Health: Cancer

Baroness Finlay of Llandaff Excerpts

Wednesday 9th July 2014 Lords Chamber

[Earl Howe]

My Lords, there is no shortage of investment in radiotherapy and no barrier, indeed, to clinically appropriate access to radiotherapy. A lack of trained staff to operate the machines is not the reason that the use of SABR has fallen. The reason is that the clinical and commissioning decisions have been taken to reflect the evidence of what is clinically effective for certain cancers. That is why clinicians are no longer commissioning this form of radiotherapy for cancers which do not respond adequately to that form of treatment.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise, though, that there are times when commissioning has to invest to save and has to support evaluation while a treatment is ongoing, and that the new forms of stereotactic radiotherapy have very good local control rates? For example, in lung cancer the rates have improved from 20% to 30%, with 15 to 20 treatments, to about 70%-plus with only three to five treatments. For patients to be treated nearer home, the costs saved to other parts of the care system need to be considered in the commissioning decisions, where you have better local control and lower knock-on healthcare effects.

[Earl Howe]

Yes, my Lords. Radiotherapy, particularly of this kind, is highly cost effective when it is clinically indicated. In fact, SABR is available in eight radiotherapy centres in England. The number of centres providing this treatment is increasing, with over a quarter having equipment capable of delivering the treatment. Current evidence supports treating only a small number of patients with this treatment: that is, in early-stage lung cancers for patients who are unsuitable for surgery. That is about only 1,000 patients a year.

National Health Service: Nursing Staff

Baroness Finlay of Llandaff Excerpts

Monday 16th June 2014 Lords Chamber

[Earl Howe]

My general answer to my noble friend is that it is not for the Government to decide how many nurses hospitals should employ. We have not done an impact assessment. That is a matter for local hospitals to judge. They are in the best position to do that, based on the needs of their patients and local communities. What the Government should do, and are doing, is to ensure that staffing levels are available for public scrutiny and comparison on a patient safety website. That work is currently in train. It will now be much more evident to patients and the public what their local hospital is doing in terms of safe staffing ratios.

[Baroness Finlay of Llandaff (CB)]

My Lords, before seven-day working comes in, are the Government ensuring that senior nurses are also taking part in the seven-day rota to ensure that their expertise is available both in hospitals and in the community to support other nurses at more junior grades?

Health: Transition to Adult Health Services

Baroness Finlay of Llandaff Excerpts

Wednesday 11th June 2014 Lords Chamber

[Earl Howe]

The noble Baroness raises an important point and I can reassure her that we are addressing the full range of complex needs in children and young people. She may also be interested to know that Health Education England will be working with the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health to develop a training course that will allow GPs to develop a specialist interest in the care of young people with long-term conditions. The aim is to introduce the course in September 2015. It will include a particular emphasis on the transition from childhood.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise the need for a champion, such as we have had with Dr Lidstone in Wales, who has completely transformed the transition for children with life-limiting illness?

[Earl Howe]

My Lords, the noble Baroness makes a good point. I would remind her that the national clinical director for children, Jackie Cornish, is also the national clinical director for transition, so it is very much centre-stage for her.

Care Bill [HL]

Baroness Finlay of Llandaff Excerpts

Wednesday 7th May 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, my amendment is Amendment 41A. As this is a new stage of the Bill, I declare my interests as a consultant and trainer with Cumberlege Connections, president of GS1 and chair of a foundation trust.

I am grateful to the noble Earl, Lord Howe, because we have clearly come quite some way since he introduced at Third Reading in your Lordships’ House the amendment relating to the rules on hospital closures. I hope, however, that he might see his way to moving a little further this afternoon. Closing hospitals is never an easy thing to do and I see a number of former Ministers in your Lordships’ House who bear the scars of hospital closure decisions. In my view, there is no doubt an urgent need to reorder and reconfigure services to allow for the centralisation of many specialist services to improve patient outcomes. Where the clinical evidence is persuasive, I would always support those service changes. We need to be more wary where service changes take place purely on the grounds of financial problems in a particular trust, especially if those changes have a negative impact on well run neighbouring services, where consultation is truncated and if there is an uneven playing field between the different commissioners—which is the subject of the amendment of the noble Baroness, Lady Finlay.

This all arose because of the problems in the use of the special administrator mechanism in the case of Lewisham. The South London Healthcare Trust was in huge financial difficulty; a special administrator was appointed and recommended that Lewisham hospital should have its A&E department downgraded and lose some other services as well. This caused outrage locally because Lewisham was not part of the South London Healthcare Trust, but was a well run and popular hospital, pitchforked into helping to solve a problem that was not of its own making. This ended up in the courts, which found against the special administrator and the Secretary of State. The judge concluded that the Lewisham GP commissioners had not given support to the proposal, which consequently constituted an additional reason why the decision of the Secretary of State could not stand.

The noble Earl, Lord Howe, always reminds the House that the legislative power that was used in the case of Lewisham was enacted under a previous Government. Indeed it was, but I stress that the original power was designed for something entirely different. It put in place measures to dissolve and rescue a trust through administrative reconfiguration. We never saw it as a vehicle for back-door reconfiguration across the health economy. The concern about Clause 118 is that it could allow hospitals to be downgraded or closed simply because they happen to be near a failing one.

I have listened carefully to what the noble Earl has said about the uses of this power. In both Lewisham and Staffordshire, where the power has been used in relation to the previous legislation that the noble Earl has amended, it has run into considerable trouble. In Staffordshire, where the process has also been used, an announcement was made in the last week or so that it has been put on hold. Essentially, the proposals of the special administrator have been roundly rejected by the local community, which shows the issues and problems when this mechanism is used to reconfigure services rather than simply deal with an immediate financial problem of a trust in great difficulty.

In the debate in the House of Commons, there was obviously much concern about this. The Government agreed that a committee should be established, under the chairmanship of Mr Paul Burstow MP, to produce guidelines on the trust special administration process. My amendment is simply designed to give those guidelines some statutory force. The decision of the Government to agree to this was very important and I am sure that, when the guidelines are produced, they will be sensible and set the context in which this mechanism can be used in the future.

However, my argument to your Lordships this afternoon is that it would give even more assurance if those guidelines had to come before your Lordships’ House and the other place for scrutiny and presumably for a decision to allow them to go through if they were found to be acceptable. I follow the precedent set by the Mental Health Act 1983, which gives Parliament a veto over the code of practice that provides guidance to those who undertake duties under that Act. The noble Earl has clearly moved a great deal on this issue over the past few days but it would be nice if he moved a little further.

As he responded to my amendment and that of the noble Baroness, Lady Finlay, perhaps I may save time for the House by asking him a question about the amendment that he has tabled in response to the noble Baroness. In his letter to us of yesterday’s date, he said:

“Our amendment would ensure that agreement is obtained from each commissioner on the basis that the administrator’s recommendations meet the objectives of the trust special administration and that they do so without harming essential NHS services they commission from any other affected trusts”.

He went on to say:

“Essential services at other affected trusts would be defined according to the same legal criterion that applies to commissioners of the trust in administration, thereby ensuring parity between all relevant commissioners”.

The wording that I want to ask the noble Earl about is:

“Our amendment would ensure that agreement is obtained from each commissioner”.

Does that mean that any one commissioner therefore has a veto over an eventual decision? That is how I read his letter. If so, does he agree that if that were used in the case of Lewisham, because the Lewisham CCG objected to the proposals, the proposals would not have gone ahead? If he does agree with my interpretation of his letter, how does he square that with what Dr Dan Poulter said in the Commons on 11 March, reported at col. 267? He said that while all local commissioners have an equal say, NHS England will arbitrate in the event of a disagreement. If, in the end, NHS England will arbitrate, that does not fill me with great confidence. NHS England will simply agree in the main with the original recommendations, because I am afraid that that is the track record of NHS England. In order to get absolute clarity here, I wonder whether the noble Earl could clear up any confusion around that.

[Baroness Finlay of Llandaff (CB)]

My Lords, I wish to speak to my Amendments 43A and 43B. I start by thanking the Minister and the Secretary of State for the amount of time they have afforded to me in discussing the concerns that lie behind my amendments. It is indeed correct that I was concerned that one clinical commissioning group commissioning from a failing trust could have a disproportionate say over the future. The government amendment, as tabled, addresses those concerns and I am most grateful to the Government for it. It establishes parity of commissioners by ensuring that there is no harm to essential services. I am also relieved that the Government are stating that the same legal criterion will be applied. Therefore, standard-setting across the services will establish that parity.

One of my concerns relates to the guidance. I would be grateful if the Minister could confirm that the committee of which Paul Burstow is the proposed chair will continue to exist. I think that there has been a lack of confidence among the public as a result of the publicity surrounding what happened at Lewisham. It will be very important that the guidance is seen to be drawn up and reported on separately. I must admit that I am uncertain about the mechanism for that. However, I certainly would be concerned if the detail of how the process is laid out is not openly and independently reviewed. The current guidance has to be rewritten anyway and that process could restore public confidence.

Health: Liver Disease

Baroness Finlay of Llandaff Excerpts

Tuesday 6th May 2014 Lords Chamber

[Earl Howe]

My Lords, I, too, learnt with great sadness of the death of Elena Baltacha, and was also unaware of the history of her medical condition. It is not appropriate for me to comment at the Dispatch Box on whether she should have received a liver transplant. However, I can say that transplant services are very active in this country. More and more liver transplants take place compared with a few years ago, and there are better techniques to ensure their tolerability in patients. If I can find out some more information, I will be happy to write to the noble Baroness.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that a strategy needs to be far wider-reaching than health, given that alcohol abuse results in two-fifths of crimes being alcohol-fuelled and in a cost to society of £55 billion a year? That sum would be recouped in part if the unit price of alcohol was raised by 10%, which would help to decrease the binge drinking which results in young people ending up in liver units with fulminant end-stage liver disease.

[Earl Howe]

I agree with the noble Baroness that if we are to tackle liver disease we need to look as broadly as we can at the causes of alcohol misuse. We remain concerned about the wide availability of cheap, discounted alcohol and will soon take action to ban sales of alcohol below cost, where the price is equivalent to duty plus VAT. As regards minimum unit pricing, that remains a policy under consideration, but it will not be taken forward at the moment while we gather further empirical evidence. We do not want to launch a policy that may have unintended consequences.

Tobacco: Packaging

Baroness Finlay of Llandaff Excerpts

Thursday 3rd April 2014 Lords Chamber

[Earl Howe]

I am very grateful to my noble friend. I confirm that we intend to have a consultation period of six weeks. That is as long as we think it needs to be to enable everyone with an interest, both for and against this measure, to make their views known and to enable us to factor in any considerations we may not yet have had an opportunity to consider. Although I have not seen the YouGov report to which my noble friend refers, I suspect she is absolutely right that public opinion is moving in the direction that Sir Cyril has advocated, and that we are going with the grain of what most people think. Most right-thinking people want children to be protected from the harms of tobacco. I hope that we will have public opinion behind us, should we decide to go ahead with this.

[Baroness Finlay of Llandaff (CB)]

My Lords, like the noble Baroness, Lady Tyler, I strongly welcome this report. It is an extremely readable, clearly laid out and very balanced review. I remind the House that it is 60 years since the original Doll and Peto observations that tobacco was linked to an early death. Their follow-up study, 50 years on, showed that those men who smoked only cigarettes and continued smoking had a life expectancy 10 years shorter than non-smokers. There is a long history behind this.

Looking at standardised packaging, it is worth noting that, as this report has highlighted,

“the pack has become the main promotional platform for the tobacco industry to recruit and retain customers”.

As has been said, the evidence from Australia is that plain packaging gives the impression that the cigarettes are lower in quality and less satisfying than those in the previously marketed packaging.

I would like to ask the Minister about standardised packaging, which comes from having listened to the debate in the other place after the ministerial Statement. I am concerned that there may be scaremongering going on over jobs. This type of standardised packaging is complex packaging and anti-counterfeit measures require complex design and printing techniques which this country is extremely good at. Our printing and packaging industry probably is one of the world leaders in developing really good types of packaging where anti-counterfeit measures can be included.

It is of concern that the term “plain” is still being used, which is completely different from complex standardised packaging. HMRC inspectors are clear that they can detect counterfeit standardised packaging more easily than the current commercial types of packaging when those are counterfeited. I seek reassurance from the Minister that the regulations will include the inability for the tobacco industry to do what is being done in Australia. One or two extra cigarettes are included as a loss leader for the same price as a packet of 20 as a promotional activity to make the packet more attractive. I also seek reassurance that the standardised packaging will be standardised on the outside; that there will be a standardised number of cigarettes inside; and that there will not be the ability to include tempting extra gifts, whether that is cigarettes or anything else. Does the Minister have any idea when the six-week consultation that he outlined will start and when the completion date is likely to be?

[Earl Howe]

The noble Baroness has raised a number of important points. As regards the effect on jobs, this is exactly the sort of question that we want people to address when responding to the consultation. If there are legitimate concerns about jobs, we want to hear about them. We want to understand exactly what the concerns consist of and whether they are robustly supported by evidence. The noble Baroness drew attention to the word “standardised” and asked me whether by that term we intended it as an antithesis to the word “complex”. I would rather say that standardised is the opposite of branded because it is the branding that is in focus here. As she will have seen from Sir Cyril’s report, he makes some very powerful points about the effect of branding. He said that,

“industry documents show that tobacco packaging has for decades been designed, in the light of market research, with regard to what appeals to target groups. Branded cigarettes are ‘badge’ products, frequently on display, which therefore act as a ‘silent salesman.’ Tobacco packages appear to be especially important as a means of communicating brand imagery in countries like Australia and the UK which have comprehensive bans on advertising and promotion”.

The word “standardised” is intended to signify a commonality of rather bland packaging, subject of course to European Union rules. I am sure that the noble Baroness is aware that the draft tobacco directive makes provision for a number of features to be included in the packaging; for example, 65% of the surface area of a packet of cigarettes will need to comprise of warnings. The minimum size of a packet of cigarettes will go up to 20 cigarettes and packets of 10 will be illegal. Other provisions are designed to prevent tobacco companies from using their packaging in whatever way to entice people to smoke, which includes free gifts and other features.

[Baroness Finlay of Llandaff]

Before the noble Earl sits down, may I remind him that I asked about the timescale?

[Earl Howe]

I beg the noble Baroness’s pardon. It is a little early for me to be specific on that. I have been as specific as I can on the timescale in which we hope to introduce regulations, but I will need to come back to the noble Baroness on the timescale for their implementation.

NHS: Midwives

Baroness Finlay of Llandaff Excerpts

Monday 17th March 2014 Lords Chamber

[Earl Howe]

The noble Lord is right. We recognised that issue at the outset of the Government, which is why we were determined that the number of midwives in training should be increased. It is now at a record number of 6,000. The number of trained midwives is increasing—that is, full-time equivalent midwives practising in the NHS rather than just on the register. We are heading in the right direction, but there is a long way to go.

[Baroness Finlay of Llandaff (CB)]

Will the Minister assure the House that the report from the Royal College of Obstetricians and Gynaecologists on the unique learning environment of the labour ward has been addressed in the curricula and the learning environments by HEE? That report highlighted bullying by some senior midwives of junior and student midwives and of medical students, which was making the learning environment particularly difficult and stressful and accounted for some of the high attrition rates.

[Earl Howe]

The noble Baroness raises the extremely important issue of bullying. Bullying is not to be tolerated in any environment in the NHS. I am not aware of the extent to which Health Education England has factored that particular point into its plans. I would be amazed if it had not, but I will write to the noble Baroness with an answer.

Medical Act 1983 (Amendment) (Knowledge of English) Order 2014

Baroness Finlay of Llandaff Excerpts

Tuesday 11th March 2014 Grand Committee

[Baroness Finlay of Llandaff (CB)]

My Lords, I rise, somewhat cautiously, as the third medical speaker in a row. I welcome the order.

It is worth noting that in 2013, the GMC had 13 fitness- to-practise cases that involved concerns about the language skills of doctors. In its 2011 review, the England Revalidation Support Team found 66 cases where the responsible officer has dealt with linguistic concerns. Part 3 of the order is therefore particularly important because it relates to fitness to practise. I hope that we will have an assurance today that in a fitness-to-practise procedure the doctors will not themselves be paying for the English language competence test. I have a bit of a concern, if they are paying for it themselves, that there may be a seeking out of a centre that is different from another centre, so it has to be fully conducted by the GMC, although it seems completely reasonable that the payment for the test prior to licence to practise is borne by the person applying for a licence to practise.

I understand from the GMC that it will be using the International English Language Testing System—IELTS—which costs from £130 to £145 depending on where you sit it, and that that will remain valid for about two years, on the recommendation of the Commonwealth. There is evidence that language skills, if they are not used, begin to decay after about two years.

It is also important to recognise that in this order we are talking about “ordinary” English language; we are not talking about testing medical English. It has been suggested that the dictionary for medical English is about the same size as the dictionary for another European language. It is a huge language. However, many of the words are very similar across the different European languages—although, of course, they are very different in some other languages.

We are talking about the ability of a doctor to take their medical knowledge and translate it into what you could call everyday English so that they can communicate it to patients. One point that I hope will be part of a fitness-to-practise procedure, however, is a recognition that communication involves far more than language. In terms of communication skills and communicating, although about 20% of communication is verbal, much of it is non-verbal. When you look at complaints against doctors in relation to the way they have communicated, although they sometimes have very good English language skills, other aspects of their non-verbal communication might reveal an attitude that is below the standard that one would expect from somebody on the GMC register.

I have to say, from my experience of teaching postgraduate students, that at Cardiff University they are required to sit the IELTS. It is a good test of English language skills. Since it was introduced as a statutory requirement by the university, we have found that it has become easier to teach and to mark the work done by those whose first language is not English. When teaching communication skills, it is easier to separate out the non-verbal problems from the verbal problems.

My view is that this is an important regulation. The ability to look back at those currently practising in the UK about whom there are concerns is crucially important and the GMC needs to be empowered to do so. I would just sound a note of caution following on from the remarks of the noble Lord, Lord Turnberg; of course we do not know what is set out in the curricula of different places. Medical students can graduate from some universities with almost no patient contact at all. If they are moving into training jobs, there is a concern that the baseline level of their medical training may be very different. This order may be the first step towards looking at the competences that we expect of a doctor coming from anywhere in the world in relation to practising in the UK.

[Lord Kakkar (CB)]

My Lords, I declare my interest as a member of the General Medical Council and I would like to take this opportunity to congratulate the noble Earl and Her Majesty’s Government on dealing with this important issue in what I think we can all agree is a very sensitive way. There is no question but that our health services are vitally dependent on a steady flow of doctors coming from all parts of the world, including the European Union. Not only can they learn from our healthcare system, they can also serve in it. But it is absolutely right that a professional regulator must enjoy the confidence of the public, and it is the responsibility of the General Medical Council first and foremost to ensure that patients are protected and that clinical practice in our country is safe.

For that confidence to exist, the public have to be sure in their own minds that the elements of what they would consider to be essential clinical practice—the ability to practise in a responsible and safe way—are met and tested by the General Medical Council whenever it feels the necessity to do so. The ability to communicate effectively, and therefore to use our language in a way that the public and patients appreciate and would expect, is an essential part of the responsibility of the regulator of the medical profession. As we have heard during this short debate, it is anomalous that the GMC is able to ask that question of potential registrants and licensees from outside the European Economic Area, but has not been able to do so of those who come from within the European Union. It is quite right that the Government have focused on this issue and decided to act in this fashion.

The fact that this order makes provision not only for the question at the time of licensing of a professional, when concerns about language skills might have been raised during the provisional registration process, but also that the new category of considering the ability to use language and to communicate becomes part of the broader question in fitness-to-practise considerations, is vitally important. It means that not only at the time of coming on to the register and being licensed to practise in this country, but throughout the practice itself, the public and patients can now feel confident that the General Medical Council will be in a position to act if it needs to do so. The importance of that cannot be overestimated.

We have heard about the additional question of competence skills, which is a matter that your Lordships have considered in the course of a number of debates in the Chamber over the past few years. The issue remains to be addressed, but I think that most would agree that ultimately, wherever a doctor comes from in the world, whether they have trained and qualified in our own country, elsewhere in the European Union or elsewhere in the world, they should be expected to demonstrate their skills to the same standard and to deploy those skills throughout their professional career in a way that enjoys the confidence of the people of our country.

NHS: General Practitioners

Baroness Finlay of Llandaff Excerpts

Wednesday 26th February 2014 Lords Chamber

[Earl Howe]

My Lords, there is no doubt that the general practitioners bit the Government of the day’s hand off, 10 years ago, and they had every reason to do so with the money that was being offered to them. However, while a feature of that contract was the quality and outcomes framework, which was a good idea in itself, it has resulted in a lot of box-ticking for GPs and it is that element which we have drastically reduced in the contract for next year. That will be helpful in freeing up GPs’ time.

[Baroness Finlay of Llandaff (CB)]

My Lords—

[Lord Grocott (Lab)]

My Lords—

Children and Families Bill

Baroness Finlay of Llandaff Excerpts

Wednesday 29th January 2014 Lords Chamber

[Lord Ribeiro]

I greeted that event with jubilation. I would not want that grandson to go through life having his young lungs damaged by cigarette smoke. I am concerned about that. Cigarette smoke contains a cocktail of carcinogens: arsenic, cadmium, formaldehyde, benzene and in particular the fine particulate matter that comes out of cigarettes when they are smoked. This can cause long-term damage and illnesses.

My Amendment 62, which mimics the Private Member’s Bill that I took through this House in 2012, serves to make parents and the public aware of the risks and to provide educational programmes to rehabilitate them through smoke-free driving awareness courses. I believe strongly in education and behavioural change, rather than the imposition of punitive measures. It is about providing incentives to change behaviour, not dissimilar from the police driving course which noble Lords may have been offered if they have ever been unfortunate enough to have been caught speeding. There may be some in this Chamber who can endorse the benefits of that.

In that sense, my amendment is exploratory, seeking to obtain answers from the Government on two specific issues. The first is education to change behaviour, as I explained. Here, I applaud the Government for their successful advertising campaign launched last year, with its graphic films of children assaulted by smoke in the back of cars while parents in the front are oblivious to the damage being done behind them, probably because the driver has a window open and therefore assumes that all the smoke is going outside. I should like assurances from my noble friend that the Government will repeat that successful campaign and undertake an extensive evaluation of its effects. We must know that behavioural change is happening.

I am sure that the Government have taken note of the Welsh Government’s Fresh Start Wales campaign. I made reference to this at Second Reading and asked whether the Government would again consider mirroring what the Welsh Government were doing. That Government are due to report in the spring on the result of their campaign, following which they reserve the right to introduce legislation if no improvement in behaviour is apparent.

My second question to the Government relates to a national consultation, which should involve the public, the profession and the retailers, to decide whether legislation or non-legislative measures are required to protect children from smoking in confined spaces. I am pleased that my noble friend has asked Sir Cyril Chantler to undertake an independent review of the public health evidence on standardised tobacco packaging and its effects on public health. Might he perhaps also consider asking Sir Cyril, at the conclusion of this review in March, to undertake a similar review of the effects of second-hand smoke on children travelling in cars? There is plenty of evidence out there but what is now needed is the clinical evidence that shows that smoke causes long-term damage. We know that the long-term sequelae from smoking in adults are quite severe. If we can demonstrate that they start at a very early age, that will be very good evidence for taking action now rather than later.

My amendment provides the Government with measures to change behaviour. They may have started with good intentions—and I am sure that they have. Standardised tobacco packaging will reduce the risk of smoking and its damaging effects on children. I hope that the Government will take the view that legislation, although difficult, may need to be considered. However, for legislation to work, I understand that it must be proportionate and enforceable. In this respect, my amendment is probably defective, as it will be difficult to police and to enforce, much in the same way, I suppose, as is the case with the mobile phone offence, which is legislated for but is difficult to police.

I hope that my noble friend will provide me with some of the concessions that I seek. I do not think that they are small ones but they will help to ensure that over the next year, and certainly over the next three months when we hear the results of the Welsh review and Sir Cyril Chantler’s review—and it is to be hoped that he will extend that further—we will have more information on which to make a decision as to whether we should introduce legislation or non-legislative measures.

[Baroness Finlay of Llandaff (CB)]

My Lords, I have put my name to Amendments 60 and 62. I will first address Amendment 60 on standardised packaging and move on to the amendment to which the noble Lord, Lord Ribeiro, has spoken so eloquently. I hope to avoid covering the ground that has already been covered. In terms of standardised packaging, those of us who contributed in Committee to a very powerful and widely supported debate across the House are grateful to the Government for having done exactly what they said they would; namely, take the proposal away and look at it. They have returned with an elegant amendment. Before finally legislating, it seems wise to have an independent review by Sir Cyril Chantler.

This is definitely a public health and a child protection measure. I should like to address that briefly but not repeat what was said previously. The Minister has already said how many children start smoking before the age of 18. That figure is particularly high in looked-after children, where about one-third report that they are current smokers. However, when looking at children in residential care, the figure rises to more than two-thirds. There is a real problem with very vulnerable children.

In 1999, the tobacco industry’s magazine, World Tobacco, said that,

“if your brand can no longer shout from billboards … it can at least court smokers from wherever it is placed by those already wedded to it”.

The problem is that we know that tobacco is a highly addictive substance, and that the products of tobacco damage health and do not have any positive benefit. Recently, a study published in the European Journal of Public Health has shown that,

“the removal of brand imagery from tobacco packaging reduces the appeal of tobacco products, including perceptions of brand attractiveness and smooth taste and perceptions of lower tar or lower health risk”.

Those perceptions are an illusion. The study was in the UK, and I am sure that it will be considered in the evidence review and that Sir Cyril will be an independent reviewer in every sense.

It is worrying that it has taken us so long to get to this point. Like other noble Lords who have put their name to this amendment, I sincerely believe that the day will come when we will see standardised packaging. That day is not far off, because research study after research study reports are reinforcing that standardised packaging is making cigarette packs less attractive to young people.

I have had discussions with Her Majesty’s Customs as regards illicit trade. It pointed out that it is not that difficult to detect counterfeit standardised packaging, just as it is not difficult to detect other counterfeit packaging. Indeed, the cover marks, number codes and security marks are the clue, rather than the bald, external appearance of the pack. It also is well aware that tobacco firms have been producing and exporting cigarettes far in excess of any known demand in a stated target market abroad, knowing that this excess production will be smuggled back into the UK. The tobacco companies appear to have been complicit with what has been termed the illicit trade. It seems logical that this move and the government amendment are because of child protection issues and the importance of preventing children from starting to smoke.

On tobacco and smoking in cars, the British Lung Foundation study, which was addressed by the noble Lord, Lord Hunt, included another set of figures which I hope the House will consider. One has to remember that the children responding in the study were of an age at which they could answer competently. When asked about being a passenger in a car, 31% said that they had asked someone to stop smoking but 34% said that they had not dared to ask because they were too frightened or too embarrassed. The child in the back seat, belted in, is effectively imprisoned in the vehicle for their own safety while travelling. They are stuck there. They have no control over what the adults do, and it is worth remembering that they do not feel able to do anything about it either. As was pointed out by the noble Lord, Lord Hunt, if they are in a house, they can move to another room or another area and the volume of space is much greater than in a car.

[Lord Cormack]

Would this amendment apply to open-topped cars such as sports cars where children would presumably not be at risk?

[Baroness Finlay of Llandaff]

It is worth pointing out that the noble Lord, Lord Ribeiro, has already indicated that he will not press his amendment, which is quite specific, and the amendment in the name of the noble Lord, Lord Hunt, simply addresses the ability to bring forward regulation but does not specify what those regulations should be. I respectfully suggest to the noble Lord, Lord Cormack, that his question is an important one for us to have at a later stage, in the event that the House decides to support the amendment of the noble Lord, Lord Hunt.

My last point relates to my home country of Wales, where I am delighted that the problem of tobacco consumption has been taken seriously. The results of the Welsh campaign will be published fairly soon. But it is with regret that I have to note that at the end of the first year of the campaign, 22% of smokers still pointed out that smoking was allowed in their car at any time. There is a perception that if it is allowed it is okay. I am concerned over the results that will come forward from the education campaign, although I fully support the campaign itself.

I remind the House that we had a parallel debate over seat belts in cars. Yet the seat-belt wearing rate increased in the UK from 25% before legislation to 91% after legislation. That was introduced alongside awareness campaigns. We cannot have legislation without a large education and awareness-raising campaign. The efficacy relates to the education and awareness-raising campaign rather than to any kind of punitive measures that go alongside it.

[Lord Faulkner of Worcester]

I added my name to Amendments 57BB, 60 and 62 and will speak briefly to those, but I start by congratulating the noble Earl on bringing forward his Amendment 57B and for overseeing a significant change in government policy on the subject of standard packaging. Like many of your Lordships, I was heartened when I heard the then Public Health Minister, Anna Soubry, around a year ago saying that the Government were minded to go down the standard packs route and then bitterly disappointed last summer when the plans were suddenly dropped. Various conspiracy theories were propounded at the time and I will not go into those now, but it looked as if the issue was dead, at least for the foreseeable future.

At that point, it seemed sensible to look at whether there was any possibility of adding a standard packaging amendment to another Bill, which might not immediately present itself as the most appropriate, in order to be able to give the House the opportunity to debate the issue and come to a view on it. With the help of staff in the Public Bill Office—about whom I cannot speak highly enough, as their help was invaluable in framing our original amendment in Committee and the subsequent amendment that we tabled for today—we were able to bring the issue to the Committee and approach the issue in an entirely cross-party and non-party way. The amendment that we put together was signed by the noble Baronesses, Lady Finlay and Lady Tyler, the noble Lord, Lord McColl, and myself.

Amendment 60 is an improved version of what we had in Committee, but the Government’s amendment today is a great improvement on that as well. I congratulate them on picking up a number of the points that were defective in ours and coming forward with one that, I think, is very effective. Tobacco control should not be a party-political matter; it should be the common concern of everyone who cares about the health and the well-being of the public. As we have heard from the Minister, smoking-related disease still kills more than 100,000 people across the UK and is by far the most common form of preventable death—it accounts for more premature deaths than the next six most common causes put together.

As most smokers start as teenagers, the teenage market is the one which the tobacco companies are anxious to promote, which it is the responsibility of all of us to try to prevent. Two-thirds of existing smokers report that they started before their 18th birthday, and around two in five before they were 16. The younger the age at which they start, the greater the harm is likely to be, because the early uptake of the habit is associated with subsequent heavier smoking—of the sort that the noble Lord, Lord Forsyth, experienced with his mother and her 60-a-day habit—high levels of dependency, a lower chance of quitting and a higher chance of death from smoking-related disease.

For the tobacco industry to keep its market, it is necessary for it to recruit new smokers every year. That is because older smokers die or quit—or indeed lose their lives prematurely as a result of their habit. Since most smokers start when they are young, it follows that, for the industry, young people are the most important target group of potential new consumers.

We know what the tobacco industry would do in this country to promote its products if the law and the authorities allowed. Indeed, we probably know more about the commercial strategies of the tobacco industry than about any other major industry in the world, in large part because so many previously confidential documents were made public as a result of the US master settlement agreement with the industry in 1998.

Given the restrictive legislation around marketing and advertising tobacco in the UK, the industry is left with few options to promote its products. Of these, the most important is now packaging. Packs can be used to market and advertise, to create brand identities and to help present an image of smoking that may indeed seem “cool” to a curious teenager. There are many diversionary arguments advanced by the tobacco industry and the front groups it funds so lavishly about why we should not proceed with standardised packaging. So we hear tobacco industry claims that the UK is being flooded with illicit tobacco and that standard packs will make the problem worse. But the level of illicit trade has fallen sharply since it peaked back in 2000, and the security features on existing packs will also be present on standard ones. Both our amendment and the Government’s would allow the Secretary of State to specify packaging requirements that would enhance and not reduce product security, and make smuggling and counterfeiting more difficult.

However, the tobacco industry’s real, core argument is quite simple. It is advancing the proposition that its claimed so-called “intellectual property rights” trump the requirements of public health—or to put it more sharply, that its right to design products designed to get children addicted is more important than the children’s right to be protected from that addiction and the health damage that it causes. I believe that the overwhelming majority of your Lordships, and indeed Members of the other place, reject the tobacco industry’s arguments and want to make cigarettes as unattractive to children and young people as possible. So, as I said at the beginning, I warmly welcome the Government’s amendment. I congratulate the Minister on bringing it forward and on his announcement regarding proxy purchasing of tobacco products by adults for young people, and the regulation of e-cigarettes, about which we shall hear more at Third Reading.

I am not going to speak about smoking in cars because the speeches on that subject by the noble Lord, Lord Ribeiro—with whom I agree, and whom I congratulate on his perseverance in taking a Private Member’s Bill through your Lordships’ House on this subject—and the noble Baroness, Lady Finlay, have covered the main points. However, I strongly commend the points that my noble friend Lord Hunt made about the desirability of moving towards a smoke-free atmosphere in cars where children are trapped and subject to appalling levels of second-hand smoke.

I am very happy indeed to support the government amendment. We shall not be pressing our own amendment on standard packaging, but I shall be supporting my noble friend.