Health: Birth Defects

Baroness Jolly Excerpts

Wednesday 6th November 2013 Lords Chamber

[Baroness Jolly (LD)]

I am grateful to the noble Lord for securing this debate on this very important issue, and I thank all noble Lords for this thoughtful and informative debate. The department is considering this issue very seriously. We know that approximately one in every 1,000 pregnancies is affected by a neural tube defect, which can result in miscarriage, neonatal death or lifelong disability. We also know that poor folate status is an established cause of neural tube defect-affected pregnancies, and therefore how important folic acid is for women of childbearing age. I will take your Lordships briefly through the detail of how the Government are currently taking action to reduce the risk of women having insufficient levels of folate—a risk that may result in potential neural tube defects such as spina bifida in unborn children.

It is possible to get all the folate you need from food in a healthy diet, but for women who are trying to conceive or are newly pregnant, getting enough particularly matters. That is why, since the 1990s, the Department of Health has advised women who can become pregnant to take folic acid supplements before conception and for the first 12 weeks of pregnancy, and to increase their intake of folate-rich foods. That advice is promoted as strongly as possible through all the channels we use to communicate with women and health professionals. NICE guidance ensures that health professionals are equipped with comprehensive advice on folic acid and on action to take with women who may become pregnant.

For women, advice is disseminated through a variety of sources such as the NHS Choices website, which sets out why folic acid is important for pregnancy and gives guidance on taking supplements. The Department of Health also provides funds to the charity Tommy’s to produce The Young Woman’s Guide to Pregnancy, which advises young women to take folic acid. Start4Life, a campaign to give the best start in life to nought to two year-olds, gives information on five key healthy behaviours during pregnancy, one of which is taking folic acid and vitamin D supplements. Their leaflets are written in a friendly and accessible style and are very popular with healthcare professionals as a tool to facilitate conversation with parents and expectant parents. The NHS Information Service for Patients offers to send e-mails and texts to women and their partners in the fifth week of pregnancy to remind women to take their folic acid.

Folic acid supplements are widely available and cost as little as £1 for a month’s supply, but are also available on NHS prescription. Pregnant women and women who have had a child in the previous 12 months are exempt from prescription charges, as are people on certain benefits or those who qualify through the NHS low-income scheme. We also offer free vitamin supplements containing folic acid without an NHS prescription to pregnant women and new mothers in very low-income families throughout the UK who are supported by the Healthy Start scheme. More than 150,000 pregnant women and new mothers are eligible to claim vitamins through that scheme. However, we know that some women do not take supplements, and of those that do, some start too late. That is of real concern to the Government and health professionals, and an area on which the Chief Medical Officer is keen to see action, as she set out in her recent annual report.

In 2000 the Committee on Medical Aspects of Food Policy first recommended the fortification of flour with folic acid to reduce the risk of NTD-affected births. Your Lordships will be familiar with the developments of the scientific advice since then. The Government are very grateful for the full advice which has been provided by consecutive expert committees and for the rigour and scrutiny with which the Scientific Advisory Committee on Nutrition—better known as SACN—considered the issue for its report in 2006 and its subsequent reviews of evidence. The noble Lord, Lord Rooker, will know that SACN sought to understand and clarify the risks of fortification carefully as it sought to make clear the benefits of its recommendation.

The advisory committee concluded in 2006 that mandatory fortification of flour with folic acid would reduce the risk of NTD-affected pregnancies, but that there was a potential risk to some population groups, particularly older people, including a potential increased risk of bowel cancer. In 2007, the then CMO asked SACN to further consider the evidence in this regard. In 2009, SACN’s majority view was that the new evidence did not provide a substantial basis for changing the original recommendation. However, it recommended fortification only if accompanied by a number of other actions, including restricting voluntary fortification of foods with folic acid, developing guidance on supplement use for particular population groups, and implementing measures to monitor evidence of long-term exposure to intakes of folic acid above the guideline upper limit per day.

SACN’s recommendation about monitoring and review explicitly reflected concerns around the potential for the numbers of people consuming levels of folic acid above the guideline upper limit. Health Ministers considered it prudent to ensure that all available evidence on the risk of colon cancer was peer-reviewed and in the public domain, which noble Lords referred to earlier, and the evidence was published in the Lancet this January. Following publication, Ministers confirmed earlier this year that they were taking stock of the issue. I assure the noble Lord who, as former chair of the Food Standards Agency, will understand this better than many, that because of the complexity of the issue it is essential that we weigh up carefully the risks and benefits in coming to a decision, and that we fully think through the implications of the other recommendations made by SACN. We are now doing that, and, thanks to the expert scientific committees and the consideration of this by the FSA and others, there is a wide range of evidence and advice to consider.

I pay tribute to the work of the voluntary sector, and in particular to one organisation mentioned earlier in this debate, Shine, which supports individuals and families as they face the challenges arising from spina bifida. It works tirelessly to raise awareness of the importance of folic acid and in May this year held the first ever national Folic Awareness Day.

Noble Lords have asked many questions, and I will work through them in the time I have available. However, if there are any still outstanding I will be happy to write to noble Lords after the debate. The noble Lord, Lord Rooker, asked whether we had talked to Ministers in Scotland, Wales and Northern Ireland. As noble Lords are aware, food and health policies are devolved issues and discussions on fortification outside England are for those Administrations. However, the views of those authorities will be taken into consideration by Ministers.

[Lord Rooker]

I am sorry to interrupt, but this dismissal of devolution is symptomatic of Westminster; it just does not do devolution. Rather than simply saying that it is a matter for them, it would be better to have a UK-wide policy. Is the Minister admitting that Ministers in England—this is what we are talking about here—have not discussed the matter with Ministers in Scotland, who may take their own route, as they are free to do, and that the four chief medical offices have not discussed the issue among themselves?

[Baroness Jolly]

My Lords, I am telling noble Lords what I have been briefed. I am more than happy to write to noble Lords and, if they are happy for me to do so, leave the letter in the Library for everyone to check. I will also need to respond to the noble Lord, Lord Rooker, on his question regarding terminations.

The noble Countess, Lady Mar, asked about the risks and benefits, and assessing impacts, of fortification, giving due consideration to the implications of additional recommendations by SACN. We will take into account the views of the Chief Medical Officer, who raised the issue in her annual report, and of the devolved Administrations. The other point raised by the noble Countess was on ensuring that NTDs are avoided in pregnancy and on preventing vitamin B12 masking. We need to get this right. SACN considered the amount of folic acid to recommend and also recommended developing guidance on supplement use for particular population groups, along with implementing measures to monitor evidence of long-term exposure to intakes of folic acid. We are carefully weighing the benefits and risks of SACN’s recommendations and will take account of all views.

The noble Baroness, Lady Grey-Thompson, asked what foods would be considered for fortification. Currently, breakfast cereals are voluntarily fortified with folic acid in the UK. The FSA considered other foods, including soft drinks, fruit juice, milk and chewing gum, when it made that recommendation, but the consumption rate of these products is not considered to be universal across women of child-bearing age and would therefore not be suitable for fortification. Other foods were also considered. Bread was finally decided upon as the universal food as—to answer a point raised by both noble Baronesses—it is universally consumed across the population and all socioeconomic groups: more than 90% of households eat bread. Fortification of wheat flour would also include other wheat-based products such as pizzas, pastries and biscuits.

I think I have replied to several points that were raised.

[Lord Hunt of Kings Heath]

My Lords, will the Minister write to noble Lords—clearly the Government will have to consider this—and set out a timetable on when they will come back to Parliament with an answer?

[Baroness Jolly]

That sounds eminently sensible. I am happy to write to noble Lords to give them that information. I hope that I have provided reassurance—I am not convinced that I have—that the Government are committed to reaching the right decision on the fortification of flour with folic acid, doing proper justice to the work of SACN and others and ensuring that, while seeking to deliver the benefits, we minimise the potential risks. In the mean time the Government will continue to raise awareness of the need to take folic acid supplements and are supportive of all those who are raising awareness of this issue. I thank the noble Lord for securing the debate.