Medical Innovation Bill [HL]

Lord Ribeiro Excerpts

Friday 23rd January 2015 Lords Chamber

[Baroness Gardner of Parkes]

My Lords, I support this amendment. I was surprised that the Government took a line similar to my own on the previous amendment because I was greatly reassured by what noble Lords said on that point. In this case, and right from the start of the passage of the Bill, we have all believed it essential to fully record what happens. The whole aim of this has been not only to give hope to people via an innovative treatment but also to have research that will benefit other people in future. No one has for a minute queried the need for recording the cases and results. I would be amazed and shocked if the Government denied that today.

[Lord Ribeiro (Con)]

My Lords, many noble Lords will remember the disasters that occasioned the introduction of laparoscopic cholecystectomy in the 1990s. Quite a few patients suffered as a result of the innovation of our surgeons playing with a new instrument, new tools and a new operation. At the time, I was secretary of the Association of Surgeons of Great Britain and Ireland. In recognising the problems, we introduced a voluntary register of all surgeons undertaking the procedure and got a very good response. Admittedly, it was not compulsory and not every surgeon introduced their data to it, but the net effect was that when we analysed our data we were able to identify where many of the problems lay. That led to further research and proper control trials in the procedure. We were able to turn to that from an innovation used by a succession of surgeons as and when they felt necessary, without any good evidence on how best to use it. On that basis, and mindful of the benefits that we saw in the 1990s, I would very much support some form of register to ensure that, if an innovation is introduced, we have the information, can go back and refer to it again, learn from the mistakes and improve the outcome.

[Lord Winston]

My Lords, briefly, I support the amendment of my noble friend Lord Hunt of Kings Heath as well. I was reminded by the noble Lord, Lord Ribeiro, of laparoscopic surgery. Of course, we gynaecologists were doing that 20 years before the noble Lord was and we did not have as many deaths. Having said that, what the surgeons did with laparoscopic surgery and recording those events was really important in bringing down the complication rate and the haemorrhages that occurred. That is a very good example and the noble Lord is to be thanked for bringing it to the House. It is exactly what would be covered here.

I would be astonished if the Government seriously opposed this amendment. I was very unconvinced by the noble Baroness, Lady Jolly, in the previous stages of the Bill. She did not seem to take on board exactly what we were trying to say about the need for keeping proper records, which is important in all sorts of ways. If you keep a record and it is done under this Bill then you are effectively legally protected. For that reason if no other that would be important, but in any case we have to build up the knowledge of our experience. We do that automatically in the laboratory. Every single thing we do in the laboratory, whether negative or positive, we record in our laboratory books. If we do not, we are not doing good science or science useful to the public. Here in innovative medicine, we are—whether we like it or not—doing a form of science because we are exploring our knowledge about what a treatment means. That is what science means. I urge the Government to support the amendment. I feel very strongly about this. If the Government were reluctant to support it and my noble friend Lord Hunt were to divide the House, I would certainly join him.

Alcohol-related Disease

Lord Ribeiro Excerpts

Wednesday 17th December 2014 Lords Chamber

[Earl Howe]

My Lords, increasingly, GPs are being made aware of the need to upskill in this area. Of course, it is not just GPs but local authorities who have responsibilities in the arena of public health to make sure that excessive drinking is discouraged. I can write to the noble Lord with the precise details of the GP training that I am aware of.

[Lord Ribeiro (Con)]

My Lords, does my noble friend agree with Professor Roger Williams, author of the Lancet commission report on liver disease, that with more than 1 million admissions per year due to alcohol-related conditions, and the developing tsunami of obesity cases, many of whom will present with non-alcoholic fatty liver disease, services will be seriously stretched in the future? What efforts are going to be made to try to stem this tide?

[Earl Howe]

My noble friend is right. I am afraid that the figures for hospital admissions over the past 12 years make gloomy reading. Admissions relating to alcohol-related illness have more than doubled. We welcome the recent falls in alcohol consumption that we are witnessing, and the falls in alcohol-related deaths, but we should not be complacent—and we are not. Harms such as liver disease, as well as social impacts such as crime and domestic violence linked to alcohol, remain much too high, and Public Health England is giving priority to alcohol issues from this year, particularly through support to local authorities.

NHS: Funding

Lord Ribeiro Excerpts

Monday 17th November 2014 Lords Chamber

[Earl Howe]

My Lords, tackling health inequalities is one of the major tasks facing NHS England. It is built not only into its mandate but into legislation, and we expect NHS England to address it at every level—both in the acute area and in the community. It is of course up to local commissioners to prioritise their funding, but we expect to see over the next few years a shift from care in the acute sector to care in the community, both to prevent acute admissions and to ensure that people stay healthy for longer in their own homes.

[Lord Ribeiro (Con)]

My Lords, the 2004 GP contract, which was introduced by the party opposite, forced GPs to come off on-call rotas at night and at weekends, thus removing them from out-of-hours services. The impact of this on our emergency departments has been quite dramatic. Will my noble friend confirm that the introduction of the Better Care Fund will go a long way not only to integrate these services between primary and secondary care but to remove pressure on our A&E services in the acute sector?

[Earl Howe]

I agree with my noble friend that the primary purpose of the Better Care Fund is clearly to make care better, but it is also a major step forward in making our health and care services more sustainable, and moving to a preventive model that delivers care closer to home and keeps people healthy in the community. GPs have a major part to play in this and I am encouraged by the extent to which they are now engaging in the task of addressing the BCF.

People with Learning Disabilities

Lord Ribeiro Excerpts

Thursday 12th June 2014 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I thank the noble Baroness, Lady Hollins, for initiating this debate, which challenges us to achieve the exhortation in the gracious Speech for Her Majesty’s Government to continue work to build a fairer society. I believe the Government are trying to do so but, while the concept of a fair society is apparent in our everyday lives through the experiences of those we meet, it is less clear in relation to mental health, intellectual disability—or learning disability, as I will refer to it—and those with physical health needs.

Part of the problem lies in the education and training of doctors, who ultimately are the leaders who set the example which junior doctors follow. Your Lordships may wonder why, as a retired surgeon, I would have anything to say about learning disabilities. First, I must declare an interest as one of my family members has Down’s syndrome, a condition associated with learning disabilities and premature mortality compared to the national norm.

In the late 1970s and 1980s when I was appointed a consultant surgeon, mental hospitals which previously had been no more than asylums were closing all over the country. I worked as a consultant surgeon to Basildon and Orsett hospitals and part of my contract required me to visit South Ockendon hospital, which was a mental institution. There I undertook consultations and occasional operations—some of them quite major. On looking through the hospital records of one of the patients I was amazed to find that the cause of admission in 1950 was “imbecile”. Many patients in those days found themselves in institutions as no one could cope with their condition or behaviour.

The care that these patients received in the five years I attended was superb. You could have eaten a meal off the out-patient parquet floor, which was cleaned and polished to perfection. Despite the subsequent closure of the hospital through alleged incidents of ill treatment of patients, I never witnessed any treatment other than kind consideration and attention to the individual patients under its care. We are all horrified by the stories at Winterbourne View and Mid Staffordshire but within these institutions, like South Ockendon, there was also compassionate care.

My point in making these observations is that subsequently, when the hospital closed and the patients were managed in the community, I had no recourse to seeing them in their natural habitat, supported by caring nursing staff, who knew them and could care for their needs. Indeed, the nurses would often interpret for those unable to speak intelligently.

In the Confidential Inquiry into Premature Deaths of People with Learning Disabilities report, of the 247 patients who died, 30% had limited verbal communication and 22% did not communicate verbally at all. Patients would often arrive in my out-patients’ clinic with no detailed information about their learning disabilities, which led inevitably to delays and searching for records to make sure one had all the relevant information. How easy it would be in this computer age to give every one of those patients a memory stick on which their medical records were stored. I believe that the Government are making efforts to achieve such personalised medical records. Unlike the failed IT projects of the past decade, we could make a case for targeting just this one vulnerable group, and using that as a project to see whether it can actually work.

Public Health England is producing guidance for people with learning disabilities which help those who are old enough to be enrolled in the various screening programmes we have. As a colorectal surgeon, one of the most important screens is that for bowel cancer. I can assure noble Lords that, for the initiated, understanding how to use and perform the screens can be quite difficult. The conclusion of the review is that despite the lessons learnt from previous reports and recommendations, the professions are either unaware of or do not include in their normal practice adaptions to services that would assist those with learning disabilities. Identifying patients with learning disabilities who have acute conditions can be difficult and can lead to delays in diagnosis and treatment. A good carer or parent might be able to interpret symptoms but, as the report identifies, delay or problems in diagnosis or treatment are the weakest links in the pathway of care.

There are also problems around identifying needs and providing appropriate care in response to changing needs. More than one-third had difficulty communicating their pain, and for those with acute abdomens it could prove difficult for admitting surgeons to make a diagnosis. In our current surgical practice there is an overreliance on scans, whether they be ultrasound, CT or MRI scans, whereas a good history is usually a shortcut to a working diagnosis. Those skills need to be recognised and utilised. Learning disabilities may also be a contributing factor to premature death, to which the noble Baroness, Lady Hollins, referred. We need better systems for flagging up patients with learning disabilities who attend outpatients or are admitted. Our medical students, junior doctors and all health professionals need to be made aware of the needs of people with these disabilities.

We also need to apply the parity of esteem that we have talked about on previous occasions by treating everyone, whether they present with physical conditions, mental conditions or learning disabilities, exactly the same. The Government can assist in this, and I am pleased to hear that Health Education England is making progress in this respect. It should also take note of the Greenaway report that resulted from the Shape of Training review. In the striving effort to make doctors more generalist in their approach rather than specialist, we must ensure that we take into account the problems related to learning disabilities and mental health in general. The education of health professionals is key to this, both for those in the service and for those yet to come, so that a fairer society that includes people with no physical conditions can be realised.

National Health Service: Hospital Beds

Lord Ribeiro Excerpts

Wednesday 11th June 2014 Lords Chamber

[Lord Ribeiro (Con)]

Would my noble friend like to ask the noble Lord, Lord Kennedy of Southwark, how funding is undertaken in Germany? German hospitals are funded on the basis of length of stay. In this country, we have demonstrated that we can get patients home much more quickly, particularly after surgery, with the use of day case surgery. Furthermore, Sweden has fewer beds than we do.

[Earl Howe]

My noble friend makes the case very eloquently that it is very difficult to compare different health systems. We should pay credit to the NHS for performing very efficiently and effectively in the face of rising demand over recent years.

Care Bill [HL]

Lord Ribeiro Excerpts

Wednesday 7th May 2014 Lords Chamber

[Lord Owen (Ind SD)]

My Lords, I speak to my Amendment 45E. A recent comment article in the Lancet starts off with the words:

“Trust in the protection of confidential patient data in England seems to be at an all-time low given recent breaches in releases of patient data and the finding that hospital data have been sold to companies with insufficient oversight”.

There is no question or doubt that the research base in this country—particularly the base in pharmaceuticals and medical bioscience—is now at a very high level. Of course, it is because of this that there is a very strong debate over whether AstraZeneca should be taken over by the very large American pharmaceutical company Pfizer.

However, we also have to recognise in this debate that without confidence and the free exchange of information in this world of science data, research will be very badly damaged. Already we know that very serious members of the medical profession want to institute not the present opt-out system but an opt-in system. Most of us know that that will make great inroads into the effectiveness of our data. There are also some GPs who, because of their concerns, now actively encourage patients to use their right to opt out. This is therefore very urgent, and I welcome that the Government, in recognition of the crisis of confidence, have instituted a six-month pause. I understand that the pause has now been extended and that there is no artificial deadline.

In that context, there is another root cause for concern. We have been making data available to the pharmaceutical industry and other areas of commercial science for some time. Perhaps I should declare an interest. For 16 years—I am now off the board—I was on the board of Abbott Laboratories in Chicago, one of the very big American healthcare companies. However, well before that I was a neuroscientist at St Thomas’s Hospital and worked in the early 1960s with ICI, using its remarkable pharmaceutical research product, beta-blocker drugs—one of the great discoveries which led to James Black winning a Nobel Prize. I therefore have no need to assure noble Lords of my belief that a thriving commercial sector in pharmaceutical and other research is an important addition to the research that goes on in universities and hospitals up and down the country.

However, it is a fact that when you embark on a new extension of data being available to commercial operations outside the public sector, people demand and expect much higher safeguards. Before moving my own amendment and shoring it up, I looked very carefully at whether it was possible to get agreement on a mechanism to keep data in the public sector unless commercial organisations have expressed consent. That was seen by many people as blocking commercial activity, and it was not possible to reach agreement on it. That makes it even more important that we should have a statutory form of oversight.

The amendment I placed on the Order Paper proposes a new clause that would place on a statutory footing the current non-statutory Independent Information Governance Oversight Panel, which was set up by the Secretary of State. The present chairman, Fiona Caldicott, has the support of many people in this area, both in this House and outside. However, its present non-statutory terms of reference need to be given the authority of a statutory imposition. The new clause would also require persons and bodies across the health and social care system to have regard to its advice. It defines the relevant information; I strongly agree with the two previous amendments tabled by the noble Lords, Lord Turnberg and Lord Hunt. It is absolutely necessary to make it crystal clear what “promotion” means. It has different meanings in many different contexts—some perfectly acceptable and some borderline objectionable. There are other detailed aspects of the amendment, but it is pretty clear in its intent.

The medical profession is not the only body that ought to be considered in this. The Royal Statistical Society has made it clear that oversight and public trust in enforcement could improve the situation. It says that a new statutory body is likely to be needed to fulfil this role. Statisticians are as worried about the loss of confidence that is developing over medical data as anyone in the medical profession—they are the actual people who handle this.

I am pleased, indeed proud, that the amendment is supported by the Wellcome Trust. There is no better trust in the world than the Wellcome Trust. It is also supported by the charities that are associated with medical research, which also know the importance of the Wellcome Trust’s money and expertise. I have talked to the Minister about this and I will leave my comments for when I formally press the amendment, as I do not want to traduce what he is going to say to the House. He explained his position with his usual courtesy, but I remain of the view that, if we are to hold, restore and, in the future, enlarge public confidence—because I believe a greater exchange of information has huge potential—we have to listen to these concerns.

Whether we like it or not, people expect answerability, not just from NHS England, which is a quango, but also from the Secretary of State. Parliament has a role in this, and the issue is every bit as sensitive as some of the others that we brought under statutory oversight, such as embryology, the whole question of DNA and research into all these areas. We thought that they were so sensitive that Parliament should have a say, at least, and should know whether Ministers are taking actions that have qualifications, or even objections, from a statutory body so that we can make a determination. It is in that spirit that I will later seek to press the amendment.

[Lord Ribeiro (Con)]

My Lords, when many members of the public, and patients in particular, feel that their data may be mis-sold to insurance companies or other bodies that may use them either to increase premiums or for their own personal benefit, then we have a problem. Earlier this afternoon we had assurances from the Minister that that would not be the case. This must be information that is used for non-commercial purposes, which has been made very clear. It is important, too, to remember that patients can opt out. I have heard these expressions about the difficulties that they may have with GPs who might prevent their doing so, but they have a choice. They may well opt out. I believe that if we go ahead with care.data and provide the information as needed, many patients, in time, will see the benefits of this and will choose to opt back in.

We have also talked about the need, again, to have anonymised data and to prevent it going anywhere other than the non-commercial areas. Patients also have a right to decide what to do with their data; it is enshrined in the NHS constitution that they have rights on the disclosure of their personal data. I personally feel that all patients should have their own information—they should have their own notes. They should have a memory stick with their records and have ownership of their records. They can then determine, in the circumstances, where that information goes.

Many people are horrified by the idea of patients having their own records. I had experience of this in 1973, when I was a surgeon working in Ghana. Patients would come with their own notes, moth-eaten and dog-eared. The reason was very simple: if their notes were in the hospital, a certain bribe had to be paid before those notes could be released. Patients have always been suspicious about what happens to their notes. Give them to them—that is what I would say.

The proposal from the noble Lord, Lord Owen, for yet another layer of scrutiny above what is being proposed, is something that we should consider very carefully. He referred to the fact that it would be for the Secretary of State and NHS England to make those decisions. However, noble Lords will recall that when we debated this matter not that long ago, the noble Lord, Lord Willis, and others put forward a proposal for the Health Research Authority. If this Bill goes through, the Health Research Authority will have the authority to decide how information is disclosed. Therefore, I speak very strongly in support of the care.data programme. It is important for patients to be reassured and that point has been well made from all sides of the House. They clearly have to have that reassurance. However, I see no need for an extra layer or an oversight panel. That would provide just one more barrier for researchers to climb.

Health: Folic Acid Fortification

Lord Ribeiro Excerpts

Wednesday 2nd April 2014 Lords Chamber

[Earl Howe]

My Lords, we will announce a decision by Easter. I am aware, as the noble Lord is, of the impatience that many people have shown about this matter. However, it is right that the Government balance both the risks and the benefits of a policy that would see the mandatory fortification of a staple food. I think that that is a responsible course to take.

[Lord Ribeiro (Con)]

My Lords, is my noble friend convinced that the evidence for introducing folic acid into white bread flour is irrefutable, given the fact that successive Governments have tried to introduce fluoride into water for all of us but have failed to do so?

[Earl Howe]

My Lords, there are risks associated with the fortification of flour with folic acid. That was pointed out by the scientific committee and was why its recommendation was conditional on certain things taking place. As it pointed out, there is a potential for significant numbers of the population to be pushed above the guideline upper limit for folic acid. We have to take those issues seriously in reaching a balanced decision.

Food and Soft Drink Industry: Sugar

Lord Ribeiro Excerpts

Tuesday 11th February 2014 Lords Chamber

[Earl Howe]

My Lords, tackling obesity calls for action by the widest possible range of partners, including the food industry but also including schools. That is what we are trying to do through the responsibility deal. Our National Child Measurement Programme, the School Food Plan, the School Games and the money that we are putting into school sports funding—£150 million a year—all contribute to the joint effort across government to influence the way in which calories are consumed by children. I have encouraging news on that front, which is that the level of child obesity is now the lowest that it has been since 1998, so we are moving in the right direction.

[Lord Ribeiro (Con)]

My Lords, I congratulate the noble Earl on leading on the successful amendment in this House which led to the vote going through the other place yesterday on smoking in cars. Can he further protect children by tackling the issues around obesity? What are the Government doing to encourage the soft drinks industry to take action on calorie reduction as part of the responsibility deal?

[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.

NHS: Seven-day Working

Lord Ribeiro Excerpts

Thursday 6th February 2014 Lords Chamber

Asked by

[Lord Ribeiro]

To ask Her Majesty’s Government what assessment they have made of the implications of introducing seven-day working in the National Health Service.

[Lord Ribeiro (Con)]

My Lords, in opening this debate I must first record my interests in the register and my chairmanship of the Independent Reconfiguration Panel. I support the introduction of a seven-day service, promoted by Sir Bruce Keogh, medical director of the NHS, but I believe that it should focus on emergency and urgent care, which is currently poorly provided at weekends. The move to a seven-day service has the support of the Medical Royal Colleges, NHS Confederation, NHS Employers and the BMA, but why is it necessary?

When I was a consultant, I often provided an emergency service at weekends, initially every four weekends and then every eight as staffing numbers increased. That was a requirement to go into the hospital to deal with emergencies when they occurred, rather than a commitment to be there all day as I would be during the week. What has changed is, of course, the increasing number of elderly patients with comorbidities requiring care and the findings of the Francis report that patients felt vulnerable at weekends when,

“staff absences and shortages are more noticeable”.

A report commissioned by NHS London in 2011 found that increasing cover by consultants in acute medical and surgical units at weekends could prevent 500 deaths a year in London. Further evidence in the Journal of the Royal Society of Medicine in 2012, analysing 14.2 million admissions in NHS hospitals in England in 2009-10, found that patients admitted on Sundays were 16% more likely to die than those admitted on Wednesdays, and 11% more likely to die if admitted on Saturdays. The Dr Foster Hospital Guide in 2012 reported similar findings, confirming that a higher level of senior medical staff at the weekend is associated with lower mortality. The case for change in respect of emergency admissions has been made and now something must be done.

Despite a reduction of acute beds by a third in the past 25 years, the number of unplanned admissions of those over 65 continues to rise, with some 2 million admissions a year. Length of stay is also important: for those under the age of 65, the average length of stay is three days but for over 65s it rises to nine days and for those over 85 it is 11 days. To prevent unplanned admissions we need more consultants because consultants make the decisions. They are able to decide whether patients can be sent home or need to be admitted. Junior doctors often lack the confidence to do that. We also need the infrastructure and systems in general practice and social care to allow those patients to be treated nearer their home. That must also be available at weekends.

My noble friend the Minister will no doubt point out that “seven-day working”, as this debate is titled, is not the same as a seven-day service. I agree but the public need to be clear what sort of service they receive. When we promise them the same service at weekends as in the week, they will assume that that implies seven-day working. That means that there will need to be a massive expansion of consultant numbers. I have recently heard the figure of 1,800 quoted as likely. Do we actually have enough qualified trainees to fill those posts—and trainees of the right calibre? Over what timescale do we expect to have this expansion? If the service is to be both for elective procedures, including routine operations, and emergencies, then a bigger challenge is funding and the staffing of theatres, X-ray rooms, and pathology and scientific laboratories—all of which must be supplied if we are to provide the same service at weekends as we do during the week.

We should not promise what we cannot deliver. The seven days a week forum report commissioned by Sir Bruce Keogh, which the Library kindly sent round as a briefing document for those involved in this debate, identifies 10 clinical standards that are evidence based. Three of them incorporate standards developed by the Academy of Medical Royal Colleges, whose committee on this was chaired by the president of the Royal College of Surgeons—so I have a slight inside track on what was developed. The standards cover the patient’s experience through to the transfer to the community. They focus mainly on the management of emergency admissions. Of the 10 standards, eight revolve around hospital care. They recognise that a one-size-fits-all solution cannot be applied in this situation and that what will work best is usually based around local solutions. But there is an emphasis on emergency care that does match the rhetoric of providing care for all at the weekend.

The NHS Confederation and NHS Employers recognised that we already work seven days a week, but it is how we do that work that is in question. Changing to a seven-day service could be liberating for many staff. I heard one lady consultant on southern TV last week say how much she enjoyed working at weekends. I think she worked at Southampton General. One reason she enjoyed working at weekends was that it provided a better work-life balance for her family. We should grasp the opportunity that this offers to use our workforce more flexibly. With the increasing feminisation of the workforce, remembering that more than 60% of our medical school intake is female, it is important that we take families, children and women into account when we design our workforce of the future. It is also important that many women with children would find working at weekends helpful because it would mean that their partners were there to look after the family and home while they were away working. I am not against that but will put forward some arguments as to why we should deal with the emergency problems first.

We also need to be much more creative about how we utilise some of our older, senior staff. I say that advisedly as I retired at 64 and was doing emergency admissions until the age of 60. How I could have done that between 60 and 64 I do not know; I feel for my colleagues who still do. Between the ages of 55 and 60, you could take most senior doctors off the emergency on-call rota and have them there providing mentorship for more junior consultant colleagues, and perhaps undertaking elective work at weekends if that could be managed.

Much could be done to achieve seven-day care but I am daunted by the cost of implementing both an emergency and elective service at weekends. The seven-day services improvement programme, which I believe was due to start in January this year, is focused in its first year on emergency care and the provision of enhanced recovery pathways and diagnostic and support services. The programme freely admits that its big challenge is how to actually develop those diagnostic and support services. I wonder where it will focus its attention in the next two years of the three-year programme it has set out. In addition, what are the likely costs of staffing a seven-day service in both primary and secondary care? The figures of £3 billion, from the Department of Health, and £32 billion, from the BMA, have been quoted as the cost of introducing seven-day care right across the piece in primary, secondary and social care.

From my experience of service reconfiguration, the public want high-quality care, but are wary of change, particularly if it affects their local hospital. We have seen the benefits of such service change, particularly here in London. Stroke services, acute heart condition services and trauma care concentrated in fewer centres have already delivered improved outcomes, so we have the evidence. A new project in Northumbria to produce a specialist emergency care hospital, which is due to open in 2015 at a cost of £200 million, is an example of a local solution to rural problems. Local solutions driven by clinicians and co-designed with the public can lead to centres of excellence.

It is important that we focus our attention on delivering an emergency service. If we base this on the 22 trauma centre networks that were designed by Profession Keith Willett and Sir Bruce Keogh, the success of the centres will trickle down to the spoke hospitals which are linked to them. By aiming for this low-hanging fruit, we can demonstrate success to the public, and the effectiveness can be translated to elective care. However, I do not think we are yet in a position where we can provide care at the weekend in the way we go shopping at Tesco and Sainsbury’s. Please do not forget the European working time directive, which applies to junior doctors and equally to consultants, because the SiMAP and Jaeger agreements are still there and they will require compensatory rest for consultants who work at weekends.

I have identified barriers to change. I am not a naysayer, but I have concerns about staff and cost implications, particularly with an austerity budget designed to reduce our deficit, GP contracts—will they be asked to work nights and weekends again?—the ability of social services to cope with seven-day working and whether payment by results can be adjusted to take account of the increased emergency work. I support the proposals for a seven-day service, but I have misgivings about implementation and the costs involved. I hope the Minister will be able to reassure me.

[Baroness Jolly (LD)]

My Lords, I remind noble Lords that this is a time-limited debate and, with the exception of the Minister, speeches are restricted to four minutes. When four is on the clock, time is up.

Children and Families Bill

Lord Ribeiro Excerpts

Wednesday 29th January 2014 Lords Chamber

[Lord Hunt of Kings Heath]

No, my Lords, I do not think that that is covered in my amendment—although, of course, it is open to the noble and learned Lord to propose an amendment to increase the scope of the measure. I would give such an amendment all due consideration.

I refer noble Lords to an inquiry into smoking in private vehicles by the All-Party Parliamentary Group on Smoking and Health, carried out in 2011, which concluded that the evidence from smoke-free public places was that legislation would be necessary to reduce exposure to cigarette smoke in cars. That is the basic case I am making. At this stage, I am asking noble Lords to support the principle of a ban. If my amendment were accepted, I would be very happy to work on a cross-party basis to consult on the type of offence that should be put in place. I have not gone as far as the noble Lord, Lord Ribeiro, and his colleagues in terms of specifying the offence because I think that needs further consideration and discussion.

We would not be alone in legislating to protect children from the damage of smoking in cars. Seven other countries already do so, including four US states, 10 of the 13 Canadian provinces and all but one jurisdiction in Australia. As far as the public are concerned, a YouGov poll in 2011 found that 78% of adults in Great Britain agree that smoking should be banned in cars carrying children younger than 18 years of age. Just as significantly, perhaps, a British Lung Foundation survey in 2011 found that 86% of children want action to be taken to protect them from cigarette smoke in cars. I think that we should listen to the voice of children in this respect. I hope that noble Lords will support the amendment that I shall propose later.

In concluding, I should have pointed out to noble Lords my health interests in the register, including being chairman of a foundation trust, a consultant and trainer with Cumberlege Connections and president of GS1.

[Lord Ribeiro (Con)]

My Lords, the amendment of the noble Lord, Lord Hunt of Kings Heath, is compelling but fails to acknowledge the impact of second-hand smoke on children in confined spaces or in the home, as we heard in an earlier debate. For this to happen, the public, particularly parents, have to be educated about the harm that second-hand smoke can do to young children’s lungs. The noble Lord identified some of those problems. That is why I believe that education and behavioural change are important.

As a doctor, I recognise the damage that second-hand smoke can cause, and in particular the long-lasting effect it can have on the lungs of young children. Just this Sunday, I was present at the birth of my first grandson out of six grandchildren.

[Noble Lords]

Hear, hear.

--- Later in debate ---

[Lord Ribeiro]

I greeted that event with jubilation. I would not want that grandson to go through life having his young lungs damaged by cigarette smoke. I am concerned about that. Cigarette smoke contains a cocktail of carcinogens: arsenic, cadmium, formaldehyde, benzene and in particular the fine particulate matter that comes out of cigarettes when they are smoked. This can cause long-term damage and illnesses.

My Amendment 62, which mimics the Private Member’s Bill that I took through this House in 2012, serves to make parents and the public aware of the risks and to provide educational programmes to rehabilitate them through smoke-free driving awareness courses. I believe strongly in education and behavioural change, rather than the imposition of punitive measures. It is about providing incentives to change behaviour, not dissimilar from the police driving course which noble Lords may have been offered if they have ever been unfortunate enough to have been caught speeding. There may be some in this Chamber who can endorse the benefits of that.

In that sense, my amendment is exploratory, seeking to obtain answers from the Government on two specific issues. The first is education to change behaviour, as I explained. Here, I applaud the Government for their successful advertising campaign launched last year, with its graphic films of children assaulted by smoke in the back of cars while parents in the front are oblivious to the damage being done behind them, probably because the driver has a window open and therefore assumes that all the smoke is going outside. I should like assurances from my noble friend that the Government will repeat that successful campaign and undertake an extensive evaluation of its effects. We must know that behavioural change is happening.

I am sure that the Government have taken note of the Welsh Government’s Fresh Start Wales campaign. I made reference to this at Second Reading and asked whether the Government would again consider mirroring what the Welsh Government were doing. That Government are due to report in the spring on the result of their campaign, following which they reserve the right to introduce legislation if no improvement in behaviour is apparent.

My second question to the Government relates to a national consultation, which should involve the public, the profession and the retailers, to decide whether legislation or non-legislative measures are required to protect children from smoking in confined spaces. I am pleased that my noble friend has asked Sir Cyril Chantler to undertake an independent review of the public health evidence on standardised tobacco packaging and its effects on public health. Might he perhaps also consider asking Sir Cyril, at the conclusion of this review in March, to undertake a similar review of the effects of second-hand smoke on children travelling in cars? There is plenty of evidence out there but what is now needed is the clinical evidence that shows that smoke causes long-term damage. We know that the long-term sequelae from smoking in adults are quite severe. If we can demonstrate that they start at a very early age, that will be very good evidence for taking action now rather than later.

My amendment provides the Government with measures to change behaviour. They may have started with good intentions—and I am sure that they have. Standardised tobacco packaging will reduce the risk of smoking and its damaging effects on children. I hope that the Government will take the view that legislation, although difficult, may need to be considered. However, for legislation to work, I understand that it must be proportionate and enforceable. In this respect, my amendment is probably defective, as it will be difficult to police and to enforce, much in the same way, I suppose, as is the case with the mobile phone offence, which is legislated for but is difficult to police.

I hope that my noble friend will provide me with some of the concessions that I seek. I do not think that they are small ones but they will help to ensure that over the next year, and certainly over the next three months when we hear the results of the Welsh review and Sir Cyril Chantler’s review—and it is to be hoped that he will extend that further—we will have more information on which to make a decision as to whether we should introduce legislation or non-legislative measures.

[Baroness Finlay of Llandaff (CB)]

My Lords, I have put my name to Amendments 60 and 62. I will first address Amendment 60 on standardised packaging and move on to the amendment to which the noble Lord, Lord Ribeiro, has spoken so eloquently. I hope to avoid covering the ground that has already been covered. In terms of standardised packaging, those of us who contributed in Committee to a very powerful and widely supported debate across the House are grateful to the Government for having done exactly what they said they would; namely, take the proposal away and look at it. They have returned with an elegant amendment. Before finally legislating, it seems wise to have an independent review by Sir Cyril Chantler.

This is definitely a public health and a child protection measure. I should like to address that briefly but not repeat what was said previously. The Minister has already said how many children start smoking before the age of 18. That figure is particularly high in looked-after children, where about one-third report that they are current smokers. However, when looking at children in residential care, the figure rises to more than two-thirds. There is a real problem with very vulnerable children.

In 1999, the tobacco industry’s magazine, World Tobacco, said that,

“if your brand can no longer shout from billboards … it can at least court smokers from wherever it is placed by those already wedded to it”.

The problem is that we know that tobacco is a highly addictive substance, and that the products of tobacco damage health and do not have any positive benefit. Recently, a study published in the European Journal of Public Health has shown that,

“the removal of brand imagery from tobacco packaging reduces the appeal of tobacco products, including perceptions of brand attractiveness and smooth taste and perceptions of lower tar or lower health risk”.

Those perceptions are an illusion. The study was in the UK, and I am sure that it will be considered in the evidence review and that Sir Cyril will be an independent reviewer in every sense.

It is worrying that it has taken us so long to get to this point. Like other noble Lords who have put their name to this amendment, I sincerely believe that the day will come when we will see standardised packaging. That day is not far off, because research study after research study reports are reinforcing that standardised packaging is making cigarette packs less attractive to young people.

I have had discussions with Her Majesty’s Customs as regards illicit trade. It pointed out that it is not that difficult to detect counterfeit standardised packaging, just as it is not difficult to detect other counterfeit packaging. Indeed, the cover marks, number codes and security marks are the clue, rather than the bald, external appearance of the pack. It also is well aware that tobacco firms have been producing and exporting cigarettes far in excess of any known demand in a stated target market abroad, knowing that this excess production will be smuggled back into the UK. The tobacco companies appear to have been complicit with what has been termed the illicit trade. It seems logical that this move and the government amendment are because of child protection issues and the importance of preventing children from starting to smoke.

On tobacco and smoking in cars, the British Lung Foundation study, which was addressed by the noble Lord, Lord Hunt, included another set of figures which I hope the House will consider. One has to remember that the children responding in the study were of an age at which they could answer competently. When asked about being a passenger in a car, 31% said that they had asked someone to stop smoking but 34% said that they had not dared to ask because they were too frightened or too embarrassed. The child in the back seat, belted in, is effectively imprisoned in the vehicle for their own safety while travelling. They are stuck there. They have no control over what the adults do, and it is worth remembering that they do not feel able to do anything about it either. As was pointed out by the noble Lord, Lord Hunt, if they are in a house, they can move to another room or another area and the volume of space is much greater than in a car.