What is BIA-ALCL?

In 2016, the World Health Organisation (WHO) defined a new type of anaplastic large cell lymphoma (ALCL),), which is,is itself,itself an uncommon type of non-Hodgkin lymphoma with several subtypes. The WHO labelled this new variant as breast implant associated anaplastic large cell lymphoma or BIA-ALCL*. It has specific diagnostic criteria, which include positive expression of the marker CD30, negative for ALK,anaplastic lymphoma kinase (ALK), and a distinct cell morphology.

The MHRA’sMHRA investigation into BIA-ALCL continues and, as with all issues examined by us, we take an evidence-based approach across a range of data sources. Research into this area is yet to provide the answer as to how BIA-ALCL develops. There are several theories. One is that surface texturing on implants may play a role. There are three3 main surface textures which coat a breast implant;implant: smooth, textured, and polyurethane. Research is continuing in the UK and in other countries around the world to better understand how BIA-ALCL develops.

Current UK advice

Information for patients

The most common symptom for people with BIA-ALCL around breast implants,implants is fluid collecting around the implant (‘late’ seroma). You might notice a fairly quick, but painless, increase in size of the affected breast, usually over a few weeks. In some cases, it can affect both sides at the same time.

Most cases have happened years after surgery. Very rarely BIA-ALCL has been found when a lump develops next to an implant, or withinin the tough fibrous tissue that can build up around an implant (called a capsule).

The European Commission’s Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) final opinion on BIA-ALCL reports that the occurrence of BIA-ALCL is uncommon.

However, it is important that you know about the risks if you already have, or are considering having, breast implants. If you develop a seroma, a breast lump or swelling around your implant more than a year after having the breast implant, you should ask your implanting surgeon for advice. Also tell your GPGP, who may need to refer you to your local NHS Breastbreast Carecare service.

Before you have breast implant surgery, it is important that you talk with your surgeon to discuss the benefits and risks as part of a shared decision-making process. You should make sure that you understand the risks involved before giving your informed consent** to the treatment option that is right for you. The MHRA recommends that prospective individuals are provided with information about breast implant surgery and possible complications either in written format or via an online link to information sheets jointly written by the Association of Breast Surgery (ABS(ABS)),, British Association of Aesthetic Plastic Surgeons (BAAPS(BAAPS)) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS(BAPRAS)).. These associations are some of our clinical stakeholders. They aim to increase understanding of their field, share learnings, inform patients and align with our patient safety goals.

If you have developed a problem with a breast implant you should tell your surgeon and GP and also report it through the MHRA Yellow Card Scheme.

Information for healthcare professionals

Clinicians have a legal obligation to discuss the potential risk of BIA-ALCL when seeking informed consent of new patients, and with any patient returning for review of their breast implants.

When reporting a case of BIA-ALCL in patients with breast implants, surgeons are reminded to include (where it is known):

• the patient’s CD30+/-, ALK +/- status
• full details of the device, including manufacturer, model, surface texture (as identified by the manufacturer)
• the presenting clinical features and the subsequent management
• other information including the dates of initial implantation, revision, and explantation
• information on previous implants, particularly whether tissue expanders have been used and for how long

This information is vital to enable the MHRA to build a better picture of the prevalence of this issue, which contributes to the global effort to better understand this disease.

Report any suspected or actual adverse incidents involving these devices through your healthcare institution’s local incident reporting system and/or your national incident reporting authority as appropriate:

• report incidents in England, and Wales
• report incidents in Scotland,
• report incidents in Northern Ireland, Wales.

Please also ensure the patient’s details are included in the Breast and Cosmetic Implant Registry (BCIR)).. Patient consent is no longer required for this information to be recorded and doing so will not breach General Data Protection Regulation (GDPR) rules.

Providing this information to the registry is a legal obligation under section 259(1)(a) of the Health and Social Care Act 2012.

Reports to the MHRA

Anyone can report any incident relating to a medical device or medicine to us through our Yellow Card scheme. We collect and analyse all reports of ALCL in patients with breast implants and tissue expanders. Tissue expanders are medical devices used to expand the breast tissue in preparation for breast implant surgery.

Reporting data on BIA-ALCL

• As of 31 December 2021,2023, we had received 81 reports of confirmed BIA-ALCL where the surgery occurred in the UK and 6 reports where the surgery occurred outside of the UK.

• The current estimated incidence of BIA-ALCL, based on confirmed cases where surgery occurred in the UK, is 1 per 16,500 implants sold.

TheAll confirmed cases have been found in patients with breast implants that met the WHO diagnostic criteria for BIA-ALCL. The number of confirmed cases reported to the MHRA has increased by four25 since the last update in December 2020.2021.  

Obtaining confirmation of reports from 2024 is currently in progress.

The estimated incidence is calculated by dividing the number of confirmed cases of BIA-ALCL by the number of breast implants and tissue expanders sold in the UK. It does not include BIA-ALCL cases where the surgery occurred outside of the UK. This is called an ‘estimate’ because some cases of BIA-ALCL may not have been reported to the manufacturer or the MHRA, and not all implants sold in the UK have been implanted into patients.

Of the confirmed cases of BIA-ALCL in people with breast implants in the UK, there has been one death reported to the MHRA. TwoThree deaths from ALCL were reported to the MHRA which did not meet the WHO diagnostic criteria for BIA-ALCL. The overall survival rate for patients diagnosed with BIA-ALCL is 89% at 5 years. This rate is significantly higher for patients with Stage I disease who undergo complete capsulectomy and implant removal (see Journal of Clinical Oncology). Furthermore, studies show, 93% of patients are disease free at 3 years follow-up, which is an excellent prognosis when treated appropriately (see American Society of Plastic Surgeons).

ALCL can also occur in the breast due to other causes. Therefore, the number of reports we receive may not only be related to the breast implants. However, we still need to collect reports of ALCL in people with breast implants to build up a better picture of what is happening.

The MHRA is working to deliver greater transparency of medical device data. This will ensure that both patients and clinicians are better informed on the benefits and risks associated with breast implants when deciding on the option that is right for them. Greater transparency includes providing a more detailed breakdown of the total number of confirmed reports of adverse incidents as shown below.

Cases of BIA-ALCL where the patient has only had one implant or one pair of implants (primary cases)

Cases of BIA-ALCL where the patient has only had one implant or one pair of implants are classed as primary cases, which are shown in Table 1.

Table 1. Breakdown of 4062 primary confirmed BIA-ALCL cases as of 31st31 December 20212023 by;by manufacturer, surface texture of the implant and all-time sales, all of which have been implanted in the UK.UK

N.B.Note: Thethe table excludes 3 reports ofwith an unknown manufacturer.manufacturer and 3 non-UKreports surgeriesassociated havewith alsonon-UK beensurgeries, removed, leaving 4062 total cases.

Confirmed casescases by by implant surface texture	Allergan	Eurosilicone SAS	Mentor Medical Systems B.V.	Nagor Limited	Polytech Silimed Europe GmbH	Silimed	Total
Smooth implant casescases (number (number of sales)	0 (9,827)0 (9,827)	0 (2,693)0 (2,867)	0 (17,322)0 (24,466)	0 (12,088)0 (19,773)	0 (9)0 (3)	0 (3)0 (56,936)	0 (41,942)
Textured implant casescases (number (number of sales)	27 (522,175)42 (522,163)	1 (36,026)1 (29,862)	4 (353,347)5 (400,043)	4 (153,068)11 (161,172)	1 (10,793)0 (22,625)	0 (22,625)59 (1,135,865)	37 (1,098,034)
Polyurethane implant casescases (number (number of sales)	0 (0)0 (0)	0 (0)0 (0)	0 (0)0 (0)	0 (0)0 (0)	0 (965)2 (22,531)	1 (22,531)2 (22,531)	1 (23,496)
Cases of implants with an unknown texture	21	0	0	0	0	01	2
Sales of implants with unknown texture	0	41,14748,598	0	0	0	048,598	41,147
Total casescases  (total (total sales)	29 (532,002)43 (531,990)	1 (79,866)1 (81,327)	4 (370,669)5 (424,509)	411 (165,156)(180,945)	1 (11,767)2 (45,159)	1 (45,159)62 (1,263,930)	40 (1,204,619)

History of multiple implants

Where a patient has had multiple implants over time, and they are all of the same texture and from the same manufacturer, they can be linked to a case of BIA-ALCL, as shown in Table 2.

A full implant history can be difficult to obtain for patients who have had multiple implants. It can also be difficult to ascertain which implants are associated with the BIA-ALCL because it can take years to develop. However, in their final opinion in 2021, SCHEER state that almost all cases of BIA-ALCL were found with breast implants with a textured surface.

Table 2. Breakdown of 8 confirmed BIA-ALCL cases as of 31 December 2023 by manufacturer,manufacturer and all-time sales, implanted in the UK, where the patient has a history of multiple implants of the same type of breast implant.implant

Previous implants are from the same manufacturer and are the same surface texture as the implant at the time of diagnosis.

	Manufacturer		Allergan		Mentor		Nagor		Silimed		Total
Confirmed cases where previous implants are from the same manufacturer and same surface texture as the implant at diagnosis	4	2	1	1	8
Manufacturer sales	532,002531,990	370,669424,509	165,156180,945	45,159	1,112,9861,182,603

There are 3942 cases where patients have received multiple implants from different manufacturers, or received implants of different surface textures, to the implant at the time of diagnosis of BIA-ALCL, or where the manufacturer details are unknown, or the surgery happened outside of the UK. For these cases, BIA-ALCL cannot be linked to a particular implant, therefore are not shown in the tables above.

Any breast implant surgery carries some risk, and each surface texture of implant has different benefits and risks. For more information on this, please see Information about BIA-ALCL for people with breast implants.

Notes onand datalimitations presentationto the data 

The numberMHRA ofcontinually BIA-ALCLreviews casesdata andacross salesimplant includetypes bothand tissueall expandersmanufacturers andthat sell breast implants.

Theimplants salesin figuresthe presentedUK for trends in the tablesincidence aboveof areBIA-ALCL. forWe eachinvestigate manufacturerany andtrends foridentified alongside all theiravailable breastevidence implants and tissueif expandersany soldnew inor theincreased UK.risks are confirmed, we will take appropriate action to ensure these are communicated to patients and healthcare professionals.   

PatientsThe withMHRA BIA-ALCLconducts inextensive bothinvestigations breastsand arefollows rare,up howeverwith whenmanufacturers, found,surgeons itand ismembers reportedof asthe twopublic casesto maintain the accuracy of BIA-ALCL. reports. However, there are limitations and caveats to how the data should be interpreted:

• If the numberdata shown is a representation of breastBIA_ALCL implantsincidence andas tissueof expanders31 soldDecember increases,2023 then- obtaining confirmation against the numberWHO criteria of casesreports offrom BIA-ALCL2024 mayis alsocurrently eventuallyin increase.progress

• the However,sales notfigures presented in the tables above are for each manufacturer and for all their breast implants and tissue expanders sold in the UK have(this beenmeans implanted.that Weif do not know the number of breast implants thatand havetissue beenexpanders implantedsold intoincreases, patients.

  Therethen isthe nonumber evidence of ancases increased risk of BIA-ALCL associatedmay withalso anyeventually specificincrease manufacturer;- therehowever, is not aall statisticallyimplants significantsold difference in the occurrenceUK ofhave BIA-ALCLbeen betweenimplanted, we do not know the manufacturersnumber of productsbreast soldimplants inthat thehave UK.been implanted into patients)

• Therethere are other breast implant manufacturers that are not named in the tables above.above This- this is because these manufacturers do not have any reported cases of BIA-ALCL associated with their breast implants,implants in the UK.UK This(this may be due to a number of factors, including manufacturers only recently selling on the UK market;market, so,so their sales figures are lower, or cases of BIA-ALCL may not yet have been reported to the MHRA, or may not have happened because BIA-ALCL may take years to develop.develop) 

• on average, symptoms of BIA-ALCL occur 7 to 10 years after the implantation - some manufacturers may show a proportionately higher number of cases compared to their total sales due to a longer presence on the market

• if a manufacturer discontinues breast implants in the UK market, their reporting rate of BIA-ALCL cases is likely to continue to rise as the estimated time to onset is many years after breast implants have been implanted and their sales figures will not have increased

• this data cannot be used to compare differences in incidence between manufacturers  

• patients with BIA-ALCL in both breasts are rare - however, when found, it is reported as 2 cases of BIA-ALCL

Incident reporting in the UK

As part of the regulating the use of medical devices, manufacturers must submit adverse incident reports (AIRs) for incidents that occurred in the UK. This system is to ensure that the benefits of medical devices used in the treatment of patients outweigh any risks associated with the device. AIRs are reviewed and, where appropriate, action is taken to prevent the issue from happening again, or to reduce the risk of adverse events.

We also receive AIRs directly from healthcare professionals and patients. It is not compulsory for healthcare professionals to report incidents directly to us, but we strongly encourage this, and it is recommended by many professional standards.

AIRs by members of the public are voluntary.

Every report counts. We monitor the safety and performance of breast implants and tissue expanders and encourage reporting of any adverse incidents through our Yellow Card scheme. We use a range of data sources to find any signals of harm and where necessary, take action to reduce risk and maximise benefit to patients.

All reports are sent to the manufacturer of the device (if known and patient details are anonymised as appropriate) to help the monitoring of the safety of medical devices.

Healthcare professionals should input patient details into the BCIR. As this registry progresses it will help us to get a better picture of the incidence of BIA-ALCL. This will further aid us in our role of monitoring the safety of breast implants and tissue expanders.

MHRA actions

Patient safety remains our highest priority. The MHRA continues to collect and analyse a range of information from patients, members of the public, UK healthcare professionals and other sources about this issue so we can build a fuller picture of the occurrence of this uncommon disease in association with breast implants. Where necessary, we will take further action as quickly as possible.

Medical Devicedevice Alertsalerts (MDA)

The MHRA has informed surgeons about the potential risks of BIA-ALCL in patients with implants in Medicalmedical Devicedevice Alertsalerts issued in February 2011 (MDA/2011/017) and updated in July 2014 (MDA/2014/027), and most recently in July 2018 (MDA/2018/027).

These alerts advise surgeons to strongly encourage patients to check for symptoms such as lumps, swelling or distortions through continued regular self-examination and to consult their GP or implanting surgeon if they have concerns. The alerts in 2011 and 2014 advised surgeons to report cases of BIA-ALCL to the MHRA and the alert in 2018 also advised surgeons to include the risks of BIA-ALCL in consenting patients for breast implant surgery as part of shared decision making.

TheWe MHRA regularly reviewsreview the information itwe provides to hospitals, clinics and surgeons to determine if any updates are required. FurtherWe will publish further or updated advice is issued as appropriate.

TheWe MHRAhave has changed the way itwe issuesissue safety information to healthcare providers. We stopped issuing Medicalmedical Devicedevice Alertsalerts (MDAs) in September 2020. ThisSafety pagecommunications concerning medicines, medical devices and other healthcare products describes the different communications that thewe MHRApublish. publishes. Note that the advice in many MDAs remainremains valid until and unless they are archived. If you were signed up to receive Medicalmedical Devicedevice Alerts,alerts, you need to now subscribe to receive Nationalnational Patientpatient Safetysafety Alertsalerts and Devicedevice safety information.information.

MHRA Expertexpert Advisoryadvisory Groupgroup

To assist us in our work, and to advise us on how we communicate and engage with patients and healthcare professionals on implantsimplants, we have formed an independent expert advisory group;group: the Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG) who are working with us to review the risks associated with breast implants.

Members of the group have world-recognised expertise and are helping us to provide a greater understanding of the disease and potential risk to patients to help guide any further necessary MHRA action.

PRASEAG havehas published an information documentdocument: (informationInformation about BIA-ALCL for people with breast implants)implants based on important questions the surgeons on the group have received during consultations with patients.

Information about BIA-ALCL for people with breast implants

PRASEAG havehas also been pivotal in creating UK clinical guidelines for healthcare professionals involved in the diagnosis and treatment of people with BIA-ALCL. The clinical guidelines have been published in the following journals:

• British Journal of Haematology
• European Journal of Surgical Oncology
• Journal of Plastic, Reconstructive & Aesthetic Surgery

Certain members of the group have contributed to a paper providing guidelines on the pathological diagnosis and management of BIA-ALCL, see here and here.

PRASEAG Chair

PRASEAG is chaired by Mr Nigel Mercer, Consultant Plastic Surgeon and immediate past President of the Federation of Surgical Specialty Associations. He is also a past President of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS) and twice past President of the European Association of Societies of Aesthetic Plastic Surgery (EASAPS).

PRASEAG Vice-chairmembership 

The Vice-chair of PRASEAG is Miss Fiona MacNeill (Consultant breast surgeon, past President of Association of Breast Surgery).

PRASEAG Membership

PRASEAG membership currently consists of Presidentspresidents and/orand representativesone ofrepresentative from the Association of Breast Surgery (ABS), the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) along with representatives from the following organisations:

• Breast and Cosmetic Implant Registry (BCIR)(BCIR)
• British Society of Haematology
• Global BIA-ALCL Network Forum
• Royal College of Pathologists
• Royal College of Radiologists
• Joint Council for Cosmetic Practitioners (JCCP) 
• Cosmetic Practice Standards Authority (CSPA) (vacancy)

Areas of expertise covered by PRASEAG include:

• Geneticgenetic epidemiology
• Haemato-oncologyhaemato-oncology with a special interest in lymphoma
• Oncoplasticoncoplastic and reconstructive breast surgery
• Pathology-pathology - surgical infection and microbiology
• Pathologypathology - cellular and molecular tumour biology
• Patientpatient advocacy (vacancy)
• Plasticplastic and reconstructive surgery
• Radiologyradiology (medical imaging)
• Toxicologytoxicology and immunology

Collaborations

UK

We work closely with clinical stakeholders including the Association of Breast Surgery (ABS), British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS).

The Joint statement between ABS, BAAPS, BAPRAS & MHRA on BIA-ALCL,BIA-ALCL, July 2018 (PDF, 78.5 KB, 2 pages) remains relevant.

The Breast and Cosmetic Implant Registry (BCIR)(BCIR)

The Breast and Cosmetic Implant Registry (BCIR)(BCIR) was launched by NHS Digital in October 2016 to capture the details of all breast implant procedures undertaken in EnglandEngland, byScotland bothand Northern Ireland. Both the NHS and independent healthcare providers.providers can submit data to the registry.

The registry aims to provide the data needed to detect any early safety signals in relation to an implant and provide a mechanism for managing patients in the event of an implant recall. This will further aid the MHRA in its role of monitoring the safety of breast implants for patients.

Patients can request through their surgeon, hospital, or clinic where they were treated, that their details are added retrospectively to the BCIR.BCIR.

Projects

We have worked with a research organisation to better understand how patients and the public perceive the risks associated with having breast implants. This research study consisted of in-depth interviews and surveys with patients. We are working to improve how the risks are communicated to patients, at consultations, through written materials, including all forms of advertising and social media. We have asked manufacturers of breast implants to clearly state the risk of BIA-ALCL on their product information leaflets.

EU

The MHRA was part of an EU taskforce monitoring BIA-ALCL with the aim of getting a picture of the issue across Europe and to understand the scientific issues surrounding the disease. Further work was undertaken relating to this (see below).

International activities

The MHRA’s response to recent international activity (November 2020)

We continue to regularly monitor and review all available evidence and emerging information about the safety of breast implants. We will update our advice where necessary. PeopleBased on ongoing data, people with breast implants do not need to have them removed in the absence of any symptoms that have been associated with this uncommon form of cancer. This advice is consistent with all international regulators.

If people have any questions about their implants, they should speak to their implanting surgeon or GP.

The European Commission’s Scientific Committee on Health, Environmental and Emerging Risks

The European Commission’s Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) has a mandate to provide advice on the state of scientific knowledge regarding a possible connection between breast implants and anaplastic large cell lymphoma. SCHEER have published theirits final opinion on BIA-ALCLthe safety of breast implants in relation to anaplastic large cell lymphoma, which was open for public consultation until December 2020. One of the recommendations is for more research to be undertaken and this is in line with advice issued by the MHRA in relation to the management of asymptomatic patients who have breast implants.

ANSM (the(French French regulator)

On 6-76 to 7 February 2019 the French regulator ANSM held a public meeting on BIA-ALCL. Their expert advisory group published their recommendations on the use of textured breast implants.

On 4 April 2019 ANSM published a precautionary decision to restrict the use of certain types of textured breast implants and polyurethane coated breast implants in France.

Implants with very strong texturing, such as macro-textured implants and polyurethane implants, remain prohibited in France.

PRASEAG produced a joint statement.

statement: Statement from the Chair of the PRASEAG, 4 April 2019 (PDF, 66.6 KB, 1 page)

In January 2023, ANSM published new data on breast implant market surveillance in France.

Dutch National Institute for Public Health and the Environment (RIVM)

On 19 November 2018 we participated in the workshop of an international expert group consisting of EU taskforce members, regulatory authorities, manufacturers and representatives of the scientific and medical professional bodies on BIA-ALCL.

While most cases of BIA-ALCL have been reported in patients with textured implants, at that time they concluded there is not enough scientific evidence of a causal relationship specifically between textured implants and BIA-ALCL. ASee the summary of the meetinginternational canexpert bemeeting viewedon hereBIA-ALCL.

Following the French announcement in April 2019, the Dutch Regulatorregulator asked RIVM to interpret the French action relating to certain macro-textured and polyurethane coated breast implants. The RIVM report on breast implants and the risk of BIA-ALCL was published on 17 May 2019.

The Dutch regulator also published a response to the RIVM report on the ANSM action.action.

The advice provided by the Chair of PRASEAG in the 4 April 2019 statement above remains unchanged.

FDA (USA regulator)

On 25-2625 to 26 March 2019 the FDA held a public meeting to discuss breast implants. At this meeting, an advisory panel considered the continued availability of breast implants, but no recommendation to restrict any type of breast implant was made to the FDA. The majority of patients who presented at the meeting highlighted the importance of the informed consent process.

The EU taskforce presented a joint oral statement at the FDA meeting.

meeting: Oral contribution from the European Taskforce on Breast Implant Associated-ALCLAssociated-ALCL for FDA Hearing on Breast Implants, 25 – 26 March 2019 (PDF, 26.8 KB, 2 pages)

The FDA released a press statement on the outcome of this meeting.meeting.

TGA (Australian regulator)

On 2629 SeptemberOctober 20192020 the TGA (Australia)updated announcedtheir awebpage planon tothe take regulatory action to limit the use of some textured breast implants and tissue expanders sold in Australia. Australia operates under a different regulatory framework to the UK. Implants available in Australia are listed on the Australian Register of Therapeutic Goods (ARTG)(ARTG). whichMore caninformation beis foundavailable on the TGA website. 

In 2024, the TGA published Australia’s breast implant risk management framework, which outlines their website.processes to identify and manage risk relating to breast implants.

Health Canada (Canadian regulator)

Health Canada completed an update to its 2017 safety review on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This updated review was triggered by newly reported Canadian cases, as well as newly published literature and information issued by international regulatory agencies. 

On 27 May 2019, Health Canada notified Allergan of the suspension of the licences for Biocell breast implants.

Engagement with other regulators

The MHRA has also been in contact with regulators aroundin theother world,countries, including Canada and Australia sharing information about this disease to gain a global view of how it has been affecting their populations. Differences in the occurrence of the disease in different populations is important in understanding the mechanisms which may be involved in its cause.

Additional information on ALCL

UK professional associationsassociations:

• British Association of Aesthetic Plastic Surgeons (BAAPS)
• British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS)
• Association of Breast Surgery (ABS)

Regulatory agencies from outside the United KingdomKingdom:

• Thethe Australian Therapeutic Goods Administration (TGA)
• Thethe United States Food and Drug Administration (FDA)
• Health Canada
• German regulator (BfArM)

Footnotes

*(BIA-ALCL)’A provisional WHO entity distinguished from other ALK- ALCL’ – Blood Journal, Swerdlow, S.H, (2016), Vol. 127, No. 20, p.5

**Informed consent - links to websites for devolved administrations: Scotland, Northern Ireland, Wales.