§ The Minister for Social Security and the Disabled (Mr. John Major)
With permission, Mr. Speaker, I wish to make a statement on the Government's response to the McColl report on the artificial limb and appliance services. As the House will know, these important services are administered directly by my Department and the working party was invited to consider them and to make recommendations for the improvement of efficiency and patient care. I am most grateful to the members of the working party for the comprehensive and dedicated manner in which they tackled this task.
The report made wide-ranging and detailed recommendations concerning the organisation and management of the services; the nature of the contracts for the supply of limbs; the quality of the limb-fitting services; and the desirability of closer links between the full range of hospital, community care and local authority services. Action has been taken already to implement many of the recommendations.
We have strengthened substantially the top management of the limb and appliance services by appointing a general manager to head a specialist disablement services division; supported by a new director of operations, and a new director of procurement from the National Health Service.
We now propose to extend the principle of general management throughout the limb and appliance service in order to implement the far-reaching changes we envisage. We intend to reorganise the service into regions with boundaries that are conterminous with those of the National Health Service. Each region will be headed by a senior manager responsible for the entire limb and appliance service in that area. We are also, as I told the House on 17 February, improving the range of wheelchairs that are provided. Pilot projects to improve transport arrangements for patients are under way and improved management systems are alrady in place.
We believe the quality of limb fitting by prosthetists is vital to patient welfare. The McColl report was critical of the level and quality of prosthetic training. We agree that it should be improved. We wish to see professional training and the status of prosthetics upgraded. We have therefore established a joint working party with the limb industry and the Orthotic and Prosthetic Training and Education Council to review speedily the present arrangements for prosthetic training and to make recommendations for improvement. We have already received an interim report from the working party and expect a final report within three months; I shall report further to the House when this is received. I anticipate that implementation of any recommendations will make provision both for initial training leading to a qualification and subsequent in-service training.
We also agree with the McColl report that we should seek improved contracts for the supply of artificial limbs. We are therefore pressing the limb industry to agree to new contractual arrangements that will increase competition and encourage a quicker and more flexible service. Discussions with this aim in mind are continuing and we attach great importance to this principle.
One of the most important conclusions of the McColl working party was that it would be inappropriate for the 152 limb and appliance services to remain under the direct control of the Department of Health and Social Security. I wish to make clear that we accept that recommendation and propose to act on it.
We have therefore decided to establish an interim management board, in the form of a special health authority, with effect from 1 July this year. The authority will be accountable directly to me. I am delighted to announce that my noble Friend Lord Holderness has agreed to be chairman of the new authority. My noble Friend is a distinguished former Member of this House and has a long and proven record of commitment to disabled people. I have no doubt that he will be an excellent chairman.
We envisage the board will have about eight members and their names will be announced shortly following further consultation with the chairman. We shall of course also have regard to the provisions of the Disabled Persons (Services, Consultation and Representation) Act 1986 in appointing board members. However, the House may care to know that I have already invited Professor Ian McColl, chairman of the McColl working party, to join the board as vice-chairman so that the views and knowledge of the working party will be readily available. I am delighted to report that Professor McColl has accepted, and I know that this delight is shared by my noble Friend.
The McColl report identified an imperative need for stronger links with the occupational therapy, physiotherapy and rehabilitation services offered by the National Health Service. We agree with this recommendation. To achieve this aim in the interests of patient care we have concluded that, in the longer term, the right organisational framework for the limb and appliance service would be alongside these services within the regional and district health authorities. This is also the view of the recent report on disability published by the Royal College of Physicians.
Clearly, however, this is a far-reaching change which cannot, in our view, be carried into effect immediately. The process of transition will need very careful management to safeguard the interests of all involved, whether patients or staff. We shall expect the new authority to complete this task in time for integration to take place on 1 April 1991. The instrument establishing the authority will set this as the end date.
The new authority will have a threefold responsibility: to oversee the planning for the eventual transfer of the services; to build upon the improvements already under way; and to run the service for this transitional period. It will have power to appoint its own senior staff. The special health authority will be given its own budget for 1987–88 and planning figures for the two following years. Special arrangements will be made to safeguard the level of funding available throughout the period of the special health authority's life and for a period after integration with health authorities. The authority will also be charged with devising safeguards to ensure that continuity of the services is maintained following integration.
Staff who are currently employed in the service will be invited to work for the new authority. Their existing terms and conditions will apply and the authority will be required to ensure that their interests are protected. Discussions with trade unions and staff will begin today.
The authority will be responsible for the whole of the artificial limb service, for the wheelchair service, and for the provision of appliances to war pensioners. The 153 Government remain committed to ensuring that the status of war pensioners continues to be recognised. We will ensure that the new authority reflects that commitment. Decisions on the future of the artificial eye service will be taken when the current review of the service is complete, but this may also be added to the special health authority's responsibilities. The departmental vehicle schemes will remain directly administered by the DHSS.
The decisions I have announced today represent the most far-reaching changes in the artificial limb and appliances service since its inception. They follow the recommendations of the working party. They meet the aspirations of disabled people, and I am confident they will improve the services available to them. I believe it is right to end the uncertainty of recent years.
The Government look forward to working with the new authority to build a better future for the patients they will serve.
§ Mr. Alfred Morris (Manchester, Wythenshawe)
In thanking the Minister for his statement, I am sure the whole House will acknowledge the importance in human terms of the study undertaken by Professor McColl and his colleagues. May I remind the House of the words of the then Minister for Health when he published the report on 27 January 1986, over 13 months ago? He said that the report hadconfirmed that the services are falling below standard in several respects".and that it hadidentified a number of matters which must be tackled vigorously if the quality of care we want for patients is to be secured and delivered efficiently and economically." — [Official Report. 27 January 1986; Vol.90, c.391.]I must, therefore, ask the Minister why it has taken over 13 months for us to receive today's statement. This surely does not suggest that the Government have been tackling the issues with any urgency or vigour.
The most fundamental question now is whether the Minister agrees that people with disabilities in the United Kingdom deserve a wheelchair and artificial limb service which is equal to the best in the world? Is he satisfied that his statement today will achieve that result? Will the new authority be totally independent so that it can act solely in the interests of disabled people? The chairman is himself a disabled person, but how many users of the artificial limb and appliance service will be members of the authority? Will the Minister also establish an advisory committee of ALAC users so that he will have direct feedback from disabled people themselves?
Can the Minister say any more about the training and upgrading of prosthetists and about giving them responsibility which starts, if possible, before the amputation and lasts until the patient is totally satisfied with the artificial limb? How will employment opportunitis be affected, and can the Minister say anything further today about the Hanger dispute, which he himself has described as "causing distress, worry and inconvenience," not to mention the deep sense of injustice felt by a dedicated work force?
What improvements to transport arrangements for patients does the hon. Gentleman envisage? In relation to artificial arms, will he accept that current hand covers are abysmal and cause considerable distress, especially to young people? On wheelchairs, is he satisfied that his statement will lead to the provision of a safe and comfortable wheelchair which is suitable for each 154 individual who needs one, especially for growing children whose needs can change very quickly? Many of them, sadly, are terminally ill and since we cannot add years to their lives, ought we not at least to add life to their years by making the best possible provision?
How will what has been decided affect physiotherapists and others in the overworked and underpaid professions supplementary to medicine? How will approved repairers be affected, and will they be enabled to stock enough spares to reduce delays in repair and maintenance? Is the Minister aware that one wheelchair user who is well known to many of us, on both sides of the House, has been waiting over nine months for a simple repair? As he is Bert Massie, assistant director of RADAR, who knows the ropes as well as any disabled person in the country, what must the position be for people without his knowledge arid contacts? Will the Minister respond to the desire for occupant-controlled powered outdoor wheelchairs, especially among people over pension age who do not qualify for mobility allowance?
The Minister's statement dealt with many complex issues. Does he agree that they deserve to be debated as soon as possible?
Finally, will the Minister agree that to finance any improvements for some disabled people by reducing benefits or services for other disabled people is not on, and that the recommendation to fund outdoor wheelchairs by abating mobility allowance must be rejected? Does he recognise that, in the week before the Chancellor intends to give away several billion pounds to people whose resources already far outstrip their needs, to cut a benefit paid to people with the least resources and the greatest needs would be wholly unacceptable to this House?
§ Mr. Major
The right hon. Gentleman has raised a number of detailed points to which I shall endeavour to respond. I am grateful to him for his kind words, with which I agree, about Professor McColl and the McColl report.
The right hon. Gentleman asked about the time taken to produce our response. It has certainly taken a year to produce it, but it is better to take a sufficiency of time to produce the right response than to make an early response which perhaps does not meet what is required. I think that the right hon. Gentleman's words confirm that the statement meets the aspirations of disabled people, and that was the prime concern that we had in mind.
In so far as providing the best service in the world is concerned, it is certainly my clear ambition to ensure that the service is substantially better than it has been hitherto. That was the message of the McColl report. That is what the changes are intended to achieve, and I believe that they will do so. The special health authority will have the same degree of independence as any other special health authority and will, as I mentioned in my statement, report directly to me and, through me, to my right hon. Friend the Secretary of State. I shall refer the matter of an advisory committee on artificial limb and appliance centre users to my noble Friend to consider.
As I mentioned in my statement, we wish to see improved training of prosthetists, both before taking their qualification and subsequently in in-service training. We wish also to upgrade their status. Discussions upon that matter will continue. We shall provide full details of employment opportunities to trade unions and staff at our 155 first meeting, which is to commence this afternoon. I believe that they will be found to be satisfactory by the staff concerned.
I am bound to say that Hangers has maintained a high degree of service over recent months. As I have stated on previous occasions when reporting on the unfortunate dispute, we remain in daily contact with the company. I am pleased to tell the House that the backlog is diminishing steadily and the service is substantially improving. I hope that the backlog will be wholly cleared before too long.
The right hon. Gentleman referred to powered wheelchairs and the abatement of mobility allowance. I am not attracted to the principle of an abatement of mobility allowance to provide an alternative improvement elsewhere in the service. The special health authority will be aware of my views upon that point.
In concert with the chairman and vice-chairman, I shall consider future disabled board members at an early date. It is highly likely that other disabled people will be appointed. I must emphasise that they will be appointed not because they are disabled but because they are able, whether or not they are disabled, for they have a big job to do.
The McColl report was primarily concerned with efficiency and stated that substantial savings could be made by a more efficient service. If that proves to be the case, such savings will be available for the special health authority to use as it thinks fit on services for disabled people.
§ Mr. Roger Sims (Chislehurst)
I congratulate my hon. Friend on his positive and far-reaching proposals. They will be widely welcomed, not least by our constituents who have to take advantage of such services. I was glad to hear that he intends to introduce an element of competition into the supply of limbs. Will that competition extend to other forms of equipment? Can the Minister give us some idea of how wide a range of contractors will be given the opportunity of supplying equipment to the service?
§ Mr. Major
I should be unwise to go too far down that line except to state that, as a matter or principle, for the reasons set out in the McColl report and others, we are committed to wide competition. At present, we are discussing contracts with the present suppliers. My hon. Friend is entirely right to point to the benefits of competition among existing suppliers and, no doubt in the future, among other suppliers as well.
§ Mr. Jack Ashley (Stoke-on-Trent, South)
I warmly welcome the ending of the old system of inefficient management control and excessive profits. Will the Minister assure the House that the service will always be geared to providing limbs for the individual, that limbs will not be mass produced and that they will always be free of charge? Does he recognise that a glaring omission from his statement was the need for specialised amputations? That matter was mentioned by McColl, who said that a quarter of amputations are unsatisfactory. One can replace inadequate artificial limbs, but one cannot re-do inadequate amputations. Will the Minister consider the creation of a specialised amputation service?
§ Mr. Major
I shall certainly discuss the right hon. Gentleman's last point with the special health authority. 156 As the right hon. Gentleman will understand, I am bound to say that it raises far wider matters than those that fall naturally within my remit. Let me make it perfectly clear to the right hon. Gentleman that our policy is that every type of limb should be available to every patient at every centre. We want them to have the best possible limbs that we can provide, for it is critical to their standard and future style of life. That is our clear intention.
§ Dame Jill Knight (Birmingham, Edgbaston)
Does my hon. Friend recognise that there will be great pleasure at the Government's swift response, once again, to an expert report? However, may I ask him whether the term "appliance services" includes ileostomy and colostomy appliances? Will there be machinery within the new set-up for research into complaints that appliances, such as artificial hands, are unsatisfactory and could be better?
§ Mr. Major
I am most grateful to my hon. Friend for her kind remarks. The service is principally related to artificial limbs, whether upper or lower limbs, and to the wheelchair service. It may also include the artificial eye service, though that has yet to be determined, and the various services for war pensioners, wigs and orthopaedic equipment. It does not include the other specific matters that were mentioned by my hon. Friend.
§ Mr. Simon Hughes (Southwark and Bermondsey)
The Minister will be aware that we welcome thoroughly the report, as we welcome also the work done by Professor McColl and his working party. One of the conclusions to which the working party was forced to come was that the disabled have been very badly served.
It would be appreciated if the Minister could say this afternoon that the new special health authority will have true independence to say exactly what is needed by the disabled, that it will also have the budgetary capability to deal with what is required and that, tied in with the annual presentation of the special health authority's report to the Minister over the four-year transitional period, it will be possible to have a debate in the House about how the proposals are being implemented. Major criticisms have been made. However, the proof of the pudding will lie in how well the special health authority is allowed to get on with its important job.
§ Mr. Major
I agree with much of what the hon. Gentleman has said, and I am grateful to him for saying it.
As for a debate on this subject, that is a matter for my right hon. Friend the Leader of the House, who will have heard what the hon. Gentleman said. No doubt he will contemplate holding a debate both this year and in future years.
As for independence, I touched on that point in my answer to the right hon. Member for Manchester, Wythenshawe (Mr. Morris). The concern and importance that we attach to independence could not be more clearly illustrated than by the appointment of my noble Friend Lord Holderness as chairman. The extent to which we are committed to the principles of the McColl report could not be more clearly illustrated than by the fact that we have invited Professor McColl to serve as vice-chairman of the management board and by the fact that he has accepted.
As for funding, I mentioned in my statement that we shall be protecting the funding during the life of the special 157 health authority and for a short period after it is subsumed within the National Health Service. Therefore, the hon. Gentleman's points, well made, have been well met.
§ Sir Hugh Rossi (Hornsey and Wood Green)
I add my congratulations and thanks to my hon. Friend for his far-reaching statement. The McColl committee was set up originally to look at inherent weaknesses in the artificial limb system that has existed not only for the last 13 months but for many decades, including the period when the right hon. Member for Manchester, Wythenshawe (Mr. Morris), who was so churlish in his acceptance of this statement, was Minister.
I am somewhat disappointed by my hon. Friend's cautious approach to the monopoly that is enjoyed by a handful of firms whose attitude has been less inclined towards giving a service to clients and patients than towards satisfying DHSS officials who are their ultimate paymasters. It is that more than anything else that led to the setting up of the McColl committee, as I am sure my hon. Friend will recognise.
§ Mr. Major
My hon. Friend makes some powerful points, though with typical modesty he does not mention that in fact it was he who established the McColl committee some years ago. I believe that many disabled people, both now and in the future, will thank him for having done so.
I take entirely to heart my hon. Friend's remarks about the apparently cautious approach to monopoly. We are in the midst of discussions, and at this moment anything other than a cautious approach would not be well made. However, I emphasise to my hon. Friend and to others that our objective is competition and efficiency in the interests of both the National Health Service and the patients.
§ Mr. Ernie Ross (Dundee, West)
Will the Minister say whether the statement made last week for Scotland by his noble Friend Lord Glenarthur reflects the way in which he would have responded had he had the responsibility for the supply of artificial limbs in Scotland and whether the body that he is discussing will have responsibility in Scotland? The Minister will know that the McColl report differentiates clearly between the practices in Scotland, which are to be preferred, and those in England and Wales. Does he agree with my right hon. Friend the Member for Manchester, Wythenshawe (Mr. Morris) that there should be an early debate so that those different practices can be discussed?
As an hon. Member sponsored by the unions with which the Minister's associates will be discussing the proposals, I should like to ask him whether he could arrange a debate, once we know the outcome of those discussions, so that the House can be informed whether those who have been concerned with the supply of limbs are happy with the Minister's statement.
§ Mr. Major
On the question of a debate, I can only reiterate the remarks that I made a moment ago.
I do not have responsibility for the artificial limb service in Scotland, but I am aware of the provisions in the statement made by my hon. Friend the Minister for Health a few days ago. The special health authority applies to England. For a long time there have been separate systems to deal with the artificial limb and appliance service in other parts of the United Kingdom.
§ Sir John Page (Harrow, West)
Is my hon. Friend aware that hon. Members on both sides of the House will be delighted to learn that Lord Holderness has accepted the position of chairman of the new board. As an amputee, he has special insights, and as a former Minister responsible for pensions and national insurance, he will be able to work his way through the bureaucratic jungle. He and Professor McColl will make an extremely strong team.
§ Mr. Major
I am grateful to my hon. Friend. I am sure that my noble Friend will not only work his way through what my hon. Friend has described as the bureacratic jungle, but where such a jungle is shown to exist, I am sure that my noble Friend will trample all over it. I share my hon. Friend's view and cannot conceive of a better chairman for the authority than my noble Friend.
§ Mr. Martin Flannery (Sheffield, Hillsborough)
Does the Minister agree that one of the valuable by-products of the work of Professor McColl and his colleagues has been the democratic pressures that have been exerted on many of us by people who are chronically disabled and who are waiting for the report to come out and to see what the Government will do? Will he accept that this has brought into action many Members of Parliament who hitherto did not know a great deal about this matter but who have now visited the prosthetists in their workshops, and looked at the chairs.
Have we made a real advance in giving more of the chronically disabled access to the dual-purpose, battery-powered wheelchairs because, when we table questions on it in the House, letter after letter comes to us from a wider grouping of people than we ever thought needed such chairs?
§ Mr. Major
The early part of the hon. Gentleman's observations are entirely accurate. Many hon. Members on both sides of the House have expressed concern and interest in this important report.
As for battery-powered wheelchairs, and indeed wheelchairs generally, one of the principal responses of the McColl report was to suggest that there may be substantial room for improvement in the wheelchair service and possible savings to be made in its organisation and administration. I reiterate the point that I made a moment ago. If those savings are made under the management of the special health authority, they will be available to that authority to use in the wheelchair service or elsewhere in the service of disabled people as it thinks fit.
§ Mr. John Hannam (Exeter)
In welcoming my hon. Friend's announcement, I should like to thank him especially for the extensive consultation that he has had with all the disabled persons' organisations, outside as well as within the House. I congratulate him on his decision to establish a management structure outside the DHSS, and also on the appointment of Professor McColl as vice-chairman of that structure. Will my hon. Friend pay particular attention to the use of modern technology in the design and fitting of wheelchairs and artificial limbs?
§ Mr. Andrew Faulds (Warley, East)
In view of the fact that one of my constituents, a heavily built middle-aged lady, had to wait the best part of a year for her right leg, and in the light of the statement this afternoon, which we 159 welcome, when can she and others expect a real improvement in fitting, provision and servicing — immediately, in a few months, or after a couple of years?
§ Mr. Major
The changes that have been made in recent months are already showing a substantial improvement. If the hon. Gentleman's constituent, or, indeed, a constituent of any hon. Member, finds herself in that sort of circumstance, I hope that hon. Members will draw it speedily to my attention. We now have a management structure which should ensure speedy treatment for those who fall into the circumstances set out by the hon. Gentleman.
§ Mr. Lewis Stevens (Nuneaton)
I, too, congratulate my hon. Friend on the excellence of the Government's positive response which will give great encouragement to the disabled and those who work with the disabled. I know that he is aware that one of the problems facing disabled people is the difficulty of obtaining appointments at limb centres and then of obtaining transport to and from them. Has he any initiatives in mind to ease that problem?
§ Mr. Major
My hon. Friend is entirely right. One of the principal operational problems for disabled people has been, first, obtaining an appointment and then finding the transport to take them to the appointment and home again. In both instances we have management initiatives in mind which we think will substantially ease and solve those problems. That will be welcome. I am also considering a specific budget to be administered locally by the artificial limb and appliance centres to deal specifically with transport problems.
§ Mr. Dennis Skinner (Bolsover)
Is the reasoning behind the Minister's statement today about implementing the recommendations in the McColl report to try to provide a better, quicker and more effective service at the point of delivery for people who lose limbs in the mining industry and industry generally, as many of my constituents have done? The Minister is prepared to set up a new authority which obviously has quango implications.
Will the hon. Gentleman bear in mind that scores of workers at Hanger want to return to work to provide limbs quickly and efficiently? Indeed, they could do so if only the Minister or one of his colleagues visited the management there and intervened, as the Government have done in some issues recently. The Government are well known for getting involved in all sorts of dramas and crises. Why do not the Government tell the management that they want the limbs produced more quickly and that the way to do it is to get those men and women back to work?
§ Mr. Major
We certainly require the limbs more speedily, which is why we have set up arrangements for there to be daily contact with the company. I am pleased to tell the hon. Gentleman that that objective is being met increasingly. However, it would be neither productive nor proper for me to intervene directly in the dispute. Our objective is the one that the hon. Gentleman accurately set out: we need a better service for the disabled.
§ Mr. Peter Bruinvels (Leicester, East)
I welcome my hon. Friend's responsive and caring statement. Any improvements in limb fitting are to be particularly welcomed. One of my constituents had three replacement limbs, none of which fitted properly and she had to go to 160 Scotland to get them done properly. I congratulate my hon. Friend and thank him on behalf of all disabled people.
§ Mr. Tom Clarke (Monklands, West)
In view of the Minister's welcome references to the Disabled Persons (Services, Consultation and Representation) Act 1986, does he accept that the sections which deal with assessments will be particularly helpful to the various committees that he mentioned and to Professor McColl in identifying individual needs at a given stage in the life of disabled people? Can he tell the House when the orders will be introduced?
§ Mr. Fred Silvester (Manchester, Withington)
May I press my hon. Friend on the dual-purpose, indoor-outdoor wheelchair? One of the discussions around the report was about young people who suffer from diseases which will shorten their life expectancy. What is the position of the fairly rapid provision of suitable wheelchairs for those people?
§ Mr. Major
I assume that my hon. Friend has in mind patients suffering from muscular dystrophy and similar afflictions. Today I cannot say precisely what the position will be on that. It is a matter which we shall wish to discuss with the chairman and other members of the special health authority. Clearly, there are particular technical and design difficulties with such a wheelchair, apart from the other problems, of which my hon. Friend will be aware.
§ Mrs. Virginia Bottomley (Surrey, South-West)
Does my hon. Friend agree that the artificial limb and appliance centres now serve a different and aging population compared with that which the centres were introduced to serve in 1915? While one welcomes the recognition in his statement of the needs of war pensioners, they are now only a minority of the users of the service. Is he aware that his statement will be warmly welcomed by those who want to see an effective and up-to-date service for the disabled?
§ Mr. Major
I am grateful to my hon. Friend for her remarks. She is right; the artificial limb and appliance centres now treat a different clientele from what would have been their typical clientele a few years ago. In recent years the improvement in the service has been substantial, and I am grateful to the many staff who work in the service who have helped to bring it about.
§ Mr. Patrick Nicholls (Teignbridge)
I welcome my hon. Friend's response to the McColl report. Does he agree, particularly in view of the comments of my hon. Friend the Member for Hornsey and Wood Green (Sir H. Rossi), that the time now appears to have come when contracts for the supply of artificial limbs should be put out to competitive tender?
§ Mr. Nicholas Winterton (Macclesfield)
As a member of the Social Services Select Committee with a particular interest in this area, and having recently met Professor Kennaway of Imperial college and Dr. Montgomery of the University of London, may I tell my hon. Friend that his statement will be warmly welcomed by all those with any knowledge of the disabled and of those who need artificial limbs and appliances?
Will my hon. Friend take on board two points which need immediate priority attention? The first concerns the training of prosthetists, which is of the utmost importance. Will he give further consideration to that? The second is that it is now time that the facilities of the companies that supply the DHSS are increased so that limbs are not just available for those who need them, but are made to suit the patients. That is long overdue.
§ Mr. Major
My hon. Friend has a long-standing interest in this matter, so I am especially grateful for his support. We are seeking to conclude the work of the working party studying the training of prosthetists as speedily as possible and I hope that we can carry its recommendations into effect with the objectives that my hon. Friend set out. I entirely take my hon. Friend's point about competition, which is an important one.
§ Mr. Alfred Morris
As the Minister knows, my principal concern today, indeed my duty, was to reflect the many worries expressed to me by disabled people and their organisations. I fully accept, and I hope the whole House will appreciate, the importance of the role of the hon. Member for Hornsey and Wood Green (Sir H. Rossi) in this matter.
With regard to a debate, will the Minister join me in an appeal to the Leader of the House, who has been an interested observer today—he is in reflective mood—for parliamentary time to look in more detail at decisions which are so deeply important to severely disabled people?