow for many factors. If we have a client with expensive dressings it comes out of the wards budget. Some dressings cost thousands for a relatively short course of treatment. Some wards are more likely than others to require this type of dressing and therefore the budget suffers. Another rising cost seems to be the use of interpretors, which can cost hundreds of pounds for only a few hours work.
I work on a ward where the nursing staff is mainly made up of young women and there also seems to be something in the water! There have been up to four or five members of staff off on maternity leave at any one time, when the budget only allows for two. Therefore the ward budget paying for maternity leave, plus the extra cover costs incurred by this leave means that the money left for basic supplies and equipment is diminished, basically affecting client care. How can this be fair? Could there not be a central budget within each hospital to cover costs like these, which probably balance out over the whole NHS trust?
I'm sure I don't need to tell you that nurses are feeling very demoralised and undervalued. Surely for the government to want NHS clients to receive the best care this issue needs to be addressed and steps made to improve it?
A. Alan Johnson: I hope that you will recognise the huge advances made in pay and conditions and indeed in the number of nurses since 1997. Agenda for Change was an enormously important agreement with all the unions and Royal Colleges and it gave nurses a substantial real terms increase in salary. I'm not trying to curry favour here but I was the Minister in a previous capacity who defended the pension arrangements for nurses, teachers and civil servants.
The pension is, of course, an important part of the package. Last year's staged pay increase caused understandable concern and resentment. I haven't got time to go into that here, but what I can say is that I've recently concluded negotiations on a pay deal that will give nurses an 8.1% pay increase over the next three years. RCN and Unison fought very hard to tackle issues such as the long banding structure and those on low pay and we've done a lot in this deal to address those concerns as well as setting up on-going discussions to do more in this area.
In the context of public sector pay, which in the last 10 years has risen by more than private sector pay, I do think nurses have received fair treatment although given the work that they do I can understand the feeling that more should be done.
Q. Bramshott: Why is it that we are encouraged to have regular dental check-ups, but not regular health check-ups? Surely an annual/bi-annual check up for weight, blood pressure, cholesterol etc would flag up problems early and save money in the long run?
A. Alan Johnson: There is a debate about the value of annual/bi-annual check-ups particularly because of the concern that GP surgeries, pharmacies etc will be full of the worried well whilst those people who are particularly prone to certain diseases are not catered for.
Nevertheless you will have seen our announcement recently about vascular checks, where everyone between 40 and 74 will be seen on a call and re-call basis every five years which will really help in the fight to prevent illnesses such as heart disease, kidney disease and diabetes.
Q. VeniVidiVickiQV: Mr Johnson, do you boycott Nestle? Have you signed the Breastfeeding Manifesto? It would appear not, but I would urge you to do so.
A. Alan Johnson: No I don't boycott Nestle and I'll get back to you on the breastfeeding manifesto issue.
Q. emmybel: Do you feel you've missed your chance to become leader of the Labour Party after Blair left? Were you tempted to put your hat in the ring?
Q. saffy1: I'd like to know how you think Gordon Brown is doing? Do you think he'll survive the current turmoil?
A. Alan Johnson: As I said to somebody who asked me this yesterday - I think Gordon Brown is a serious man for serious times. If you want somebody who will invite the cameras in while he shakes out the Shreddies over breakfast he's not your man and he won't be telling how many girls he kissed behind the bike shed.
That's not to say that Gordon's not good company - he's just a very private man and he is absolutely focused on the major problems which this country faces. I suppose you wouldn't expect me to say anything other than this, but I really do believe that he's a good man, leading a good government that's doing good things.
Q. stoppinattwo: Alan, do you use cut and paste? I ask because your typing is very nice and you could teach some peeps on here a thing or three about speed typing.
A. Alan Johnson: I have found a wonderful way of improving my typing both in relation to the quality and the speed - she's called Sue!
Stoppnattwo: So you're talking and Sue is typing. I knew it - no man can speed type and think at the same time.
Q. sitdownpleasegeorge: The way things are all going a bit Pete Tong for old Gordon at the minute, I'm sure AJ will get another crack at the job before too long. Mr Johnson. Do you believe that all women should have the right to give birth the way they prefer, even if that means they opt for an elective c-section?
A. Alan Johnson: I think this takes us back to the question of choice but on a far more profound level. I do instinctively feel that a woman should have the choice of how they give birth. Maternity Matters is the policy that was developed with a wide range of interested parties. It means that by 2009 all women giving birth will have more choice over how to access primary care, for instance they can self-refer to a midwife rather than a GP if they wish. They will also have more choice in antenatal care, in where to give birth and in accessing postnatal care.
he two problem areas that prevent me from saying that there should be an absolute choice in these matters is that the NHS probably couldn't afford to give c-sections on request and, in any case, I feel it should remain the decision of the clinician as to whether to go down that route. The other problem is that the extended choice we've given on elective surgery cannot yet be extended to maternity care. I think its very important that women are able to choose the maternity hospital that they want to use but that's something that will take a little longer to implement.
Q. ktmoomoo: I would like to know about the postcode lottery! I wish to have an operation but I live in Lincoln and NHS say no , but if I was living somewhere else it would be yes. I think this is so unfair as this opperation would be life-changing for me. I have appealed twice now with no luck. I'm distraught.
Q. RTKangaMummy: Hello Mr Johnson. Why do the prescription charges go up in England BUT down in Scotland? Why is that fair?
A. Alan Johnson: The most common complaint about postcode lottery is the availability of drugs but you have pointed to another aspect relating to procedures. The policy is that once NICE has approved a drug or procedure it should be available everywhere. This is an area that we are considering addressing in the NHS Constitution that we plan to publish on the 60th Anniversay of the NHS in July.
There is a problem in respect of the amount of time that it takes for NICE to properly consider whether to license drugs or procedures. In the period up to licencing, PCTs have discretion. I think the way we should seek to resolve this, particularly with cancer drugs, is by speeding up the NICE proceedure, if we possibly can. One final point on this - if the NHS isn't to be a hugely centralised command and control system so that it can be clinically led and locally driven there are bound to be differences between different regions of the country. But this shouldn't relate to the availability of drugs and procedures as I've mentioned above.
Many people have asked about Scotland - I support devolution. It was a Government policy successfully implemented and we cannot complain that having devolved power, the Scottish Executive decide to do things differently. However, the basic principles of the NHS haven't changed and issues such as free prescriptions and car-parking etc whilst important do not represent the central issues around which the NHS is established.
JustineMumsnet: Thanks everyone, and to Alan (and Sue) especially for his thorough responses and for staying a bit longer than you should have. Alan has promised to come back to us on a few things and we promise to make sure he does and to keep the pressure on with regard to miscarriage and a nationwide code of practice.
Alan Johnson: Thank you very much for all of your posts - as a former postman I'm used to dealing with a different form of communication but this was very interesting and genuinely enjoyable. For more information on what we're doing on health you can also visit www.labour.org.uk!