National Health Service: Sustainability

Lord Cormack Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Cormack (Con)]

My Lords, it is a great pleasure to take part in this debate, which was so splendidly introduced by my friend, the noble Lord, Lord Patel. We have had many conversations about this in the early morning in the Truro Room, so I was very confident that he would make a splendid speech, which he did. This is a refreshing debate because it has been marked by consensus. I single out the speeches of the noble Lord, Lord Warner, and my noble friend Lord Mawhinney, both of whom, in slightly different words, made the case for saying, “The time for using this as a political football is over”. We need to work from both sides of the House. No substantial difference of opinion has been expressed so far during this debate, and I hope that I will not depart from that.

When I first entered another place 45 years ago I was a very humble PPS in the Department of Health and Social Security, where a very few Ministers—one in this House, three in the other place—looked after the whole of health and social security. When I reflect on that, I reflect on how far we have moved away from that tight-knit and rather efficiently run pattern. Of course, we now have a much larger population and a much larger surviving population. When I entered the other place I did not have a single constituent with artificial knees or hips, or with a transplant. I even wrote to those who attained the age of 80, which would not be possible now. We have moved on.

As the noble Baroness, Lady Emerton, reminded us, it is well over 70 years since Beveridge, and 67 years since the NHS came into being. The sort of commission or inquiry which has been called for today is therefore desperately overdue. It is not the first time that a commission has been called for in your Lordships’ House. I made the call in earlier debates introduced by the noble Lord, Lord Turnberg, in which the noble Lord, Lord Patel, participated. We need an inquiry or a commission, and I would favour the latter. It must be an open-ended inquiry, with an open agenda. Nothing must be off-limits. My noble friend Lord Fowler made that plain in his speech. All forms of funding must be looked at. We have to have a plurality of funding if we are to have a sustainable NHS. Whether the extra funding comes from compulsory insurances or certain charges matters not, but it has to come—we have to have a quality service that does not lurch from crisis to crisis, from one application of sticking plaster to the next. It is crucial that we attain that.

I have a great deal of confidence because my noble friend Lord Prior, who will answer this debate, was himself very recently a notable and innovative chairman of the Care Quality Commission. I hope that he will bring the experience he acquired in that important role to his role as a Minister in the department. He succeeds a greatly loved Minister in our noble friend Lord Howe. Let us now, freed from the constraints of coalition government, have the sort of boldness that the Chancellor expressed in the Budget speech yesterday. Let us have a commission or an inquiry that will look at every aspect of the NHS and of care, and which will in particular look at funding.

All of us here believe in the NHS. There is not a politician of sense or sensitivity in any party who does not believe that. However, we must not be constrained by outmoded philosophies. We must look at the NHS and at the society it serves, and see what we can do to give it the quality service that will take us through this century and into the next. Today we heard the statistics; we know how many people will develop difficult conditions that need very sensitive treatment, sometimes for years. Many of the problems we talk about today were not problems when I was elected to the other place, because not only did some of the drugs and techniques not exist, but people then would have died long before they needed the attention we are now calling for.

I hope that we will have a positive response from my noble friend on the Government Front Bench and that at the very least he will tell us that he will have serious conversations with the Secretary of State on this. However, if it comes to naught, which I hope it does not, we in your Lordships’ House should establish one of our special committees to look at these issues. I know, looking across and around the Chamber, that we have enough expertise; many of the people who could contribute to such a committee have spoken today. This problem will not go away. It must be addressed, and we must make sure that it is. A commission and inquiry is an idea whose time has come, and we must ensure that it happens.

National Health Service

Lord Cormack Excerpts

Thursday 8th January 2015 Lords Chamber

[Lord Cormack (Con)]

My Lords, it is a pleasure to follow the noble Baroness. How good it is to have her back among us. She is a testimony to the care that she has received. It is good for her to remind us of some of the problems that are faced by those who have to undergo spinal surgery.

I begin my remarks by referring to the noble Lord, Lord Liddle, because he ended with a plea for consensus and for taking the NHS out of party politics, and I endorse that entirely. He also made clear how important and central funding is. That is the issue.

Let us remind ourselves that the health service is, in effect, via Beveridge, the product of a grand coalition. Whether we will ever have a grand coalition like that again, I do not know; I certainly hope that we will never have the war that created it. However, it may be that the strange results in June could make that an infinitely preferable solution to the SNP holding the balance of power—but I must not digress because I wish to say that we are not serving the interests of the country or the health service by bandying about words such as “privatisation” and “weaponisation”. We have to focus on the service, what it needs and the funding it needs, and there has to be—I have said this many times in this House and in another place—a plurality of funding.

When I entered the other place in 1970, I did not have a single constituent with an artificial hip or an artificial knee, let alone a transplanted heart. By the time I left, 40 years later, the situation was very different. When I first entered the other place, I used to write a letter to every 18 year-old coming of age, and I used to write a letter to every 80 year-old, because it was quite an achievement in those days to reach the age of 80. I could not have done that in 2010. That is really the underlying problem. We are living longer, we have far better medical techniques, drugs and cures, and we are still relying on a single funding base.

I would like to see a commission set up after the election—Frank Field would be an ideal chairman—to look at funding and to rule nothing out. We have charges at the moment for prescriptions for certain people. Many GPs of my acquaintance say that it would cut down the absent rate—people who do not turn up for their appointments—if we charged for them. We could have a charge for those who are in hospital if they are in full-time employment. I quite like the Field idea of a hypothecated tax. We could have £1 on every bottle of alcohol and 50p on every packet of cigarettes devoted specifically, absolutely and totally to the NHS. We could have a system, as other countries do, of obligatory insurance. I am not particularly commending any individual one of these remedies, but I am saying that there are many alternatives.

The noble Lord, Lord Turnberg, who introduced this debate very splendidly, made the point that there has to be—he did not use the words—a plurality of funding, and there does. We should have a commission under a respected figure—and I believe that it would be entirely right that that respected figure should come from the left of the political spectrum. I do not believe that the Labour Party can for a moment claim entire credit for the National Health Service—of course it cannot—and I am proud of what Conservative Governments have done, but it was brought into being under a Labour Government and I see no reason why a respected figure whom we could all trust could not chair such a body, which would be broadly representative, to look at these alternatives, ruling absolutely nothing out.

Another thing that we should look at is what treatments are properly available under the National Health Service. If somebody is smashed up in a car crash, of course plastic surgery should be available on the NHS without any charge—but should a man or woman be allowed to change their shape through plastic surgery on the NHS? No. We have to look at a whole range of things, and we have to say what is appropriate for a world-class National Health Service to deliver to all people and how we contribute best to it.

After all, we all do contribute to it through our taxes—those of us who pay taxes, and the vast majority of us do. If there are additional charges here or there, and if there is a hypothecated tax such as Mr Field has recommended and the noble Lord, Lord Liddle, has endorsed, that is fine, but let us get this out of the petty party-political arena. Health is of supreme importance to all of us. There is no politician in any party who is not sincerely dedicated to the health of the people—of course there is not. Let us accept, as the noble Lord, Lord Liddle, said, the absolute integrity and sincerity of those on all sides of the political spectrum. Let us say that funding is the fundamental issue and let us try to get a consensual answer to the problems to which I have alluded.

NHS: Five Year Forward View

Lord Cormack Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

My Lords, I thank the noble Lord, Lord Walton, for his welcome of the Statement and indeed of the Five Year Forward View, which I think commanded a great deal of support from many quarters. He asked about the seven-day working plans for the NHS. Part of the Better Care Fund plans involves local areas committing, in one form or another, to seven-day working. Unless we have seven-day working in hospitals, we cannot hope to achieve the smooth and timely discharge of patients. That means a change in approach by a number of professionals. It does not mean that every professional will need to work seven days a week—no one has ever suggested that—but it means a shift in approach by social services, and by consultants in hospitals, in a way that in some areas we have not seen. In other areas this is already happening, and we can build on those models.

On the noble Lord’s question on biomedicine and orphan drugs, he is of course as well informed as he always is on these matters. Orphan drugs, as and when they come forward, can indeed be expensive, particularly if they are termed a stratified medicine applicable to only a narrow cohort of patients. In those instances we will expect NICE to make an assessment of these high-cost, low-volume treatments under its new methodology for those drugs. NICE is already engaged in a number of work streams in those areas. It is right that we take that approach. We have to have some methodology that commands confidence, to ensure that the NHS receives treatments that are not only clinically effective but provide value for money.

[Lord Cormack (Con)]

My Lords, I thank the Minister and congratulate him on what he has said. However, does he not accept that at the end of five years, welcome though this new injection of money is, there will be even greater demands and greater needs? Will he reflect on the debate introduced last year by the noble Lord, Lord Patel, where almost every speaker from all sides of this House indicated that there is a need for a plurality of funding if our National Health Service is to avoid further problems and disasters? Will he therefore reflect on the wisdom of establishing, with all-party support, a royal commission on the funding of the NHS that can look at everything and rule nothing out? If we are to have a world-class service through this century, we cannot resort to sticking plasters from time to time; we must have a new model of funding.

[Earl Howe]

My Lords, my noble friend, as ever, has rightly identified the likelihood of greater and greater demands on our health service over the coming years. Certainly, building a non-partisan consensus is something to be desired regarding the way that we fund our health service. Having said that, I can tell my noble friend that there has been no thinking whatever on the part of Ministers to depart from the current model of funding for the NHS. We believe passionately that the NHS should be free at the point of use, regardless of ability to pay. That is one of the core principles on which the NHS has been founded since 1948 and it is paid for out of general taxation. While I take on board my noble friend’s desire to look afresh at this area, I think that we have some way to go before cross-party talks need to take place. We are clear that we can proceed on the current basis.

Medical Innovation Bill [HL]

Lord Cormack Excerpts

Friday 24th October 2014 Lords Chamber

[Lord Cormack (Con)]

My Lords, my noble friend Lady Gardner is right to talk about hope. It has been said that the real poor of the 21st century are those without hope, but there is a worse condition and that is to have false hopes. There was a very moving article earlier this week in the Times by Melanie Reid, writing from her wheelchair. Those of us who read her columns from time to time can only admire her courage, resilience and sense of reality. She was writing in the context of the gentleman in Poland who has been given some form of locomotion as a result of brave, innovative surgery.

We are all very conscious of the background to today’s debate, which is different from that to the Second Reading, because, since then, we have had, as has already been mentioned, the Ebola outbreak and the need for untried and untested treatments because they are the only things that might conceivably offer some hope. We have also had the extraordinary affair of the young boy taken to Prague for treatment that he was not apparently able to have in Southampton, and we had the grotesque spectacle of his parents being put in jail. It was the most dreadful story.

Those remarks are merely in preface because I strongly support the aims and objectives of my noble friend. He has done this House a service in bringing this Bill forward, but he has done more than that, because since the Second Reading, he has clearly listened. He has had long conversations with Sir Bruce Keogh, the Secretary of State and others, and has striven to make his Bill much better than it was at Second Reading. We are all very much in his debt for that.

I readily acknowledge that we have heard some powerful speeches today from people who truly know what they are talking about. I readily concede that this Bill is not perfect now. I believe that if we are to legislate on this front we need to get the best possible Bill to become an Act of Parliament and speed must not be the only criterion we take into account when we are legislating on such a complex issue.

It was very moving to hear what the noble Lord, Lord Winston, said about some of his own experiences. The account given by the noble Lord, Lord Turnberg, of the surgeon at 30,000 feet also brought home to us how incumbent it is upon those with medical and scientific knowledge to be able to react quickly. The whole purpose of science and medicine is to innovate, otherwise people are merely being repetitious, and if you are merely repetitious then you cannot make true progress.

I think that there is a way forward on the legislative front this morning. I hope that we can today accept the amendments that the noble Lord, Lord Saatchi, has thoughtfully and helpfully tabled, and I believe that there should be another stage, a Report stage, where in the light of the amended and improved Bill, people such as the noble Lord, Lord Winston, whom I admire greatly, and the noble Lord, Lord Turnberg, who has done so much himself, can sit down with the noble Lord, Lord Saatchi, and further improve the Bill, so that when it goes to another place it has the benefit of that vast reservoir of medical talent and experience which is unique to this Chamber.

If ever anything justified the existence of this Chamber, it is a debate such as we are having this morning, where people who have really achieved great things in their chosen field are able to bring the benefits of their experience to our counsels.

I hope that this morning we can accept the amendments of the noble Lord, Lord Saatchi, and that he will then consult the noble Lords, Lord Winston, Lord Turnberg, and others, so that when we have further amendments on Report, we can make the Bill as foolproof and comprehensive as possible. It can then go to another place, where I hope that they can expedite its progress to the statute book.

[Lord Winston]

My Lords, perhaps I may intervene briefly before the noble Lord, Lord Cormack, sits down. He refers to the Ebola virus and to proton beam or carbon beam therapy—I am not sure which it was—and the boy who eventually went to Prague, I think it was. In the case of carbon beam or proton beam therapy, there is extensive medical literature about the treatment, so it is not innovative in the context of the Bill. I suggest to the noble Lord that with regard to the Ebola virus, although a very experimental vaccine has been given that has not been tested, there has been extensive discussion in all sorts of circles, including the New England Journal of Medicine, which is one of the leading journals in the world of medical practice, of whether such plasmas or vaccines should be given. That is fundamentally different from the Bill. I thought that the subject of Ebola might well come up, and I just wanted to make it clear that that threat is a very different issue and would be outside the scope of the Medical Innovation Bill.

[Lord Cormack]

As that was meant to be an intervention, I suppose that I had better respond. I was merely mentioning things that had happened since Second Reading; I did not begin to suggest that they were relevant to the Bill. I mentioned them by way of background, but of course I take the graciously worded rebuke and entirely accept what the noble Lord, Lord Winston, just said about the scientific background to both those examples.

[Lord O’Donnell (CB)]

My Lords, like the noble Lord, Lord Giddens, I am not a medic. I rise to speak because I think that this issue creates all sorts of problems and challenges in which my experience in public policy and economics can help. To me, what determines innovation is essentially economic. Economists have studied for a long time precisely how you get innovation in systems. I will not lecture noble Lords on the medical side. It is important that we operate with our heads, not our hearts, in this, so you will not get any emotional stories for me; I will be boringly analytical. I think that this is an issue about evidence-based policy.

We know that markets will not solve the issues that the noble Lord, Lord Saatchi, raises in the Bill. The incentive structures are such that the pharma companies will go for those areas where they can sell large amounts of drugs. Rare cases will be problems. One issue I have as someone who cares enormously about evidence-based policy—I gave a lecture at the Royal Statistical Society earlier this week on this, when I went on at length, which I will not repeat—is how you generate the right amount of data to handle this problem. I received a briefing from the BMA which said that there was no evidence to support such things. Of course there was no evidence; that is the whole point. We have to find ways to generate evidence.

I strongly support the Bill. In that, I am with Sir Michael Rawlins, president of the Royal Society of Medicine and former head of NICE, who knows about the analysis, so I take the medic side as given. I am very pleased that the noble Lord, Lord Saatchi, has accepted the safeguards. If you believe, as I do, that the really important part of this is the generating of evidence, we need something in the Bill to state that we will record evidence and register it correctly. That makes a lot of sense, but as a good former civil servant, I look forward to hearing the Minister’s reply and hope that he will reassure me that there is an equivalent way to do that. If that is true and is as solid, I will accept that; but in its absence, we need to make sure that we learn, that we get every innovation documented so that we build up the evidence base. That is what this is about—innovating safely and successfully.

NHS: Patient Data

Lord Cormack Excerpts

Tuesday 25th February 2014 Lords Chamber

[Lord Walton of Detchant (CB)]

My Lords—

[Lord Cormack (Con)]

My Lords—

[The Chancellor of the Duchy of Lancaster (Lord Hill of Oareford) (Con)]

Let us hear briefly from the noble Lord, Lord Cormack, and then we can go to the other side.

[Lord Cormack]

Will my noble friend assure the House that the leaflet which was recently sent out, and which was far from satisfactory, will be replaced by something that really communicates what people need to know?

[Earl Howe]

My Lords, I am aware of concerns around the leaflet. Many people have said that they have not received it, which is clearly a concern. NHS England, which is leading on the development of the programme, will consider how to ensure that it engages fully with stakeholders and the public over the coming weeks and months and respond to the concerns that have been raised. The Government will also be engaging with stakeholders to see what we can do from a broader perspective.

Children and Families Bill

Lord Cormack Excerpts

Wednesday 29th January 2014 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, they are two different issues. I certainly do not propose that we legislate in relation to people’s homes. The differences lie, first, in the scale of the health issue. As I have already indicated, the amount of second-hand smoke that a young person is likely to inhale in a car generally will be very much higher than in a person’s home. Secondly, by and large there are usually rooms in a person’s home that are not used for smoking, so there is more of an element of choice. I accept that this is a continuum, but I assure the noble Lord that it is not my intention to propose a ban on smoking in people’s homes. There are specific circumstances that make the banning of smoking in cars while children are present a particular health issue.

[Lord Cormack (Con)]

I am grateful to the noble Lord. Surely, my noble friend Lord Forsyth highlighted a very important point. He talked about small flats; there are small flats where there may be several children and only one living room. What is the logic of the noble Lord’s argument in that case? Personally, I do not think we should invade private space; that is my position and I may seek to defend it later. There is no logical difference between a single child in a car and four children in the living room of a small flat.

[Lord Hunt of Kings Heath]

My Lords, I do not accept that. Clearly, in relation to a child travelling in a car we are going to debate where the balance lies: whether a car should be regarded as a private entity in which the state ought not to intervene, or whether noble Lords consider that a child’s health becomes the paramount concern.

A private car is rather different from a home; the health damage to a young person inhaling smoke in a car generally will be much greater than in a person’s home. I do not want to repeat the point that I have already made to the noble Lord, Lord Forsyth, although I may be tempting him to intervene again. However, within a home there are likely to be opportunities for young people to avoid the smoke-filled parts of that home.

--- Later in debate ---

[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.

--- Later in debate ---

[Lord Patel (CB)]

My Lords, I am delighted to take part in this debate. Before I start, I shall not miss this opportunity to chide both Front Benches. I have spoken about this in the past and tabled many amendments on different health Bills. The last time that I tried was with the Labour Government. The Minister taking the legislation through was not the noble Lord, Lord Hunt, but the noble Baroness, Lady Thornton. I did not succeed on that day in getting my amendment through. Obviously, the government Benches were not going to support me, but I did have the support of the noble Baroness, Lady Barker, who is not in her place and who was the Front Bench health spokesman of the Liberal Democrats. I did not have the support of the noble Earl, Lord Howe, at the time—hence I did not succeed.

However, I am delighted to congratulate the Government on having, in a step-wise fashion—and as a result of efforts made by many other noble Lords, including the noble Baroness, Lady Finlay, and the noble Lord, Lord Faulkner—reached a place where they can bring forward an amendment to address the public health evidence that plain packaging will make a difference to the uptake of smoking of cigarettes, in particular by children. I am particularly delighted that the government amendment includes not just external packaging but internal packaging. I remember my days as a young medical student, when one would rush out and buy Sobranie Black Russians because the cigarettes were wrapped in nice black paper with gold tips. At the same time, we would also buy a packet of Sobranie Cocktails to impress the ladies we were taking to dances because they came in multicoloured wrappers—so packaging makes a difference, even to a young medical student.

I am therefore delighted to see the Government’s amendment. I have no doubt whatever that Sir Cyril Chantler, whom I know well as a friend, will be absolutely meticulous in looking at the evidence. I am convinced by the evidence and I hope that he will be, too.

Let me turn to the issue of smoking in cars when children are present. I have taken the trouble to look at all the evidence about second-hand smoke in confined spaces. I have looked at the public health evidence from the Surgeon General of the United States, from Australia, from New Zealand and from Great Britain—both epidemiological and observational studies. The findings are quite interesting: undoubtedly, second-hand smoking is harmful. It is harmful to children—more so because their metabolic rate is higher, so any injurious substances that they inhale are bound to have a greater effect. It is harmful also to adults, particularly older people who have respiratory conditions or cardiac disease. It is harmful also to pregnant mothers who do not smoke, among whom there is a higher rate of still-births and infant deaths because of the epigenetic effects of the inhalation of injurious substances during their pregnancy. It is worse if they smoke during their pregnancy, but even if they do not, the effect of second-hand smoke is harmful to them.

There is further evidence, mentioned by the noble Lord, Lord Ribeiro, that some of the injurious substances in tobacco smoke persist on certain surfaces for a very long time. So this issue is not just about smoking when there are children in a car; it is also about making that car harmful to children because injurious substances persist. That also applies to any confined space. So the question is: what legislation will have the greatest public health effect? Will it be legislation that stops smoking in cars when children are present? Will it be legislation that bans smoking completely? Of course, it will be the latter, but that will not be possible—such legislation is too draconian. Could it be a good educational programme that teaches people that if you smoke in front of children, whether in a confined space or in an open space, or if children just see you smoking, that is wrong and harmful?

I was accused by my wife of smoking 20 to 40 cigarettes a day. All young doctors smoked in those days; it was the thing to do. Not all doctors smoke these days. When I saw my daughter, who was 11 months old, watch me lighting a cigarette, it was the day that I stopped smoking. She might object to me giving her age, but she is past 40—just, and she is a cancer doctor, so she understands these things. I felt that her observing me lighting a cigarette would be as harmful to her as her taking up smoking. The issue that we should therefore debate is what would have the greatest public health gain, whether for children—more importantly for children—or for young adults, older people and pregnant mothers.

The amendment of the noble Lord, Lord Ribeiro, seeks more targeted education and some consultation to find the evidence. The amendment of the noble Lord, Lord Hunt, seeks to have on the statute that a regulation must be brought in. I was talking about regulations pertaining only to cars. The evidence that I have looked at would suggest that we should ban smoking in cars completely, because that way there would be no possibility of anybody smoking in cars and leaving injurious substances behind that may harm children. That may or may not be a better deal than that proposed by the noble Lord, Lord Hunt, but my plea is, “Let us look at what would be the best public health gain”.

[Lord Cormack]

My Lords, I begin by congratulating my noble friend Lord Howe on his amendment. I wholly support what he said about packaging and about appointing Sir Cyril Chantler. I have the good fortune of knowing Sir Cyril. Like the noble Lord, Lord Patel, who spoke a moment ago, I believe that he is a man of impeccable integrity and great knowledge and I am sure my noble friend could not have chosen anyone better. I do not want to dilate on that subject.

I have smoked two cigarettes in my life. I was 15 years old; they were Woodbines and it was behind the bike shed. They were thoroughly disgusting—I have never smoked since and I never want to smoke. I am afraid I cannot say the same for my wife, although I think she has cut down a bit; she certainly does not smoke in my presence, either in the car or at home.

It is beyond doubt that we can and should accept everything that has been said about the dangers of smoking by the noble Lord, Lord Patel, and my noble friend—my friend in every way—Lord Ribeiro. We should do everything possible to deter people from smoking. I am sure I speak on behalf of everyone in congratulating my noble friend Lord Ribeiro on the birth of his grandson. I would be entirely in favour of the parents of the grandson of the noble Lord, Lord Ribeiro, being sent a note about the dangers of smoking. I would be entirely in favour of the parents of every newborn child being specifically warned about the dangers to children of passive smoking. I would be entirely in favour of increasing the taxes on cigarettes. I would be in favour of extra insurance premiums for people who smoke. I would not object to there being a column about smoking on car insurance forms, and, if you tick the smoking box, there being an extra premium that goes directly to the battle against smoking. I would be entirely in favour of all those things or permutations of them. There are many that we could all think of.

However, when it comes to the question of smoking in motor vehicles, my noble friend Lord Ribeiro introduced his amendment skilfully, tactfully and undogmatically. I have no argument with that, but I believe that his essential premise is wrong. To advocate any law that is going to be exceptionally difficult to police and enforce, and moreover brings the state into the private space of individuals, is to be deplored.

[Baroness Howarth of Breckland]

My Lords, can I just ask the noble Lord about the whole of the child protection law as it stands at the moment, which is in every private space to protect children from neglect, emotional harm and, indeed, abuse within their own homes.

I believe that this is actual harm. It is extraordinarily difficult to police every home, as we know from what happens to social workers and social services every time something occurs in a local authority because the policing has been so difficult. That does not stop us having legislation to ensure that in private space, the child is protected from harm. We have heard from the noble Lord, Lord Patel, just how harmful it is. Were it left to me, I would legislate in the private space of the home. Having been brought up in a two-bedroom house on a working class estate, I think that my lungs have suffered. I am just pointing out that we legislate for private space, because that point has been raised on a number of occasions.

[Lord Cormack]

My Lords, that was really a speech rather than an intervention. There is all the difference in the world between the physical or sexual exploitation of a child and smoking. Smoking is not an illegal activity. Some of us may wish that it were, but it is not. It would be wholly impractical, as the noble Lord, Lord Patel, made plain in his remarks, for us to outlaw smoking. That is a road down which we cannot go. Therefore, to invade the private space of individuals who are committing a perfectly legal act seems to me a step too far. That is why we should look at other means. I have mentioned taxation and increased insurance premiums; there are many routes down which we could go to make it more and more difficult for adults to smoke in the presence of children.

Most importantly, it is up to experienced people such as the noble Baroness and my noble friend Lord Ribeiro to ensure that there is a well informed education campaign so that no one is in any doubt that smoking is a harmful activity and that inhaling passive smoke is dangerous and injurious to health. I am with the noble Baroness and my noble friend on that all the way, but the invasion of personal space—prosecuting people for what is a legal activity—seems a step too far. That is why, while I welcome and applaud the amendment introduced by my noble friend Lord Howe—if there were a Division, although I am sure that there will not be, I would enthusiastically go into the Lobby to support him—I cannot support something that I believe is a step too far in the invasion of personal space, which would also be monumentally difficult to enforce. We have to bear in mind the responsibilities of the police, whose job it would be to stop the cars and ask the questions.

[Lord Hunt of Kings Heath]

Does not the noble Lord accept that, although there may be difficulties of enforcement, the very fact of passing a law combined with the kind of educational programme that he supports is likely to have a positive effect?

[Lord Cormack]

No, frankly, I do not. I respect the noble Lord—he knows that—and we agree on many issues, but we will have to disagree on this one. I think it would make the job of the police even more difficult than it is at the moment and endanger what popularity they have with many law-abiding citizens. It is a burden that we should not place on them.

I repeat: let us do everything we can to educate; let us do everything we can to deter; let us have the plain packaging; let us listen very carefully to what Sir Cyril says in his report; but let us not take the ultimate step that the noble Lord advocates.

[Baroness Masham of Ilton (CB)]

My Lords, I shall be brief. I congratulate the Government on having listened about packaging of tobacco. I also support the amendments to protect children from people smoking in vehicles. Apart from damaging children’s health, smoke gets in their eyes and is very unpleasant. There are also small babies and pregnant mothers whose unborn children need protecting. I hope that the noble Earl can give the House some assurance that there will be regulations that will protect these vulnerable babies and children. I would add that people with asthma, and all chest problems, should also be protected because this is really dangerous for their health.

--- Later in debate ---

[Baroness Hughes of Stretford (Lab)]

My Lords, this has been an important but very long debate. However, my name is attached to three of the amendments in the group and I beg the indulgence of the House to make a few comments in, I hope, concluding the debate before the Minister responds. I want to thank the Minister in particular for his role in responding to the widespread support for standardised packaging within and beyond the House. The crucial role that he personally played in the Government conceding on this measure is recognised across the House. I am also grateful for his commitment on the record today that it is the Government’s clear intention to implement these measures as soon as possible, subject to the outcome of the evidential review. I hope that he can further confirm that the action will follow very swiftly in response to the questions raised by my noble friend Lord Hunt and the noble Baroness, Lady Howarth, about the timetable.

The Government’s intention to bring forward at Third Reading measures to ban proxy purchasing of cigarettes and e-cigarettes, taken together with this amendment on standardised packaging, will make a significant difference to the exposure to and take-up of cigarettes by young people. However, there is one other distinct and significant health hazard to children from smoking that we should include in this package of measures, and that is in relation to smoking in private vehicles and enclosed vehicles.

Our Amendment 57BB would simply enable the Government to bring forward regulations to make it an offence to expose children to tobacco smoke in cars, once the Government, with others, had reviewed the detailed implications and practicalities that such a measure would entail. That process of review and developing regulations would take account of all the questions raised across the House today about what if, would it mean this and would it mean that. It is an enabling amendment.

When it was first proposed by the noble Baroness, Lady Finlay, in Grand Committee, I was profoundly struck by the power of her argument about the particular vulnerability of children in this very enclosed situation and the impact on their health and development at their immature stage. It is obvious. I have heard no dissent in the House today about why passive smoking by children in cars is a very bad thing and ideally should not happen. I will not rehearse those arguments, which have been very well made again today by Members across the House.

However, I want to focus briefly on concerns that have been expressed about the amendment and the arguments against it. There have been three main arguments. One is the basic libertarian argument that people should be free to do what they like in their cars because they are private spaces and should not be fettered. But when we are considering freedoms, as we have done in our history, there is always a balance. Freedom for some is often at the expense of freedom for other people. The balance we are considering here is between the freedom for adults to smoke in cars when they like and the freedom for children not to breathe in that smoke in a situation from which they, by definition, as several noble Lords pointed out, cannot escape.

When responding to the noble Baroness, Lady Howarth, the noble Lord, Lord Cormack, for whom I have great respect, as he knows, said that there is a difference between smoking, which is a legal activity, and other things that we have prohibited in the home in relation to children. But the things that we were talking about then, such as neglect of children and the beating of children, have not always been illegal in the home. They were made illegal because they are particularly harmful to the well-being of children. We take it for granted now that such things are illegal but they were not always. We invaded that private space because of the need to protect children. The same argument applies. Because of the degree of damage that we know smoking in cars causes, we should apply the same argument here.

[Lord Cormack]

I have been thinking a lot during this debate. Is not the answer to make it obligatory for all new cars to have a smoke alarm fitted?

[Baroness Hughes of Stretford]

That particular measure would not deal with the issue of prohibition, so I cannot see how it would necessarily help. The alarm may go off, but if it is still legal for adults to smoke with children in the car, there would be no consequence to its going off. There are precedents, because this is a child protection issue, for our proceeding along this route.

The second argument was: if cars, why not private homes? There have been contributions today that have made it clear, citing research by the British Lung Foundation and other bodies, that there are real and qualitatively different levels of risk to children from the smoke in a confined space, from which they cannot escape, compared to that in homes. Yes, children will be harmed in some homes where space is limited. That is undoubtedly true. But the potential for children to escape those spaces is clearly there in a home situation. They can go outside as well. In a car, the toxicity levels and the fact that the child is trapped make that a distinctly different situation, of which we should take account with this amendment.

The third argument has concerned the difficulty of enforcement.

Care Bill [HL]

Lord Cormack Excerpts

Tuesday 29th October 2013 Lords Chamber

[Lord Hamilton of Epsom (Con)]

My Lords, I am a great supporter of the Care Bill, and my disagreement with my noble friend the Minister is on an extremely small point. When I went to see my noble friend the Chief Whip and stated my intention to press this amendment to a Division if it was not accepted by the Government, she said that she was very unhappy about people pressing Divisions at Third Reading. I have a lot of sympathy with her on that issue, but the problem is that when my noble friend Lady Barker tabled her amendment, it had a fantastic amount of support from all over the House—although not unanimous support, as the noble Lord, Lord Warner, had reservations. If he does not mind, I shall come back to those in a minute. My noble friend the Minister said that he would look at this matter again and come back at Third Reading—and that is where we are now.

I am a little naive and overoptimistic, and as the amendment tabled by my noble friend Lady Barker referred to spiritual well-being, I assumed that any amendment tabled by my noble friend the Minister would also include references to spiritual well-being. Instead, the government amendment would merely add the words “and beliefs”, so that local authorities would have to take into account,

“the individual’s views, wishes, feelings and beliefs”.

I do not regard that government amendment as meeting the legitimate desires of the noble Baroness, Lady Barker—with my support and that of many others—even half way. If anything, it takes us about a third of the way. It is a compromise, but it does not go very far towards meeting our original desire.

The problem is that the provision as amended would continue to deny the role of spirituality for carers and those facing chronic illness. The South West Yorkshire Partnership Foundation Trust says:

“Spiritual care can help you make the best use of all your personal and spiritual resources in facing and coping with the doubts, anxieties and questions which can arise in a health setting or when you are ill.”

That illustrates the problem that faces the Minister. The whole concept of spiritual well-being has not just been dreamt up recently by people who want to influence the Care Bill; it is a concept that has been adopted by the National Health Service since 2002, and it is already incorporated in NHS guidance for professionals and patients.

At the risk of boring the House, I shall read out some NHS advice:

“Provider units, including NHS trusts should make adequate provision for the spiritual needs of their patients and staff”.

That comes from NHS Management Executive, HSG(92)2. Here is another quotation from the NHS:

“NHS staff will … be sensitive to and respect your religious, spiritual and cultural needs at all times”.

That comes from Your Guide to the NHS, dated 2002.

“All NHS Trusts should ‘Make provision for the spiritual needs of all patients and staff from all faith communities’”.

That is from New Guidance DOH on NHS Chaplaincy, also dating from 2002. Indeed, my noble friend the Minister paid tribute on Report to the hospital chaplains, who perform an important role in the spiritual context. We have to ask why, if spiritual well-being is a commitment by the National Health Service, it cannot also be a commitment for local authorities.

I now turn to the concerns of the noble Lord, Lord Warner, who is chairman of the All-Party Humanist Group. He was concerned on Report that the clause might be discriminating against humanists. There is no question of that at all. The clause is focused on individual well-being. If an individual desired to have their spiritual well-being promoted, the local authority would be required to do that. On the other hand, if the individual expressed no desire to have their spiritual needs attended to then they would not get any form of spiritual counselling. That works well in the NHS, where you do not hear of an atheist’s interests being overridden. There is no reason why it should not work equally well with local authorities. Indeed, the Home Care Association, the London Borough of Hillingdon and the Social Care Institute for Excellence have all made reference to the importance of people’s religion and spiritual needs.

My amendment would not wreck the Care Bill. It is a tiny amendment that would make no difference whatever to the main purpose of the Bill. I am not asking the Minister to go the extra mile—merely the extra yard. Surely it is right to bring the local authorities into line on the question of spiritual well-being with the NHS. Surely it must be right to give solace to those many people who believe that there is a spiritual dimension to their lives. It would be particularly important for those in their declining years.

The Minister has rightfully won himself a reputation for dealing with your Lordships’ House with courtesy, politeness and understanding. I ask him now to show courtesy and understanding and to support my amendment.

[Lord Cormack (Con)]

My Lords, I support my noble friend, which is why I put my name to this amendment. I spoke briefly when it was first debated a couple of weeks ago and I am delighted to add my voice now.

I hope that the House will feel that what we are discussing is an important matter, but one that does not in any sense reflect on the Bill and would not impede the Bill’s limitation. All that it would do is give a degree of solace to many people for whom the spiritual dimension of life is crucially important. That is very simple but very profound. It behoves this House, of all places, to put this in the Bill.

I accept, without any reservation whatever, the good intentions of the Minister, for whom we all, in all parts of the House, have very high regard. He is a man of diligence and sensitivity, and he always tries to meet the legitimate concerns of his colleagues in all parts of the Chamber. I say to him today, with the greatest possible respect, that while he has tried to meet us, he has not quite succeeded on this occasion. The phrase “feelings and beliefs” is not a substitute for the word “spiritual”.

As my noble friend Lord Hamilton said, this would in no sense damage the concerns or interests of humanists and others. If someone did not wish to have spiritual care or to have their spiritual needs taken into account, then so be it. However, there are many people, especially, as my noble friend said, those in the evening of their lives, for whom this is an exceptionally important dimension of those lives. I urge colleagues in all parts of the House to recognise the profound importance of this simple amendment and, if my noble friend feels inclined to test the opinion of the House, to react sympathetically. I hope that that will not be necessary, however; my noble friend has referred to the misgivings of the Chief Whip over Divisions on Third Reading. Like him, I understand those reservations, but the fact is that the Minister said that this was a matter to which we would return at Third Reading, and that he would try to table something. He has been as good as his word in tabling it, but I do not believe that he has quite met the points that concerned my noble friend Lord Hamilton and I, and many others. Therefore, the best possible solution to our dilemma this afternoon would be for the Minister to accept this modest amendment. I hope that he will do that and avoid the Division which the Chief Whip would so regret.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, before I move to the matter in hand, I thank noble Lords for the tremendous dedication that they have shown to the scrutiny of the Bill during its passage through the House. It is a landmark piece of legislation, and I hope that the House will agree that the changes that the Government have made in response to the debates that we have had have strengthened the Bill so that it will pass to the other place in an even better state. Many noble Lords across this House have dedicated impressive time and energy to improving the provisions in all parts of the Bill, but time does not permit me to thank all noble Lords individually, as I would like to. However, I thank again those noble Lords who played such an important role in improving the Bill as members of the pre-legislative scrutiny committee.

I turn to my noble friend’s amendment. Under Clause 1, local authorities must promote individuals’ well-being and must also have regard to individuals’ views, wishes and feelings. As I set out during our debate on Report, we consider that these provisions mean that a local authority would take a person’s spiritual views, wishes and feelings into account in promoting their well-being. However, in response to concerns raised by a number of noble Lords on Report, I have now tabled an amendment to make it absolutely clear that these matters should be considered where they are of importance to the individual.

My amendment adds “beliefs” to the matters to which a local authority must have regard when exercising care and support functions. Having regard to someone’s beliefs includes their spiritual beliefs; for example, ensuring access to an appropriate figure of religious authority during palliative care. This approach achieves the same aim as Amendment 1 in the name of my noble friend Lord Hamilton, but I suggest to him and to the House that the government amendment is preferable, for two reasons.

First, my amendment quite deliberately does not refer specifically to “spiritual” well-being, but applies instead more widely to beliefs, which was the point made very effectively by my noble friend Lady Barker. That is because we do not wish to exclude those who may not consider themselves to have “spiritual” beliefs. That issue was raised by the noble Lord, Lord Warner, on Report, in relation to humanists.

Secondly, despite the comments of the noble Baroness, Lady Warnock—to whom I listened as always with great attention—spiritual well-being is not a well understood or defined concept. It carries a risk because it may confuse the practical application of the well-being principle on an individual level. There is another problem here. My noble friend’s amendment would effectively mean that local authorities had a duty to promote an individual’s spiritual well-being or beliefs. It is not appropriate to require a local authority to promote spiritual matters, except in so far as they affect the emotional well-being of a person.

[Lord Cormack (Con)]

This is a question not of local authorities promoting but of their protecting. There is surely a real difference there.

[Earl Howe]

I hope that my noble friend will on reflection agree that promotion is very much a part of the local authority’s role here. However, subsection (2) makes adequate provision as regards the emotional well-being of a person.

My noble friend Lord Hamilton compared what we are proposing in the Bill to the situation in the National Health Service. The NHS does not have a duty to promote spiritual well-being and, if it did, that potentially would have the negative consequences that I outlined. Having said that, the noble Baroness, Lady Emerton, is of course right—the NHS must take a patient-centred approach when planning and delivering services, and that would naturally include having regard to an individual’s beliefs where relevant. It is exactly this position that the Bill will replicate for local authorities when they plan and deliver care and support. To support the NHS in fulfilling its functions the Department of Health has produced best-practice guidance on NHS chaplaincy but I struggle to understand how that can equate to a duty in primary legislation on local authorities to promote spiritual well-being as my noble friend would have it.

Care Bill [HL]

Lord Cormack Excerpts

Wednesday 9th October 2013 Lords Chamber

[Lord Deben (Con)]

My Lords, I support what my noble friend has just said. I have to say to the Minister that this amendment is rather necessary because there is a generalised belief that forces in our society are determined to marginalise that which has actually made our society and has had such an influence on the provision of healthcare for our people. The history of healthcare in Britain shows that it was fundamentally founded by those of faith. That does not say anything about anyone else, but it does say that if we want holistic medicine—I am not a great believer in anything other than orthodox medicine, so I am not encouraging all kinds of what I consider to be alternatives, which are best left alone—we have to understand that it is about the whole person, and for many people this is a most important part of the whole person. For this not to be in the Bill will be seen by many as another example of society specifically seeking to marginalise an important section of our community on whom we depend widely for many of our voluntary activities, and certainly on whom we have depended and do depend for our health services. I hope very much that the Minister will take this point seriously.

[Lord Cormack (Con)]

My Lords, I would like very briefly to support what my two noble friends have just said. Surely this is not the Government conceding to a secular society and surely they recognise that for many sick people, the spiritual dimension is extremely important. It is not a question merely of healing physical ills and curing physical diseases, it is a question of recognising that many people, particularly as they near the end of their lives, have a great need to fall back upon their faith, and that should be recognised and encouraged. For the life of me, I cannot see what the Government are doing here and I hope that my noble friend will be able to give us a satisfactory answer. I am only sorry that the Bishops’ Benches appear to be empty this afternoon because one would have liked to have heard a contribution from them.

[Lord Harries of Pentregarth (CB)]

My Lords, as someone who remains a Bishop, on behalf of my old friends on the other side of the Chamber, I would like to support this amendment. As the Bishop of Oxford, I remember visiting one of the brand new universities, which thought of itself in very secular terms. Nevertheless, the university was adamant that it should have a chaplain because it believed in whole-person care, and an essential element of whole-person care was the spiritual dimension. We need to take that into account.

We also need to take into account the fact that we now live in a multifaith society, and for those of some religions in particular, it is very important that they have someone with religious authority in contact with them in the final stages of their life. There are good reasons for supporting this amendment.

--- Later in debate ---

[Lord Cormack]

If this is explicit for the National Health Service, why can local authorities not be treated in precisely the same way?

[Lord Warner]

I am trying to help the Minister. If he does agree to provide the assurances sought by noble Lords to look again, could he see whether if he moved in the direction they suggest, he would be discriminating against humanists?

NHS: Keogh Review

Lord Cormack Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

I applaud that and we should all celebrate the success of outstanding hospitals—there are many in the health service—which have led the way in improving mortality rates over the past few years. The noble Baroness is quite right. Indeed, Sir Bruce suggests that those hospitals should now be asked to partner with some of the hospitals that are struggling in certain respects to show the way, whether that is on governance, on systems in A&E, on quality of surgical outcomes or whatever it happens to be. That is an appropriate idea, and we should undoubtedly ensure that it is taken forward. However, as the Statement itself reflects, the 14 hospitals that are under the microscope at the moment are not representative of the quality of care that the NHS delivers day in and day out, which is of a very high standard by any benchmark.

[Lord Cormack]

My Lords, I accept what my noble friend has just said, but he will understand that there will be concern throughout the country at this very disturbing indictment—because that is what the report is. Will he talk to the new chief inspector to consider whether we can have a form of assessment of hospitals—the noble Lord, Lord Warner, effectively referred to this—so that patients throughout the country know whether their local hospital is graded as being excellent or not? Will he also ensure that there is a debate on the Floor of this House, as there will be on the Floor of the other House?

[Earl Howe]

I can certainly use my best endeavours through the usual channels with regard to my noble friend’s latter question. On his first point, he is absolutely right. That is what led us to believe that aggregate hospital ratings, provided that they are produced in a sophisticated and careful way, will be very informative to the general public and to patients in a local area, and to professional staff within the health service. The Healthcare Commission, of old, used to produce aggregate ratings. They fell into disuse and, I have to say, into some disrepute, because they were so broad brush as to be meaningless. When we asked the Nuffield Trust to look at this area, it told us very clearly that, as long as we adopted a nuanced and sophisticated approach so that what was assessed was not just a hospital trust or an individual hospital within that trust but rather the performance of individual medical teams and units within a hospital, we would provide useful information to the public. However, that information needs to be accessible.

Mid Staffordshire Foundation Trust Inquiry

Lord Cormack Excerpts

Tuesday 26th March 2013 Lords Chamber

[Earl Howe]

My Lords, the main drivers and levers for increased integration will come from other directions, such as: the systems we are putting in place at local authority level and health and well-being board level; more sophisticated tariffs; better commissioning arrangements between the NHS and social care; and the financial imperative that all commissioners and providers now face. That will mean an imperative to ensure that resources are not wasted and are deployed to the best effect of patients.

We must also remember that the NHS outcomes framework will be the benchmark by which the success of the service is judged, just as the social care outcomes framework will act in that sphere in an equivalent way. The major domain in both areas is the patient experience. If we believe that integration is above all to be defined by reference to the patient’s experience, we can expect commissioners across the piece to address commissioning in a way that avoids disjointed care.

[Lord Cormack]

My Lords, is my noble friend aware that many people in Staffordshire will welcome this report but will wonder whether the present chief executive is the best person to oversee the implementation of the many recommendations to which my noble friend has referred?

[Earl Howe]

My Lords, it was a signal feature of the Francis report that he consciously avoided pointing the finger at individuals. The chief executive of the NHS did not have the finger of blame pointed at him. The House may be interested to know that I regard Sir David Nicholson as a truly outstanding public servant who has done an enormous amount of good for the NHS since becoming chief executive.

The benefit of hindsight is wonderful but we must remember that in the years in which these dreadful events took place the National Health Service was held to account by reference to two main indicators: access to care and waiting times, and finance. Above all, it was the arrival of the noble Lord, Lord Darzi, as a Minister and the Secretaries of State whom he served that saw the transformation of the NHS from an organisation that was concerned just about numbers into one that really appreciated that quality matters. Therefore, to accuse those with positions of responsibility with regard to Mid Staffs of overlooking the fact that quality was poor is to place a wholly unfair retrospective expectation on them.