Tobacco Products and Nicotine Inhaling Products (Amendment etc.) (EU Exit) Regulations 2018

Lord Rennard Excerpts

Tuesday 4th December 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Lord for this opportunity to discuss e-cigarettes. It is also a great opportunity to press the Minister on the Government’s Brexit situation. I do not think that we have heard him on this matter before. It is interesting to reflect on the confidence set out in the Explanatory Memorandum that,

“as a responsible government, we will continue to proportionately prepare for all scenarios”.

That is just as well because I do not share the Minister’s confidence that the future is at all clear or, indeed, that all scenarios have been planned.

I am sure the regulations are sensible but the Explanatory Memorandum takes us back to our debate when they originally came through your Lordships’ House, during which a number of us expressed concerns that the directive on which they were based takes too draconian a view on e-cigarettes. I happen to think that e-cigarettes are one of the most successful public health measures to help reduce smoking that we have ever seen. It is a great pity that some elements of the public health community that I know well and love have such a downer on e-cigarettes that they have encouraged a disproportionate approach to their regulation. In Grand Committee, the argument was put that e-cigarettes should be regulated in a completely different way from tobacco-based products. I remain convinced of that.

Of course, we must be very careful about the potential impact on young people. I know there are those who think that attractive advertisements and the way e-cigarettes are marketed can sometimes lead young people to take up smoking. The evidence for that is very dubious. We know that e-cigarettes are attractive to people over whose heads most public health campaigns completely fly. Although I fervently hope that we do not exit the EU next March, if we do and if the Government bring forward at some point new regulations on tobacco products in general, I hope they will take note of our debates and look at e-cigarettes in a completely different way.

[Lord Rennard (LD)]

My Lords, there are those—I am certainly not among them—who welcomed the idea of Brexit because they did not like the restrictions on the promotion of tobacco that we agreed across the EU. Contrary to the biased and selfish claims made on behalf of the tobacco industry, these regulations have been successful in reducing significantly the prevalence of tobacco smoking and its related diseases. We should never forget that tobacco products shorten the lives of half the people who smoke.

The tobacco lobbyists will be disappointed with the regulations because they show that they have lost the argument and there is now cross-party consensus on tackling tobacco-related problems. As the Minister said, even if we have the disastrous no-deal Brexit that some of those people want, the regulations will allow for a set of pictures, as currently used in Australia, to continue to appear on cigarette packs in the UK to warn smokers of the terrible damage done to their health by smoking.

As the Minister said, the regulations have the support of the excellent Action on Smoking and Health, of which I am a former director. Of course, they have my support too, but I would like to remind the Minister that the Tobacco and Related Products Regulations 2016 require the Secretary of State to review those regulations and publish a report before 20 May 2021. Some of the important points made by the noble Lord, Lord Hunt of Kings Heath, should be examined when that report is made. Some of us also feel passionately that e-cigarettes can and must be promoted effectively as an alternative to smoking tobacco, but in such a way as not to encourage people who have never smoked tobacco to take up an addiction to nicotine. I would like the Minister to confirm as well as he can that there will be no going back on our successful tobacco regulation policies, which are doing so much to improve the health and life expectancy of so many people. We should do nothing that reverses the excellent progress being made on this issue.

[Baroness Thornton (Lab)]

My Lords, I apologise to the House for being a minute or so late. I am afraid that business moved too quickly and the lift too slowly.

As the Minister said, the current regulations for tobacco and related products are designed to promote and protect the public’s health. Speaking as a veteran of tobacco regulation from the previous Labour Government and the Minister responsible for the point of sale retail advertising regulations that put tobacco products out of sight in our shops and supermarkets, all those actions were rigorously and energetically opposed by the noble Lord’s party and the Minister’s predecessor but one. I welcome the Government having definitely seen the light on this; it is wonderful. I am pleased to learn that the Government’s priority is to maintain the same high standards after the UK leaves the European Union, if that is indeed what happens.

The noble Lord and I are discussing regulations that will be necessary if there is no deal. I suspect they are the first of many. We have a whole load of embryonic and blood things to discuss next week. I wonder whether that is really a productive use of his time or mine.

On what these regulations do, in the event of no deal we will be obliged to introduce legislation to ensure that the policies and systems in place to regulate tobacco products and e-cigarettes will continue to function effectively and maintain continuity with current arrangements. The website and the Explanatory Notes use the words “where possible”, so I suppose my first question to the Minister is to explain the words “where possible” and where the current arrangements might not be possible.

If the UK leaves the European Union in March 2019 with no agreement in place, that will mean, as the noble Lord said, that the tobacco products directive and the tobacco advertising directive will no longer directly apply to the UK—which is ironic, as we were the pioneers in these matters all those years ago. UK domestic law that implements these directives, such as the Tobacco and Related Products Regulations 2016, would remain in force.

My understanding is that these regulations’ purposes are threefold: to introduce a new domestic system to allow producers to notify e-cigarettes in accordance with existing rules; to introduce a new domestic system to allow producers to notify tobacco products in accordance with existing rules; and to introduce new picture warnings for tobacco products, already mentioned by noble Lords, based on the picture library owned by the Australian Government. The noble Lord and I have both learned that the pictures in use at the moment come from a library based in Brussels. We will no longer have access to it.

I thank ASH for its views and vigilance on these important matters, and for its participation in the consultation process. I agree with it that the system set out for notification of e-cigarettes and novel tobacco products in the consultation document is pragmatic and practical, and would minimise the additional work involved in the notification process if there were to be a no-deal Brexit. Products notified to the UK prior to the UK leaving the European Union would not require re-notification and data will be accepted in the same format as currently submitted. Those arrangements seem satisfactory.

For the purpose of providing an alternative to the current picture warnings in the event that the UK leaves the EU with no deal, since we would no longer have access to the rather revolting and graphic pictures in the SI—I have not seen any other legislation with pictures in it, but this instrument has them; I suggest that if noble Lords have not read the statutory instrument they should at least open it and look at the pictures it contains—the Minister has said we will switch to the ones used in Australia, which I gather are even more horrible. However, I remind the Government that, in the longer term, the Tobacco and Related Product Regulations 2016 require the Secretary of State to review the regulations and publish a report before 20 May 2021. This review needs to examine the objectives intended to be achieved by the regulatory provision made by these regulations, and to assess how far they have been met and whether they remain appropriate. That will allow a review of quite a fast-moving area in terms of product development to take place. Does the Minister agree that is the case?

For the purpose of providing an alternative to the current picture warnings in the event that the UK leaves the EU with no deal, switching to the pictures from Australia is a short-term quick fix for this emergency. However, current best practice in Australia and the UK is to rotate, regularly review and update those health warnings. Therefore, it is essential that in the longer term the Government review the warnings—they are currently being evaluated by the Australian Government—and find ways to increase the number to allow for rotation, as is currently the case. When can we expect that review to take place?

I do not need to add to my noble friend Lord Hunt’s remarks about the importance of vaping and its role in reducing smoking. These statutory instruments serve their purpose.

Health: Diabetes

Lord Rennard Excerpts

Wednesday 31st October 2018 Lords Chamber

[Lord Rennard (LD)]

My Lords, I refer to my interests in the register. I congratulate the noble and learned Lord, Lord Morris of Aberavon, on securing this debate and on his personal tenacity in pursuing the important issue of helping people with type 1 diabetes to secure access to new technologies that might help them to manage their condition better. My own interest in diabetes is long term and personal. My father was one of the first people to benefit from the development of insulin in the 1920s; he developed diabetes probably as a result of the shock he experienced having a leg amputated following injuries to it during the First World War. Because of insulin he was able to live quite a long life for someone born in 1889. I was born in 1960, when he was 71. His survival for so long was testament to the effectiveness of insulin in saving lives and helping people to live with a condition that, until then, had been known to have fatal effects for thousands of years.

I was diagnosed with type 2 diabetes at the relatively young age of 34, almost 25 years ago. My lifestyle, related to my work in politics, was extremely poor for a long period. By the time that I was 45, I was on insulin as well as tablets. In my late 40s, I was warned that even the maximum levels of every form of medication available would not sustain me into my 50s unless I changed that lifestyle fundamentally.

However, changes to lifestyle are not so relevant to people with type 1 diabetes, and not always achievable for those of us with type 2 diabetes. The consequences of poor diabetic control are the same for people with either type 1 or type 2 diabetes. My own poor diabetic control some years ago is probably responsible for the fact that both my feet now suffer from a condition called foot drop. This means that I need to wear ankle foot orthoses, known as AFOs, and, like all other diabetics, I have to take great care of my feet.

I have been fortunate to receive great support from the diabetic team at St Thomas’ Hospital. I was there yesterday and was pleased to be told that my long-term control, as measured by my HbA1c blood glucose level, remains very good at present. It has been helped by changes in lifestyle, including those that have resulted from a GP referral for some physical fitness training—which I certainly needed—the acquisition of my Fitbit monitor and recognition that I needed to eat more healthily and consume fewer products filled with sugar, which for many people is a very addictive ingredient.

I know from friends with type 1 diabetes how much harder it is for them to maintain good control, whatever they do. They have to test their blood with finger-prick tests eight or more times per day and can observe their blood sugar levels increasing rapidly or falling dramatically, sometimes without any apparent explanation. The emergency services all too often have to pick up someone who has collapsed, with many people thinking that they are perhaps drunk when in fact they are suffering from a “hypo”. I experience hypos rarely, but type 1 diabetics are much more vulnerable to them.

The problems associated with both types of diabetes have grown rapidly in prevalence and are likely to do so even more in future. Diabetes UK said on Monday that some 500 people with diabetes die prematurely each week. I regularly read distressing accounts of how more than 6,000 foot amputations per year result from diabetic-related conditions, many of which are preventable. If not managed effectively, poor diabetic control results in loss of sight, kidney disease and a much greater prevalence of strokes and heart disease.

The most recent NHS National Diabetes Audit report on complications and mortality shows that men and women between the ages of 35 and 64 living with type 1 diabetes are three to four times more likely to die prematurely than those without the condition. Men and women in the same age range who have type 2 diabetes are up to twice as likely to die prematurely.

What can be done? Control is of course the key, and I have no doubt that wider use of FreeStyle Libre, a flash glucose monitoring system, is assisting a number of people, particularly those with type 1 diabetes, to improve their control. I have looked at the Medtech innovation briefing from NICE and the devices appear immediately cost effective compared with, let us say, the costs of 10 finger-prick tests per day. The evidence of benefit to long-term blood sugar control is not yet so clear, but I know from my own experience that behaviour is changed in a positive direction when you are regularly alerted to your blood sugar levels. This is, in my view, much more likely to be the case with such a flash monitoring device than with the more traditional blood glucose meter.

There was very strong evidence in the report suggesting that users of a flash glucose monitoring device suffered far fewer hypos, experiences that can be very unpleasant and quite dangerous. The fact that such devices can now potentially be prescribed as a result of their inclusion in Part IX of the England and Wales drug tariff a year ago is very welcome but, as the noble and learned Lord, Lord Morris of Aberavon, said, there is still far too much variation between CCGs in their provision, and the guidelines from NICE are very restrictive. In the recent Question that he referred to, he suggested that around 30% of CCGs are not yet considering prescribing these devices.

I know that the aim of reducing variation in the management and care of people with diabetes by 2020 is included in the NHS England mandate, but can the Minister tell us a little more this evening about exactly how this will be achieved? There are implementation plans to facilitate the wider provision of flash glucose monitoring systems; how are these progressing? We all know that we need to rely on NICE conducting some sort of cost/benefit analysis for any such product, but is the Minister satisfied that its processes for analysing the costs and benefits of new technologies aimed at improving diabetic control are sufficiently long term? Does he accept that any such analysis for public policy should factor in all the long-term costs to the NHS and the welfare system of poor diabetic control, as well as the wider benefits to the economy and to society of helping people to achieve good control?

Flash glucose monitoring, real-time continuous glucose monitoring and insulin pumps may all provide technological solutions to help people with type 1 diabetes live healthier and happier lives for very much longer. There is, for example, a much greater provision of insulin pumps in the United States than in this country, and this is not simply because the US has a greater love of technology than we do. Overall, the US healthcare system is known to be massively inefficient and ineffective compared to our own NHS but, with an insurance-based model, you know that the insurance companies evaluate the long-term costs to their businesses of dealing with the complications that arise from poor diabetic control. These insurance companies appear to have decided, on sound business grounds, that much greater provision of insulin pumps saves them money in the long run, to say nothing of the wider benefits to patients and everyone else.

I look forward to the Minister’s comments on these issues and what he has to say about how technological innovation may help some of the problems associated with diabetes.

Hepatitis C

Lord Rennard Excerpts

Monday 9th July 2018 Lords Chamber

[Lord O'Shaughnessy]

I would need to write to the noble Baroness specifically about minority women. I do know that there are specific programmes taking place in towns and cities across the country to support minority groups where there is a high prevalence, and I mentioned the south Asian group, which has increased screening and diagnosis. It has reduced mortality, which has been affected. Clearly, that is something we need to do more of.

[Lord Rennard (LD)]

My Lords, does the Minister accept that NHS England may in the past have been too restrictive in its use of the relevant drugs? How might improved procurement policies result in greater use of those drugs, including more innovative products, as well as providing better value for the NHS in reducing the prevalence of hepatitis C?

The Long-term Sustainability of the NHS and Adult Social Care

Lord Rennard Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Rennard (LD)]

My Lords, I draw the attention of the House to my entry in the Register of Lords’ Interests.

Some years ago, when I was advising my noble friend Lord Ashdown on what to say during elections, I asked him to avoid using the phrase “rationing” when it came to talking about the NHS because the phrase is perceived very negatively. But in reality, trying to meet ever-growing demands with resources that are not growing proportionately will always mean having to ration those resources in some way.

The noble Lord, Lord Patel, and his committee are to be congratulated on their report. It does much to address the issue of NHS sustainability—much more than the Government seem willing to admit is necessary, at least publicly. The problem results from both significant demographic changes and a reluctance in the past to ask people to pay higher levels of taxation to fund the consequences of people living far longer, needing pensions for far longer, and needing much more healthcare intervention, particularly to deal with long-term conditions.

Forty years ago, a man who had worked and paid taxes for 50 years retired at 65 and lived, on average, for just two years in retirement. The cost of his pension and his healthcare was therefore not very great. Today, a man is expected to live for 20 years in retirement. His state pension, therefore, has to be paid for 10 times as long as was the case 40 years ago. Women may live for longer, but both women and men on average will now expect to have 12 years of good health in retirement but eight years when more active health and care intervention will be required, some of it very expensive.

We have had great economic growth over the last 40 years, and this has financed far greater levels of taxpayer support for the NHS than might ever have been expected during most of the last 70 years. Even so, the increasing level of taxpayer funding for the NHS is not keeping pace with the growing demands on it, or with the demands for social care. So we need people to pay more for their health and social care, and to recognise that the most efficient way of doing so is via general taxation to pay for a national health service and to integrate this properly with social care.

The noble Lord, Lord Layard, referred a few moments ago to a MORI opinion poll. I draw the House’s attention to the recent British Social Attitudes survey, which showed that most voters now back tax rises to fund the NHS if it needs more money—and, as the noble Lord, Lord Prior, indicated, it most certainly does. Options for paying more taxes found support in that survey from 61% of people. It showed that the alternatives—for example, charging for non-medical costs such as hospital food, or paying £10 to visit a GP—received just 21% support. The latter approaches are, I think, quite unacceptable.

The highest level of support in the survey was for people to pay more through a separate tax that would go directly to the NHS. A 1p increase in the basic rate of income tax, for example, would produce an additional £6 billion per year. However, it seems to me that a much more radical restructuring of the income tax and national insurance system is required to fund what is needed. I wish the Select Committee report had been less equivocal about hypothecating taxes for the NHS, because I believe that that is the only way forward by which people will agree to pay more taxation.

However, in my view the report was right to say that the long-term sustainability of the NHS requires more than an increase in taxpayer funding. For example, we need to do much more to reduce the demands on the NHS caused by factors such as the escalating rates of obesity and diabetes, and problems with alcohol misuse, and we still need to reduce further the prevalence of smoking tobacco.

In trying to tackle all these issues, we have to overcome the powerful lobbying interests of the food and drinks industry, as we have largely done with the tobacco industry’s activities in this country. We need also to promote healthier lifestyles. At this point, I should declare my interest in having benefited from a GP referral programme that successfully encouraged me to take more physical exercise. The result of that may not be immediately self-evident—but your Lordships should have seen me 10 or 20 years ago.

We also need to make much more effective use of technology to improve the functioning of the NHS, which has been far too slow in replacing paper and fax-based correspondence with electronic communication. Much greater use must also be made of assistive technology, whether funded publicly or privately or through the increased use of personal health budgets. Providing specialist equipment to children that reduces the likelihood of surgery in later life, adapting people’s homes, whether with grab rails, stairlifts or specially adapted kitchens, and ensuring that people have the most appropriate assistive technology to enable them to live their life to the fullest and most independent degree possible should become a much greater priority in the decades ahead.

That is all absolutely essential if we are to curb successfully the escalating demands on the NHS and, at the same time, enable more people with disabilities or long-term conditions to enjoy more gainful employment and contribute positively to society and to the economy.

Prescription Drugs: Dependence

Lord Rennard Excerpts

Monday 19th March 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Earl highlights a very important issue, and I reassure him that the review will look not only at the nature and causes of dependence on the drugs in scope, which include antidepressants, but at the correct and most evidence-based treatments for withdrawal.

[Lord Rennard (LD)]

Will the review by Public Health England be able to look specifically at alternatives to prescribing drugs, such as acupuncture, which is shown to be very effective in the relief of pain and reducing symptoms of anxiety, and perhaps also mindfulness, which has been shown to improve the mental health of very many people?

[Lord O'Shaughnessy]

I can attest to the benefits of both those courses of treatment. The review will look at prevention of dependency in the first place and in doing so will look at alternative courses of treatment. Of course, in the end there is a balance to be struck between the clinical needs of the patient and the right course of treatment. It is about making sure that clinicians are as informed as possible.

Emergency Hospital Admissions

Lord Rennard Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord O’Shaughnessy]

I agree with the noble Lord about funding. The Government have now made £9.4 billion of extra funding available to local authorities over three years, including in the most recent local government funding settlement. The noble Lord makes a good point about bed capacity: it had shown a downward trend for a long time before stabilising in recent years. I point to two successes this winter. The first is the improvement in delayed transfers of care—we have really started to get some traction on that. The second is about £60 million, I believe, of funding that went into providing extra bed capacity over winter. Occupancy levels are too high. The NHS is getting better at managing it more efficiently, but we certainly need to do better.

[Lord Rennard (LD)]

My Lords, does the Minister accept that part of the problem with emergency hospital admissions is the difficulty people have in accessing their GPs? Some of this is perhaps because of the high levels of stress among GPs, but there is also recent evidence suggesting that it is because of the £1 million pension cap imposed on GPs, which means many more of them are retiring before the age of 60. Surely, in the interests of the NHS, this particular cap should be looked at again.

[Lord O’Shaughnessy]

Although the number of early GP retirements has been rising, the number of total GP retirements has been falling, which is encouraging. It is also important to point out that, while the pension cap obviously applies to everybody, it has not had the impact that the noble Lord described on dentists or consultants, so there is something more to it. It is to do with how GP services are structured and providing support for that partnership model. That is what we are trying to do at the moment.

Alcohol: Minimum Unit Pricing

Lord Rennard Excerpts

Wednesday 28th February 2018 Lords Chamber

Asked by

[Lord Rennard]

To ask Her Majesty’s Government what assessment they have made of the cost benefits to the National Health Service and police of introducing minimum unit pricing for alcohol in England.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, data from the Sheffield University alcohol policy model in 2015 estimated that, in 10 years, minimum unit pricing could on an annual basis reduce alcohol-related deaths by 356, alcohol-related hospital admissions by 28,515, and crime by 34,931 crimes. Minimum unit pricing remains under review and the Government will consider the evidence of its impact once it is available.

[Lord Rennard (LD)]

My Lords, figures issued today by the Institute of Alcohol Studies suggest that, for each hour worked, it is possible to buy three times as much supermarket beer as was the case 30 years ago. Given the statistics which the Minister cited from the University of Sheffield, is it not urgent that we act to prevent the sale of perhaps four cans of beer in a supermarket for as little as £1?

[Lord O’Shaughnessy]

As I said, the Government are looking at this issue and, following the Supreme Court judgment, the Scottish Government can move ahead with their plans. The issue is not about the lack of evidence on whether reducing drinking has health benefits, but about making sure that any new system is implemented in a way that is fair on those who drink sensibly, particularly those on low incomes. The approach we have taken up to now is to use the tax system judiciously, including high duty levels for drinks such as white cider. As we move ahead and look at the evidence, we have to consider not just the health benefits but the economic costs that could be imposed on perfectly sensible drinkers.

Smoking: Vaping

Lord Rennard Excerpts

Tuesday 19th December 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is right; we are looking at the guidelines at the moment, with Ofcom and the Advertising Standards Authority. There are limits on what we can do on vaping under the current regulations, but we will have the opportunity to look again at this issue as we leave the European Union, and reconsider our domestic legislation.

[Lord Rennard (LD)]

My Lords, vaping has proved an effective way for many people to give up smoking tobacco—but there are, of course, no inherent health benefits in taking up vaping if one is not already addicted to nicotine. Does the Minister agree that we should seek regulations that allow the promotion of vaping solely as an alternative to smoking tobacco, and not something that people not already addicted to nicotine should be encouraged to take up? Can he tell us when Public Health England will publish its report on e-cigarettes, which was due in 2017?

[Lord O'Shaughnessy]

I think that the noble Lord is making the point that we need a balanced approach. We want to emphasise the relative health benefits, but we must also recognise that harmful effects can come from nicotine in itself. Obviously, we want to get to a position in which people are not smoking and not taking nicotine at all, and the relative benefits of the different ways people can go about that are taken into account. I think that the UK has a sensible approach. I am afraid that I do not have the date when the Public Health England report will be published, but I will write to the noble Lord with that information.

Nurses and Midwives: Numbers

Lord Rennard Excerpts

Monday 4th December 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree with my noble friend’s point on communication. I shall certainly look at whether we can do that better as an NHS. It is why I do not miss an opportunity from the Dispatch Box to say how much those nurses are valued and how much we want them to stay. That is what the Government are committed to doing. I mentioned the increase in the number of training places which my noble friend has pointed out. New UCAS data out today show that the picture is slightly better even than when we talked about it last week. Although the total is slightly down on last year, it is the second-highest number of nurses recruited in the history of nursing being a degree profession.

[Lord Rennard (LD)]

My Lords, is this not a problem particularly given that 35,000 nurses and midwives left the profession last year? Does the Minister agree with the Royal College of Nursing that the problem is made worse by the loss of student bursaries, deterring more mature students from applying to train as nurses and denying the profession the benefit of their valuable life experience?

[Lord O'Shaughnessy]

Retention is critical. A number of nurses have gone through return-to-practice programmes to make sure they can come back into the profession. I recognise that today’s UCAS data show that while the number of applications has risen among the under-21s, it has fallen among the over-21s. It is important to point out that financial support is available for those people, in terms of both help with childcare and extra financial support. Now, for the first time, we are providing funding for second degrees if they are in nursing.

NHS: Winter Staffing Levels

Lord Rennard Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for raising this. We have discussed a number of times the impact of the test on recruitment from countries other than the UK. It is entirely sensible for the NMC to look at this. On nurse training, I hope she will have been reassured by the announcement from my right honourable friend the Secretary of State for Health at the Conservative Party conference that we will deliver a 25% increase in nurse training places from 2018-19 onwards.

[Lord Rennard (LD)]

My Lords, is not part of the problem for the NHS, and for hospitals in particular, during the winter that so many people have difficulty in accessing their GP? The number of GPs has fallen by 3% over the last two years. Is it not, therefore, counterproductive that the Government have been cutting funding for community pharmacies when many more people should be seeing their pharmacist and not seeking to see their GP or even turning up at A&E units?