Swine Flu

Oral Answers to Questions — Work and Pensions – in the House of Commons at 2:30 pm on 10th January 2011.

Alert me about debates like this

John Healey (Wentworth and Dearne) (Lab) ( Urgent Question): Thank you, Mr Speaker, for allowing this urgent question to ask the Secretary of State for Health if he will make a statement on the Government's preparations for and response to the current flu outbreak.

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health 3:33 pm, 10th January 2011

Every winter, flu causes illness and distress to many people. It causes serious illness in some cases and, unfortunately, some deaths. I know that each death is a tragedy that will cause distress to family and friends.

The NHS is again well prepared to respond to the pressures that winter brings-it has responded excellently this year. I thank in particular general practitioners, who each year work tirelessly to look after the health of their patients-especially this winter when the weather, as well as flu and other viruses, has presented challenges.

The rate of GP consultations for influenza-like illness is currently 98 per 100,000 people, down from 124 per 100,000. Those figures are lower than the numbers recorded during the pandemic in 2009-10 and below epidemic levels, which are defined as 200 per 100,000 people. The most recent data showed that 783 people were in critical care in England with influenza-like illness.

Where necessary, local NHS organisations have increased their critical care capacity, in part by-regrettably-delaying routine operations that require critical care back-up. That is a normal local NHS operational process; critical care capacity is always able to be flexible according to local need. We have also increased the number of extracorporeal membrane oxygenation beds, for patients with the most severe disease, from five to 22. A seasonal flu vaccine is again available this year. Our surveillance data show that the vaccine is a good match to the strains of flu that are circulating.

GPs in England order seasonal flu vaccine direct from the manufacturers, according to their needs. Vaccine supply is determined in the early part of the year, for autumn delivery. We recently became aware of reports of flu vaccine supply shortages in some areas in England. We are working with the NHS locally to ensure available supplies of surplus vaccine are moved to where they are needed. In addition, the H1N1 monovalent vaccine is now available to GPs for patients who are eligible for the seasonal flu vaccine.

The Government continue to take expert advice from the Joint Committee on Vaccination and Immunisation. Last year, the JCVI advised for the first time that, in addition to usual risk groups, healthy pregnant women should be vaccinated with seasonal flu vaccine. It did not recommend that children under the age of five outside the at-risk groups should be vaccinated. On 30 December, the JCVI assured me that this advice remains appropriate.

The number of deaths in the UK this winter from flu, verified by the Health Protection Agency, currently is 50. The number of deaths from seasonal flu varies each year, with over 10,000 deaths from seasonal flu estimated in the winter of 2008-09.

Antiviral medicines can also help clinical at-risk groups who have been exposed to flu-like illness. We notified clinicians that the use of antiviral medicines in these groups was justified and, at their discretion, with other patients. We have given access to the national antiviral stockpile to support that.

We are making publicly available for the first time a range of winter performance information, published on the Winterwatch section of the Department's website. I wrote to all Members last week to inform them of the NHS response to flu, and updated them further in a written statement published this morning.

Photo of John Healey John Healey Shadow Secretary of State for Health

I thank the Health Secretary for that statement, but the truth is that he has been slow to act at every stage of this outbreak, and that is putting great pressure on the NHS across the country. It is working flat-out in our local hospital in Rotherham. We have had to open extra beds, and since last Tuesday have cancelled all non-urgent surgery. Four of the 50 patients in the UK who have so far died linked to this flu have been in Rotherham, and two were constituents.

The Health Secretary talks about seasonal flu, but we knew this would not be like normal winter flu because we knew swine flu would be dominant, so the central question for the Health Secretary is why he made less preparation for a flu outbreak that was expected to be more serious. Why did he axe the annual autumn advertising campaign to help boost take-up of the flu jab and help the public understand who is at risk and what treatment is available? We know it works, and this was a serious misjudgement.

Why was the Government's first circular to midwives, urging them to help get pregnant women to take up the flu jab, not sent out until 16 December? Why has there been no move to offer vaccines through antenatal clinics, and why are the Government not publishing details of the numbers of pregnant women who are seriously ill or who have died, as they are with other groups that are most at risk?

With proper planning and preparation, we should not have seen GPs and pharmacies running out of the vaccine in some areas last week, nor should we have seen parents confused about the treatment available for their young children. I hope last week's figures mean we may be over the worst, but, with 783 people in critical care and a long winter still ahead, what steps will the Health Secretary take if the numbers of ill people continue to rise? Can he now, today, give the House the reassurance he has failed so far to give the public, which is that he really has got a grip on this situation? Finally, when all the bodies he is relying on to sort out this situation will be abolished under his internal organisation, what assurance can he give the public that this will be any better handled in the future?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I share the right hon. Gentleman's deep sadness at the deaths in Rotherham and join him in expressing clearly my condolences to the families of his and other Members' constituents who have died. Regrettably, there will, I fear, be further deaths from flu-that is in the nature of the winter flu season-but I have to explain to him that we are in the midst of a seasonal flu outbreak that has not reached epidemic levels. Neither is it a pandemic, which is clearly a different situation in which a novel virus, to which there is not acquired immunity, is in circulation.

The right hon. Gentleman asked some specific questions. First, on having to cancel operations, I have made it clear that that is, unfortunately, a consequence: if the NHS's critical care capacity is under pressure, it cannot admit large numbers of patients for elective operations that might require critical care back-up. The seasonal winter flu outbreak has led to an increase in the number of patients with flu in critical care beds, although they still constitute only about one fifth of the total number of critical care beds, and I pay tribute to hospitals across the country that have increased their critical care capacity, particularly in intensive care, to deal with the situation.

We are also providing assistance to the NHS. I am sorry that the right hon. Gentleman did not refer to my important announcement last Tuesday that, because we made savings in the Department of Health's central budgets, on things such as management consultancy costs and the IT scheme, we have been able to issue this financial year-in other words, starting now-an additional £162 million to primary care trusts throughout England. They will be able to use that money directly with their local authorities to facilitate the discharge of patients. There are currently about 2,500 patients in hospital who could be discharged if the appropriate arrangements were in place. That will accelerate the relationship with social care that we are looking for.

It is pretty rich for the right hon. Gentleman and the Labour party to say that there should not have been any shortages. The number of vaccines supplied to the United Kingdom was determined before the Government took office. It was determined under the previous Administration, in the early part of last year, not by this Administration. Furthermore, it was equally not just presumptuous but unhelpful for him, during the Christmas period, to talk inaccurately about whether children under the age of five should be vaccinated. He knows perfectly well that like his predecessors we take advice from the Joint Committee on Vaccination and Immunisation. With the chief medical officer, we asked the committee to look at the issue again, and it met on 30 December and reiterated its advice that young children should not be vaccinated. So for him to stimulate press reports suggesting that parents should have their children vaccinated, when the expert advice was not that that should be done, was deeply unhelpful.

The right hon. Gentleman's final point was about the organisations. It is clear to me that, by abolishing the Health Protection Agency and bringing its responsibilities inside the Department of Health under the new Public Health England, we will have a more integrated and more effective system for responding to seasonal flu in future years.

Several hon. Members:

rose -

Photo of John Bercow John Bercow Chair, Speaker's Committee for the Independent Parliamentary Standards Authority, Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons

Order. Many right hon. and hon. Members are seeking to catch my eye. If I am to have any realistic chance of accommodating the interest of most Members, short questions and answers alike will be essential.

Photo of Nicky Morgan Nicky Morgan Conservative, Loughborough

The Secretary of State is right that general practitioners are on the front line, and it is to them that patients will turn. Does he have any thoughts on the case of a constituent of mine who contacted me yesterday to say that he has been trying to get a vaccination, but has been unable to do so because he wants to have one after 4 o'clock in the afternoon, when he can get away from work? He does not want to jeopardise his job and is finding it difficult to access the vaccination before then, but GPs would rather vaccinate in the morning.

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

The arrangements that individual GP surgeries make for ordering and administering doses of the vaccine have been, since October, for them to make. From our point of view, as soon as we were aware that local supply would not necessarily match local demand in the places it should, we took the decision last week to make available the NHS stockpile-there are 12.7 million doses of the H1N1 vaccine-and I can tell my hon. Friend that 20,000 doses began to be distributed this morning. There is no reason why we cannot meet the requirement for vaccinations, whether through GPs' own doses and local arrangements, through issuing NHS prescriptions that can be fulfilled at local pharmacies or through surgeries ordering the H1N1 vaccine from us.

Photo of Gerald Kaufman Gerald Kaufman Labour, Manchester, Gorton

Happy new year, Mr Speaker. Is the right hon. Gentleman aware-he should be because I have written to him about this-of serious concerns in my constituency about the shortage of flu vaccine, including for chronically sick people? Will he tell the House, in the most specific way, what action he is taking to ensure that sufficient flu vaccine is available in the city of Manchester and in Greater Manchester?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

May I reiterate to the right hon. Gentleman that the amount of vaccine supplied to the United Kingdom is determined by manufacturers on the basis of discussions with not only the Department, but others, and that the vaccines are ordered by individual GP surgeries? The total amount of vaccine was 14.8 million doses, which is comparable to the level in previous years. Although GP surgeries have shortages, because of the preparations made during the pandemic in 2009 and given that the principal strain of flu circulating is the H1N1 strain-it is not the only strain, but it is the most relevant to guard against for many in the at-risk groups under the age of 65-we made it clear that we would back up GPs who had any shortages with access to our stockpile of H1N1 vaccine. Orders have come in and they are being filled.

Photo of John Pugh John Pugh Liberal Democrat, Southport

Governments do not control diseases yet, but in my constituency elective surgery has been cancelled and pharmacies have run out of vaccine. What is the serious long-term alternative to the over-provision of last year and the localised under-provision of this year?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I do not think one can say that there was over-provision during the pandemic, because one could not have been at all clear about the nature of the progress of H1N1. However, what that meant is that we have the stockpile of vaccine available to back up the NHS this year. My hon. Friend makes a very good point, because there is clearly an issue to deal with regarding how this is properly managed. Before Labour Members start talking from a sedentary position, they might wish to re-examine the 2007 flu review. It was conducted by the Department of Health under the previous Administration and recommended that there should be central procurement of flu vaccine in England, but the previous Administration did nothing about it.

Photo of Kevin Barron Kevin Barron Chair, Standards and Privileges Committee

Can the Secretary of State tell us why the midwives association was not written to until 16 December?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

We made it very clear that everyone in the at-risk groups was going to be contacted through their GP surgery, and it is the responsibility of GPs to have done that.

Photo of Mark Pawsey Mark Pawsey Conservative, Rugby

I am grateful to my right hon. Friend for the information that he has provided so far, but I wonder whether he could reassure the parents of a 13-year-old boy. They came to see me on Saturday because their son is egg allergic and also suffers from asthma, and they are concerned about the availability of a flu vaccine this year.

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I will certainly write to my hon. Friend about this, but I am confident that one of the number of vaccines that are available will be suitable for his constituent.

Photo of Hugh Bayley Hugh Bayley NATO Parliamentary Assembly UK Delegation

Last week, 30 beds at York hospital were occupied by people with suspected or confirmed cases of flu. That is costing the local NHS £7,500 a day-£50,000 a week-and that money could be spent on treating patients with unavoidable conditions. What lessons will the Secretary of State learn from the failure to promote the uptake of the flu vaccine this year to ensure that we do not encounter a similar problem next year?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

The hon. Gentleman's question is based on a false premise, because the level of vaccine uptake this year among over-65s is 70% and among under-65s is 45.5%, which is comparable to previous years. He did not refer to this, but because we made savings we provided the NHS with considerable additional resources in the last three months of the year precisely to manage winter pressures and ensure that beds in hospitals are available.

Photo of David Tredinnick David Tredinnick Conservative, Bosworth

I congratulate my right hon. Friend on the increase in the critical case capacity and in the number of extra corporeal membrane oxygenation-ECMO-beds from five to 22, which has made a difference. Will he also pay tribute to others who help in these situations, such as the manufacturers of homeopathic medicines and homeopathic chemists? They provide preparations that may be suitable for people, such as the constituent of my hon. Friend Mark Pawsey, who are unable to take flu vaccines and others who choose not to do so.

W

More useful information on homeopathy: http://www.quackwatch.org/01QuackeryRelatedTopics/homeo.html

Submitted by Wesley Mason Read 1 more annotation

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I am grateful to my hon. Friend for that question. His local hospital, the Glenfield in Leicester, leads on specialised ECMO bed services. In this country, we have increased the number of ECMO beds; we have more per head of population than any of the developed health economies, including the United States. As for treatments and vaccinations, I continue to rest upon the scientific and expert advice. Indeed, I hope that patients will consult their clinicians about their treatments.

Photo of Valerie Vaz Valerie Vaz Labour, Walsall South

Will the Secretary of State say whether he took the decision to delay the advertising campaign and, if so, when?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I announced just after Christmas the "catch it, bin it, kill it" campaign. I had not -[Interruption.] Let me explain to Opposition Members. In 2009, the campaign took place in November. Why? It was because the spread of flu took place in late October, early November. Therefore, it occurred at the point at which there was a substantial spread of the influenza in the community. That is precisely what we did this year.

Photo of Henry Smith Henry Smith Conservative, Crawley

As an asthma sufferer, I am pleased to report that just this morning I had the benefit of the flu jab and it was professionally and painlessly administered. However, constituents have come to me concerned about, in one case, a child who has had the respiratory syncytial virus, or RSV and, in another case, an adult who has had pneumonia, who have been denied the flu vaccine. Will he examine how the guidance to GP practices can be amended to include such groups?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I will of course write to my hon. Friend about the nature of the advice provided by the joint committee, but we follow and have followed at each stage the advice given to us by that independent expert committee, the Joint Committee on Vaccination and Immunisation. I will certainly write to him to explain how it has determined the at-risk groups for these purposes.

Photo of John Spellar John Spellar Shadow Minister (Foreign and Commonwealth Affairs)

Earlier, the Secretary of State made the astonishing admission that he has done nothing since the Labour Government left office. He rightly drew attention to the work being done for at-risk groups. However, emergency planning requires the sustaining of the emergency services. Why is he not giving priority to those who work for the emergency services-the police, the fire and ambulance services?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I have two points for the right hon. Gentleman. First, all NHS staff, including ambulance staff, are eligible for the vaccine. Regrettably, when I last, under 20% had availed themselves of that opportunity. I wish that it were higher.

Photo of Liz Kendall Liz Kendall Shadow Minister (Health)

"Wish"? Does the Secretary of State think wishing is enough?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

They are all offered it, so they can all be provided with it. I am not in a position to require people to take a vaccine. We are not providing mandatory vaccination in this country yet, and I do not suppose that we shall.

Secondly, I was not admitting that I had done nothing-on the contrary. What the right hon. Gentleman perhaps does not understand is that one cannot simply order additional large-scale supplies of a vaccine. A long process of manufacture is required, as it is an egg-based culture system. The amount is ordered in the spring for autumn delivery, so the amount was determined in the spring. When I entered office in May, there was not any reason particularly to think that we would need more than in other flu seasons, and we knew that we had the back-up of the H1N1 vaccine if we needed it. In early August, I made it clear that I intended to review further the system of procurement, distribution of flu vaccine and its supply. That review is ongoing and will be published shortly.

Photo of Jeremy Lefroy Jeremy Lefroy Conservative, Stafford

Does my right hon. Friend agree that the reason that acute beds are under such pressure at this time of swine flu is that we do not have sufficient step-down or community beds into which people can transfer from acute beds?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

My hon. Friend makes an important point. Primary care trusts and local authorities working together should now be able to have confidence that the resources are available in this financial year-and £648 million will be available in the next financial year, and more in years beyond-to improve the relationship between health and social care not only through things such as step-down beds, but through operating, for example, hospital at home services, community equipment services and home adaptations to ensure that only those people who need to be in hospital are in hospital.

Photo of Gisela Stuart Gisela Stuart Labour, Birmingham, Edgbaston

There have been several reports about children having to travel extremely long distances to access critical care in children's hospitals. Is the Secretary of State satisfied that there is sufficient capacity for paediatric intensive care and high dependency care?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

Yes, I am. The hon. Lady will know that there have always been occasions when paediatric intensive care capacity in a particular hospital is full and when it is necessary for children to be taken a distance. On Christmas eve, I was at the intensive care unit at Alder Hey and I want to pay tribute to the tremendous work done by staff there. They acknowledge that this was not just about H1N1. One reason the committee did not recommend vaccinating all children under the age of five was that children, particularly very young children, were in intensive care because of a combination of H1N1 and/or bronchiolitis and RSV. A range of conditions was impacting at that moment on very young children.

Photo of Luciana Berger Luciana Berger Shadow Minister (Energy and Climate Change)

Several chemists and GPs' surgeries in Merseyside have run out of the flu vaccine, leaving at-risk patients unable to obtain the jab. The Health Protection Agency has highlighted Liverpool as having significantly higher rates of swine flu than the English average. Will Liverpool therefore receive a higher proportion of the £162 million that the Secretary of State has made available to primary care trusts to help those affected?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

The £162 million will be allocated to primary care trusts based on the social care allocation formula, which will be the same for next year. Any GP surgery, or for that matter the primary care trust in Merseyside, is free to come to us to order supplies from the national stockpile of the H1N1 vaccine to ensure that those who require vaccination can receive it.

Photo of Kevin Brennan Kevin Brennan Shadow Minister (Education)

In his answer to my hon. Friend Valerie Vaz, the Secretary of State was clearly giving an after-the-fact justification for his failure to act on the winter awareness campaign earlier in the year. He is fond of telling anyone who ventures to criticise him that they are completely wrong. Will he admit that on this occasion, as far as the awareness campaign is concerned, he was the one who was completely wrong?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

No, absolutely not. I was simply pointing out to Opposition Members that the principle that applied in 2009, which was that the point at which flu was circulating in the community was the point at which the "catch it, bin it, kill it" campaign was initiated, was precisely the same principle that I applied this year.

May I say in response to Luciana Berger that the supplies of vaccine provided to primary care trusts or GPs' surgeries from the national stockpile of swine flu vaccine will be provided free?

Photo of Chris Leslie Chris Leslie Shadow Minister (Treasury)

To be absolutely clear on that answer, does the Secretary of State have any regrets whatsoever about not proceeding with the flu publicity campaign?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

No. I have made it perfectly clear that the principle we applied is exactly the same and was based on the medical advice given to me, which was to pursue an awareness campaign on respiratory and hand hygiene at the point at which flu was circulating in the community. That is what I was asked and that is the decision I took.

Photo of Tom Greatrex Tom Greatrex Shadow Minister (Scotland)

Will the Secretary of State comment on the worrying media reports emanating from Scotland that at a time when there were shortages of vaccine the Department of Health was scrabbling around trying to get supplies from other countries when there was a surplus in Scotland, but it never asked the Scottish Government? Is that the case, or is it nationalist mischief making from Edinburgh?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

All I can tell the hon. Gentleman is the simple truth. In the early part of last week, we asked manufacturers whether they had additional supplies. I believe that some additional seasonal flu vaccine that is licensed for use in this country probably will be made available. In any case, we have the H1N1 vaccine to support the immunisation, where required. Early last week, we did ask Scotland. The amounts that would have been available in the short run were not significant at all, so it was better for them to be retained in Scotland because there might be a continuing need for the vaccine there, rather than here.

Photo of Anne McIntosh Anne McIntosh Chair, Environment, Food and Rural Affairs Committee

Will the Secretary of State explain when in the course of the year the vaccine would normally be ordered?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

It would normally be ordered between March and May.

Photo of Paul Flynn Paul Flynn Labour, Newport West

H1N1 deaths are especially tragic because they involve people with expectations of a long life. Last year, 65,000 deaths were anticipated but fewer than 500 died with swine flu and 150 died of swine flu. If the priorities of the health service are not to be distorted, should not we approach this problem with a sense of both caution and proportion?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I share the hon. Gentleman's deep regret. H1N1, unlike many previous flu strains, does not particularly impact on the elderly; it impacts on younger people and on younger adults in particular. That is the principal reason why we are seeing a relatively larger number of people occupying critical care beds. The NHS response has been to accelerate the provision of critical care capacity and of ECMO beds in particular.

Photo of Ian Paisley Jnr Ian Paisley Jnr Shadow DUP Spokesperson (Work and Pensions), Shadow DUP Spokesperson (Environment, Food and Rural Affairs)

The Secretary of State will be aware that tragically there have been 14 flu-related deaths in Northern Ireland during this winter. Given that that figure is proportionately higher than in other parts of the United Kingdom, what discussions has he had or does he intend to have with his counterpart in Northern Ireland to assess why the proportion is so much higher and whether there is a black spot with regard to that disease?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

The figure of 50 deaths to which I have referred is the total number of deaths verified by the Health Protection Agency. There have been more deaths than that, but they have not been verified to have been caused by flu. I cannot comment on the relationship between the number that I quoted for the United Kingdom as a whole and that for Northern Ireland, because we are not dealing with comparable figures. My colleagues in the devolved Administrations and I will continue to keep in touch. It is important for us not to be simplistic about this. There are differences in vaccine take-up between Administrations-they are not major, but they exist. There are differences in the prevalence of swine flu, and the prevalence of flu in Northern Ireland is very high compared with England-it is even a great deal higher than that in Scotland. Happily, the number of deaths is only ever a very small proportion of the people who contract flu. To that extent, it is difficult to draw from the number of deaths conclusions about the nature of the response to flu overall, not least because the prevalence is overwhelmingly among people who are not in the at-risk groups, who, I hope, were vaccinated.

Photo of Denis MacShane Denis MacShane Labour, Rotherham

Mr Speaker, I am not sure whether you have noticed that since the Secretary of State started making his excuses for this problem, Government Front Benchers and Back Benchers have looked more and more unwell. Will the Secretary of State confirm that he has had the flu jab and that he has made sure that his Front-Bench team have had it?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I take this issue seriously, even if the right hon. Gentleman does not. As it happens, I fall into one of the at-risk groups, because I had a stroke in 1992, so I have had the flu jab. I would not ask members of my ministerial team who are not in the at-risk groups to have the vaccination, because it is not recommended.

Photo of Toby Perkins Toby Perkins Shadow Minister (Education)

The biggest tragedy is that the Secretary of State has learned no lessons whatsoever from what has happened. As a result, it is likely that the same mistakes will be made in the future. His answers about the advertising campaign are completely unconvincing. Will he explain why he cancelled the advertising campaign, which GPs were demanding at the time, to increase the take-up of vaccinations?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

I cancelled no campaign; I proceeded only with the awareness campaign on respiratory and hand hygiene. An advertising campaign aimed at the general population would not have been effective, and I was advised that there was no evidence that it would be effective. We knew who the at-risk groups were, and it was possible to reach them directly rather than engaging in wider advertising.

Photo of Owen Smith Owen Smith Shadow Minister (Wales)

Will the Secretary of State tell us what role primary care trusts and strategic health authorities are playing in dealing with the crisis? Will he explain what dismantling the SHAs and PCTs will do in terms of central planning for future crises?

Photo of Andrew Lansley Andrew Lansley The Secretary of State for Health

The role of SHAs and PCTs is, as in previous years, to manage the NHS response to winter pressures. In future, the commissioning consortiums together with the NHS Commissioning Board, will fulfil similar responsibilities. In future years, there will be a stronger ability to integrate the response of the Department of Health and the Health Protection Agency, working together as one new organisation, Public Health England, which will have a stronger public health infrastructure.