NHS England: Health and Social Care Act 2012

Lord Patel Excerpts

Wednesday 7th May 2014 Lords Chamber

[Earl Howe]

My Lords, I do not accept that CCGs are subject to unreasonable controls from NHS England. It is the task of NHS England to support CCGs and hold them to account, and that is what I believe it is properly doing, not least through the outcomes framework. Ministers are not intervening on the question of mental health funding because funding is just one part of the story when it comes to parity of esteem. We have set NHS England a strategic objective to make measurable progress towards achieving true parity of esteem for mental health. NHS England is responsible for allocating funds to clinical commissioning groups, which are best placed to invest in services that meet the needs of their local communities. However, we will of course hold NHS England to account for that. What we must not do is to single out certain elements of the equation at this stage.

[Lord Patel (CB)]

Can the Minister say whether the Ministers in the Department of Health are happy that NHS England has recommended a 20% deflater to tariffs for mental health that destroys any possibility of achieving any kind of parity of esteem?

[Earl Howe]

My Lords, we are not happy with that and, as I have said in the House before, Ministers have made it very clear to NHS England that this decision is both surprising and unwelcome in view of the need to maintain parity of esteem. NHS England, the NHS Trust Development Authority and Monitor are addressing this issue vigorously and we have regular discussions with those bodies to ensure that mental health services do not suffer.

Care Bill [HL]

Lord Patel Excerpts

Wednesday 7th May 2014 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I will speak to my Amendment 45D, although I may speak to the other two amendments, in the names of the noble Lords, Lord Owen and Lord Turnberg, as well, because they are relevant to the whole debate.

There is no question that the NHS has a rich reservoir of patient information. If we can exploit it to the full, its use could enhance care, aid early diagnosis and be a rich source of data for the development of new medicines and treatments. There is no argument at all here between the Opposition and the Government on this. The noble Earl reminded me that I took through legislation in 2002 that set the foundations for what we are now debating. He will recall that I was then arguing for us to use the potential of NHS information to the full. The noble Earl then, supported memorably by the noble Baroness, Lady Cumberlege, was a mite worried, I recall, about patient confidentiality. I think, however, that we reached a broad consensus that this is information to be brought together and used, but alongside safeguards that have public confidence. This is simply the issue that is before us at the moment.

Under the extension of the scheme, the Health and Social Care Information Centre can require GPs to upload patient data in an identifiable form from every GP practice in England. This will be linked to the Hospital Episode Statistics and other data sets. The information centre is a body corporate that can require a health and social care body to provide information—including confidential information. That is all well and good. The problem is that the centre and NHS England have botched its implementation, so much so that the scheme had to be withdrawn, originally for six months until the autumn, but my understanding is that the chief executive of the NHS, in evidence to the Health Select Committee, said that that date no longer applied. Perhaps the noble Earl could, when he winds up, comment on that.

My own view is that this is a dead duck. The Government will not be in a position to enable the scheme to go ahead any time before the election because so much public confidence has been lost. This is not surprising. Clearly, the information centre and NHS England took an inadequate approach in their public communications effort and there was a lack of effectiveness and accountability. It is clear that there are concerns about whether such information can be kept confidential in practice, and there is a worry that pseudonymised data could, in certain circumstances, be manipulated to identify a particular patient. There have also been concerns, referred to by my noble friend, about inappropriate use for commercial reasons, such as by insurance companies. I make a big distinction here: I would want the pharmaceutical industry to be able to use that information in research and development. That is absolutely legitimate.

There is also concern about general practitioners and their approach. Before the decision was made to suspend the scheme, there were worrying signs that a number of GP practices would not co-operate or would advise their patients to opt out of the system. It is important to recognise that we will automatically be part of the system as patients unless we opt out. Again, I agree with that principle. It is the only way to operate it. However, I am not convinced about having to go to my GP, if I can get an appointment, which is quite arguable at the moment, and having to talk to my GP—or, even worse, the receptionist—to say that I want to opt out of the scheme. There are real concerns about this system. Unless the GP body as a whole is confident that it is going to run with this, it will be destroyed because so many people will be encouraged to opt out that it will not achieve what it is meant to achieve.

I agree with the Royal Statistical Society which argues that we need a robust response to restore public confidence. Of course, I welcome the changes that the Government have made as a result of debates in the other place and in your Lordships’ House. The question, however, is: do they go far enough to restore public confidence? In my view, they do not. The Government have to make the bold statement that the system cannot be allowed to run under the people who are running it at the moment. They have lost people’s confidence. I cannot put this across strongly enough to the Minister: if you talk to organisations that know about the subject, you find that they are clear that they now do not have confidence in the people who are running the system.

That is why the Motion of the noble Lord, Lord Owen, is so important. He is basically saying that we need an external body that is independent and can give total oversight to the scheme. I support my noble friend’s amendment as well. I agree that it would be better in primary legislation than secondary, but there is no harm in having some secondary legislation to back up what we may agree in your Lordships’ House today.

In the Commons, the Government introduced amendments regarding the use of the term “promotion of health” for the purposes of the dissemination of information. Of course, “the promotion of health” could be a very open-ended definition. There was some fear in the other place that commercial companies—say, food and drink companies—could argue that they needed information for a public health campaign. My Amendment 45D seeks to provide reassurance by asking for regulations to be laid that are explicit about the circumstances in which information concerning the promotion of health can be used.

In supporting my own amendment, I say again to the Minister that there is no disagreement whatever about the importance of care.data, about the need for it to be successful or about the huge benefit to our country if it becomes successful. Success, though, is not guaranteed, and at the moment I believe it is unlikely unless the Government make changes. I hope that the House and the Minister will be sympathetic to these amendments.

[Lord Patel (CB)]

My Lords, I will speak very briefly. I will not repeat everything that has been said but I support what was said by the noble Lord, Lord Turnberg, particularly about the use of data for biomedical and other medical research. I have been involved on several occasions with perinatal epidemiological research, and such data are vital for that. There is no doubt that we need to be certain that core data will be available for research purposes.

I had not thought that “the promotion of health” might be construed as applying to the food industry; I had interpreted the phrase to mean epidemiological and public health research. However, if the interpretation includes the promotion of health by the food industry, then of course I support it absolutely.

I would be content to have this in secondary legislation at this stage, as the noble Lord, Lord Hunt, mentioned. However, there is no doubt that the way in which the issue has been handled by Public Health England has lost confidence. It could have been handled better, and I hope that Public Health England has learnt lessons from it.

[Noble Lords]

NHS England.

[Lord Patel]

NHS England, not Public Health England. My apologies; sometimes I do not focus well, for reasons that are not obvious to your Lordships. I have some problems that occur. I mean NHS England. I wondered why the Minister was looking at me so curiously. I was about to check whether I was dressed correctly.

I understand that NHS England got this information to the public by doing a mail shot to every household. Some people received it but most people I have asked, among friends and family, do not seem to have done so. On top of that, the mail shot was not clear about what it was asking patients and the public to do. It was actually asking them to decide whether or not they wanted to opt out of their information being collected. That is the kind of process that has brought about a lack of confidence in how this has been progressed.

NHS: Mental Health Funding

Lord Patel Excerpts

Wednesday 2nd April 2014 Lords Chamber

[Earl Howe]

The right reverend Prelate raises an important dimension of this whole issue. We have been looking at ways to overcome inequalities in access to services, which includes better access for black and minority ethnic communities to mental health services. For example, we know that people from BME communities have been less likely to use psychological therapies. To tackle that, the department is working with the Race Equality Foundation and other stakeholders to understand why that is so and to understand inequalities around access to other mental health services and what can be done to improve that. NHS England is also working with BME community leaders to encourage more people to use psychological therapies.

[Lord Patel (CB)]

Has the Minister any comment on the fact that Monitor and NHS England have recommended, pro rata, 20% greater cuts in funding for mental health services than for acute services?

Health: Folic Acid Fortification

Lord Patel Excerpts

Wednesday 2nd April 2014 Lords Chamber

[Earl Howe]

There is a range of routes whereby we ensure that, as far as possible, women are advised on folic acid intake, particularly those women of childbearing age who may be thinking of starting a family. That includes the Start4Life information service and other media routes. I am not aware of specific media campaigns in this area, but if I can be enlightened on that I will write to my noble friend.

[Lord Patel (CB)]

The Minister commented that no other European country has adopted fortification. Does he agree that the reason for that is that no other European country has the same incidence of neural tube defects as we have here in the United Kingdom? The incidence is far greater in the United Kingdom.

[Earl Howe]

That is an issue that we will of course weigh up as we look at the risks and benefits and take a decision, as we will in the next few days.

Regenerative Medicine: S&T Committee Report

Lord Patel Excerpts

Thursday 13th March 2014 Lords Chamber

Moved by

[Lord Patel]

To move that this House takes note of the Report of the Science and Technology Committee on regenerative medicine (1st Report, HL Paper 23).

[Lord Patel (CB)]

My Lords, I invite noble Lords who have just taken part in the education debate to stay, if they want to enrich their education. However, while they make a decision on that, I am pleased to introduce this debate on the Science and Technology Committee’s inquiry into regenerative medicine.

Our chairman of the committee and of the inquiry, the noble Lord, Lord Krebs, could not be here but, on behalf of the committee, I thank him for his brilliant chairmanship. I also thank our special adviser, Professor Fiona Watt FRS. The committee was well and expertly advised by her. I also thank our clerk, Mr Chris Atkinson, all the staff of the committee and all its members, some of whom are taking part in this debate. I thank all noble Lords who are taking part, particularly the Minister, the noble Earl, Lord Howe, and the noble Lord, Lord Hunt, on the Opposition Front Bench.

I declare my relevant interests. I am a professor and chancellor of the University of Dundee, a fellow of the Academy of Medical Sciences and of the Royal Society of Edinburgh, and I have previously chaired various stem cell committees in the United Kingdom.

Regenerative medicine is an umbrella term for the medical specialty of the regeneration of human tissue, organs and cells. It has the potential to treat or cure disease. Possible treatments range from curing neurological disorders to eventually repairing hearts. Our inquiry sought to pinpoint the UK’s strengths in regenerative medicine, identify barriers to translation and commercialisation—in the case of commercialisation, primarily dealing with treatments in the healthcare market—and recommend solutions.

The UK has an enviable potential resource in the National Health Service, with access to hundreds of thousands of patients in one system and a strong science base in this field. The Government have also been paying significant attention to developing this field. Together, these factors could combine to benefit patient well-being and the health of the UK economy. Basic science translation and commercialisation in this field are being well supported in other countries. However, there are growing concerns that, despite positive progress so far, the UK could fall behind in this area and miss out on opportunities to translate basic science into commercially viable treatments as the science develops. The opportunity cannot be missed. The UK could and should be a world leader in this field.

It is for that purpose that the committee chose to limit its inquiry to the regulatory framework for the translation of science and commercialisation. The key areas of inquiry were the research base, the application of science, barriers to translation, barriers to commercialisation and international comparison. The call for evidence was issued in July 2012. The committee was informed by a seminar held prior to our inquiry at King’s College, and during the inquiry some members of the committee visited the California Institute for Regenerative Medicine in San Francisco, often referred to as CIRM, for three days of intensive seminars and discussions. CIRM is an impressive organisation and, in many aspects, is quite special—in its inception, its funding and its delivery and scale—and is likely to deliver regenerative treatments in the near future.

We published our inquiry report and the voluminous evidence in July 2013 in HL Paper 23, and I now turn to the report and its findings and recommendations. The term “regenerative medicine” is used to refer to methods to replace or regenerate human cells, tissues or organs in order to restore or establish normal function. This includes cell therapies, tissue engineering, gene therapy and biomedical engineering, as well as more traditional treatments involving pharmaceuticals, biologics and devices.

Perhaps I may give some examples. Bone marrow transplantation, which is well understood by many, is the original stem cell therapy. Another is the use of pancreatic islet transplantation for certain types of difficult-to-control glycaemia in type 1 diabetes. Another is the use of skin cells to treat burns. Less well known perhaps is the use of gene therapy to treat lipoprotein lipase deficiency and autologous cell therapy to treat cartilage defects in knees. Treatments likely to be available in the next four or five years are those that support the body’s own regeneration and repair mechanisms. Others are treatments using cells, including embryonic stem cells, for certain eye conditions, such as retinitis pigmentosa and age-related macular degeneration, which affects 30% of the population over the age of 60. The hope is that eventually there will be treatments for Parkinson’s disease, cardiovascular disease and diabetes, and cures for diseases for which we currently have no treatment.

Through their various publications on regenerative medicine and life science strategy, and funding for research, the Government have recognised the potential of regenerative medicine and life sciences generally to improve both health and the UK economy. This is valued, and our report says that we value the Government’s support. The UK has a strong science base, reflected in the number of much-cited publications, multiple academic centres of excellence and the three Nobel laureates of recent times: Sir Martin Evans, who is still working in the field of cell biology, Sir Robert Edwards and Sir John Gurdon.

The UK currently has nearly 40 early-phase clinical trials involving stem cells. There are more than 76 projects funded in basic science and early-phase trials. So far, it is good news. However, when it comes to translation, the theme that permeated our inquiry was that of uncertainty. Those who gave evidence asked for proportionate regulation and a clearer path from bench to bedside. The current system was described as a sort of great frustration. We make recommendations for improvement. Similar comments were made about clinical trials, despite the recognition that the NHS affords the best environment for clinical trials. The Government need to address the issue to make the UK more effective.

The Cell Therapy Catapult reported delays in starting trials, and similar comments were made by others. Furthermore, the delivery of regenerative medicine treatments, particularly involving living cells, produces challenges for manufacture and delivery on a large scale. If the UK is to be competitive and be attractive to companies from outside, both investing in the UK and using UK facilities, the Government need to support and invest in infrastructure development. The committee recognised that setting up the Cell Therapy Catapult has significant potential but to achieve it, alternative funding channels will need to be explored.

We make some suggestions. We make several recommendations for evaluation and pricing of treatments and look to NICE to devise suitable models, including value-based pricing. Covering all the areas, we make 24 recommendations to help ensure that the potential of regenerative medicine is realised. To bring it all together, we asked that an expert working group be set up with an independent chair. On the whole, we welcome the Government’s positive response to our report and hope that they will ensure that the recommendations will be taken forward. However, I do have some questions.

What progress has been made to ensure that the regulatory process for clinical trials is simplified? What plans do the Government have to encourage investment in large-scale manufacturing facilities for regenerative medicine products? What action has UKTI taken to improve the chances of the UK being the location of the development and manufacture of regenerative medicine therapies?

Although the Government did not accept our recommendation of an independent chair for the expert working group, they accepted the establishment of such a group, and we are pleased that Sir Michael Rowlands is to chair it. What terms of reference have been given to Sir Michael’s committee, and when is it expected to report?

In conclusion, regenerative medicine has the potential not only to save lives but, with the NHS as a resource, also to support the UK economy. We can be the world’s centre for developing regenerative medicine. I commend the report and beg to move.

--- Later in debate ---

[Earl Howe]

My noble friend anticipates some news that I was about to convey. He is right: the Health Research Authority is the organisation created to deliver the streamlining of research approvals. It has completed its feasibility study. The results demonstrated that NHS R&D assessments could be integrated with elements of the research ethics committee review into a single HRA assessment for the approval of all research in the NHS. Department of Health officials are scrutinising the business case submitted by the HRA as part of standard governance processes, and approval of the case is subject to the proposals demonstrating value for money. Consideration of the business case is well advanced and we would anticipate that this process will conclude shortly.

The noble Lords, Lord Patel, Lord Turnberg and Lord Hunt, asked me about support for manufacturing, in particular as regards large-scale trials. The Cell Therapy Catapult has recently completed its survey of regenerative medicine manufacturing capacity in the UK, and an appraisal of national capability is planned on an annual basis to keep abreast of the evolving needs of the area and to ensure that the UK remains globally competitive. The 2013 survey and analyses that the Cell Therapy Catapult compiled have been shared with stakeholders. The key findings of the survey, including a demand forecast, have been shared at various meetings in the UK, including at the Regenerative Medicine Expert Group, and at meetings of the advanced therapeutic products manufacturing community and will be published shortly. The survey output, along with analysis of demand, was used to make a proposal to BIS for further investment to fill the cell manufacturing gap and support late-stage clinical trials. The investment proposal is currently being assessed.

The noble Lord, Lord Patel, asked what action UKTI has taken to improve the chances of the UK being a location for the development and manufacture of regenerative medicine therapies. UKTI has consulted extensively with UK stakeholders and has developed a new UK regenerative medicine sector proposition, which was launched in December 2013 at the World Stem Cell Summit in San Diego. Training on the materials has been rolled out to a number of its overseas teams, with more training to follow in the coming months.

The noble Lord, Lord Hunt, made some criticism of the MHRA in the context of progress on adaptive licensing. This issue was also raised by the noble Lord, Lord Turnberg. The MHRA has been involved with a discussion group at the European Medicines Agency in developing guidance, case studies and draft calls for expressions of interest to go out this year. One has to remember that work on adaptive licensing must be conducted within the context of European law. We had hoped that this would be issued last year but there has been a delay, as the European Commission has wanted to be satisfied that proposals can be accommodated in the existing regulatory flexibilities. I can tell the noble Lord, Lord Hunt, that we continue to be actively involved in pushing the EMA in bringing this work forward, and I have been personally involved in overseeing that.

Distinct from the concept of adaptive licensing is the early access to medicines scheme. This is designed to enable earlier UK patient access to highly promising medicinal products before they are licensed. This is expected to be announced very soon. It will operate within the current regulatory structure, and is voluntary and non-statutory. The MHRA will provide a scientific opinion on promising new medicines that will treat, diagnose or prevent life-threatening or seriously debilitating conditions without adequate treatment options before the medicines are licensed. Further details will be announced in the near future.

My noble friend Lord Willis asked about NICE’s value-assessment process. NICE, in consultation with stakeholders, keeps its methodologies under review to ensure that they remain fit for purpose. Our priority is to make sure that we get the best possible results for all NHS patients with the resources that we have, which means using taxpayers’ money responsibly and getting good value for money. We have asked NICE to look at how drugs are assessed so that patients can get the treatments that they need at the best value for the NHS and so that the price that the NHS pays is more closely linked to the value that a medicine brings. NICE will carry out a full public consultation before implementing any changes. I would just add that NICE is a key member of the Regenerative Medicine Expert Group, which will look at and provide recommendations on the evaluation and commissioning of these novel medicines and their adoption in the NHS.

My noble friend Lord Selborne and the noble Lord, Lord Turnberg, referred to developments in Japan. We are aware of the Japanese plans, and the report on the approach is being considered by the expert group. As noble Lords have mentioned, the Japanese Government are exploring ways in which the regulatory process there might be changed to support earlier evaluation of the clinical effectiveness and adoption of regenerative medicines within their health system following evidence of safety. Earlier this year, a Department of Health official, along with Foreign Office officials, attended a conference in Japan where the plans were discussed. The details have yet to be worked out but a watching brief will be maintained with the contacts that were made. A report of the conference has been made available to the expert group for consideration.

The Government look forward to receiving the Regenerative Medicine Expert Group’s strategy and action plan. We anticipate that this will provide a platform to help ensure that the UK will be in the lead in realising the exciting medical and commercial potential of these cutting-edge treatments.

[Lord Patel]

My Lords, I thank the noble Earl for his detailed response and all other noble Lords who have taken part in this debate. It has been a very good debate, which went wider than the inquiry report. I look forward to another debate when the report of the expert working group comes out; we will know then whether progress has been made.

Motion agreed.

Health: Folic Acid

Lord Patel Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, as I have explained on earlier occasions, it is very important that we use the latest data to reach a robust and defensible view of the risks and benefits on this issue. We will take the new National Diet and Nutrition Survey data on folate status into account when we do reach a decision. As for the position taken in other countries, while a number of countries have introduced mandatory fortification of flour with folic acid, others notably have decided against it, including Ireland and New Zealand.

[Lord Patel (CB)]

My Lords, the single most effective public health measure, which would prevent the birth of babies with severe spina bifida and lifelong disability, would be 400 micrograms daily of folic acid. Why would we not do that as a public health measure, when all the scientific evidence is already there?

[Earl Howe]

My Lords, in recommending the fortification of flour with folic acid, the Scientific Advisory Committee on Nutrition also advised that action should be taken to reduce levels of voluntary fortification, which, as the noble Lord knows, is applied to a number of breakfast cereals, for example. That is no easy matter. It would be necessary to avoid folate levels exceeding recommended limits and to put action in train to achieve that. There are other conditions and advice attached to the SACN recommendation; it is not quite as straightforward in practice as the noble Lord might suggest, although I recognise that the recommendation from SACN is there.

Health: Meningitis B Vaccine

Lord Patel Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

Last October, in recognition of concerns about the methodology currently used for assessing cost-effectiveness of vaccines, the JCVI agreed that a working group should be formed to consider two issues: first, how the impact of vaccination programmes to prevent rare diseases of high severity should be best assessed; and, secondly, whether there were aspects of cost-effectiveness in relation specifically to children that should be addressed. It is a complex issue both economically and, indeed, ethically. We should not expect a report from that group, once it has been established, until next year at the earliest.

[Lord Patel (CB)]

My Lords, the vaccines that my friend, the noble Lord, Lord Turnberg—he is a friend, at least as regards medical matters—talked about are developed through a new kind of science, which does not involve the use of eggs or any other animal material, and therefore is not only more effective but produces fewer side-effects, particularly in children. The vaccine that we are talking about is for a particular type of meningitis. The new vaccine may not be considered as cost-effective as a conventional vaccine. However, if you take into account clinical side-effects, the new vaccine may be considered cost-effective, so a different kind of assessment must be carried out that is based not just on conventional cost-effectiveness.

[Earl Howe]

The noble Lord makes a series of very important points. I know he will understand that it would be wrong for me to be drawn into going into too much detail on the clinical and cost-effectiveness of this vaccine because that is the job we have given to the JCVI.

Food and Soft Drink Industry: Sugar

Lord Patel Excerpts

Tuesday 11th February 2014 Lords Chamber

[Earl Howe]

My Lords, I think that the compliment should be paid to my noble friend Lord Ribeiro for the part that he played in bringing about the amendment on smoking in cars. A number of soft drinks companies have taken action to reduce calorie content in their drinks. Coca-Cola has reformulated its Sprite product. AG Barr pledged to reduce the average calorific content in its portfolio of drinks. I have mentioned Sainsbury’s and Tesco’s actions on their own brands. Premier Foods has reformulated various products and reduced sugar in those. Therefore, we are making headway and I think that the responsibility deal is proving its worth.

[Lord Patel (CB)]

Does the Minister think it might be advisable to ask the Government’s Scientific Advisory Committee on Nutrition to define a standard of added sugar that should not be exceeded in 100 millilitres of fluid or 100 grams of food?

[Earl Howe]

I believe that I am right in saying that the experts would advise that it depends on the product that we are looking at. One cannot make a blanket rule for every type of food and drink.

Children and Families Bill

Lord Patel Excerpts

Wednesday 29th January 2014 Lords Chamber

This has been an interesting debate. Is it better to have legislation or a public-education campaign? The latter would probably be effective. My own view, backed up by the statistics on wearing seat belts given by my noble friend Lady Finlay, is that having the two together is the most effective. We are not talking either/or; it is a clear case of both/and. I hope that today we send out a message, loud and clear from this Chamber, that it is simply not acceptable to expose your children to second-hand smoke in the car.

[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.

Health: Flour Fortification

Lord Patel Excerpts

Tuesday 21st January 2014 Lords Chamber

[Earl Howe]

The noble Lord is absolutely right. I agree with him that the incidence of rickets is a cause for concern. At the same time, he characterises the case for mandatory fortification as incontrovertible. There are risks that SACN pointed out. Its advice to government stated that fortification of flour with folic acid might have adverse effects on neurological function in people aged 65 years and over with vitamin B12 deficiency. Treatment with folic acid can alleviate or mask the anaemia and therefore delay the diagnosis of vitamin B12 deficiency, which can lead to irreversible effects.

[Lord Patel (CB)]

The noble Earl referred to two things. His immediate answer just now suggested that folic acid levels might interfere with B12 anaemia in older people. That would require a dosage of about 15 milligrams per day; the dosage we are talking about for fortification would hardly reach 1 milligram per day. The risk, therefore, is pretty minimal. Secondly, he suggested in his opening Answer that the folate level of the population might help to devise the policy. How would that help to devise the policy for women in early pregnancy who need the folic acid to reduce the incidence of neural tube defects?

[Earl Howe]

I am sure the noble Lord would agree that we have to take a decision based on the most up-to-date data. The data that we had prior to this were 10 years old and it is important to take a decision in the context of the nutritional state of health of the population. On his first question, all I can say is that the risk to which I referred was considered as part of SACN’s overall assessment and we will draw on that in reaching our decisions on the fortification of flour and give it the appropriate weight that it deserves.