Hormone Pregnancy Tests

Alex Cunningham Excerpts

Thursday 16th November 2017 Commons Chamber

[Steve Brine]

The step that we will take is to implement the report’s recommendations. As I have already said, the way the families were handled when they came down to speak to the expert working group could have been a lot better, which is the understatement of the day, and I apologise for that on behalf of the MHRA.

[Alex Cunningham (Stockton North) (Lab)]

A constituent who took one of the Primodos tests and whose son was born deaf visited my surgery on Friday, and she is deeply disappointed with the latest outcome. The Minister said a few minutes ago that checks had to be made before the final report was published, so what hope can he offer her and other parents that the matter will not be swept aside, that work will continue to flush out the truth and that the affected families will be properly supported?

[Steve Brine]

All I said is that there were checks to be made to ensure that the report was as readable and as accessible as possible. We are confident in the report, and we are not going to sweep it away and forget about it and move on to the next story; we will implement the recommendations.

Tobacco Control Plan

Alex Cunningham Excerpts

Thursday 19th October 2017 Commons Chamber

[Sir Kevin Barron (Rother Valley) (Lab)]

I beg to move,

That this House has considered the Government’s publication of the new Tobacco control plan.

I begin by thanking the Backbench Business Committee for allocating time for this very important debate. I also welcome the Minister to his new post in the Department of Health, and I am sure he will hear much more about this issue in the months to come.

I have no financial interest, but I should mention that I am an honorary fellow of the Royal College of Physicians, as it is heavily involved in the debate on tobacco.

I have repeatedly called in this House for the publication of a comprehensive tobacco control plan to replace the Government’s previous plan, “Smoking Still Kills,” which expired in 2015. I welcome the Government’s publication of this new five-year strategy this summer, which seeks to achieve what they term a “smokefree generation”.

Despite a long-term reduction in smoking rates, tobacco use remains the leading cause of preventable premature deaths and ill health, accounting for about 100,000 deaths each year in the UK. In addition, 23% of all hospital admissions for respiratory problems in 2014-15 were directly attributable to smoking. I thoroughly welcome the falling adult smoking rates in England—down from 46% in 1974 to 15.5% in 2016—but I have to say to the Minister and to the House that we cannot take this work for granted. That is why we need the tough but achievable targets that the new current control plan contains.

Smoking and the harm it causes are not evenly distributed, as hon. Members will know. People in more deprived areas are more likely to smoke and less likely to quit. Smoking is increasingly concentrated in more disadvantaged groups and is the main contributor to health inequalities in England. Men and women from the most deprived groups have more than double the death rate from lung cancer of those from the least deprived areas of the UK. I am not saying there is exactly a north-south divide, but where money is divided in such a way that is likely to happen. Rates do vary between north and south on occasion, as we see if we examine smoking during pregnancy rates, which vary from 2% in the Central London clinical commissioning group area to 27% in the Blackpool CCG area.

[Alex Cunningham (Stockton North) (Lab)]

Data produced by Public Health England show that in my local authority area 18.1% of women smoke at the time of delivery compared with the national average of 10.6%. The plan says that it will reduce the prevalence of smoking during pregnancy. Does my right hon. Friend agree that every CCG and local authority will have to have sufficient funds to carry this work forward?

[Sir Kevin Barron]

Clearly that is the case. I agree with this publication and its intention, but there will be issues to address on different forms of funding. I will discuss that a little later in my speech. We can see from the two figures from central London and Blackpool that there is a challenge out there; this difference alone can have a dramatic impact on health inequalities, as maternal smoking causes up to 5,000 miscarriages, 300 perinatal deaths and 2,200 premature births in the UK each year.

In my area of Rotherham alone, the smoking rate among people in managerial and professional occupations is about 10.2%, but that leaps to 29.4% among those who have never worked or are long-term unemployed. Such facts clearly show that we are still struggling to get through to certain groups within society, and the Government must do more to identify ways of getting through to these difficult-to-reach groups.

--- Later in debate ---

[Sir Kevin Barron]

I am going to go on to discuss some of the issues relating to that situation. As I said, dentists are the only ones who normally see healthy people. I am aware that some GPs—we have one sat here in the Chamber—talk to healthy people even though these people do not think they are healthy at the time, but the situation is a little different for dentists. This early identification is crucial, as mouth cancer patients have a 90% chance of survival if the condition is detected early, but that plummets to just 50% if their diagnosis is delayed.

I say to the hon. Gentleman that I worked in an industry where people used to chew tobacco because we could not smoke at work. I tried it once at the age of about 16 and I am pleased to say that I never went near it again, although I used to smoke cigarettes when I came up from underground—that is a long, long time ago now. The general health implications of smoking are well known and documented, but mouth cancer often gets overlooked. This is the point: despite its killing more people in the UK than cervical and testicular cancers combined, there is still an alarming lack of public awareness towards oral cancer. There are thousands of chemicals contained in a single cigarette, and their point of entry is the mouth. Smoking helps to transform saliva into a deadly cocktail that damages cells in the mouth and can turn them cancerous.

Pharmacy teams also have an important role to play in promoting and encouraging attempts to stop smoking; as Members will know, in Healthy Living pharmacies and others, this is part of the job they do in advising people. These teams can be trained to be very effective in that. This often occurs in the community, but hospital and GP-based pharmacists are also well placed to offer this support. They are well placed to offer stop-smoking interventions with behavioural support and medication. In fact, the National Pharmacy Association is re-evaluating its position on e-cigarettes. As frontline healthcare professionals, pharmacists and dentists are exquisitely positioned to make a difference to health outcomes.

The Government must look to protect public health funding for stop-smoking services in particular if their aims are to be achieved. A growing number of local authorities have already stopped providing stop-smoking services for general smokers. The King’s Fund also highlighted that in 2017-18 local authority funding for tobacco control faces cuts of more than 30%. We have seen the transfer of commissioning responsibilities for public health services to local authorities, and subsequent cuts to the public health grant. A study by Cancer Research UK and ASH—Action on Smoking and Health, an organisation I have been involved in for more than two decades—found that 39% of local authorities reduced their smoking cessation budgets, despite the public health budget being ring-fenced by central Government. These are the issues that are happening down below, but we need to be aware of them.

All this has led to a reduction in mass media campaigns to motivate quitting, which are so vital to direct people towards the services that are on offer. Only this morning, I saw that the British Lung Foundation has published a report showing, yet again, that stop-smoking support is one of the most cost-effective treatments for people with COPD—chronic obstructive pulmonary disease.

Recently, in my role as vice-chair of the all-party group on smoking and health, I visited a smoking-cessation service—the one led by Louise Ross in Leicester. The team in Leicester have been trailblazers in the use of e-cigarettes for cessation purposes. They told me that Leicester’s stop-smoking service was the first in the country to go “e-cig-friendly” on No Smoking Day 2014. Since then, the team has built up a comprehensive bank of knowledge and insights, developed from many discussions with both vapers and smokers, that can be drawn on to help people get the best advice when they decide they have had enough of smoking. I had a discussion with a nurse who works in that service and who was using e-cigarettes in working with pregnant women to try to address our awful statistics on the effect of smoking in pregnancy. Most smoking-cessation services could do worse than talk to the people in Leicester about exactly what they are doing on that.

There has clearly been an increase in e-cigarette usage since the publication of the previous strategy in 2011: in 2012, there were some 700,000 e-cigarette users, and that had risen to 2.8 million by 2016. There is growing evidence to support the successful use of e-cigarettes as a smoking cessation aid. The Office for National Statistics found that in 2016, some 470,000 people were using e-cigarettes as an aid to stop smoking, while an estimated 2 million people had used the products and completely stopped smoking. I believe that e-cigarettes played a huge part in the beating of the target in the previous tobacco control plan. It is clear that e-cigarettes do not suit everyone, though, so there still needs to be a wide range of licensed stop-smoking medication to use alongside much-needed behavioural support.

[Alex Cunningham]

Some 4,000 people in my Stockton North constituency use e-cigarettes and 14,000 people still smoke. Can my right hon. Friend envisage a day when e-cigarettes are available on prescription, like other products?

[Sir Kevin Barron]

I actually had this conversation in Leicester, although I was not going to mention it in my speech. There is an issue—I think it was in a column in one of the national newspapers many months ago and I have tried to avoid it. If somebody avoids spending £20 or £25 a week on cigarettes, should they get free NHS prescriptions, if they are eligible, to help them to quit? There is a debate there, but I shall say no more than that at this stage.

I asked the team in Leicester what they thought about e-cigarettes on prescription for people who are eligible for free prescriptions, and they said that there might be a case for doing it for a month to break the person away from the cigarette-smoking habit and get them on to e-cigarettes. For the purposes of this debate, I shall leave that where it sits, but there might be a case for it. We clearly need more evidence on the use of e-cigarettes for smoking cessation so that we can make a better estimate.

[Sir Kevin Barron]

I shall address that briefly, because I know that other Members wish to get involved in the debate. The simple answer is that that is one of several issues that need to be addressed.

The best thing smokers can do for their health is of course to quit smoking altogether, but it is clear that e-cigarettes are significantly less harmful to health than smoking tobacco. Public Health England found that e-cigarettes are around 95% less harmful than smoking cigarettes. My instinct is that the remaining 5% is down to the fact that they have not yet been tested for long enough for it to be said that there is little or no danger at all. There is no evidence that e-cigarettes act as a smoking gateway for children or non-smokers, but research is still needed on their long-term use, and it should be carried out. Quitting smoking is always best, but there is clearly a hard core of smokers who have so far struggled to quit; they must be the people we focus on. It is worrying that an ASH survey found over a three-year period that the number of people who thought that e-cigs were “as or more dangerous” than cigarettes rose from 7% to 26%. That is why we need Government-funded research. I find it incredible that statistic is moving in that direction, rather than the opposite, although I must say that the debate on e-cigarettes, both in the Chamber and elsewhere, has not always been particularly clear.

Other innovations are continuing the “nicotine revolution”. Manufacturers are developing additional smoke-free products to persuade heavy smokers who would not otherwise quit smoking to switch to smoke-free alternatives, among which are the heated-tobacco products that have come on to the scene in the past year or so. Referred to in the “novel tobacco products” category of the tobacco control plan, such products could be the next step to reaching those hard-core smokers who, although they did not get on with e-cigarettes, are looking for another way out of smoking. I was pleased to see in the plan that Public Health England will continue to lead the investigation into the use of novel products as stop-smoking tools, with the evidence updated annually, and that PHE acknowledges that novel products are currently the most popular aid to stopping smoking in England.

Many people are wary of so-called novel products and the fact that many are produced or funded by tobacco companies. We must recognise that tobacco companies have in the past been extremely dishonest about the harms of smoking and the products they have sold, so we urgently need more research on these devices, and I hope the Government’s annual review will help to provide more information. I have been anti-tobacco for more than two decades in this House, but we should not ignore the potential benefits for people who have not been able to stop with more traditional smoking-cessation products just because some of these products have tobacco connections. It is vital that we all focus our minds on the reality of getting people off this habit that is still killing people and shortening the lives of more than 100,000 of our fellow citizens every year.

Many of the products I am talking about are covered by the EU tobacco product directive, which has resulted in many good things, including the establishment of reporting and notification requirements for tobacco products. Nevertheless, stakeholders have raised issues with some of the other requirements, and we may be able to use Brexit as a chance to look at the directive. I understand that we have been thrown into the TPD at the last minute. We have had the debate and I do not want to bore anyone with it further. We need to move on, because that is what happens in politics sometimes. We need to talk about what should be happening now and in future for the sake of our fellow citizens. Brexit is coming, so we should not be tied into a timetable for any changes to the TPD—although I do not even know the potential timetable for any further debate on Brexit. Nevertheless, if there is any discussion about changes to the TPD, we need to ensure that all stakeholders are involved in working groups to design a directive that works for the good of the United Kingdom, taking into account the issues I have mentioned.

For all its positives, there is a glaring problem with the tobacco control plan, and we all know what it is: money. Although not short on lofty ambitions, local authorities face huge strain and will not be able to deliver the kind of joined-up smoking-cessation services that the tobacco control plan deserves. Luckily, there are people who can help. Tobacco companies have made a fortune selling cigarettes. We might well argue that they got us into the mess we are now in, so it is only right they get should us out of it. They have the resources and customer base to help smoking cessation tools to get straight to the people who need them most. If the industry is willing to commit to a future based on e-cigarettes and other reduced-harm products, we should take them up on the offer and allow the Government and local authorities to partner with them to ensure we have the financial and technical assistance needed to help smokers to quit. I would not have said that five years ago, but five years ago we did not have these products that can clearly help a lot of our fellow citizens to get off cigarettes.

[Alex Cunningham]

It was remiss of me earlier not to pay tribute to my right hon. Friend for all his work on this issue in recent years. Will he talk a little about people with mental health conditions and the fact that the tobacco control plan emphasises the need for parity of esteem in their treatment, in a similar way as there should be parity of esteem between the treatment of mental health conditions and the treatment of the general population? For that parity of esteem, the professionals who work with people with mental health conditions would need the necessary expertise and education. Will my right hon. Friend join me in encouraging the Minister to step up education for mental health professionals so that they, too, can be part of the campaign to help people to quit smoking?

[Sir Kevin Barron]

I will indeed. The use of e-cigarettes in mental health institutions or in prisons could go a long way towards alleviating some of the problems in such institutions. When I was Chair of the Health Committee, we looked into smoking in public places in 2005-06, and we saw tobacco in effect being used as a form of control in some institutions, and everyone knew the damage it was doing to the people in those institutions. A lot of institutions have moved on now, though. It is a matter for the Prisons Minister, not the Minister who is present, but we need to consider the availability of e-cigarettes in such institutions so that we can get people away from this life-threatening habit.

In conclusion, the tobacco control plan offers the groundwork for a comprehensive strategy that is much broader than just cessation and that must include measures that reduce uptake as well as those that increase quitting. They should include reducing the affordability of tobacco by increasing taxation, which has been happening in this country for many years now. I will certainly have a close eye on the Budget in a few weeks’ time, as we need a renewed commitment from the Government to the tobacco tax escalator. Any money that is raised should be ring-fenced for use in smoking cessation and mass media campaigns to motivate quitting and enforcement of age of sale, which is also an issue. When the mass media campaigns ended after the 2010 general election—people were no longer seeing them on television or in other parts of their life—the demand for smoking cessation services reduced.

We all want a smoke-free society as soon as possible. We on the Labour Benches, and even some tobacco companies, are now saying that as well, so the Government could not ask for a better opportunity to take this further, to do it more comprehensively and with more success. The challenge now is to make sure that reality lives up to these ambitions. The tobacco control plan needs to be properly implemented and built on if we are to achieve those goals.

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[Michelle Donelan (Chippenham) (Con)]

I am delighted to have the opportunity to speak in today’s debate on the Government’s tobacco control plan, which was unveiled in July 2017 and is supported by the British Heart Foundation. It is a co-ordinated effort to bring together the NHS, the Department of Health and local government to tackle smoking.

Although smoking in the UK is declining, the problem should not be underestimated. There are still 7.3 million adult smokers in the UK, and more than 200 smoking-related deaths a day in England, which costs the NHS millions every year. I welcome the plan and the £16 billion that has been ring-fenced by the Government for local public health services until 2021.

Those who use a local stop-smoking service are four times more likely to quit. The figures are astonishing. As the daughter of a smoker of more than 20 years, I have seen at first hand the journey that needs to be replicated to achieve the goal of a “smoke-free generation”.

The success of the 2011 to 2015 tobacco control plan reduced adult smoking rates from just over 20% to just over 15%. The aim now is to reduce rates to 12% and lower by 2022. That is not only right, but essential. We must work to save the 79,000 preventable deaths in England per year and the £11 billion that smoking is costing the economy.

Smoking is not a necessity. A cigarette is not a fashion accessory; it is the way towards lung and mouth cancer, strokes and heart disease and a host of other ailments and illnesses that kill. Let me be clear: I believe in choice and individual freedom, but I also believe that the Government have a role not only to guide, but to signpost and to promote the choices that will lead to healthier lifestyles. That is why I am so proud that the Government are prioritising the issue of smoking.

Some people have said to me: “Michelle if people want to smoke, let them.” I respond by saying that we must arm those people with all the information—the warnings and the facts. We must work together to deglamorise smoking. As has been pointed out, the smoking industry also has a responsibility to play its part. We must guide people and steer them to make informed choices. We must also discourage them, otherwise we will have to pay their NHS bills—money that could be spent in other sectors of the NHS. I often ask people, “If smoking were invented today and we knew all the risks and effects, would it be so freely available and popular?” Armed with the facts, we often make different choices in life.

My mother started smoking in an era when the health consequences were not known. I saw her struggle, desperately trying to give up. My Dad describes that time as a caricature, with my mother wearing anti-smoking patches and smoking cigarettes, while chewing anti-smoking gum and seeing a hypnotist, all at the same time. She simply tried everything. All the hypnotist did was to get her on to menthol cigarettes and give her a fear of hypnotists, so that did not go quite to plan. That taught me that, to break the cycle, it needs to be killed at the root, and people need to be prevented from smoking in the first place. I must add that my Mum has now not smoked a cigarette for seven years. [Hon. Members: “Hear, hear.”] Instead, she has e-cigarettes. Although that cannot be seen as the answer, it is very much part of the solution.

As part of the tobacco control plan, I want to touch on the support provided for pregnant workers, which aims significantly to reduce the likelihood of a person smoking while having a child. Currently, more than 10% of pregnant women smoke, and the plan is to get it down to 6%. Smoking during pregnancy increases the risk of stillbirth. Babies born to mothers who smoke are more likely to be born underdeveloped and in poor health. It is important that we give those mothers all the support and information available. For example, within the plan, NHS England will work to reduce smoking in pregnancy through carbon monoxide testing at antenatal care facilities and referrals to stop smoking services through the Saving Babies’ Lives care bundle.

Support, advice and information are crucial. We must make sure that all mothers are aware of the dangers of smoking. I urge us to be bold—bold with our information and bold with our warnings.

[Alex Cunningham]

Information is key to this matter as well. ASH has told me that the Government no longer have the measure of the number of people with mental health conditions who smoke. Does the hon. Lady agree that the Government need to re-establish a national measure for smoking rates among people with mental health conditions, as that will aid planning and the provision of services?

Autism Diagnosis

Alex Cunningham Excerpts

Wednesday 13th September 2017 Westminster Hall

[Alex Cunningham (Stockton North) (Lab)]

I was asked to speak in this debate by one of my constituents, Nichola, who has a three-year-old son called Thomas. My hon. Friend the Member for Stockton South (Dr Williams) referred to them.

This is a very personal story but, before I get into it, I add my tribute to Daisy Chain, the charity based only a few hundred yards from my home in Stockton North that supports children with autism and their parents. I am pleased that the great Daisy Chain team are represented here today.

Thomas has many autistic traits, such as communications difficulties and limited speech, and is behind in all areas of development, including having sensory issues. He will have to wait more than three years for a formal autism diagnosis. That is simply not good enough, and the consequences could follow Thomas through the rest of his life. He has been refused an education, health and care plan; the very fact that he does not have an official diagnosis of autism means that it is harder for him to get one, so Thomas is at severe risk of falling even further behind his peers.

High-quality and appropriate early years education is critical for all children. I am sure that we are all aware of how important those years are in the development and future opportunities of a child, and yet we are in danger of denying that high-quality and appropriate education to Thomas and many children like him.

Thomas struggles in busy, loud environments, and he can lash out as a result. He needs special attention, extra care and that education, health and care plan. He attends a mainstream nursery that has gone beyond what it needs to do for Thomas, ensuring that he has a one-to-one staff member with him at all times. However, that has cost implications for the nursery, and it is not fair on Thomas or the other children. He needs a place in a specialist nursery—again, that takes us back to the education, health and care plan, and the official autism diagnosis. What a vicious circle!

Nichola has to begin applying for schools for Thomas to attend next September, but there is no education, health and care plan—I keep having to say that—so the process will be all the harder. At the moment, he is facing the prospect of mainstream school, which would not be suitable. Thomas is still in nappies and does not have the self-awareness that other children his age have.

I have already mentioned the Daisy Chain Project. It was founded in 2003 and serves as a haven for families across the Tees valley. Nichola speaks highly of the support that they get there. It provides a respite service but, again, without an official diagnosis, Nichola cannot access that support. I worry that young children such as Thomas will be left behind while their peers flourish. I worry that parents do not and will not have the support they need.

Families and education providers up and down the country are doing their best to cope, but they should be able to do so much more than just cope. We need a specific strategy for young people to secure early diagnosis and we need appropriate plans to support them. I hope that the Minister will tell us how we can do so much better.

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[The Parliamentary Under-Secretary of State for Health (Jackie Doyle-Price)]

It is a pleasure to serve under your chairmanship this morning, Mr Howarth. Thank you for giving so many Members the opportunity to speak, because the debate has been extremely valuable. I congratulate the hon. Member for Enfield, Southgate (Bambos Charalambous) on securing it. The discussion was highly informed and showed how important Members consider the issue to be. That is to be celebrated, given the 2009 starting point that my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan) mentioned.

There have been significant advances in the treatment of people with autism, notwithstanding the serious issues raised today. I will not pretend that things are as they should be, because clearly they are not. Our ambition is for people to receive a timely autism diagnosis, but the cases that hon. Members have raised today make it clear that the standards that families deserve, and that they have a right to expect, are not being met. All Members who said that we need to do more are right. I give the House an assurance that I am determined about our need to do better.

I look forward to cross-party work with the all-party parliamentary group, and to the review of where we have reached since the Autism Act 2009. I welcome the input of all Members, because only by understanding the real-life experiences can we make everything work better. In Government we tend to work through such things as targets and processes, which ignore the fact that we are dealing with real people. When we are dealing with people who have conditions such as autism, the processes can leave them behind. It is down to all of us to be the conscience and to ensure that all our public services work better in this field. We do have a sense of urgency on this.

I want to deal with some of the common points that have been raised. Many Members wished to know when the autism data will be published. Our intention is that the data will start to be collected from next April, with a view to publication in 2019. That is hugely important, because it will enable us to see which local areas are doing the job and which are not. There is nothing like transparency to hold people to account and to ensure that we get the consistency and delivery of service so that nobody is left behind.

The Care Quality Commission and Ofsted are currently undertaking a five-year rolling programme of inspections, looking at how things are being implemented in local areas, how health services are working and how education authorities are dealing with education, health and care plans, which were mentioned in earlier contributions. We all know, and have witnessed, that so much is dependent on local leadership. If we can highlight good practice and where things are going well, as well as where things are not, we will be able to generate the pressure to increase performance across the board.

My right hon. Friend the Member for Chesham and Amersham mentioned mortality rates for people with autism. I know that the Minister for Disabled People, Health and Work, my hon. Friend the Member for Portsmouth North (Penny Mordaunt), shares my concern that people with autism and learning disabilities tend to get left behind when it comes to employment and access to health, which has an impact on mortality rates. She and I are very much prioritising that. I look forward to engaging with the all-party parliamentary group on those issues too, because we will have much to learn from its expertise.

The hon. Member for Worsley and Eccles South (Barbara Keeley) specifically asked whether we would commit to including autism in the primary care register. We have said that we expect GPs to do that and that we want to spread that good practice. We will be working with NHS Digital to do exactly that. Again, I am open to any suggestions in that space.

With regard to access to further services following a diagnosis, that is very much the space of local commissioners, but the inspections by the Care Quality Commission will enable us to hold local commissioners to account on exactly that.

[Alex Cunningham]

The Minister knows how frustrated parents are by the delay in getting an official diagnosis, but it is the knock-on effect on other assessments, such as education support plans, that really adds to their burden. Will she give any advice to local authorities and CCGs to look beyond the official diagnosis, to make some of those other things happen?

[Jackie Doyle-Price]

We very much send the message that parents of children with autism are entitled to good services and that is what they should expect. We need to spread that good practice and collect those data, in order to highlight exactly where it is not happening. When we look at the work that the Care Quality Commission has done to highlight good practice, we should be able to get some messages. We are looking for transparency to drive performance and to have those conversations. The NHS mandate for 2017-18 sets a priority for the NHS to reduce health inequalities for autistic people, so that is very much part of NHS England’s conversations with local CCGs.

Reducing Health Inequality

Alex Cunningham Excerpts

Thursday 24th November 2016 Commons Chamber

[Alex Cunningham (Stockton North) (Lab)]

I, too, thank the hon. Member for Totnes (Dr Wollaston), the Chair of the Health Committee, for bidding with colleagues for this crucial debate and the Backbench Business Committee for granting the time. There is probably no other person in this place who is better placed than her to talk about health inequalities, and her speech demonstrated that clearly. It was both challenging and thorough. It is a pleasure to follow the hon. Member for Erewash (Maggie Throup), and it was good to learn a bit more about obesity.

Many will say that health inequality stems from the overarching inequalities in education and opportunity across the country and even within communities, and that is true. My right hon. Friend the Member for Kingston upon Hull West and Hessle (Alan Johnson) outlined the historical context of that. However, I would say that health inequality starts even before birth—before a child is born into affluence or poverty; long before they have the opportunity to start at a good nursery or are left to make do with what is left; and years before they start making their own life choices.

Yes, health inequality begins in the womb and the child’s development can be very much restricted or enhanced by the diet of the mother, her tendency to drink alcohol or smoke in pregnancy, and dozens of other factors relating to antenatal care and access to general practitioners. Where people live has a major impact on all those things, but the effect can be mitigated by the actions of the NHS, local authorities and, of course, the Government. They can all, given the resources, make the kind of interventions that are needed to support people where that support is needed. The issue is one of resources, which are needed for everything from mounting campaigns to discourage smoking in pregnancy to providing the best hospital facilities in the areas of greatest need.

I will talk about my area, the borough of Stockton-on-Tees, and the north-east of England to illustrate the reality of health inequalities and the poverty that plays its own part in people’s life chances and life expectancy, and to show just why Government policy is putting the brakes on the progress we made in the years up to 2010. I will start with some facts. There is a life expectancy gap of 17 years between men in the most deprived ward in Stockton and a man in the least deprived ward, and the gap is over 12 years for women. That gap has increased by two years over a five year period, and unless we take immediate measures, I fear it will continue to grow.

Child development is an important contributor to health equity, as the successes and opportunities that children receive contribute to their quality of life later on. The English average for children achieving a good level of development at five years old is 60%, but in Stockton the figure is just 50%. A child who has a low quality of health due to parental lifestyle is more likely to be out of school more often due to illness, especially when it comes to dental health, with 72% of children in the most deprived areas having decayed, missing or filled teeth. My right hon. Friend the Member for Kingston upon Hull West and Hessle offered much more information on that problem and solutions to it.

In my constituency, the biggest causes of early death are cardiovascular disease, cancer and smoking-related diseases. The number of hospital stays due to alcohol-related harm is 808 worse than the average for England. That represents 1,500 stays per year. The rate of self-harm hospital stays is 225 worse than the average for England and the rate of smoking-related deaths is 320 worse.

Sadly, the positon in the north-east region is similar and there are some startling statistics, many of them related to alcohol. Some 57% of people living in the north-east, or about 1.2 million individuals aged 18 or over, have suffered at least once due to the drinking of others in the last 12 months. Some 62% of people know at least one heavy drinker. Males, younger age groups and those who drink the most were more likely to know a greater number of heavy drinkers. A third of north-easterners drink above the Government’s recommended limits on a daily or almost daily basis, and one in five binge drinks on a weekly basis. More than 60% of us worry about violence caused by drinking and 90% of us are concerned about people being drunk and rowdy in public. There is a strong relationship between alcohol and crime. Almost half of all crime is alcohol related and that is having a significant impact on individuals and communities.

While smoking rates in the north-east have declined over the past two decades, Fresh, a great charity, reports that 18.7% of adults still smoke and nearly 9,000 children in the region start smoking every year, according to Cancer Research.

The north-east has the highest rate of economic inactivity in England. Between July 2014 and June 2015, 25.3% of the working-age population in the region was economically inactive, with over a quarter of that inactivity due to ill health. The regional unemployment rate remains the highest in the UK at 7.9%, while life expectancy is lower than the English average. Men and women in the north-east typically live over a year less than the national average.

My constituency and much of the north-east reflect the picture across poorer parts of the country, and the evidence from charities and experts on these issues show them to be highly significant. A British Lung Foundation briefing on health inequalities found that people living in the poorest areas will die, on average, seven years earlier than those in the richest areas. There is a strong correlation, which is backed up by much evidence, that shows that a person’s affluence and opportunities affect their health. Cancer Research UK has carried out research that shows that inequality is linked to 15,000 extra cases of cancer in England and that children from the most deprived groups are twice as likely to be obese than the least deprived groups.

So there is quite a dire picture across the north-east region, but that is not for want of action by health groups, local authorities and charities. They have had some remarkable successes over the years, despite the poor hand dealt them, but they need the support of the Government to make even better progress. To reduce health inequalities, we need to provide more resources to support those who seek help; to invest in our health services to detect illnesses earlier; to ensure that healthcare has a greater role in schools; to stop those 9,000 children a year taking up smoking; and to ensure that the NHS has the means to look after and treat everybody who needs it.

Back to Stockton, how do we ensure that those who live there are not at a significant disadvantage from birth compared with those in more affluent areas? We must start from the beginning. By investing in early years education, we can make sure that all children have the best start in life and reach their key development milestones to the best of their ability. As I suggested earlier, we can start before they are even born.

The borough council has taken a number of measures to address the health inequality within the borough. The delivery of the health and wellbeing strategy is increasingly being targeted at those who most need support. For example, the Stockton seasonal health and wellbeing strategy co-ordinates a targeted approach to make sure that those who need the most support are getting it. Some 18,000 people have received winter warmth assessments to make sure their homes are prepared for the winter months, and Stockton Borough Council is working with Public Health England to implement a child dental health programme in schools, including even in nursery—isn’t that sad!—and for reception children. In our poorest wards, the council runs a community-led initiative focusing on three key outcomes for children up to three years old: cognitive development; speech and language development; and nutrition. These schemes are ensuring that children have more opportunities to break a cycle of health inequality in some areas of my constituency, and some areas in the wider country, and promoting a healthier and safer upbringing.

As I keep repeating, however, all these schemes need resources, but those are sadly diminishing as each year goes by. I could bleat on about the poor deal the north-east got from the coalition and is now getting from the Tory Government—the movement of health resources from the north to the south and the huge cuts to local authority spending, which have impacted on their ability to maintain the services they need in order to close the equality gap—but I will not. I will, however, remind the Government that while new hospital projects in Liberal Democrat and Tory constituencies planned by the last Labour Government went ahead in 2010, the one to serve my own and neighbouring constituencies was axed.

Our health professionals and trusts do a remarkable job in our area in the most difficult of circumstances, and I hope that one day soon they will have the 21st-century hospital and facilities they need to serve our community and help close that inequality gap. Perhaps the provision of that hospital should form part of the sustainability and transformation plan for our region. Instead we face the potential downgrading of our hospital and the potential loss of our accident and emergency department.

The challenge posed by health inequalities, not just in my area, is bigger than any individual parent, and bigger than any local authority or health trust. We must have a unified strategy to ensure that health inequality is a thing of the past and that my constituents, as well as those of many other Members, have the best start in life and a good quality of life. We need earlier intervention in schools, more support for those suffering from mental health problems, and greater action to break the cycle of health inequality in the poorest areas of the country.

I am well aware that we heard one of the gloomiest outlooks for our country from the Chancellor for decades when he delivered his autumn statement yesterday. He spoke of the uncertainty ahead, of rising debt and borrowing and falling growth and tax revenues. My great fear is that in the tough years ahead, partly as a result of the Government’s failure properly to fund public health, the NHS and social care, we will see health inequalities grow, not reduce, and that the huge gap in life expectancy will not be closed for many decades to come.

We should have a country not where the future opportunities and health of children are determined by their socioeconomic status or the availability of resources to tackle the issues of smoking, alcohol, drugs and inactivity, but where children yet to grow up or be born have the freedom to choose whichever path they want to take without negative health implications holding them back.

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[Fiona Bruce (Congleton) (Con)]

On the doorstep of No. 10, our Prime Minister, taking up her leadership mantle, gave an inspirational social justice speech, aimed at ensuring that we reduce health inequalities, including by addressing the stark realities of the mental health challenges that so many families in our communities live with daily. I want to speak about that, about the importance of healthy early relationships in life—even beginning before birth—and about the mental health challenges that can be involved. I would like to conclude with a reference to the implications of alcohol harm, wearing my hat as the chair of the all-party parliamentary group on alcohol harm.

Building healthy relationships—beginning before birth—and establishing them in our earliest years as building blocks in our family and community life are absolutely key for the prevention and reduction of mental health problems in childhood and throughout later life. That starts in the womb.

Let me commence by setting out some key facts from the early lives of our children here in the UK. Depression and anxiety affect from 10 to 15 of every 100 pregnant women. Over a third of domestic violence begins in pregnancy. One million children in the UK suffer from problems such as attention deficit hyperactivity disorder, conduct disorder, emotional problems and vulnerability to chronic illness, which are increased by antenatal depression, anxiety and stress. The UK has the world’s worst record for breastfeeding. Some 50% of three-year-olds experience family breakdown. Some 15,700 under-twos live in families classed as homeless.

By addressing some of those social determinants of health inequality, beginning even before birth, we could help exponentially, in terms of not just the physical but the mental health of so many of our young people, and that help would last their whole life long. We need to support our youngest, so that we can increase their life chances and reduce the health inequalities that get in the way of their achieving their full potential.

Points on the compass of scientific advancement are increasingly showing us the direction of travel in terms of the social determinants of health, and they significantly point towards the experiences of bump, birth and beyond. The top policy recommendation in Marmot’s “Fair Society, Healthy Lives” report, which was referred to by the hon. Member for Glasgow East (Natalie McGarry), and which was published as long ago as February 2010, was to give every child the best start in life. The “1001 Critical Days” manifesto, which is the UK’s only children’s manifesto with the support of eight political parties, was launched three years ago in response to that report.

A child’s development is mainly influenced initially by their primary care giver—usually their mother but often their father—and by others who are engaged with helping with their parenting. Parenting begins before birth. We have known for a long time that how we turn out depends on our genes and on our environment. Scientists now realise that the influence of the environment begins in the womb, and how the mother feels during her pregnancy can change that environment and have a lasting effect on the development of the child. So we all need to support and look after pregnant women, for their sake and that of future generations.

A stable and secure home learning environment is critical in the early months. Children, right from their infancy, need to be protected, nourished, and stimulated to think and explore and to communicate and interact with their parents and others. Babies are primed to be in relationships, and their earliest relationships really matter for the “ABC, 123” building blocks that lead to school-readiness. A young child’s earliest relationships develop their social brain, which will influence their later life. Eighty per cent. of our brain significantly develops in the earliest years and through our earliest relationships. I am focusing on that because it shows that healthy relationships really matter for our health and well being throughout life.

[Alex Cunningham]

I know we are trying to make this a non-partisan debate, but does the hon. Lady recognise that all the things she is talking about require resources? Some of our most needy communities have seen a loss of those resources in recent times, and we need to do something to redress that.

[Fiona Bruce]

I thank the hon. Gentleman for that intervention.

We need to focus on the fact that learning about and enjoying healthy relationships is a key determinant of future health, both physical and mental. Between 1.3 million and 2.5 million years of lives are lost as a result of health inequality in England. Many children never reach their potential throughout their life partly because of a lack of healthy relationships in their early years. Relationship breakdown is a significant driver of poverty and health inequality. A comprehensive cross-departmental strategy to combat health inequality must include measures to strengthen healthy relationships and combat relationship breakdown, which is at epidemic levels in our country.

I am chair of a mental health charity for children in my constituency called Visyon, which is overwhelmed by requests on behalf of children as young as four. When I asked its CEO how many of the problems of the children it helps are the result of poor early relationships in the home, he looked at me and said, “Virtually all of them.” This is an absolutely critical factor in a child’s early development and healthy life, particularly in relation to mental health. Interestingly, a wide-ranging survey by the Marriage Foundation published in May 2016, involving thousands of young people, found a noticeable difference between the self-esteem levels of children who were brought up in stable households and those who were not. Self-esteem acts as a predictor of a range of real-world consequences in later life.

When relationships break down, as they do in all socioeconomic groups, it disproportionately affects children in low-income families because they are less resilient in combating the impact. Half of all children in the 20% of communities that are least advantaged now no longer live in a home where they have healthy relationships—where, for example, both parents are still with them by the time they start school. I am not saying that a child cannot have a healthy relationship with one parent or another, but it is important that we grasp this nettle and appreciate that healthy relationships with a range of people—including, ideally, a mother and a father—are good predictors of early health. We should support that, and the Government and Health Ministers should be brave enough to tackle the issue. For too long, Ministers have shied away from looking at healthy relationships, yet we are happy to help and educate young people about how to build healthy bodies for physical health in life.

Relationship breakdown is a root cause of poverty. When relationship breakdown happens, households often suffer dramatic income reductions. There is also an impact with regard to infant mortality rates, hospital admissions and mothers in poor health.

I agree that we need more funding to strengthen relationships, to provide the early support that is needed in many different ways. We need to consider extending children’s centres so that they can become family hubs that provide support for the whole family. The recent report of the all-party parliamentary group on children’s centres, of which I am the chair, made that recommendation. We need to look at the availability of couple relationship advice, not just parenting advice. Sex and relationship education lessons in schools need a much stronger focus on relationship education. We need to provide a family services transformation fund, so that local authorities can share best practice. We need to do all of that to ensure that we give children the best start in life, and in particular to tackle the serious challenge of the mental health problems experienced by so many schoolchildren. So many headteachers say that it is a major issue with which they have to grapple.

In the final part of my speech, I want to refer to the different but not entirely linked issue of alcohol harm. I say that it is not entirely linked because people who experience or fall into addiction are often looking for a source of comfort in life that is missing from their relationships. I am not saying that it is not right to enjoy drinking, but it needs to be healthy drinking. Alcohol harm is a major issue in our society and I do not believe that the Government are doing enough to address it.

The Government must do more to tackle health inequality. For example, in January the chief medical officer published her recommendation that it is wisest for women not to drink during pregnancy. Pregnant women are advised to make that choice, yet there has been wholly inadequate publicity for that recommendation. I speak as the vice-chair of the all-party parliamentary group on foetal alcohol spectrum disorder. We have heard heartrending evidence of the impact of alcohol on children’s lives, including their physical and mental wellbeing. It is particularly important to note that, according to the evidence that we have heard, women’s bodies tolerate alcohol at different levels, which is why the best advice is to not drink at all during pregnancy. I challenge Health Ministers, particularly in the run-up to Christmas, to get that message out so that pregnant women hear it and can make that choice.

Alcohol harm impacts on the health not just of the individual, but of those around them. One in five children under the age of one live with a parent who drinks hazardously. Alcohol is implicated in 25% to 33% of child abuse cases, and it generates a substantial bill for UK taxpayers with regard to the impact on emergency services. The all-party parliamentary group on alcohol harm will publish a report on that on 6 December, and I am pleased that my hon. Friend the Member for Totnes (Dr Wollaston) has contributed to it. I hope hon. Members will take note of it, because alcohol abuse has a disproportionate impact not only on emergency services, but on the number of accidents and fires in the home. The report will spell that out. The charity Balance has shown that between 2014 and 2015, the rate of alcohol-related admissions in England from the most deprived decile was more than five times greater than the rate for those from the least deprived decile. That puts pressure on already burdened systems.

I want to finish with a point that now arises continually in my work on alcohol harm, namely the impact of cheap alcohol. Let me tell Members a fact that may surprise or even shock them; it shocked me when I first heard it. For the cost of a cinema ticket, it is possible to buy almost 7.5 litres of high-strength white cider, containing as much alcohol as 53 shots of vodka. Many homeless people, and many people who are in a vulnerable state in life, are drinking that product, which has been likened to a death sentence. In the hostels run by the homeless charity Thames Reach, 78% of deaths were attributed to high-strength alcohol. Not for the first time, I urge Ministers, for the sake of the health of the most vulnerable in society, to consider a minimum unit price for all alcoholic drinks. That is a targeted and effective intervention that would save lives and reduce health inequalities considerably. Potentially, according to the Institute of Alcohol Studies, eight out of 10 lives saved as a result would be from the lowest income groups.

We need better education to inform young people about the effects of alcohol harm, so that they can make better choices and so impact on their own health. We need improved alcohol treatment services because they are inadequate. More than half of drug addicts receive treatment, but only one sixteenth of alcohol dependants do. We need to invest more in recovery for those who are suffering the effects of alcohol addiction and harm. We need better and more effective alcoholism diagnosis in our hospitals and better rehab programmes. We need to support education better to help people not to fall into such difficulties in the first place.

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[Alison Thewliss (Glasgow Central) (SNP)]

I am proud to participate in this debate, and I am glad that the Chair of the Health Select Committee, the hon. Member for Totnes (Dr Wollaston) has brought it before the House today. This debate is an important one, in which I have a considerable interest.

The issue of health inequalities was one of the first that I got interested in as a teenager. Sitting in my modern studies class in Lanarkshire, I could not understand why any Government would allow people in less well-off areas to disproportionately suffer ill health and die prematurely. I was frustrated when I read about the Black report and the inverse care law. I was angry then, and I am angry now that the political decisions taken here are the root cause of that mortality and morbidity that still blights too many lives in our country today. It is unacceptable that male life expectancy in parts of Glasgow should vary by 15 years, between the ages of about 66 and 81. In the case of women, the gap is 11 years. I got interested in politics because I wanted to change that: I wanted to understand why it was, and I wanted to know what I could do to help.

I joined the SNP when I was at school. I know that today’s debate has not been too party political, but I think it is important to put this on the record, because it is important to me. I joined the SNP because I could see that the health of Scotland’s people in particular was not a priority at Westminster. When I was at school there was no Scottish Parliament, and there was no way in which we could deal with the issue ourselves.

The hon. Member for Stockton North (Alex Cunningham) mentioned the Black report. The way in which that report was greeted was quite telling, as is the fact that we are still discussing many of the issues now. The Marmot report has not yet been implemented, and the obesity strategy is still not as strong as it could be. It has not been possible to tackle the underlying causes of health inequality, but I believe that if the Scottish Parliament had all the powers of a normal Parliament, we would be able to deal with them more adequately than they have been dealt with in the past. [Interruption.] Some members may disagree with me, but that is what I believe. It is past health inequality that we are dealing with now, because there is a time lag.

[Alex Cunningham]

I do not disagree with the hon. Lady, but I think she must have misinterpreted my action. It was my right hon. Friend the Member for Kingston upon Hull West and Hessle (Alan Johnson) who mentioned the Black report, and I was indicating him. No offence was meant.

[Alison Thewliss]

My apologies. I had to nip out to the loo earlier, and I must have got my wires crossed. I thank both Members for raising those issues. It is important for us to think about the context of the debate and where we are going.

I have been reading the report to which the hon. Member for Glasgow East (Natalie McGarry) referred. I pay credit to the in-depth work and dedication of the Glasgow Centre for Population Health. Its director, Dr Carol Tannahill, along with Bruce Whyte and David Walsh, lead much of that work. Along with their team of researchers, they have laid out the history of health inequality in Glasgow and in Scotland more widely. They have done a huge amount of research, and have come up with not only history, but some solutions.

In 2007, when I was first elected as a Glasgow councillor, the centre’s most recent report was “Let Glasgow Flourish”, but since then it has carried out a great deal of research on Glasgow’s “excess mortality”. It is interesting to note that that excess mortality applies across different causes of death, and across ages, genders and social strata, although it is most pronounced in members of the working-age population living in the poorest neighbourhoods, where the impact of alcohol, drugs and suicide, particularly among men, is stark. In comparison with Manchester and Liverpool, Glasgow experienced an extra 4,500 deaths between 2003 and 2007. In Scotland overall, there were an extra 5,000 deaths in each year between 2010 and 2012.

I shall not repeat what was said by the hon. Member for Glasgow East, but it is important to note that Governments knew that that was happening. The impact of their policies was known. Urban change, particularly in Glasgow, was taking place in a noticeably different way from the way in which it was happening in Liverpool and Manchester. It had a disproportionate effect on the population, and we still see the lag of that today. One of the reports produced by the Glasgow Centre for Population Health quotes from a 1971 Scottish Office report called “The Glasgow Crisis”, which noted that

“Glasgow is in a socially…economically dangerous position.”

However, nothing was done at the time. The urban regeneration in Glasgow took place in the shopping centres in the middle of the town, but did not touch the areas that needed it most.

Poverty and health inequality are incredibly difficult to turn around. They cannot be fixed by a sugar tax or any other individual health measure; a wide-ranging approach is required from all levels of government. Glasgow has worked incredibly hard, and has established a poverty leadership panel to examine some of the issues. The Scottish Government have invested heavily, and have set up a ministerial taskforce on health inequality. However, we must keep working harder and working together if we are to achieve a result.

Clyde Gateway is an urban regeneration company in my constituency. Members may wonder whether an urban regeneration company, which builds things and fixes the ground conditions, should be interested in health, but the company has been working for eight years in Glasgow and Rutherglen, and has learnt lessons from previous regeneration efforts. So far, it has managed to lower the claimant count for out-of-work benefits from 39% to 28% and the claimant count for jobseeker’s allowance from 8.6% to 4.8%. That is pretty remarkable in itself, but the company cannot go any further until it starts to tackle the underlying health issues that are keeping people out of work. It is therefore working closely in partnership with local organisations and local people. It is crucial that local people are part of the process and are not having things done to them, as was the case before. They are now part of the solution and the community is a part of what is happening.

Clyde Gateway recently signalled its intention to seek a means of tackling health inequalities. It wants to work to improve diet and cancer screening, which are both factors in the area’s ill health. There is a lot of worrying evidence that people in areas of deprivation are not taking up the screenings to which they are entitled. Those screenings include tests for cancer and free eye tests, which can also be an indicator of other conditions. I spoke to the Royal National Institute of Blind People yesterday about early intervention and the importance of people going for their eye tests. Clyde Gateway also wants to grow jobs in health and social care in the local community to make people working in the industry part of the community as well, rather than having staff coming in from other areas to “do” health to people.

I wholeheartedly agree with the notion that public health ought to be everybody’s business. It is not just for public health officials to do on their own, because the roots of health inequalities are to be found in income inequalities. So in Scotland we are tackling some of the underlying causes. The living wage uptake in Scotland now far exceeds the uptake in other parts of the country. We are supporting families and helping to improve the physical and social environment and housing. We have invested heavily in housing, because much of the ill health was coming from housing that was damp and substandard. Housing was making people ill and was not being tackled.

We have increased free school meals and continued commitments such as free prescriptions, concessionary travel and free personal care. The hon. Member for Bradford South (Judith Cummins) talked earlier about tooth-brushing and the rates of tooth decay. In the mid-1990s, when I was starting secondary school, just under 40% of children in primary 1 in Scotland—those just entering school—had no dental cavities. That figure is now just under 70%, which is pretty good and marks quite a shift, but we need to go a lot further. Initiatives such as Childsmile, through which all children in Scotland regularly get free toothbrushes and toothpaste, are helpful.

As the hon. Members for Totnes and for Congleton (Fiona Bruce) mentioned, a lot of work is being done on minimum unit pricing to reduce alcohol consumption and deal with many of the issues that lead to people buying low-price cheap alcohol, which is killing them. We have reduced smoking rates, too, by bringing in the smoking ban first, and we are doing a lot of work to encourage active living and healthy eating, and investing to improve mental health services.

As chair of the all-party group on infant feeding and inequalities, I want to take this opportunity to speak about breastfeeding and the impact it can have on health inequalities. James P. Grant, executive director of UNICEF during the 1980s, said that

“exclusive breastfeeding goes a long way towards cancelling out the health difference between being born into poverty or being born into affluence. It is almost as if breastfeeding takes the infant out of poverty for those few vital months in order to give the child a fairer start in life and compensate for the injustices of the world into which it was born.”

That is quite a statement.

Sadly, there is a huge inequality in breastfeeding, particularly in the UK. Women in areas of greater deprivation are far less likely to breastfeed. They are then also often paying for expensive formula milk, which will put a strain on their family budget.

I was once told by a Labour councillor in Glasgow that in his experience there was an inverse perverse stigma: if a woman breastfed, it made her look as though she was too poor and could not afford the formula. The cost is a big issue, however, as I highlighted in my ten-minute rule Bill last week.

Families are being penalised for a societal problem: the UK just does not provide enough support, via midwives, health visitors, peer supporters and local networks, to ensure that mums are able to breastfeed for as long as they want to. Some of the economic agenda is having an impact on those important services, and coverage is fraying, as volunteer services find it harder to cope. It is seen as difficult, and there is so much blame and shame for mums, whatever they do and however they feed their children.

Many younger women have never seen anyone breastfeed. There is also interesting evidence from Sally Etheridge that the longer that black and minority ethnic women who have come to the UK from other countries stay here, the lower their breastfeeding rates become as they begin to assimilate into our bottle-feeding culture. I believe that there is a lot we can do to improve this situation and encourage the Government in that regard. I met the Minister earlier this week and am glad that she is listening and keen to address the breastfeeding rates across the country.

The series on breastfeeding from The Lancet and the UNICEF report on preventing disease and saving resources point out that the NHS could save significant amounts of money by investing in breastfeeding services. They reckon that there would be 3,285 fewer hospital admissions for gastrointestinal issues and 5,916 fewer admissions for respiratory tract infections, which could save £10 million across the country. That is no mean feat. There would also be connected reductions in obesity and sudden infant death syndrome, as well as a reduction in breast and ovarian cancer in the mum. Breastfeeding is a significant public health intervention, as the UNICEF call to action has illustrated.

I should like to summarise a few of the suggestions in the Glasgow Centre for Population Health report, as it is the purpose of our debate today not only to look at the problems. Health interventions on smoking, alcohol and so on have helped, but the report has found that the main means of resolving health inequality is not a health intervention but a wealth redistribution. A widening gap in income has been perpetuated by different Governments over many years. Fair and progressive taxation and fair wages would make a huge difference to the gap. Ensuring that all people have a sufficient income is critical, yet this Government continue to slash social security spending, which is making people not only poor but ill.

An NHS Health Scotland report published this month said that a quarter of lone parents in Scotland rated their health as either fair, bad or very bad. Those parents have to look after children. If their health is fair, bad or very bad, they will not be able to be effective parents. The impact of food banks on health is also clear. If people cannot afford to put food on the table, they have to resort to going to a food bank to get canned meals. They do not get fresh food and vegetables; they get something out of a can that they might not even be able to heat. That will have an impact not only on their physical health but on their mental health.

The GCPH report looks at the cost of living and at how we as a society can support people to live with dignity and live a life in which they have choices. Having choices in life should not be a luxury. If someone does not have any control over what happens to them in life, it will have a huge impact on them and their family for years to come. The report also recommends affordable, warm and appropriate housing. As the hon. Member for Hackney South and Shoreditch (Meg Hillier) said, not having somewhere affordable and warm to live can have a huge impact on people. We need to learn from past mistakes and look more widely at the policies we pursue and the things that we in this House think are important, because they can have long-lasting effects, as we have seen in Glasgow.

Most significant to all of this is the adoption of the World Health Organisation’s principle of including health in all policies. This must run through absolutely everything that the Government do, because of the impact on health. Yesterday, the Chancellor failed to address health spending; indeed, he failed to address the question of health at all. He is failing the people of this country by not acknowledging the significance of health to everything else that the Government wish to achieve.

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[The Parliamentary Under-Secretary of State for Health (Nicola Blackwood)]

I congratulate the Chair of the Health Committee, my hon. Friend the Member for Totnes (Dr Wollaston), on her characteristically thoughtful opening of this debate. I thank the Backbench Business Committee for agreeing to the debate, which has been not only highly informed, but very wide ranging. I will therefore start by apologising for the fact that I will not be able to comment in detail about all the points raised, but I will reply in writing where I am not able to respond. Colleagues are right to say that the Prime Minister has made this issue a national priority, so it is not surprising that the Government share the commitment of the House to having an effective cross-Government policy that will reduce health inequalities.

We are recognised as world leaders in public health, and that has been achieved by avoiding the temptation to put health inequality in a silo. Marmot, as many have pointed out, is clear that an approach to treating health alone will not tackle what we here know are some of the most entrenched problems of our generation. We have avoided a health-only approach in the past, which is why the Chancellor’s autumn statement yesterday announced important and relevant measures such as raising the national minimum wage, raising the income tax threshold and providing, as the hon. Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, rightly observed, an additional £1.4 billion to deliver 40,000 extra affordable homes. That provision is in addition to the Homelessness Reduction Bill.

It is right that we also look to the work of industry and non-governmental actors. I am pleased to say that the food and drink industry has made progress in recent years. Its focus under voluntary arrangements has been on calorie reduction. Billions of calories and tonnes of sugar have been removed from products, and portion sizes have been reduced. Some major confectionary manufacturers are committing to cap single-serve confectionary at 250 calories, which is an important step forward. As my hon. Friend the Member for Erewash (Maggie Throup) mentioned, some retailers have played their part by removing sweets from checkouts, while others have cut the sugar in their own-brand drinks. We welcome that and urge others to follow suit. The challenge to industry to make further substantial progress remains. We should praise those who have had success, but we will continue to challenge those who lag behind.

Colleagues are right to highlight the importance of employment, and it is encouraging to see that some gaps are narrowing. As the Chancellor said yesterday,

“over the past year employment grew fastest in the north-east…pay grew most strongly in the west midlands, and every UK nation and region saw a record number of people in work.”—[Official Report, 23 November 2016; Vol. 617, c. 900.]

But there are still some who are left behind, which is why our health and work Green Paper is specifically focused on driving down the disability work gap for those who wish to work. It is this emphasis on the social, economic and environmental causes of inequalities that convinces me that public health responsibilities as they are traditionally understood do rightly sit in local government, where national action can be reinforced and resources can be specifically targeted at pockets of inequality within local populations.

Let me respond to the concerns raised by my hon. Friend the Member for Plymouth, Sutton and Devonport (Oliver Colvile) about his GP practices. When a GP practice closes, NHS England has a responsibility to make sure that patients still have access to services and are not misplaced. I am pleased to hear that he is making some progress on the matter, but if he finds that he reaches a roadblock, I will be happy to raise his concerns with the Under-Secretary of State for Health, my hon. Friend the Member for Warrington South (David Mowat), who has responsibility for community health.

Although, as a number of colleagues have said, councils have had to make savings and are acting in tough financial circumstances, they are still accessing £16 billion over the next five years from their public health grant. They have shown that good results can be achieved while efficiencies are found and the greatest effect is generated. There are a number of examples of outstanding practice to which we should pay tribute today. The HIV innovation fund, for example, which is funded by Public Health England in collaboration with local government, provides funding for services that meet local needs and offers the most at-risk populations free, reliable and convenient alternatives to traditional HIV testing. That is happening at a time when driving up HIV testing is a key public health priority.

As my hon. Friend the Member for Totnes rightly noted, however, we must focus on key determinants such as obesity, smoking, suicide and alcohol. That is the core of the challenge that we face, which is why we are working closely with our partners in the NHS, PHE, local government and schools to deliver the childhood obesity plan. That subject has been raised by many speakers today and I assure the House that the delivery of the plan has started. We have consulted on the soft drinks industry levy and launched a broad sugar reduction programme. Those measures will have a positive impact, particularly on lower income groups, which are disproportionately affected. As many colleagues have mentioned, the measures will have secondary benefits, such as better dental health and diabetes prevention.

As was mentioned by my hon. Friends the Members for Erewash and for Taunton Deane (Rebecca Pow), it is particularly important that we focus on effectively delivering a key plank of that obesity plan: the hour of physical activity every day. One of the ways in which we will make sure that is delivered effectively is by introducing a new healthy rating scheme in primary schools to recognise the way in which they deliver this and to provide encouragement. I believe that we have delivered the right approach to secure the future health of our children, but I am determined that we will implement it quickly and effectively, and I am very happy to enter into discussions about how we make sure that that implementation works.

I entirely agree with hon. Members on both sides of the House that mental health must not be forgotten when we are discussing health inequalities. We have made progress, but parity of esteem must be more than just a phrase; it must be backed by increased funding and effective reform. That is why we are investing an additional £1 billion every year by 2020 to help 1 million more people with mental illness to access high-quality care, including in emergency departments, as well as putting in place a record £1 billion of additional investment in children’s mental health. That money is funding every area in the country. We are working hard to make sure we drive these reforms to the frontline, including, as my hon. Friend the Member for Totnes said, by refreshing the suicide strategy with a particular focus on the alarming figures for suicides among young men and for self-harm.

There can be no complacency about the scale of the challenge, as the figures quoted today forcefully remind us. We know that inequalities can be stubborn to tackle. Variations in smoking rates, particularly in pregnancy, persist, and concerted efforts are required to tackle that. That is exactly why I am prioritising the tobacco control strategy so that we can use our combined efforts to target vulnerable groups, including pregnant women, mental health patients and children, and reduce those differences, not least by supporting local areas to use data effectively to understand how best to target their policies.

[Alex Cunningham]

Can the Minister offer us a timescale for the tobacco strategy?

[Nicola Blackwood]

I cannot, because I am not yet satisfied that it is as effective as I want it to be.

In addition, I am pleased with the action we have taken to introduce standardised packaging for cigarettes and other legislative measures. We have also launched the world’s first diabetes prevention programme, as mentioned by the hon. Member for Heywood and Middleton (Liz McInnes), and we had a very good debate just yesterday about how we can improve diabetes care. We also have one of the most effective immunisation programmes in the world. That shows our commitment to take firm action where the evidence guides us, but as I have said, that action must be cross-government, at both a local and a national level.

Our job is to put prevention and population health considerations at the heart of everything we do, as the five year forward view makes clear. Devolution deals are giving local areas more control over many of the social determinants of health, such as economic growth, housing, health and work programmes, and transport. The focus on integrated public health services within devolution promises to remove many of the structural barriers to prevention that we have discussed today, and it makes public health everyone’s business, exactly as the SNP spokesman, the hon. Member for Glasgow Central (Alison Thewliss), said.

However, with devolution, to which the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) referred, and as we move towards business rates retention, transparency will be ever more vital to ensuring that public health outcomes improve. That is happening, but we need to go further, and we need to do more to engage local people and their elected councillors in highlighting the unjustifiable inequalities that persist. Ensuring that transparency translates into accountability is a key priority for me, and I assure the House that I am actively involved in this matter.

Members on both sides of the House are right to launch this challenge today, and I take fully on board their suggestions of how we can collectively reduce health inequalities. However, I hope that I have made it clear that the only way we are going to make progress on this issue is to adopt a whole-Government, whole-society approach. We have to constantly remind ourselves that reducing these inequalities is for not just the NHS or Public Health England, but the whole of Government, as well as local areas, industries and, indeed, all Members of this House. Today I reaffirm my commitment to work together with the widest range of partners, inside and outside Government, to make progress on this agenda. I hope that every Member here will do the same, because we owe our constituents nothing less.

Social Care

Alex Cunningham Excerpts

Wednesday 16th November 2016 Commons Chamber

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I beg to move,

That this House notes the serious concerns expressed about the social care system, including by the Local Government Association, The Association of Directors of Adult Social Services and the Care Quality Commission; calls on the Government to urgently bring forward promised funding to address the current funding crisis and to put in place a longer-term settlement to ensure that the social care system is sustainable going forward; and further calls on the Government to ensure that the most vulnerable in society are guaranteed the adequate and sustainable care they deserve.

The Government amendment

“commends the work and dedication of those in the social care sector”.

I join the Government in that. It might be the only part of their amendment I support. It is right that we praise our care staff. Unison the union had a meeting here today with care staff from a London borough and from Leicestershire. They talked about the difficult financial situation facing care services. Some care providers are not paying a decent wage. I heard all about that from the care staff from the London borough. Care staff receive less than the national minimum wage. They are not paid for travel time and they are not paid the correct rate if they sleep over. We should value our care staff more highly, we should pay them properly, we should train them, and they should know that they do a valued job. I pay tribute to the care staff I met today. I hope that other hon. Members also attended that event and met the same care staff and that they read Unison’s report, which is called “Care in Crisis”.

Social care is “in crisis” owing to a lack of funding. So says the Conservative leader of the Local Government Association’s community wellbeing board, Councillor Izzi Seccombe, who says that

“it is no exaggeration to say that our care and support system is in crisis.”

Richard Humphries, of the King’s Fund, talks of

“a deeper existential crisis of care”.

The Care Quality Commission says that the sustainability of social care is seen as “approaching tipping point”. Ray James, of the Association of Directors of Adult Social Services, says that

“the Government must face up to the reality that social care is in crisis now and provide immediate funding to stabilise the sector.”

On the priority of providing extra funding for social care, NHS England chief executive, Simon Stevens, says that

“there is a strong argument that were extra funding to be available…we should be arguing that it should be going to social care.”

I could go on. Googling the words “social care funding crisis” returns 2 million results.

[Alex Cunningham (Stockton North) (Lab)]

It is stating the obvious to say there is insufficient money going into the system, yet we have private companies taking huge profits out of the system as well. Will my hon. Friend join me in commending Stockton-on-Tees Borough Council for setting up a not-for-profit organisation to ensure that the money goes into services instead of shareholders’ pockets?

[Barbara Keeley]

I certainly will join my hon. Friend in commending the council. It is one of the things we talked about to the care staff today. Why should people be paid vast profits from public money, when care staff are so badly paid?

The reasons for the social care funding crisis are clear: insufficient funding in the face of growing demand and a fragile market in the provision of social care. We know that people are living longer and that demand on social care services continues to increase. People aged 85 and over are the group most likely to need care, and their numbers are projected to rise sharply in the coming years. Moreover, the gap between need and funding has grown wider since 2010.

Tobacco Control Plan

Alex Cunningham Excerpts

Thursday 13th October 2016 Westminster Hall

[Alex Cunningham (Stockton North) (Lab)]

I beg to move,

That this House has considered the tobacco control plan.

It is a pleasure to serve under you chairmanship, Mr Brady. I am grateful to the Backbench Business Committee for granting us the opportunity to debate this issue in the depth and detail required. The subject has an impact on all of us, and it is right that time is allocated for a meaningful and thorough debate. I am also grateful to my colleagues from across the House who helped to secure the debate and who will, I am sure, make some incisive and insightful contributions.

I am pleased to have been part of the team that has consistently advocated tobacco control, and I am proud of the achievements we have made. The great thing about those achievements is that they have been built on strong cross-party commitment in both Chambers, with the devoted support and drive of external organisations and charities across the country that are determined to keep the harm caused by tobacco very much in the minds of the public and, of course, Ministers. Those organisations have succeeded.

A recent Action on Smoking and Health survey of more than 12,000 people found overwhelming public support for Government action to limit smoking and strong support for the Government to go further and do more. That is no surprise, really, as tobacco control is an area where Government action is highly effective.

Let me start with a parochial statistic. Back in Stockton, 250 miles up the road, smoking prevalence was estimated at 27.5%—more than one in four people—as recently as a decade ago. However, by last year various policies and interventions had seen that figure fall to 18.4%, which is a decrease of about a third. That means that some 14,000 fewer adults in Stockton now smoke than in 2005. I, for one, am very proud of that achievement.

I speak not only as a member of the all-party parliamentary group on smoking and health, the secretariat for which is provided by ASH, but as an MP who, as a humble Back Bencher, successfully pressed for the legal changes around smoking in cars when young children are present, with the support of groups including the British Lung Foundation, Cancer Research UK and the British Heart Foundation. That is on top of the principled and unwavering support I have received from north-east organisation Fresh, which covers my patch in Stockton North and whose joint conference on the harms of tobacco and alcohol I was pleased to address just a fortnight ago.

The dedication to improving public health and promoting tobacco control runs deep not only in my own psyche but in that of colleagues across the House. Back in 1998, the Labour Government introduced the country’s first comprehensive tobacco control strategy. Legislation has moved on since then to prohibit tobacco advertising, smoking in public places and smoking in cars carrying children, and to implement controls on point-of-sale displays. I welcomed all those measures, but I am only too aware that there is much more to be done.

The most recent measure was the introduction of standardised tobacco packaging, which I repeatedly called for and supported. Although the original form of the Children and Families Act 2014 contained no measures at all to protect children from the dangers of smoking or to avert uptake, the amendment on standardised packaging tabled in the House of Lords by Baronesses Finlay and Tyler and Lords Faulkner and McColl was swiftly taken up by the Government and brought to fruition.

In the spirit of debating the issues and the evidence base rather than the politics of any decision, I thank the previous public health Minister and current Financial Secretary to the Treasury, the hon. Member for Battersea (Jane Ellison), for her consistent support for tobacco control and, in particular, standardised packaging. That was duly recognised by her receipt of the prestigious World Health Organisation director general’s special award to mark World No Tobacco Day earlier this year.

A great deal was achieved under the previous plan, “Healthy Lives, Healthy People: A Tobacco Control Plan for England”. Progressive tobacco control legislation was introduced, and the three key ambitions of the plan have been achieved. Smoking rates among adults and children have fallen below the target levels, and rates of smoking during pregnancy reached the 11% target earlier this year. That illustrates perfectly why Britain is a world leader in tobacco control, with the UK coming top in a European survey measuring the implementation of key tobacco control policies and passing legislation that goes further than the requirements set out in European Union directives—perhaps that is one area in which we can expect no negative impact from Brexit. Yet there is still much to be done.

Smoking is responsible for approximately 78,000 preventable and premature deaths each year in England alone, and nearly 100,000 across the UK. In the north-east, the number of deaths from smoking-related diseases is some 30% higher than the English average. Despite the fact that we have hit the national targets on smoking prevalence laid out in the previous plan, stark variations in prevalence persist regionally and among different groups. A national tobacco control strategy should therefore be introduced without delay.

In her Downing Street speech, the new Prime Minister committed her Government to

“fighting against the burning injustice that if you’re born poor you will die on average nine years earlier than others”.

Half of that difference in life expectancy is solely due to higher rates of smoking among the least affluent members of our society, with smoking rates among those with multiple complex needs reaching as high as 80%. I am clear that we should all share that commitment.

In Stockton, just under 30,000 people smoke—that is just over 18% of the population. However, it has been estimated that 539 children between the ages of 11 and 15 start smoking in Stockton-on-Tees every year, with 964 people dying from smoking-attributable causes from 2012 to 2014. Shockingly, that is the equivalent of almost 5,000 years of life lost due to smoking. That death and disease is disproportionately borne by the poorest people in my area.

Although smoking rates among the adult population fell throughout the life of the previous tobacco control plan, health inequalities have remained stubbornly high. In 2013, for instance, smoking prevalence among people in the routine and manual socioeconomic group was more than twice that among the professional managerial group—28.6% compared with 12.9%. The picture is even worse for those who are unemployed, with smoking rates of approximately 35%. People earning under £10,000 a year are more than twice as likely to smoke as those earning more than £40,000 a year. The higher rates of smoking place a significant financial burden on poorer members of society. If the costs of smoking were returned to households, 1.1 million people, including more than 300,000 children, would be lifted out of poverty.

In Stockton-on-Tees, when tobacco expenditure is taken into account, almost 6,000 smokers fall below the poverty line, including more than 1,300 dependent children. Those innocent children not only suffer from the financial burden of their parents’ smoking but are more likely to be exposed to second-hand smoke and to try smoking themselves. We all know that those who grow up in a household where parents or siblings smoke are far more likely to become smokers themselves.

Those children may experience considerable peer pressure to start smoking, and tobacco is often more accessible to them in the community and at home, thus creating a cycle of inequality and leading to the life expectancy gap noted by the Prime Minister. Perhaps worse still is that when poorer smokers attempt to quit smoking, they are less likely to succeed than their more affluent peers.

To tackle inequalities, support to stop smoking needs to be specifically tailored to meet the needs of those in lower socioeconomic groups. Although the ambitions in the previous plan have been met and smoking rates continue to decline, they remain stubbornly high in disadvantaged sections of society. Further action is needed from the Government and the public sector to reduce smoking rates and associated health inequalities, and the new strategy is necessary to drive that action forward.

With that in mind, and given that the policy development work for a new tobacco control plan was in place for publication this summer, I would welcome the Minister telling us when the new plan will be published. I say to her that there is a standard to live up to, because the last time there was a debate about the plan in this room, the then Minister confirmed the timing of its publication. I hope we will hear about that in depth today.

Perhaps the Minister will also oblige the British Lung Foundation and outline the Government’s plans to prioritise lung health as an area for health improvement. Will she tell the House whether an assessment of respiratory health could be included in the NHS health check?

[Norman Lamb (North Norfolk) (LD)]

I am grateful to the hon. Gentleman for giving way, and I very much agree with what he is saying. He has talked a lot about inequality, which of course spreads beyond this country. I understand that some 80% of smoking deaths, which will rise to 8 million by 2030, are in lower and middle-income countries. Does he share my desire to see the Government publish the plan before the meeting in India in November? We could then see what the special fund for developing countries will be used for, because we need to have an impact there, too.

[Alex Cunningham]

I agree. With the huge proportion of deaths in lower-income countries, which are suffering even more than we are in this country, it is imperative that the report is published so that we can show a lead. We are a leading country, if not the leading country, on smoking control, and we must continue to demonstrate that.

As colleagues will be aware, stop smoking services are one of the most effective healthcare interventions. Smokers are four times more likely to quit successfully with the combination of behavioural support and medication provided by those local services. Significantly, smokers from routine and manual socioeconomic groups are more likely to access the support of stop smoking services, which have real potential and are an effective way of beginning to address health inequalities. In 2014-15, for example, more than twice as many smokers from routine and manual groups set a quit date with a stop smoking service compared with those in professional and managerial occupations. Such services are not only effective in supporting efforts to quit but can prevent the disability and distress caused by smoking-related diseases without the side effects of many of the drugs used to treat such diseases. Indeed, the National Institute for Health and Care Excellence considers smoking cessation treatment to be among the most cost-effective healthcare interventions.

Smoking cessation treatment is also cost-effective for those who already have smoke-related diseases. Take chronic obstructive pulmonary disease, for instance. Some 900,000 people in England have been diagnosed with smoking-related COPD, out of about 3 million sufferers. Some 25,000 people a year die from the disease, and the NHS spent £720 million on treatments in 2010-11. The British Lung Foundation estimates that in my constituency, people are as much as 60% more likely to be admitted to hospital with COPD than the UK average. We also discovered recently that the rate of lung disease in my constituency is the second worst in the country.

Yet COPD is a disease that is almost entirely preventable. Smoke is the cause of more than three quarters of COPD cases, and in this country exposure to such smoke is primarily through smoking. Although it is clearly better to prevent COPD through the provision of smoking cessation treatment to help smokers quit before the disease develops, that treatment can help improve quality of life even after the onset of COPD and is highly cost-effective compared with other treatments. Indeed, it is the only treatment that can prevent the disease from progressing in smokers. The cost of smoking cessation treatment for people with COPD is estimated to be £2,000 per quality-adjusted life year, whereas the cost of drug treatment for those with the disease ranges from £5,000 per QALY at the bottom end of the scale to £187,000 per QALY for triple therapy.

I am mindful that this is a co-operative debate with cross-party support, but I believe it is fair to highlight the impact of some of the Government’s economic measures on smoking cessation programmes. In 2014-15, despite all the evidence of their cost-effectiveness, approximately 40% of local authorities cut the budgets of their stop smoking services, with half of all services being reconfigured or recommissioned. It is not just local authority cuts that are happening; we are now hearing that clinical commissioning groups are also cutting funding for prescriptions to stop smoking medications and refusing to fund smoking cessation services.

Local authorities faced with huge cuts to their budgets are reducing investment not only in stop smoking services but in other areas essential to effective tobacco control. Trading standards staff, who are crucial to tackling illicit tobacco and under-age sales, are increasingly under threat. During the past six years, the total national spend on trading standards has fallen from £213 million in 2010 to £124 million today. Teams have been cut to the bone, with a 12% drop in staff working in trading standards since 2014, on top of the 45% drop over the previous five years identified by an earlier survey.

The importance of trading standards, working in partnership to deliver concerted multi-agency enforcement activity, is shown in my region, the north-east. After setting up a regional illicit tobacco partnership, the region has seen a significantly greater fall in the illicit tobacco trade than has been seen at national level, to the benefit of both public health and Government revenues. Between 2009 and 2015 the illicit market declined by more than a third in the north-east, from 15% to 9%, whereas the decline at national level was less than a fifth, from 12% to 10%.

Without sustained funding, such services are simply unable to continue to operate effectively. The new tobacco control plan therefore needs to prioritise cutting health inequalities rather than budgets, and in so doing must protect public health funding for tobacco control. I hope the Minister will confirm today that the Government will take steps to sustain protected funding for tobacco control, and will outline what those steps will look like.

I would similarly welcome hearing the Minister commit to bringing mass media spending in line with best practice evidence. Research has shown mass media campaigns to be highly effective in promoting quit attempts and discouraging uptake. In the UK, however, we are currently falling far below best practice spending on such campaigns. When funding was cut back in 2010 there was a noticeably negative impact on quitting, with a whopping 98% decrease in requests for quit support packs, a fall of almost two thirds in quit-line calls and more than a third fewer website hits. That should hardly come as a surprise, with year-on-year cuts seeing only £5.3 million spent on mass media in 2015, which is less than a quarter of the amount spent in 2009. Spending has actually declined further this year to £4 million. To make matters worse, it is not even clear how much, if any, of that budget is reserved for televised mass media campaigns.

This year’s annual Stoptober campaign, for instance, is being run without any televised advertising. Yet the evidence confirms that it is precisely such mass media campaigns that are essential to motivate quitting and to inform smokers of the useful resources provided by Public Health England to help smokers quit. Those campaigns, which discourage smoking and encourage quitting, are most effective when they are sustained and sufficient, with the best results being achieved when people are exposed to televised anti-smoking adverts around four times a month.

Again, I draw attention to my own patch and the “Quit 16” mass media campaign co-ordinated by Fresh and Smokefree Yorkshire and Humber, which focused on the damage smoking does to health. Some 16% of those exposed to the campaign, or roughly 53,300 people, cut down on their smoking. A further 8.4% made a quit attempt, and 4% switched to electronic cigarettes. That shows the clear impact that mass media campaigns have on triggering quit attempts and changes in behaviour, and the Government need to take such evidence seriously and commit to investing in mass marketing campaigns without delay.

Members will be aware that the decline in smoking prevalence in the UK since the first comprehensive strategy was published in 1998 has been comparable to that in Canada and Australia, both of which have consistently addressed the harms caused by smoking through comprehensive and sustained tobacco control strategies. Smoking prevalence has declined rapidly among adults and children in England since the Government first implemented such strategies from 1998. The latest figures show that adult smoking prevalence in England has declined by more than a third, falling from 27% in 1998 to 16.9% last year. The proportion of 15-year-olds in England who are regular smokers fell by two thirds between 1998 and 2014, hitting 8%, and the proportion of 11 to 15-year-olds who have ever smoked fell from 47% to 18% over the same period. Those are the lowest figures ever recorded for both adults and children.

None the less, smoking remains the leading cause of preventable premature death and the major reason for differences in life expectancy between the richest and poorest in society. Experience elsewhere shows what can happen if we do not review and renew our tobacco control strategy and ensure that it is properly funded. While the UK has seen a significant decline in smoking because of its comprehensive approach, the prevalence of smoking in France and Germany, which have not had any such strategies in place, has barely shifted over the last 20 years. We cannot rest on our laurels and assume that the long-term declines we have achieved will continue unabated if we do not take decisive action to review and renew our strategy.

On 14 September, Lord Prior committed the Government to publishing a new plan, with renewed ambitions to reduce smoking prevalence further and new ambitions on health inequalities and mental health. However, he would not commit to a publication date, so I repeat my appeal to the Minister to reassure Members across the House by filling that gap today. There is no clear reason to delay publication of a new plan further. If the Prime Minister’s ambition to reduce health inequalities is to be achieved, Ministers need a comprehensive strategy on tobacco control sooner rather than later.

--- Later in debate ---

[Kevin Barron (Rother Valley) (Lab)]

I declare an interest: I speak as a vice-chairman of the all-party group on smoking and health, the secretariat of which is supported by Action on Smoking and Health, a national charity.

I echo the thanks expressed by my hon. Friend the Member for Stockton North (Alex Cunningham) to the previous public health Minister, the hon. Member for Battersea (Jane Ellison), for all the work she did and her commitment to support for tobacco control. I welcome the Under-Secretary of State for Health, the hon. Member for Oxford West and Abingdon (Nicola Blackwood), to her new post; I hope that we can work together on this important issue. The previous four public health Ministers, under either the current Administration or the coalition Government, have worked very well with the all-party group and other Members who want to see progress on this issue. I also welcome my hon. Friend the Member for Washington and Sunderland West (Mrs Hodgson) to her new role as shadow public health Minister. She is going to have to get used to seeing us, as she is going to be in here quite regularly.

It was in December that I last spoke in Westminster Hall on tobacco control. I was highlighting the fact that the tobacco control plan for England, “Healthy Lives, Healthy People”, was soon to expire, and that a new plan to ensure sustained funding for tobacco control was needed. I rise today for the same purpose. England has now gone 10 months without a comprehensive strategy on tobacco control. The House was assured that a new plan would be published in the summer. I know that some political summers lapse into the autumn, but I stand here in October wondering whether this summer is going to lapse into the spring. I hope that is not the case. The Government have since stated that a publication date will be decided in due course.

I am proud that tobacco control is no longer a partisan issue but enjoys the benefits of support from all parties in this House and in the other place. However, Parliament cannot act alone. We need a Government strategy to ensure that in this period of austerity tobacco control does not slip off the agenda and that local authorities continue to see it as a crucial part of their work. The hon. Member for Totnes (Dr Wollaston) referred to Manchester in her speech. It was deeply worrying to hear what she said, because I have no doubt that, although Manchester is a much bigger place, its socioeconomic profile will be like that of my own borough of Rotherham, where, sadly, a lot of people participate in smoking.

My hon. Friend the Member for Stockton North commented on the impact of smoking in his constituency; my constituency, Rother Valley, is similarly hit by the burden of smoking. Approximately 13,660 people in Rother Valley smoke, and across the three borough constituencies of Rotherham nearly 1,500 people died prematurely from smoking between 2012 and 2014. We know the national figure and I have to say, as I have always said in similar debates, that if we were losing our fellow citizens on such a scale from any other cause—whether it was an intervention in a war or anything else—we would be much more concerned than we seem to be about people tragically dying so prematurely.

Smoking has such a dreadful impact on communities. Surveys of smokers show that around two thirds want to quit smoking and that that desire to quit is the same across population groups. However, only around a third of smokers make a quit attempt each year, and the number of people accessing NHS stop smoking services is declining. A new plan is needed to set out continued support for those people by encouraging them to make quit attempts and to access services that can offer support. Smokers are four times more likely to quit with the help of the expert support provided by stop smoking services, but a new plan is needed to guarantee funding for such services, which are currently under threat.

I have been contacted on this issue by Teresa Roche, Rotherham’s director of public health, and Councillor David Roche, Rotherham Council’s cabinet member responsible for this subject. I do not think they are related, but somebody in my office once asked whether they were. I am not too sure at this stage, but the next time I meet them I shall find out. They are part of the ambitious plan in Yorkshire and the Humber to inspire a generation free from tobacco by 2025. However, their work requires funding. I ask that that be addressed in the strategy, when it is published. The percentage of adults who smoke is falling, but the fall has been even better among teenagers and young children. Back in 1993-94, I introduced a private Member’s Bill against the advertising and promotion of tobacco. At that time, the levels of smoking among both the adult and teenage populations were far higher. Work to discourage smoking is working, and it is saving lives.

International evidence shows that funding for tobacco control activities is crucial. Members who attended the debate in December may recall me describing the situation in New York, where smoking rates declined consistently until 2010, when funding for tobacco control was cut. Smoking prevalence then began to increase until 2014, when funding was reinstated and smoking rates began to decline once more. That is one example of the well-known fact that tobacco control needs sustained funding in order to be effective. As was said earlier, after the change of Government in 2010, the removal of social marketing in the national media was clearly followed by a decline in the number of people stopping smoking. There is a direct correlation.

Funding is needed not only to secure the future of stop smoking services, but for mass media campaigns to encourage smokers to quit. We must keep them up. I understand that this year the Stoptober campaign has moved online, utilising resources such as Facebook Messenger—something on which I have to say I am no expert—to support people who are attempting to quit.

[Alex Cunningham]

It is all very well having online services, but people need to have access to those services. I know that everybody thinks every kid from a poor home has a smartphone, but that is not true. If they do not have access to IT services, they cannot benefit from the services my right hon. Friend is describing.

[Kevin Barron]

I accept that entirely. We hear all the time about people getting online to claim their benefits or whatever else, but it is quite clear that not everybody has access. Nevertheless, we are in the 21st century now and we have moved on a little. We can now sit in this Chamber using our phones for things that would have required an office 20 years ago, so we must remember that things are moving on. I do agree with my hon. Friend, though.

The Stoptober campaign will be delivered at a fraction of the cost by using new media. I await with anticipation the evaluation of its effectiveness compared with previous campaigns that have used a broader range of outlets, including TV and print media. Effective tobacco control needs to be comprehensive, encompassing all these activities to support smokers and to promote systems-wide action to dissuade people from taking up smoking.

Quitting smoking is incredibly difficult. As we have heard, electronic cigarettes are now used by over 2.5 million people in the UK; some people estimate that the figure is 2.8 million. They give smokers access to a significantly less harmful source of nicotine and help individuals to give up tobacco. Evidence from the Royal College of Physicians—I should say here that I am an honorary fellow of that body, before it gets into the newspapers. There is no payment for that. None the less, I ought to say that I use my personal experience in these matters. Evidence from the royal college and from Public Health England shows that vaping is around 95% less harmful than smoking cigarettes.

Two new publications have further supported the argument that electronic cigarettes can make it easier to quit smoking without posing significant health risks. The first is a systematic review of the evidence from the Cochrane Tobacco Addiction Group. Such reviews are generally considered to be authoritative summaries of the current scientific evidence. The results show that electronic cigarettes containing nicotine significantly increased the chance of quitting smoking, while not showing any adverse health effects within two years of use. I know that there are some people outside who say, “We’ve got to see what this is like over decades to make sure they are perfectly safe”. I am afraid that we would have to wait decades to be able to see that. What we should concentrate on is the scientific evidence that we have available since the introduction of electronic cigarettes and make judgments on that.

The second publication has already been mentioned by the hon. Member for Totnes (Dr Wollaston). A number of newspapers have picked up on the researchers’ estimate that in 2015 electronic cigarettes helped an additional 18,000 people to quit smoking. That illustrates how electronic cigarettes have the potential to be a huge public health innovation. There is growing consensus, including charities such as the British Lung Foundation, Cancer Research UK and the Royal College of Physicians, that electronic cigarettes are a very useful tool for smoking cessation.

We all know that smoking is responsible for approximately 96,000 premature deaths across the UK, which is more than the number of deaths caused by the next six biggest causes of preventable deaths in the UK, including obesity, alcohol and illegal drugs. Electronic cigarettes have amazing potential to reduce that burden of death and disease. The Tobacco and Related Products Regulations 2016, which came into effect in May, aim to maximise the benefits from these products within a properly regulated framework. There is a clear role for electronic cigarettes as a form of tobacco harm reduction, but regulation is needed to ensure manufacturing quality and to dissuade non-smokers, including young people and children, from taking up vaping. In the UK, there is no significant evidence that non-smokers are taking up vaping, or that electronic cigarettes are acting as a gateway to smoking. However, it is proportionate to the risks posed by nicotine in any form that these products are regulated.

I wish that people would get over the fact that some of the owners of the companies that make these products happen to be tobacco companies. I do not think anyone has battled more against tobacco in this House than I have for two decades now. However, tobacco companies grow tobacco; tobacco contains nicotine; and nicotine is addictive. It is 90% safer to take nicotine through vaping than through a cigarette, and I wish that people out there who listen to these debates would recognise that fact and stop knocking on about who owns the companies that make these products. The quality of people’s lives is improving in taking people off this drug, which prematurely ends the life of 50% of people who smoke cigarettes. That is what we should concentrate on.

Before the summer recess, on 4 July, Lord Prior announced in a debate in the other place that those regulations would be reviewed within five years to ensure that they were fulfilling the aims of supporting smokers to quit, preventing uptake among non-smokers and young people, and providing appropriate regulation of products containing nicotine, including a route to medicinal licensing. Although I understand that that might be affected by Brexit, I would be grateful if the Minister could confirm that that is still the plan. I know that Brexit is something that nobody knows about, other than it is Brexit at this stage, but these are crucial, potentially life-saving things for many of our citizens and this is an issue that we need to address.

Lord Prior also committed to commissioning Public Health England to update its evidence report on e-cigarettes annually until the end of this Parliament, and to include within that its quit smoking campaign’s consistent messaging about the safety of e-cigarettes. Can the Minister tell us when Public Health England’s review and updating of the evidence for 2016 will be published, and what message about electronic cigarettes has been included in the Stoptober campaign? The one that was published by Public Health England and others in August 2015 about e-cigarettes was truly ground-breaking in showing how people with a nicotine addiction can help to save themselves from dying prematurely by using these products. Do not get me wrong, Minister and Members of this House—I would like to see people off nicotine all together, but that is a difficult thing to achieve, as we all know. We have been debating this issue for years and years, but more than 2.5 million people have voluntarily gone on to this safer system of dealing with their addiction. If we can use that to get them off the addiction all together, we should do so.

We all know that quitting smoking is one of the hardest things a person can do and we have a duty to support these people in any way we can, not only for their own personal health and well-being but for the health and economic well-being of society as a whole. A new tobacco control plan is urgently needed to make sure there is the funding and momentum to ensure that we are successful in making smoking history for our children.

[Bob Blackman (Harrow East) (Con)]

Thank you, Mr Brady, for calling me to speak; it is a pleasure to serve under your chairmanship.

It is also a pleasure to follow the speech made by my right hon. Friend the Member for Rother Valley (Kevin Barron), as I will call him in this context. I thought that it was thoughtful and, as always, well argued in its treatment of the data.

I place on the record my congratulations to the hon. Member for Stockton North (Alex Cunningham) on securing this debate, and I also congratulate my colleagues on the Backbench Business Committee on allowing it to take place. No doubt the Health Department considers itself extremely challenged by having to respond to a debate in Westminster Hall and to two debates in the main Chamber on the same day.

I also put on the record my congratulations to the Financial Secretary to the Treasury, my hon. Friend the Member for Battersea (Jane Ellison), on all the work she did for public health. Indeed, a lot of the reforms that have been made and that we are talking about today came under her stewardship.

I also congratulate the Under-Secretary of State for Health, my hon. Friend the Member for Oxford West and Abingdon (Nicola Blackwood), on securing her ministerial position. We are all looking forward to hearing her speak later on. As she is a former chairman of the Science and Technology Committee, I suspect that she will examine the scientific data and the important evidence before moving on; we look forward to that taking place.

On that subject, I echo what has already been said, namely that smoking is the No.1 public health challenge in the UK. As has been mentioned, there are almost 100,000 premature deaths every year across the whole country as a result of smoking. The fact that adding together the number of deaths caused by the next six biggest causes of preventable deaths would still not exceed the number of deaths caused by the No.1 cause of preventable death suggests that we have to address this matter. However, there is a risk that, because of the success of the tobacco control programme over the last five years, people will think the job is done. Well, I have to say that it is most certainly not done.

I declare my interest as the chairman of the all-party group on smoking and health and, as someone who has been an avowed anti-smoker all my life, I will continue to oppose smoking. I take the view that there are two categories of people here. We have to help people to stop smoking, but even more importantly we have to prevent people from starting to smoke, because we know that once people are addicted it is a very difficult job for them to give up their addiction.

As the hon. Member for Totnes (Dr Wollaston) said, we have been very successful. In the 1970s, more than 50% of the adult population smoked; that figure is now down to below 20%. That is good news. However, it still means that there is a stubborn minority and we have to get across to them how damaging it is to their health to continue smoking.

Success in this area has not happened by accident. Governments of all persuasion— including the current Government, the coalition Government before that and the Labour Government before that—have done enormous amounts of work to reduce the prevalence of smoking. Health professionals have also contributed to that, as have civil society organisations.

The position now is that the tobacco control programme finished at the end of last year. That is the reality and we need to see the new programme as soon as possible.

On this side of the House it is not unusual to hear people argue that the smoking habit is none of the Government’s business. Of course, it is an important source of tax revenue, but some people say—they are not necessarily employed or funded by the tobacco industry—that those who choose to smoke understand the risks, and have exercised their free consumer choice. I would say that informed choice and people understanding the damage they are doing to themselves is up to them, but that does not mean that we should not increase the pressure on those individuals to understand the damage they are doing to themselves and to others by continuing to smoke. I seek to make sure that we continue with the regulations and ramp up the tobacco control programme. We will soon see a situation where all cigarettes and hand-rolled tobacco are sold in standardised packaging, which has been a huge advance. We should take credit for that. Together in this Chamber, we changed Government policy through the force of our argument and the data that we provided in evidence.

I am sure that my right hon. Friend the Prime Minister is among the group that understands that the state and the Government have to interfere in this process. In her recent speech, she said that

“government can and should be a force for good…the state exists to provide what individual people, communities and markets cannot; and…we should employ the power of government for the good of the people.”

I say that she is absolutely right, and that, on tobacco control, the position is quite clear. In her very first speech as party leader, she promised to fight

“the burning injustice that, if you’re born poor, you will die on average 9 years earlier than others.”

That injustice is a clear issue for tobacco.

It would be very hard to find a more dysfunctional market than the one controlled by four of the most profitable companies in the world, who make their money selling products that they know will kill half of their lifetime customers—products that have been carefully designed to deliver a highly addictive drug, as fast as possible, to the brains of their users. If anyone were attempting to invent such a drug today, they would not get away with it, but these companies are quite clear in what they set out to do. The estimates by the US National Center on Addiction and Substance Abuse of capture rates for both legal and illegal drugs demonstrate that point powerfully. Capture rates are the percentage of users who report that they have become dependent on the drug at some point. Tobacco has a capture rate of almost a third, more than for heroin, cocaine, alcohol and cannabis. It is clear that the tobacco companies deliberately set out to ensure that their customers are addicted to the drug.

Dependency is a combination of physical and psychological factors. Social and economic factors, such as the relative availability of different drugs, when and where they can be used in a socially acceptable way, and how affordable they are, all have an impact and smoking is therefore a major contributor to poverty and health inequality. As the Marmot review concluded in 2010, smoking in the UK accounts for about half the difference in life expectancy between different social classes, and so the important commitment that the Prime Minister has made to tackling what she rightly calls this “burning injustice” cannot be met without further action on reducing smoking rates.

In my borough, Harrow, analysis based on the 2015 integrated household survey shows that about 13% of the working-age population smoke, which is above the UK average, and equates to about 25,000 people. Of the roughly 15,700 households in Harrow that include a smoker, 2,700 fall below the poverty line. About 1,000 would rise above that line if all smokers in poor households were to quit. A lot of people refer to my borough as a nice, leafy borough, but it is important to understand that there are levels of deprivation all across the country—with respect to the hon. Members opposite, it is not confined to the north and the industrial cities.

Despite that fact, I am displeased that Harrow Council has decided to consult on stopping the smoking cessation services in an attempt to save money, but I am pleased that a large petition has been initiated by consultants at Northwick Park hospital with the aim of combating that and preventing it from happening. As my hon. Friend the Member for Totnes noted, stopping smoking cessation services would be a stupid move and would increase pressure on the health service and on individuals.

I would also add that, whatever one’s views on Brexit, the reality is that over the last five years more than 10,000 adults from eastern Europe have come to live in my constituency and almost all those of adult age smoke. The tobacco control programme needs to include encouraging people to give up by reaching parts that have not been reached previously.

One important lesson that we have learned from previous control programmes is that efforts to reduce smoking must be sustained and progressive; sustained because, as I have said, nicotine is a powerful drug, it increases dependency and requires powerful interventions to persuade people to quit; and progressive because people who continue to use tobacco after the control programmes are in place can be said to have discounted their effect. For example, many smokers quit after the introduction of the workplace ban in 2006, but most did not. The need for progressive steps is particularly important when it comes to tax and price policy, because the economic impacts of tax rises on reducing demand for tobacco products depend not simply on absolute price levels, but on affordability. If taxes rise more slowly than incomes, tobacco will become more, not less, affordable and consumption will tend to rise, not fall.

That point is well understood by the four major tobacco companies, which routinely use what they call “overshifting” as a pricing device. When the Government put up taxes, the companies raise the price of their so-called luxury brands by more than the amount required by the tax increase, while raising the price of the economy brands by less than the tax increase, or in some cases not at all, so that as many low-income smokers as possible are encouraged to continue with their habit or to start smoking in the first place. That has resulted in increasing brand segmentation in the tobacco market, and was cheerfully admitted by the companies in written evidence in their recent unsuccessful court challenge against standardised packaging. One of the most important secondary benefits of standardised packaging, over and above the removal of the last permitted form of advertising and marketing of tobacco products, is likely to be the gradual collapse of this approach to marketing. The brand value of a luxury packet of cigarettes is likely to be greatly reduced when it can no longer be highly designed, but instead must consist of drab, olive colours and large photos of diseased lungs and eyeballs. It is likely to mean that future tobacco tax prices are more effective in encouraging smokers to quit, as the different brand values and prices collapse towards a middle price. If we increased tobacco prices above the escalators and ensured that the money was given to public health for prevention and cessation measures, it would be welcome.

Tobacco control policies work best in combination and should not be planned and assessed in isolation. For example, standardised packaging will no doubt encourage many smokers to try to quit, but most quit attempts fail. Smokers who try to quit have a much greater chance of success if they can get help from stop smoking services and a prescription for nicotine replacement products, whether that is patches, gum or electronic cigarettes. That will all help towards people quitting, and so it is extremely disturbing to see the results from Action on Smoking and Health’s latest survey of tobacco control work in local authorities.

ASH asked control experts from 126 local authorities about their smoking policies and budgets. Its evidence shows that funding is being cut back in two out of five areas and that half of all services are being reconfigured or commissioned, which largely seems to be with the intention of saving money, not saving people’s lives and improving their health. I completely understand the need to control public expenditure, and I know that that often requires local authorities around the country to make difficult decisions, but if that leads to closures and reductions in this vital area of public health work, there is definitely a need for some very urgent rethinking.

[Alex Cunningham]

Colleagues in clinical commissioning groups in my area tell me that they would love to spend much more money on preventative services, but they are too busy spending money on treating and curing people to invest in the longer term. Does the hon. Gentleman think there is a case for providing ring-fenced funding for public health and saying, “Let’s spend this great tranche of money now and do the preventative stuff, and get the benefits 20 years down the road”?

[Bob Blackman]

We should remember that when public health was devolved to local authorities, the money was ring-fenced. I pointed out to Ministers at the time that removing that ring fence would put at risk all public health expenditure, which can be squeezed. I think that is precisely what is happening. We are in danger of undoing all the good work that local authorities have done on public health by allowing that to happen. I, too, would welcome a ring-fencing of money for purposes such as this. We can see clearly that this is a particularly good, important service.

I am also concerned about the progressive reductions in the money spent on mass-media campaigns. As has already been mentioned, the money is going down. In 2015 we spent less than a quarter of the amount that was spent in 2009, and it looks like the spending is going to fall again this year. As has been mentioned, the Stoptober campaign is now only going to be online, with no television advertising. The benefit of large-scale television advertising is that it reaches people who are likely to smoke, so we need to look at that again.

Given the appalling damage that the tobacco industry causes, and given that those major companies are vastly profitable, I cannot see why they should not be asked to make a greater financial contribution to help solve the public health disaster that they worked so hard to create. I cannot imagine a more obvious application of the principle that the polluter should pay. I would very much like to see that commitment included in the new, overdue control plan for England.

Colleagues will remember that last December, when we had a Backbench Business debate on this subject, the previous Health Minister, my hon. Friend the Member for Battersea, announced that the tobacco control programme would be published this summer. I know that spring extends as far as November in some Government quarters, but in this case summer seems to be extending into next year. I am seriously worried, because we have reached the autumn and there is no plan in place and no date for publication. The previous plan was an excellent means of combating the appalling diseases, including cancer, pulmonary diseases, vascular diseases and various other things that are caused by smoking. It helped to improve matters and added many years to the lives of thousands of people across the UK.

Some colleagues may think that an intervention in the market is not required, but I think one is needed more than ever before. Since the programme was first published in 1998, the fall in our smoking rates has been similar to that of Canada and Australia, as has been mentioned. In France and Germany, which do not have comprehensive strategies, the rates have hardly changed in 20 years. The evidence shows that these programmes work, and that where there is no programme there is no movement forward.

The UK has an excellent record on tobacco control. The Department of Health was rightly given the prestigious Luther L Terry award last year by the American Cancer Society for its global leadership on the issue, and the UK was ranked as the world’s most successful country on tobacco control by the Association of European Cancer Leagues. We should never forget that two of the biggest tobacco firms in the world, British American Tobacco and Imperial, are based in the UK, along with Gallaher, which is now an important part of Japan Tobacco International. We simply cannot sit back and watch smoking rates fall in the UK while the tobacco industry puts more time and money into increasing consumption in developing countries.

The next conference of parties of the World Health Organisation Framework Convention on Tobacco Control takes place in India in November—next month. We are in an Indian summer, and the tobacco programme will be published in the summer, so what would be better than publishing the plan in advance of the conference in India? That would set the UK, once again, on the world leadership level.

I hope that my hon. Friend the Minister, in her response, will give a firm and early date for publication. I hope that the plan will set ambitious targets to cut heath inequalities, deal with the funding crisis affecting tobacco control work in local authorities and set specific targets to reduce smoking among vulnerable groups, including, as my hon. Friend the Member for Totnes said, pregnant women and people with mental health problems. The targets for the past five years of the programme seemed difficult, but they have all been achieved, so we should set challenging targets now that will lead to a smoke-free Britain. That has got to be our ultimate aim.

I strongly believe that tobacco control is an essential part of policy. It will enable the Prime Minister to achieve her commitments on good government and reducing health inequality. I pay tribute to the work of colleagues from all parties and in both Houses, who pressed the need for tobacco control legislation on sometimes reluctant Governments, which I consider to be one of the most important political and social advances during my time in Parliament. I hope that that work will continue until the death, disease and misery caused by smoking is finally consigned to the past. I look forward to hearing positive news from my hon. Friend the Minister about when we are going to set out the new challenges for the industry and the Department.

--- Later in debate ---

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Brady. I thank the hon. Member for Stockton North (Alex Cunningham) for bringing forward this interesting debate. I should say that I have never smoked a cigarette in my life, so if I start coughing, as I have been doing throughout the week, that is purely down to a bug that I have picked up.

When the Scottish Parliament brought in its smoking ban in 2006, I thought it was a birthday present, because it was brought in on 26 March, which is my birthday. Since 2007 my party has been in power in Scotland, where we do things a little bit differently. However, there are many parallels on this issue. The latest figures from Scotland show that tobacco use is associated with more than 10,000 deaths and about 128,000 hospital admissions every single year. It costs the NHS in Scotland £400 million to treat smoking-related illness, which highlights the scale of the problem across the UK.

The Scottish Government have implemented and overseen a number of progressive actions on smoking: increasing the age for tobacco sales from 16 to 18 in 2007; the overhaul of tobacco sale and display law, including legislation to ban automatic tobacco vending machines and a ban on the display of tobacco and smoking-related products in shops; the establishment of the first tobacco retail register in the UK in 2011; and the passing of a Bill in December 2015 to ban smoking in cars when children are present. Record investment in NHS smoking cessation services has helped hundreds of thousands of people to attempt to quit smoking.

This year, the Scottish Parliament celebrated the 10th anniversary of the ban on smoking in public and welcomed comments from the World Health Organisation, which praised the Scottish Government’s

“excellent example of global public health leadership”

for implementing its framework convention on tobacco control. In 2013, the Scottish Government published a tobacco control strategy setting out bold new actions that will work towards creating a tobacco-free generation of Scots by 2034. I hear that in the Humber there are more plans in advance of that, although I think our problem may be slightly larger. Key actions in the plan include setting the target date of 2034 for reducing smoking prevalence to 5% and eliminating it in children; a pilot of the schools-based programme ASSIST—“A Stop Smoking in Schools Trial”; and a national marketing campaign on the dangers of second-hand smoke in cars and other enclosed spaces. I echo the comments on the need for a UK-wide national campaign and media advertising.

Although the Scottish Government have long made clear their aspiration for a tobacco-free Scotland, the strategy sets the date by which we hope to realise the ambition. It is not about banning tobacco in Scotland, though if we were to discover it today we would never licence it. I remember as a child listening to the Bob Newhart radio sketches—some may remember them—and he had one about Nutty Walt and the discovery of tobacco. That was only about the crazy tobacco scene and did not even go into the ludicrous health aspects. Nor is the strategy about stigmatising those who wish to smoke. The focus is on doing all we can to encourage children and young people to choose not to smoke.

In September, the Scottish Government welcomed figures that showed that children’s exposure to second-hand smoke in the home reduced from 11% to 6% from 2014 to 2015, which I think sets us in the right direction. Health inequality is a key theme running through the Scottish National Party’s tobacco control strategy, with explicit recognition that current smoking patterns have a hugely disproportionate impact on Scotland’s most deprived communities. That is no different from anywhere else in the UK or, as we have heard from so many speakers, throughout the world.

Scotland has a proud record on tobacco control. We believe the UK Government need to get their finger out and commit to publishing their promised new tobacco control plan for England. I am a great believer that we can learn from each other and pinch good practice whenever we see it, so a good tobacco control plan for England may well help us in Scotland by exposing a few other ideas and strategies that perhaps we have not considered or pushed as firmly.

[Ms Karen Buck in the Chair]

[Alex Cunningham]

The hon. Gentleman has outlined a great catalogue of activities north of the border, in my own homeland. I appreciate that, but what new, big ideas are there north of the border that could contribute to the plan of colleagues in England?

[Martyn Day]

I thank the hon. Gentleman for that question. I have mentioned some of the key points that we are targeting, and stopping children smoking is the key aspect. The title of the strategy we are working on is “Creating a Tobacco-Free Generation”. That is important. The point has been alluded to by other speakers that stopping people smoking is more important than reducing it, although reduction is important for those who smoke because of the impact on deaths and on the health service.

We encourage the UK Government not to keep the House waiting but to fulfil their promise to publish their new plan. If they are stuck for ideas, they are welcome to look at Scotland’s 2013 plan.

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[Mrs Hodgson]

They certainly do. The situation on children smoking is quite stark. The earlier children start smoking, the more serious the consequences are for their health. Children who take up smoking are two to six times more susceptible to coughs and increased phlegm, wheeziness and shortness of breath than those who do not smoke. It can also impact their lung growth, which can impair lung function and increase the risk of chronic obstructive pulmonary disease in later life. As we heard from my hon. Friend the Member for Stockton North, 25,000 people a year die from COPD. Surely we do not want any child in this country to die in that way. The prevalence of these conditions among smokers shows it is paramount that we seriously tackle smoking among our children and young people. We do not want to see the children of today being the COPD sufferers of the future, as well as having those other conditions.

[Alex Cunningham]

I am really pleased my hon. Friend is framing the issue specifically around children. My wife, Evaline, worked as a school nurse and used to hold classes talking to young people about this. She would put forward the economic argument—“If you smoke so many cigarettes over so many days over so many months it costs £2,000, which could buy you a summer holiday.” She was then told, “No, Miss, you’ve got it wrong; it is only £3.20 a packet from Mrs Bloggs down the road.” Do we not also need to ensure we tackle illicit tobacco and ensure children understand the dangers of that as well?

[Mrs Hodgson]

My hon. Friend raises a very good point. The danger and quality of illicit tobacco can often be far worse for health than just long-term smoking. The substances used in those cigarettes can be life threatening.

I will move on to the dangers of smoking during pregnancy, which was raised by the hon. Member for Totnes. While we know the harms of living in a household with a smoker, for some that harm starts before birth as 10.6% of women are smokers at the time of delivery. That equates to 67,000 infants born to smoking mothers each year, while up to 5,000 miscarriages, 300 perinatal deaths and around 2,200 premature births each year have been attributed to smoking during pregnancy.

Smoking during pregnancy has been identified as the No. 1 risk factor for babies to die unexpectedly. According to research by the British Medical Association, if parents stop smoking, that could reduce the number of sudden infant deaths by 30%. Those are shocking figures that show the heartache and pain a mother and the family around her will go through from the horrific events of losing a baby through, for example, miscarriage, stillbirth or sudden infant death. That is especially pertinent this week as it is baby loss awareness week, which I know some of us are wearing little pins to commemorate. There is a debate currently going on in the main Chamber —there was; it has just finished—in which many colleagues gave heartbreaking accounts of their personal experiences or those of their constituents who have suffered the loss of a baby. I was able to intervene and give a personal account of my own experience.

Baby loss due to smoking is preventable if Government action is taken as soon as possible. Important work has been implemented on smoking during pregnancy that has seen the number of pregnant women smoking fall to its lowest-ever levels, but I welcome the calls from the Smoking in Pregnancy Challenge Group to see a commitment from the Minister today to work to reduce the percentage of women smoking during pregnancy to 6% or lower by 2020. It may be an aspirational figure, but it can be achieved as long as a comprehensive plan is put in place to control the use and sale of tobacco.

Regional variations, including those I mentioned earlier, must be addressed; other colleagues have mentioned them, too. We are seeing 16% of women in the north-east and Cumbria smoking at the point of delivery, compared with only 4.9% in London. This stark figure shows that more regional action and support must be offered by the Department of Health to ensure that regional inequalities are addressed. The regional variations and the other variations mentioned show that the slashing of the public health grants is a false economy when it comes to seriously driving forward the agenda on public health, especially in relation to smoking.

In last year’s autumn statement, the then Chancellor announced further cuts in the public health grant, which amounted to an average real-terms cut of 3.9% each year to 2020-21, and translates to a further cash reduction of 9.6% in addition to the £200 million worth of cuts announced in the 2015 Budget. As we know, specialist support and stop smoking services help to get people off cigarettes and to lead a far healthier lifestyle. However, cuts to public health funding have meant that it has proven far more difficult for local authorities to provide that much-needed specialist support.

In a survey of local tobacco control leads conducted by Action on Smoking and Health and commissioned by Cancer Research UK, a total of 40% of local stop smoking services were being reconfigured or decommissioned in 2014-15. In Manchester, we have seen a complete decommissioning of stop smoking services. This is even more concerning when the initial results of the 2015-16 survey show that the rate of decommissioning and reconfiguring is increasing. Therefore, I hope that the Minister will be able to commit to ensuring that we have a substantial source of funding for specialist services that help to support in particular those in lower social economic groups as well as pregnant women to quit smoking. We must end the intergenerational cycle of health inequality that I have spoken about.

It is important that we have a plan and that we have it now—a plan that continues the work of previous Governments to reduce smoking in our society. We have seen inroads into creating a healthier society, but we all recognise we have a long way to go, as the facts and figures show. The Government’s delayed plan must be published now, and it must have measures in place that will address the many variations, from geographical variation to deprivation and socioeconomic background variation.

We must see further work to address the take-up of smoking by children and young people if we are to ever achieve our goal of the next generation being healthier than the last. We need to address smoking among young people head on. Achieving a smoke-free society is within our reach, but what we do not need is further delay and hesitation by the Government; what we need is bold action.

I hope that the Minister can give us that bold action today and that she does so by finally giving us the date when the new tobacco control plan will be published. The longer we wait, the more children will take up smoking, the more people will get ill and, sadly, the more people will die. The time for waiting is over. We now need bold action.

--- Later in debate ---

[Nicola Blackwood]

I am looking closely at PHE’s expert independent review. I have asked officials to examine that closely, and they are updating the review of the evidence each year. I do not have a date for this year—I know the right hon. Gentleman asked for it—but I will write to him when I find out exactly when that will come forward.

Our approach has been comprehensive and has seen smoking prevalence fall in all age groups for both men and women. As various Members have said, adult smoking prevalence in England is now just under 17%, the lowest rate since records began, and we should take a moment to be proud of that. However, as others have said, we cannot be complacent. Smoking continues to be one of the largest causes of social and health inequalities in this country. It accounts for approximately half of the difference in life expectancy whereby, as the Prime Minister said, those on the lowest incomes die an average of nine years earlier than others. The Chair of the Health Committee, my hon. Friend the Member for Totnes (Dr Wollaston), said it so well: it has an even greater impact on healthy life expectancy, which we also need to focus on.

At national level, smoking prevalence is declining year on year. There remain significant regional and demographic variations—an issue raised by the hon. Member for Stockton North, the shadow Minister and others—with the prevalence in some population groups, such as those with mental health conditions, at more than twice the national average. That point was particularly raised by my hon. Friend the Member for Harrow East (Bob Blackman) and the former Health Minister, the right hon. Member for North Norfolk. I shall certainly look at the report that was mentioned, “The Stolen Years”.

Regional variation means that rates of smoking during pregnancy can range from anywhere between 2% in some areas to 27% in others. That is another issue that we must focus on. Given the wide variation in smoking rates across the UK, it remains crucial that local councils have the flexibility to consider how best to respond to the unique needs of their local population and tackle groups in which prevalence remains high.

[Alex Cunningham]

The Minister talked about local authorities having flexibility. Will she support ring-fenced funding in this area, which we discussed earlier?

[Nicola Blackwood]

Ring-fencing is a highly political question, but I recognise that some difficult decisions have been made right across Government to reduce the deficit and ensure sustainability. Councils have been given £16 billion of public health funding across this Parliament, on top of further NHS prevention funding. The big question is whether that is being targeted at the right public health priorities.

We have been looking at that issue closely in my office. Local PHE centres are working with local commissioners to try to ensure that evidence-based service provision remains a priority. Nationally, PHE has been putting together a range of tools to support local commissioning decisions and has convened a round-table of experts to review the situation and propose a range of actions. However, I recognise that ensuring that the right services are prioritised will require more than just providing data about cost-effectiveness and smoking prevalence. The sustainability and transformation plans are supposed to be part of the answer.

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[Alex Cunningham]

I welcome you to the Chair, Ms Buck.

I hope we have not bored people—many have passed through the Chamber this afternoon, and I am sure others are watching online—because consensus has broken out, at least on most issues. We have had an excellent debate, with the expected comprehensive contributions from colleagues across the House. I thank everyone who has taken part.

Many questions have been posed to the Minister on tobacco control and e-cigarettes, ranging from constituency-level issues all the way through to worldwide issues. I am sure she has much to reflect on. I am disappointed that she has not lived up to her predecessor’s reputation by giving us a date this afternoon. We had a bit of a laugh a few moments ago, but I am a wee bit worried that it may not happen this year. I hope she will go back to her Department and think on that.

As the Minister said, she must get the matter right, and that means focusing on the socioeconomic groups that do not have the benefits the rest of us have. There are also health inequalities to consider.

The Minister can be in no doubt that tobacco control remains very much a focus for many of us in the House and will continue to be in the forefront of our minds. I assure her, as others have, that she will have the full support of the all-party group, and of us as individual Members of Parliament, when she introduces the new plan. I just hope that will be sooner rather than later.

Question put and agreed to.

Resolved,

That the House has considered the tobacco control plan.

NHS Sustainability and Transformation Plans

Alex Cunningham Excerpts

Wednesday 14th September 2016 Commons Chamber

[Ms Abbott]

GP leaders in Birmingham said that it would appear that plans by the STP to transform general practice, and to transform massive amounts of secondary care work into general practice, are already far advanced. Only at this late stage have they been shared with GP provider representatives.

[Alex Cunningham (Stockton North) (Lab)]

Freedom of information requests have also uncovered the substantial role of the private sector in formulating these plans. GE Healthcare Finnamore, for example, is advising STPs across the south-west, and I have no doubt that work is under way for it to get larger slices of the action in the future. In the name of transparency, does my hon. Friend agree that all their boards should publish everybody who is on them, with their declared interests as well?

[Ms Abbott]

I entirely agree with my hon. Friend. All STPs should publish who is on them, what their financial interests are, and how far advanced they are in planning. However, thanks to the work of organisations such as Open Democracy and 38 Degrees—and, frankly, thanks to leaks—the picture of what STPs will mean is becoming clearer.

We know from the information we have been able to glean that the reality of STPs is quite concerning. For instance, in the black country there are plans for major changes to frontline services at the Midland Metropolitan hospital, including the closure of the hospital’s accident and emergency. The plans also propose to close one of the two district general hospitals as part of a planned merger. We know that by 2021 the health and social care system in the black country is projected to be £476.6 million short of the funds it needs to balance its books. [Interruption.] Government Members may shout now, but they are going to need an answer for their constituents when the reality of some of these proposed closures becomes apparent.

In Leicester, Leicestershire and Rutland, there are apparently plans to reduce the number of hospitals in the area from three to two. By 2021, the health and social care system in the area will be £700 million short of the money it needs to balance its books. In Suffolk and north-east Essex, the STP plan refers to the

“reconfiguration of acute services within our local hospital, Colchester Hospital University Trust”.

The whole House knows that, historically, reconfiguration in the NHS has meant cuts. There are also plans to close GP practices.

The context of these plans, of which I have given an idea, is the current NHS financial crisis. Most recently, we have heard from NHS providers about this financial crisis. They represent the NHS acute, ambulance, community and mental health services. NHS providers say that despite the best efforts of hardworking staff, including junior doctors, hospital accident and emergency performance is the worst it has ever been. Waiting lists for operations, at 3.9 million, are the highest they have been since December 2007. We ended the last financial year with trusts reporting the largest deficit in the history of the NHS: £2.45 billion.

--- Later in debate ---

[Mr Dunne]

My constituency also shares a border with Wales, so I am acutely aware that Welsh patients regrettably have to wait longer and have worse access to treatment than those in England. Many of them look to English hospitals for services that are unfortunately not available in Wales, in part due to a conscious political decision of the Welsh Government to allocate less funding to the health service in Wales.

[Alex Cunningham]

I met a young surgeon at my north-east hospital in a personal capacity last week. She was excellent and caring and was clear in what she had to explain to me. She was so dedicated that it made me proud that she worked for the NHS. I was not proud, however, to hear about the facilities with which she has to work following the cancellation of our new hospital project in 2010 by the Tory-Lib Dem Government. Does the Minister agree that we can have as many plans as we like, but if we do not have the infrastructure, we cannot deliver the care required by some of our neediest communities?

[Mr Dunne]

There is undoubted pressure on infrastructure, as there is on technology. As technology improves and becomes available to the NHS, it provides opportunity—for example, for much more care to be undertaken closer to the patient. In many cases, this can be done increasingly in or near their home. That will have consequences for our existing infrastructure estate, and some of that will lead to a reconfiguration of existing hospital services. There is a programme of renovation across our hospitals, but of course that cannot get to everywhere at the same time. I apologise to the hon. Gentleman that he does not have the shiny new hospital that he would like, but there is a building programme, which will continue in the future.

North East Ambulance Service

Alex Cunningham Excerpts

Wednesday 4th May 2016 Westminster Hall

[Mrs Hodgson]

My hon. Friend makes a valid point—we often hear about the queues of ambulances at accident and emergency. Patients have waited hours and hours for the ambulance to come, but when they get to the hospital, they sit in a queue outside. I have raised that with my local hospital. There is a huge breakdown in the system. Something is going seriously wrong, and it is completely unacceptable. Mrs Sherriff, a patient who had a suspected bleed in the brain, had to wait for more than eight hours before getting to A&E. That is truly shocking, and all those cases mentioned highlight concerns that the Government and the North East Ambulance Service must address.

I have one more issue to discuss before concluding, and that is to do with the numbers of qualified paramedics, which my hon. Friend the Member for North Tyneside (Mary Glindon) mentioned in her intervention. When waiting times are going up and demand is rising, we clearly need to look at workforce retention and recruitment. Our paramedics do an amazing job, but they cannot be in two places at the same time.

At this point, I want to place clearly on the record that I am not apportioning any blame or criticism at all to any paramedic or ambulance crew. They do an amazing job, under very difficult and trying circumstances, day in, day out, and they should not be placed in situations whereby, once allocated, they race through traffic to a call, within the appropriate time allowed, only to be faced with stressed and sometimes angry people, who say, “Where’ve you been? I’ve been waiting four, five, six or seven hours.”

[Alex Cunningham (Stockton North) (Lab)]

I congratulate my hon. Friend on securing this debate. I have an example from my constituency. A young lad, a teenager, had a road traffic accident, getting a compound fracture of the leg, but it took three hours for an ambulance to get to him.

When I met the ambulance chief executive, she told me that the problem is that the organisations that do employment and support allowance assessments are poaching qualified paramedics from the ambulance service, creating a great hole. There is a role there for Government, perhaps, to talk to the whole organisation, to see what can be done to put a stop to that.

[Mrs Hodgson]

My hon. Friend makes a valid point, which I will touch on, although he made the case well. We have to look at the slippage, to where in the rest of the health service the paramedics are haemorrhaging, and why. I will say more about that in a moment.

Paramedics are there to treat people and give them emergency—perhaps life-saving—healthcare, but before they can even start to treat them, they might first have to calm the patient and relatives down, because of something that was completely out of their hands. It is therefore no surprise that, nationally, there is a shortage of qualified paramedics, and all trusts are struggling to fill vacancies so that they can operate at full capacity. The North East Ambulance Service has a 15% shortage, and is plugging the gap with private and voluntary organisations, as my hon. Friend the Member for North Tyneside mentioned. The service has said, however, that it will be up to full establishment in a year, but how many more people will wait for hours and hours before we get to that stage?

Something therefore needs to be done about the recruitment and retention of paramedics, especially since evidence has shown that more staff are leaving the profession than ever. Also, mental health charity Mind reported that 62% of blue-light emergency service workers have experienced a mental health problem and, worryingly, one in four has considered ending their own life. It is shocking to think about the stress that those people are working under.

It is no surprise that research conducted jointly by Unite, Unison and the GMB revealed at the end of last year that more than 1,500 paramedics had left the service in 2014-15, compared with 845 in 2010-11—still a high number, but a little more than half the later figure. Of paramedics surveyed as part of other research by the three unions, 75% had considered leaving the profession due to stress and pay.

Action therefore needs to be taken on recruitment, which is why I welcome the work of my local university, the University of Sunderland, which in partnership with the North East Ambulance Service has launched a diploma programme in paramedic practice. It will pair theoretical study with practical training over two years, and it will help to address the shortages faced by not only our regional trust, but other trusts around the country. That innovative work by my local university, alongside that of the outstanding paramedic practice degree at Teesside University, which is seen as a beacon of best practice in our region, if not the country, is important and will help.

It is, however, unsustainable not to address strategically the staffing shortages and the increasing demoralisation of a workforce who are haemorrhaging away, because that is clearly having an impact on waiting and call-out times for emergencies. That is why I hope that the Minister will address those concerns, and outline what the Government are doing to deal with recruitment and retention. How will she work with my local ambulance service trust to ensure that it reaches the target of being fully operational by this time next year? How will the ambulance trust ensure that those who are recruited into the field are retained and do not slip off to work for other parts of the health service, so that we do not see further shortages down the line?

It is important that our emergency ambulance services are up to the standard that we all expect. That means working collaboratively among ourselves, as the local Members of Parliament who represent our constituents and their concerns, and with the Department of Health, NHS England and the North East Ambulance Service Trust. Our constituents deserve the best standards in our NHS, and it is up to the Government seriously to address pressures on our NHS services, especially the case of the workforce in the ambulance service.

I hope that the Minister has listened carefully to my concerns, and will listen to those that my colleagues from the north-east who have attended the debate today express. I look forward to hearing what she has to say at the end of the debate.

Oral Answers to Questions

Alex Cunningham Excerpts

Tuesday 22nd March 2016 Commons Chamber

[Mr Hunt]

What I can tell the hon. Lady is that we have 83 more doctors and 426 more nurses at Walsall Healthcare NHS Trust than we did in May 2010. The trust has a quality improvement plan, and it has had an improvement director since February.

[Alex Cunningham (Stockton North) (Lab)]

13. What recent representations he has received on the future funding of mesothelioma research.

[The Parliamentary Under-Secretary of State for Life Sciences (George Freeman)]

I thank the hon. Gentleman for raising this issue. Mesothelioma is a terrible disease from which more than 3,000 people die in this country every year. The Government are completely committed to supporting treatment, prevention and compensation. In the last three months my noble Friend Lord Prior has had a number of discussions with interested parties, and, as the hon. Gentleman will have noted, my right hon. Friend the Chancellor was able to announce £5 million of funding for a new mesothelioma research centre in last week’s Budget.

[Alex Cunningham]

The British Lung Foundation has welcomed the £5 million that the Government have announced for a national mesothelioma centre, but when will those funds be released, and how will the Government ensure that funding for research is sustained in the years that follow?

[George Freeman]

We are engaged in active discussions with the various parties, including charities such as Cancer Research UK, and we have received some interesting submissions from some of the research institutes. Over the coming weeks, we will consider how best to put that £5 million from the Government to work in order to maximise inward investment and build UK leadership in this important centre.

NHS Bursary

Alex Cunningham Excerpts

Monday 11th January 2016 Westminster Hall

[Paul Scully]

We can always talk about the NHS and the future of care, but we have three hours for this debate, and I suspect most hon. Members want to speak, so I will limit my comments to nurses. I will quickly outline the current system and talk about why I believe it needs to change, then we can debate exactly how it might change.

There are various elements to the NHS bursary. There is a non-means-tested grant of £1,000 per year. There is a means-tested bursary to help with living costs of up to £3,191 for students in London living away from home, £2,643 for students outside London living away from home, or £2,207 for students living at home. Other bursary elements include an extra week’s allowance for courses that run for longer than 30 weeks and three days each academic year. As we heard at the event that we held before the debate, the majority of such courses last considerably longer than 30 weeks; they are often up to 42 or 43 weeks a year. Tuition fees are paid directly to the higher education institution by the NHS. Students can also apply for a non-income-assessed reduced rate maintenance loan from Student Finance England of between £1,744 and £3,263, depending on their circumstances. That loan is reduced in the final year of the course.

Why change? The current system, as some, but not all, student nurses, prospective student nurses and those in higher education institutions that train nurses agree, does not always work as well as it might for students or universities.

[Alex Cunningham (Stockton North) (Lab)]

Hospitals across the country rely on recruiting nurses from as far afield as the Philippines. If these new measures are introduced, does the hon. Gentleman think that that dependence will increase or decrease?

[Paul Scully]

I would hope that it decreased. I will touch on some of the costs of recruitment later. Students who receive bursaries under the current structure have less to live on than other students, despite the fact that their courses are longer. They face particular financial hardship in the final year, when funding is reduced. In one London university in 2012-13, 63% of the entire hardship fund went to NHS-funded students, which goes to show how much the system is of concern, and in need of investigation and reform.

Funding for nursing and physiotherapy degrees is lower than for any other subject in higher education, even though the courses put much greater demands on universities than many other courses in areas such as quality assurance, laboratory space and simulation kit. Universities receive less than the courses cost to deliver in many instances. There is a cap on the number of bursaries, and more than half the people who want to train to be nurses are turned away.

In changing the system from a bursary to a loan structure, the Government propose to remove the cap on places, and they expect the reforms to provide up to 10,000 additional nursing and health professional places during this Parliament. Some people who are concerned about the withdrawal of the bursary are worried about students having no money. Even now, many students, especially in London, with its high housing costs, say that the bursary nowhere near covers their living expenses.

--- Later in debate ---

[Paul Scully]

The hon. Lady is asking the wrong person. Perhaps the Minister will respond to that question a little later.

The idea of placements came out of our discussion prior to the debate with the student nurses, who have taken time out to come to London today from as far as Liverpool and elsewhere. We talked about bursaries, and it would be a more honest description to call them a salary because these people are working hours in what are supposed to be supernumerary positions but are often not. There are student nurses sitting in the Public Gallery, and we have one person here from Brighton who explained how he was saving children’s lives prior to Christmas—it is not a supernumerary position when someone is working with babies. We have other people in critical roles who are working with patients on a range of issues, so we need to be straight about the pressures on nurses and how we reward them.

[Alex Cunningham]

I thank the hon. Gentleman for giving way to me for a second time. He is talking about bursaries being like a salary. Student nurses are doing real work when they are training on the wards, so are they entitled to some sort of payment for the real work that they are doing while they are training on the wards?

[Paul Scully]

Absolutely. We are talking about bursaries, but I would rather be straightforward and call it what it should be, which is a salary.

[Alex Cunningham]

Will the hon. Gentleman give way?

[Paul Scully]

I will not give way. I am aware that I have been talking for quite a long time, and I am sure that a lot of hon. Members want to speak. With placements, student nurses have less time than other students to do another job because, although it is 50% placement time in theory, they are effectively working 37 or 38 hours a week, so it is difficult for them to have another job to raise money for their living costs, especially as their courses last for 42 weeks a year—many other courses last for only 30 weeks a year.

--- Later in debate ---

[Wes Streeting]

I am grateful to my hon. Friend for that intervention, and I believe it will make it harder. That concerns me, because Barking, Havering and Redbridge University Hospitals NHS Trust covers part of my constituency and the other half is served by the Barts Health NHS Trust. Both trusts are in special measures, and one issue that has contributed to that has been the inability of both trusts to recruit and retain the staff necessary to provide the timely and quality care that residents in Ilford North and other parts of north-east London have come to expect.

[Alex Cunningham]

It is clear that the professionals are very worried about this issue. South Tees Hospitals NHS Foundation Trust has told a midwife in my constituency and her nurse colleagues that it wants to extend their breaks from 30 minutes to 60 minutes, which means they will have to work an extra shift every four weeks. Many of them cannot take their 30-minute break now, and they are really worried that they will have to work even more hours because the trust will not be able to get the staff it needs if the bursary scheme does not continue. Does my hon. Friend agree that for that reason, the South Tees trust should rethink its plan, and that the Government should do likewise regarding bursaries?

[Wes Streeting]

I certainly agree with my hon. Friend. The Government and the NHS underestimate the extent to which staff at all levels are both working beyond their allocated shifts to plug gaps in the service and going without breaks. Given the settings that those staff work in, it is not in the interests of patients, let alone good for the welfare of the staff themselves, for them to be tired and not taking the breaks they ought to take.