Bread and Flour Regulations (Folic Acid) Bill [HL]

Baroness Hayman Excerpts

Friday 8th July 2016 Lords Chamber

[Baroness Hayman (CB)]

My Lords, the House owes a debt of gratitude to the noble Lord, Lord Rooker, for his persistence in pursuing this case. I should tell the Minister at the Dispatch Box that I was a colleague of the noble Lord, Lord Rooker, in the days when we were both young MPs in a hurry, and he is a formidable opponent. We are, in our later years, perhaps old Peers in a hurry, but that does not mean that we are any less determined on this issue. Today, the noble Lord has provided the House with irrefutable evidence of the case for supporting his Private Member’s Bill, and in fact I think he has done more than that. A Private Member’s Bill is not the way to implement a measure that is so self-evidently important for public health. He argued for a change in government policy, and I hope that the Minister will not be put in what I know to be the profoundly uncomfortable position on the Front Bench of once more defending the indefensible on this issue.

Last night I was telephoned by my son, who told me of his frustration over the length of time it was taking to get the Government to respond on a completely different, although equally important, issue. It is an issue supported by five Select Committee chairs and committees and over 90% of parents—that of making PSHE a statutory subject in the national curriculum so that all our young people are given the means to protect themselves in today’s world. I fear that, when I explained to him that today I would be talking about an issue on which I had been campaigning for 25 years, that did not add to his optimism or enthusiasm. However, I also told him that one thing I had learned in politics was never to take no for an answer, and that applies to this issue and to his.

As I said, I first became aware of this matter in 1991. I was involved then, as I am now, in the ethics of medical research. The MRC trial, to which the noble Lord, Lord Rooker, referred, was the first trial I had ever known to end early. That was because the results were so clear that it was considered to be unethical to continue to allow one half of the group—the control group—not to receive the folic acid supplement which the other half was getting. The evidence that has had such a profound effect in the rest of the world, but not in the UK, is based on that trial.

A second reason for my concern was that in the preceding years I had helped to found an organisation called the Maternity Alliance. It was particularly involved in pre-conception care—in the health of mothers and babies. It was absolutely clear that the fortification of flour with folic acid was the most effective mechanism for delivering pre-conception and early pregnancy care, as has been demonstrated by the ineffectiveness of the supplement route, as the noble Lord, Lord Rooker, has demonstrated.

However, the main reason for my interest was that I had been having babies myself. I knew the intense anxiety of waiting for antenatal checks and then the birth, worrying about whether the baby was healthy, and thinking through what I would do in the case of an in utero diagnosis of an abnormality and having to face up to the question of whether to undergo a late termination.

A generation has gone by; I am no longer having babies, but I am having grandchildren and I see my sons, their wives and partners going through exactly the same anxieties. It is no wonder that the British Pregnancy Advisory Service says that this one measure would ensure that some of the saddest cases it sees would not need to come through its doors, and women in the devastating situation of ending a wanted pregnancy because of foetal abnormality would no longer have to do so. Beyond that, many families would not have to deal with the devastating and heart-breaking situation described by the noble Lord, Lord Rooker, of one of our colleagues and of having to support children who endure short and painful lives because of the burden of preventable disease.

In those 25 years, we have had the opportunity in this country to see not just pilot schemes of fortification of flour with folic acid but mass implementation of it. We have had the opportunity to see the effect—an up-to-50% reduction in the incidence of the neural tube defects—and to see that the theoretical risks of the policy have been investigated and not come to fruition.

The question for the Government now is how they can in all conscience continue to ignore the evidence before them and not accept what their own Chief Medical Officer, the Scientific Advisory Committee on Nutrition, the other Administrations of the United Kingdom and the rest of the world accept. I cannot believe that they maintain their position given the conclusions of every piece of research—ending with that which found in December last year:

“Failure to implement folic acid fortification in the UK has caused, and continues to cause, avoidable terminations of pregnancy, stillbirths”—

and permits “serious disability in … children”. That situation should not be allowed to continue. This Bill would not solve every instance of it, but it would do a great deal. Not to do what we can do is a dereliction of duty.

[Lord Hughes of Woodside (Lab)]

My Lords, I join the noble Baroness, Lady Hayman, in paying tribute to our mutual friend, the noble Lord, Lord Rooker, for bringing forward this Bill and I certainly hope he succeeds. The three of us, the noble Baroness, Lady Hayman, the noble Lord, Lord Rooker and I, were in the other place for some years together. I can testify to the noble Lord’s capacity for identifying a public policy that needs to be taken up and his tenacity in seeing it through. He is perhaps best known, at least among the three of us, for the so-called Rooker-Wise amendment—an unlikely duo—which was successfully introduced to a Finance Bill to make national allowances subject to the rate of inflation. He annoyed the then Chancellor of the Exchequer, Denis Healey, no end. Such tenacity is worth having and it certainly makes us in your Lordships’ House proud.

The issue of adding folic acid to flour has been around for a long time, because we share knowledge of the suffering of families who have had children aborted, who have lost children early or who have had children born with defects that last for years of their lifetime. The question must be asked: why are the Government so reluctant to move in the face of such indisputable evidence about the efficacy of adding folic acid to bread when there are certainly no signs at all of any detrimental effects in doing so? I do not know and I hope the Minister can answer that question.

At Question Time in the House—I say this without malice—the Answers given by the Minister for not doing so have been rather flimsy. He has cited the fact that health problems are improving in women, and there is no doubt about that. But beyond that, there is no reason why the Government cannot move. As my noble friend Lord Rooker said, many countries in the world already do this. The Scottish Government are considering moving on their own and have the power to do so as health is a devolved matter. It would be a great shame if that were to be the case.

Why is there such opposition? I know from personal experience how difficult it is to argue against those who, possibly for genuine reasons, are opposed to vaccination or fluoridisation of the water. I still have the scars on my back from trying to persuade Aberdeen Town Council to adopt that when I was the convener on the welfare committee there. I do not know whether it is a matter of prejudice. It cannot be ignorance because the facts are very well known. But the fact is there is huge opposition to any move to what is called public health medicine. The worst example of that is adding fluoride to the water. I emphasise absolutely what my noble friend said. Adding folic acid is not mass medication. That argument might be made in the case of putting fluoride in the water but this is a different matter altogether. This is a simple and straightforward measure that has been well documented as being successful and safe and for making people’s lives much better.

As my noble friend said, this is not a panacea. It will not eradicate NTDs, but the fact that 50% of women may be beneficially affected by this is a prize that makes it worth doing. The only slight disagreement I might have, although I may have misheard what my noble friend Lady Hayman said, is whether this is the right way to go about getting the legislation. I may have misunderstood what she was saying. But in the face of a Government unwilling to move on their own account through lack of time—and goodness knows what the Government will face in terms of time in the coming months and years—it is absolutely essential that those who have the opportunity to bring forward a Private Member’s Bill should do so.

[Baroness Hayman]

I would be more than content were the Minister to say today that the Bill in the name of the noble Lord, Lord Rooker, be taken forward with all speed and support by the Government in another place.

[Lord Hughes of Woodside]

Hear, hear to that. But in the event of that not being the case, it is the duty of this House to pass this legislation through all its stages and send it to the other place to deal with. That is imperative and essential and I am pleased to give my support to my noble friend Lord Rooker.

Health: Neural Tube Defects

Baroness Hayman Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, speakers in this House have by and large very much supported the views of the noble Lord, Lord Rooker—I entirely accept that. But I do not think that the case has been made outside this House perhaps as strongly as it has in other areas. If we are going to change the way we produce white bread in this country, a much stronger and broader case has to be made.

[Baroness Hayman (CB)]

But, my Lords, it is not just in this House, is it? It is in the Scottish Government, who I understand are now laying out plans to introduce fortification. They are supported by the Administrations in Northern Ireland and in Wales. Why is England taking this isolationist view when across the world it has not been taken? Is it correct that Sir Nicholas Wald, the leading scientific expert in this field, was granted an audience with the Minister for Health in Scotland, but not in England?

[Lord Prior of Brampton]

My Lords, I cannot answer the latter question, but I will try to find out and write to the noble Baroness. She is right that Scotland is considering this and looking at the practical issues around implementation. She is right that other countries in the world—I think 50—have done this, but many others have not, including all European Union countries.

Health: Red Cell Folate

Baroness Hayman Excerpts

Tuesday 19th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the danger of overmedication with folic acid is small, I accept that. It is not non-existent but it is small. Just so that the House knows the numbers, the number of babies aborted because of neural tube defects is about 400 a year; the number who are born with neural tube defects, alive or not alive, is about 60 a year. It is a very serious issue and one that the Government are taking extremely seriously, but we have to weigh that against the other issues of medicating the entire population.

[Baroness Hayman (CB)]

My Lords, some of us have long memories that go back to 1991, when the MRC study into this issue had to be stopped early because the results were so overwhelmingly in favour of folic supplementation. The lead researcher on that study was Sir Nicholas Wald. More than 80 countries have taken very seriously those results and have taken on board fortification of white flour. In 2015 Sir Nicholas published a paper about the lost opportunity in the UK. Is it not a matter of profound regret, verging on shame, that in this country, where the initial research was done, we are now being told that there will be a decision “in due course”? If I remember correctly, the last time the Minister spoke about this, he said that it would be very early in the new year.

[Lord Prior of Brampton]

My Lords, I think we are still quite early in the new year. I do not go back to 1991 but the noble Baroness is right: for many years now there has been a large body of scientific opinion in favour of increasing the uptake of folic acid. There is no dispute about that—I do not think there is much science to dispute. The issue is one of balancing the scientific and medical arguments with issues around choice and whether or not it is right to medicate the entire population for the benefit of a fairly small part of it.

Pregnancy: Neural Tube Defects

Baroness Hayman Excerpts

Monday 21st December 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness is absolutely right. When you know you are pregnant, it is too late to start taking folic acid, and that is the fundamental reason why the noble Lord, Lord Rooker, is pushing for fortifying flour with folic acid. However, she is absolutely right that education is fundamental to this as well.

[Baroness Hayman (CB)]

My Lords, is the Minister aware that the best tribute that he could pay to the noble Lord, Lord Rooker, and his campaign would be to make an early and positive decision on the fortification of white flour in this country? How long are the Government going to go on not taking any notice of either the scientific evidence or the evidence in practice from 78 other countries? I remember the definitive trial proving the benefit of folic acid in pregnancy in 1991. We have seen that advice alone does not work. When will the Government take action?

[Lord Prior of Brampton]

My Lords, as I said in my response to the noble Lord, Lord Rooker, this matter is being actively considered by the Minister for Public Health, and she expects to come to a decision very early in the new year.

Health: Flour Fortification

Baroness Hayman Excerpts

Tuesday 21st January 2014 Lords Chamber

[Earl Howe]

My Lords, I recognise the issues raised by the noble Baroness. We will of course take those into account.

[Baroness Hayman (CB)]

My Lords, it is more than 20 years since the MRC study on this issue first had to be abandoned because it was considered inappropriate not to give folic acid supplements to the women who were involved. When the noble Earl reads the latest study, I suggest that he will find it “incontrovertible”, to use the word of the noble Lord, Lord Turnberg. The noble Earl said in December that the Government were looking at this issue urgently. Will they now look to act urgently?

[Earl Howe]

My Lords, I give the noble Baroness an assurance that we are treating this with suitable urgency. I cannot give her a date as to when a decision will be announced but it will be as soon as possible.

Health: Birth Defects

Baroness Hayman Excerpts

Wednesday 18th December 2013 Lords Chamber

[Earl Howe]

My Lords, I am sure that that evidence will be taken into account when we take the decision, as we hope to do next year.

[Baroness Hayman (CB)]

My Lords, the Minister said that this was not a decision to be taken lightly, and that is absolutely right, but we now have the experience of 50 other countries. We have had scientific evidence on this issue for many years. The fortification of white bread flour is a targeted measure that could significantly reduce the number of pregnancies, not just births, that involve neural tube defects, and thus prevent a great deal of unnecessary and painful suffering. Will the Minister undertake to look at this matter again as a matter of urgency?

[Earl Howe]

My Lords, we are looking at this as a matter of urgency. I recognise what the noble Baroness says about the experience of other countries, but we must make policy in relation to the population of our own country, and that involves weighing up both the potential benefits and the potential downsides of any policy.

NHS: Mid Staffordshire NHS Foundation Trust

Baroness Hayman Excerpts

Tuesday 19th November 2013 Lords Chamber

[Earl Howe]

My Lords, my noble friend should be listened to with great care. Of course, I remember those cases. I was not the Minister in charge at the time she submitted those cases to the Department of Health, but she shared them with me, and I share her concerns, which are, of course, directly relevant to the matters we are discussing today. We have the new duty of candour and in April the Enterprise and Regulatory Reform Act strengthened the main whistleblowing legislation introduced by the Public Interest Disclosure Act so that an individual who suffers harm from a co-worker as a result of blowing the whistle now has the right to expect their employer to take reasonable steps to stop this. The idea is to ensure that people do not feel intimidated from speaking up. The Care Quality Commission is using staff surveys and the whistleblowing concerns it receives as part of the data in its new intelligent monitoring system. That data will guide the CQC about which hospitals to inspect. Since September, the commission’s new inspection system includes discussions with hospitals about how they deal with whistleblowers and handle them.

[Baroness Hayman (CB)]

My Lords, I declare an interest as a member of the General Medical Council. In no way do I speak on its behalf today, but it is obvious from the remarks that the Minister has made that the GMC has been working with the Government and other regulators and is committed to underlining professional responsibilities, particularly in relation to the duty of candour. That work will, of course, continue. On a personal level, I welcome the return to naming the consultant and the nurse responsible for an individual patient. It is emblematic of that personal sense of responsibility and accountability for patient welfare.

In respect of the new complaints procedure, as the Minister said, the care of patients and their safety are the responsibility of not only the named consultant and nurse but everybody in that institution. Does he agree that there is also a particular responsibility on the trust’s non-executive directors in that respect and that the new system should ensure that they are taking their responsibilities seriously? I know from decades ago, when I chaired the complaints panel at a London teaching hospital, that that resource, in terms not only of the ability to protect patients but of improving efficiency and the quality of care by understanding complaints, was a treasure trove that should not be abandoned.

[Earl Howe]

I entirely agree with the noble Baroness, who of course has immense experience in these fields. I agree with her in particular about the role of the non-executive director. If an organisation has what may look like quite a high number of complaints, it should be regarded as a sign of openness, transparency and the right kind of culture in that organisation. It is only where suspiciously low numbers of complaints have been recorded that alarm bells should start ringing. I agree that boards of directors, led and encouraged in this area by the non-executives, should make it a central part of their business to analyse complaints and make sure that they have been followed through, not just that the matters have individually been remedied but that any systemic issue has been properly addressed.

NHS: Out-of-Hours Services

Baroness Hayman Excerpts

Monday 29th July 2013 Lords Chamber

[Earl Howe]

The last thing I would ever wish to be is complacent, and I certainly am not. Whenever problems and concerns arise, we take them extremely seriously. I do not think anyone takes issue with the concept of 111. Unfortunately, however, we have seen problems arising in a few isolated cases. I emphasise that the vast majority of the country is receiving a good service. Incidentally, there is no evidence that attendances at A&E have been affected by the rollout of 111; in fact, attendances have not increased since 111 was introduced—the figures have actually gone down.

[Baroness Hayman]

I wonder whether the noble Earl could help me, because I am genuinely puzzled about the current status of NHS Direct, its funding and governance, who makes decisions about contracts and whether they are viable or not. NHS Direct was set up as a national service, paid for and provided by the NHS. What exactly is it now?

[Earl Howe]

The NHS is a provider, in certain parts of the country, of the 111 service, and other services more generally. But there is a very distinct difference between NHS Direct’s old service and the 111 service being provided now, in that 111 is a much more comprehensive service. That was an area of agreement between the Government and the noble Baroness’s own party before the last election. I sense that I have not answered the noble Baroness’s question; perhaps she would like to ask it again.

[Baroness Hayman]

Since I can quibble about my own party as I am now a Cross-Bencher, I take this opportunity to say that I am not puzzled about the 111 service—but who is NHS Direct now? Who is responsible for its governance, its funding and decisions about whether it goes for contracts?

[Earl Howe]

I apologise to the noble Baroness on two counts. NHS Direct is a separate, statutory organisation, which means that the management and controls of risk are the responsibility of the NHS Direct board.

NHS: Mid Staffordshire NHS Foundation Trust

Baroness Hayman Excerpts

Monday 11th March 2013 Lords Chamber

[Baroness Hayman]

My Lords, like others I congratulate my noble friend Lord Patel on initiating this debate. I declare an interest as a member of the General Medical Council, like the noble Lord, Lord Kakkar. That interest, of course, translates into a responsibility. So many organisations, including the GMC, have a responsibility to study Francis, to understand what went wrong, and to play their part in putting it right for other parts of the National Health Service. In particular, the GMC needs to consider its own leadership role in driving standards up; it must be not just the policeman but the coach of professionalism and high standards. It must address that tremendously dangerous disengagement from management that we saw illustrated and which defines professionalism, not as the noble Lord, Lord Kakkar did, but very narrowly as care of one’s own patient rather than responsibility for the whole clinical environment. One of the chilling things about Francis was how many people who were not bad people felt either disempowered or “aresponsible” in terms of what they could see going on elsewhere in the hospital.

The noble Lord, Lord Willis, said that as parliamentarians we had some responsibilities, too, in not having discussed the issues of values and cultures. We may not have spent many hours on that. However, we have certainly spent many hours on structures and funding systems—thousands of hours of debates in both Houses. I contend that much of the energy that has gone into reorganisations has sapped energy from the absolute fundamentals of what the NHS is about. Francis gives us the opportunity not to turn this into 290 new boxes to be ticked, but to look at the fundamental purpose and values of healthcare that need to be subscribed to, understood by and championed by those responsible for governance and professional leadership and those responsible as managers. I was brought into the NHS 30 years ago by a hugely talented and committed NHS manager, Alasdair Liddell, who died tragically and suddenly on New Year’s Eve last year. The commitment of managers to the values of the NHS, as well as to cost-effectiveness, efficiency and everything else, is hugely important.

There are other two things that I will say quickly about my first experience in the NHS in Bloomsbury. One is to echo what has been said about complaints. I chaired a complaints panel that looked at every complaint that came into those hospitals. It was a goldmine in improving service and efficiency. To ignore that goldmine is hugely damaging. There are very few heroes in the Francis report, but the complainants are heroes. They gave the opportunity to put things right beforehand.

Secondly, of course we have to look at death rates, but we have to look, too, at those doctors and whether they would recommend a hospital to their colleagues. We had a unit at UCL with pretty well the highest death rates in the country. It was the unit in which every doctor in London would have wanted their family treated, because it took the patients who would otherwise have gone to a hospice.

Health: Non-communicable Diseases

Baroness Hayman Excerpts

Thursday 6th October 2011 Lords Chamber

[Baroness Hayman]

My Lords, I have a double reason to be grateful to the noble Lord, Lord Crisp, for his introduction of today’s debate. Not only is it timely and important, it gives me the perfect justification for reversing my intention of keeping a dignified silence in your Lordships’ House until 2012. Instead, I shall use the opportunity of today’s debate to make my first speech after leaving office as Lord Speaker. This is also my first speech from the Cross Benches. In my 15 years in your Lordships’ House I have led a peripatetic life. I have spoken from the Front and the Back Benches, and from the opposition and government Benches. I fear that there is nowhere left for me to go. I look across to the Bishops’ Bench but the obstacles to that are many and insuperable, so I will probably have to stay where I am.

The reason why I feel justified in abandoning that intention of not speaking is because today’s debate chimes with so many of my interests—past and present. For four years I was the founder chair of Cancer Research UK. Having the privilege to do that made me aware of the burden of non-communicable diseases in the UK, particularly cancer, but also the growing threat and damage that those diseases cause in middle-income countries. The issue has already been raised today of their being in a way diseases of growing affluence. One needs look only at the increase in the incidence of lung cancer in China with the increase of smoking there. The noble Lord, Lord McColl, made us very aware of the dangers of diet leading to ill health in those major non-communicable diseases. It is important to recognise the role of public health in countries that are developing their health systems—public health in terms of surveillance, of education and of prevention.

There are often debates on whether health interventions in the developing world should be in terms of programmes or systems but, when DfID is looking at investment, the knowledge that we have gained in this country in terms of public health systems—based very much on having a comprehensive and truly national NHS—is an important gift that we can share with other countries. Another past interest as trustee of the Tropical Health and Education Trust also made me aware that it is not a one-way street when we talk about exchanging knowledge and healthcare professionals and practices with other countries. There is much that we can learn from the developing world in attitudes to medical problems and innovation. You need only look at the recent reports of how technology is being used in Tanzania to transfer by mobile phone the bus fare needed to women who have obstetric fistula. For them the problem is not the cost of the operation, because that is provided through charitable support to hospitals in that country; their problem is not having the bus fare to access that treatment. The innovations in technology being used through mobile phone networks can at a stroke end that problem. In that and many other areas there are possibilities to learn from other countries.

I should declare not a past interest but the only responsibility that I have taken on since leaving office in your Lordships’ House, which is as a trustee of the Sabin Vaccine Institute in the United States. That institute has as its mission:

“To reduce needless human suffering from infectious and neglected tropical diseases through innovative vaccine research and development; and to advocate for improved access to vaccines and essential medicines for citizens around the globe”.

Some noble Lords will have noticed that word “infectious” and perhaps considered that in another place I might be out of order because the debate introduced by the noble Lord, Lord Crisp, is about non-communicable diseases. I shall return to that in a moment because there are links between NCDs and NTDs that need to be explored.

Neglected tropical diseases are a tremendous scourge of the world’s poor. They are diseases of poverty. Of the bottom billion—the 1.4 billion people in the world who exist on less than $1.25 a day—virtually every man, woman and child will be afflicted by one or more of the seven most common neglected tropical diseases. These diseases have been disabling, disfiguring and blinding their victims for centuries. They have enormously debilitating effects on individuals and economies because they cause a lack of growth and well-being, not only for the patient but for the nation concerned. That is an important point to make to follow on from the noble Lord, Lord Roberts of Llandudno, in the argument about investment in overseas aid. At a time of global economic crisis, we need those middle and lower-income countries to be growing their economies, not for them to be ravaged by the effects of the diseases that make many of their citizens unable to contribute economically.

I said that I would deal a little with this interaction between communicable and non-communicable diseases. In many ways, neglected tropical diseases behave like chronic non-communicable diseases. They are chronic; their clinical manifestation—the weakening of the immune system and the resulting long-term disability—is very much the pattern of non-communicable disease. They have the same effects and therefore it is important that we recognise the interactions between them and the fact that those interactions are not only in the parallels that I have made but are in co-morbidities and often in the neglected tropical disease being the catalyst for the non-communicable disease.

There are many examples. Schistosomiasis is one of the areas in which the Sabin Institute is working on the production of a vaccine. We also know that urinary schistosomiasis is a leading cause of bladder cancer in Africa and the Middle East. Significant numbers of cases of anaemia are because of hookworm infections, and liver flukes account for a number of cancers. That connection is there and my plea today is that we do not only look at vertical programmes of health but look at the health systems that we are supporting in the developing world; and at the interaction of the sorts of social factors that have already been described, and of the communicable and the non-communicable diseases, in our attempt to end the scourge and the pain and suffering that are caused worldwide.