Health and Care Bill

Lord Faulkner of Worcester Excerpts

Lords Hansard - Part 1 & Committee stage
Thursday 13th January 2022 Lords Chamber

[The Lord Bishop of St Albans]

My Lords, Amendments 68 and 95 are in my name. I declare my role as president of the Rural Coalition. I support the broad drift of these amendments, which engage with the important issue of reducing inequalities.

Rural health and social care has often presented challenges in terms of proximity to services, the types of services available within a local area and the demographics of rural areas. It is complicated. Rural areas have a higher proportion of older residents, which is always a greater burden on healthcare services compared with areas with younger populations.

Furthermore, a variety of issues that feed into rural health and social care are beyond the remit of the Bill. In March 2017, Defra produced its Rural Proofing practical guidance to help policymakers assess the impact of policies on rural areas. At the time, this was a welcome initiative to ensure that rural interests were being adequately considered and, to quote the report, that

“these areas receive fair and equitable policy outcomes.”

Unfortunately, concerns have since grown among rural groups that this guidance has become a sort of bureaucratic box-ticking exercise in Whitehall that does not take into account the complexities of rural life.

Funding allocations are often the result of specific metrics or formulas, many of which disadvantage rural communities. For example, a 2021 report by the Rural Services Network, Towards the UK Shared Prosperity Fund, highlighted how many of the post-Brexit levelling-up funds disadvantaged poor rural areas due to way in which they measured poverty. The Department for Transport’s own 2017 statistics showed that, on average, travel from rural areas to either a GP or hospital was 40% longer by car and 94% longer via public transport when compared with travel in urban locations.

Further, 2017 figures from Rural England highlighted the higher rates of delayed transfer of care from hospitals in rural areas: 19.2 cases per 100,000 compared with 13 per 100,000 in urban locations. Analysis by the RSN has shown that, when compared with predominately urban areas, rural local authorities received significantly less grant funding per head to pay for services such as social care and public health responsibilities, in spite of the fact that they generally deal with older populations. Other problems include limited intensive care capacity in rural areas, the loss of local services through amalgamations, the relatively few specialist medical staff in rural areas, and the general staff shortage and retention issues facing rurality.

It is commendable that the Government have legislated in this Bill to introduce a duty on integrated care boards to reduce inequalities between patients with respect to their ability to access health services. My amendments would extend this principle and reduce those health inequalities with respect to where someone lives, whether it is an urban or rural area, and place a duty on ICBs to co-operate with each other for the purpose of reducing healthcare access inequalities. In effect, this is a statutory rural-proofing requirement.

This duty to consider rural access when reducing inequalities extends to co-operation between ICBs because rural areas often exist on the periphery of a large geographical region where patients in one area may reside closer to crucial services in a neighbouring board. Naturally, rural areas lack the economies of scale of urban areas, and greater cross-ICB co-operation will be required to utilise joint resources most effectively when delivering different services to rural areas that fall within border zones of ICBs.

One area where a collaborative approach between ICBs will be crucial for rural areas in the near future is the current reorganisation of non-emergency patient transport by NHS England, which will shift to ICBs shortly. Although rural areas undoubtedly are being considered as part of this re-organisation, patient transport is already a rural inequality that needs addressing. Putting rural proofing with respect to health care on a statutory footing presents a more concrete way to implement the existing rural-proofing guidance. The need for co-operation between administrative areas and for overall plans to be rural proofed will become more essential, particularly for secondary health services, if teams of specialist clinicians become increasingly consolidated in ever fewer locations.

Can the Minister outline how the Government intend to reduce the inequalities in healthcare access and funding that many rural areas face, and how they will effectively ensure that ICBs adequately rural proof their plans in line with the Government’s own guidance?

[Lord Faulkner of Worcester (Lab)]

My Lords, I am very pleased to follow all noble Lords in supporting all the amendments in this group. I congratulate my noble friend Lady Thornton on the way in which she introduced the debate when moving Amendment 11. I will speak briefly to Amendment 66, which was tabled by the noble Lord, Lord Young of Cookham, and signed by the noble Lord, Lord Rennard, and me.

It was enjoyable listening to the noble Lord, Lord Young, taking a voyage down memory lane to more than 40 years ago, when he was a Health Minister. He could perhaps have added that we would have become a smoke-free country rather earlier, had his advice and proposals for tobacco control been accepted at the time, and had he not been removed from health on the instruction of Sir Denis Thatcher and given another role in government. He is and remains a pioneer, and I am delighted to be behind him with his amendments; we shall come to other smoking amendments later.

Amendment 66 would require integrated care boards to address the leading preventable causes of sickness and death, particularly smoking. The Bill as drafted fails to get to the root causes of health inequalities and will have only a limited effect. Our amendment would correct this oversight as far as smoking is concerned. In 2019, there were 5.7 million smokers in England, one in seven of the adult population. As the noble Lord, Lord Rennard, said, in England smoking is the leading cause of premature death, killing over 70,000 people a year and leaving 30 times as many suffering from serious smoking-related disease and disability.

Health and Care Bill

Lord Faulkner of Worcester Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

Moved by

[Lord Faulkner of Worcester]

270: After Clause 148, insert the following new Clause—
“Age of sale for tobacco
(1) The Secretary of State must, no later than six months after this Act is passed, consult on raising the age of sale for tobacco from 18 to 21, and publish a report on the consultation.(2) The Secretary of State must lay the report before Parliament, and a Minister of the Crown must arrange to make a statement to each House of Parliament setting out in detail any steps which will be taken to implement the findings of the report.”Member’s explanatory statement
This new Clause would require the Secretary of State to consult on raising the age of sale for tobacco products to 21 and report to Parliament.

--- Later in debate ---

[Lord Faulkner of Worcester (Lab)]

My Lords, I move Amendment 270, and add my support to Amendments 271 to 279 in this group. I have added my name to each of these, and they will be spoken to by noble Lords in all parties in the Chamber and by the noble Baroness, Lady Masham. I pay particular tribute to them for all being present at this late hour on a Friday—but this is an important issue.

We have signed these amendments because we see them as important steps on the journey towards a smoke-free Britain by 2030, which is the aspiration the Government have identified. They are in line with the approach that has been repeatedly taken in your Lordships’ House in recent years, to reduce harm caused by tobacco smoking and which has been consistently supported by the noble Earl, Lord Howe, when he was answering for the department of health in earlier debates. His support for tobacco control measures has always been appreciated.

As recently as 14 July, your Lordships approved the Motion to Regret that I tabled, regretting that the draft pavement licences regulations were not revised to take into account the evidence of benefits of 100% smoke-free pavement licences. That was agreed by a majority of 30 in a Division.

The amendments in this group are based on the recommendations in the 2021 report of the All-Party Parliamentary Group on Smoking and Health; I declare an interest as an officer of it. The Public Health Minister in the other place has committed carefully to review these recommendations as she develops the forthcoming tobacco control plan. I suspect that we may hear a little more about that from the noble Earl.

The rationale for Amendment 270 is clear. Raising the age of sale would have a larger impact in reducing smoking rates among young adults than any other single intervention. Experimentation has been found to be rare after the age of 21, so the more we do to prevent exposure and access to tobacco before this age, the more young people we can stop from being locked into a deadly addiction from which they may never escape. Two-thirds of those who try smoking go on to become regular smokers and only a third succeed in quitting during their lifetime, with the remainder at serious risk of smoking-related disease, disability and premature death.

When the age of sale was raised from 16 to 18 in 2007, smoking rates among 16 and 17 year-olds declined by 30%. When the age was raised to 21 in the United States, there was a similar reduction there, which in the UK would equate to 100,000 fewer smokers aged 18 to 20, simply by making it harder for young adults to buy tobacco.

Raising the age of sale would also help to reduce inequalities. Compared with non-smokers aged 18 to 20, smokers in this age group are more likely to be from lower socioeconomic backgrounds. This means that the effect of increasing the age of sale would be particularly beneficial in poorer and more disadvantaged communities. The Government’s levelling-up White Paper, published earlier this week, rightly states on page 203:

“Tobacco is still one of the single largest causes of preventable mortality, and smoking rates remain high in some areas of the UK. In 2019, the UK Government set the ambition for England to be Smokefree by 2030. A new Tobacco Control Plan for England is due to be published in 2022, setting out how the UK Government will deliver on this commitment, with a focus on reducing smoking rates in the most disadvantaged areas and groups.”


Elsewhere, the White Paper states:

“These and other changes will contribute to narrowing the gap in Healthy Life Expectancy … between local areas where it is highest and lowest by 2030, and increasing Healthy Life Expectancy by five years by 2035”.


I hope that, with those very desirable aspirations, the Government may be able to accept these amendments or propose similar ones of their own on Report. These amendments are designed to help them to achieve what they want to do.

Raising the age of sale is simple and inexpensive to implement and enforce, as retailers are already required to check the age of young people trying to purchase tobacco, so it is not an additional regulatory burden. Raising the age to 21 would do more than any other measure to help achieve the Government’s ambition of a “smokefree generation” and has already proved effective in the US.

I shall conclude with a brief word on Amendment 271. This requires the Government to prohibit the free distribution of nicotine products to under-18s and to regulate the marketing of any novel nicotine products, not just e-cigarettes. Unsurprisingly, tobacco companies have shown themselves more than willing to exploit this loophole. Free vapes have reportedly been handed out without age checks in cities all around the country. After all, it is not illegal to do so, although it clearly contravenes the spirit of the existing regulations, which set the age of sale at 18. I hope the Minister will agree that the current situation is unacceptable and will take action now to prevent e-cigarettes and other nicotine products being promoted to children. Including all nicotine products, not just e-cigarettes, will ensure that any new nicotine products introduced into the UK in future will be properly regulated from the outset.

I commend all the amendments in this group to the Committee, and remind the Minister that all that Amendment 270 requires at this stage is a consultation and a report back to Parliament. Surely that is not too much to ask for a measure which has majority support among small tobacco retailers as well as the adult population, makes a major contribution to public health and reduces health inequalities. I beg to move.

[The Deputy Chairman of Committees (Baroness Garden of Frognal) (LD)]

My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely and I invite her to speak.

--- Later in debate ---

I hope I have been able to convince the Committee that, while we are sympathetic to the aims of many of these amendments, we will need to review the evidence of public health benefits from the measures and costs to business before bringing forward legislation in this area. The Government are committed to a smoke-free country by 2030. As I mentioned earlier, the independent review led by Javed Khan OBE will identify to the Government the most impactful interventions to reduce the uptake of smoking and support people to stop smoking. As I said, we will outline those plans in our new tobacco control plan to be published later this year. Against that background, I ask noble Lords to consider withdrawing or not moving their amendments.

[Lord Faulkner of Worcester (Lab)]

My Lords, it has been a fascinating debate, which has taken a little over an hour. I thank all noble Lords who have taken part, particularly those who signed the succession of amendments we have been debating. We have heard marvellous speeches from each of them. A huge number of points have been made, which we need to take away and consider in terms of what we should do with amendments such as these on Report.

I am encouraged by the tone and content of the Minister’s reply. I am particularly pleased that he did not close the door on the possibility of some form of polluter pays levy on the industry. I shall read what he said quite carefully, but that is certainly how it appeared to me. The commitment to be smoke-free by 2030 is still there, but I think we all take the view that, if we are going to reach that target, we must do more now or we will miss it. The key to that is doing something about the problem of smoking among poorer people in more deprived parts of the country.

To argue that this is just another product that people can choose whether to start or stop is complete nonsense, as all the evidence has demonstrated over the years. Apart from the fact, as the noble Baroness, Lady Northover, pointed out, that it is the only product which kills a high proportion of its users if they follow the instructions exactly as set out by the manufacturers—that is not the case for gambling, incidentally, which can be dangerous but does not cause people to die in the way that tobacco smoking does—the point about the tobacco industry is that we are not dealing with a normal industry with normal ethics or morality.

That is why the Framework Convention on Tobacco Control was adopted by the United Nations in 2005. It is a supranational agreement that seeks

“to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”

by enacting a set of universal standards, stating the dangers of tobacco and limiting its use in all forms worldwide. We have done well in following the framework convention; it is important that we follow it in engaging with the industry, which is utterly unscrupulous, as anyone who has had any exposure to it over the years will know. It denied that smoking was dangerous or caused disease, then it denied that nicotine was addictive, then it denied that second-hand smoke was dangerous, and now it is saying that it is just another product.

These are important issues which need to be looked at and addressed. I take comfort from what the Minister has said. I shall read very carefully what he and other noble Lords have said in this debate but, for the moment, I beg leave to withdraw the amendment.

Amendment 270 withdrawn.

Health and Care Bill

Lord Faulkner of Worcester Excerpts

Lords Hansard _ Part 1 & Report stage
Wednesday 16th March 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I rise to move Amendment 158 and note that the other three amendments in this group are consequential on this one.

These amendments would require the Government to consult on a statutory polluter pays scheme imposed on tobacco manufacturers to fund measures to reduce smoking prevalence and improve public health. In 2019, when the Government announced their smoke-free 2030 ambition, they promised to consider just this sort of polluter pays approach to raising funds for tobacco control. The amendments require the Government to fulfil this commitment by consulting on a statutory scheme and reporting back to Parliament within six months of the Bill’s passage. The scheme consists of two distinct parts: a levy raised from tobacco sales volumes, which would raise an estimated £700 million a year, and a price cap on tobacco products to prevent tobacco companies simply passing these costs on to smokers.

The amendments propose that funding from this scheme be used to pay for the tobacco control measures needed to achieve the smoke-free 2030 ambition. This includes greater investment in stopping smoking services, mass media public education campaigns, targeted support for disadvantaged groups, tackling the sale of elicit tobacco and preventing young people taking up smoking. There are three sets of arguments in this regard, which are all compelling. The first is the impact of tobacco on public health. The second, bluntly, is that this is in line with government policy. The third is the need for a pragmatic approach to where we are today and how we can achieve funding.

Let me just make a few points about the first of those, the impact of tobacco. First, smoking is, of course, the largest single risk factor in ill health and early mortality. Secondly, it is not a lifestyle choice; it may have been originally—as an ex-smoker, I know that—but it is also addictive, and addiction normally starts in childhood. That is why it is really important that we target younger people. Two-thirds of younger people who start smoking carry on into adult life. The current rate of decline is insufficient; smoking prevalence is coming down around the country but, currently, it would take until at least 2047 for the most disadvantaged communities to achieve the level required. Indeed, inequality is a big issue here. Given that so many noble Lords have spoken about inequalities in relation to other amendments to the Health and Care Bill, I just draw out that smoking is responsible for half of the 10-year difference in life expectancy between the richest and poorest parts of society. Whether one smokes or not has a far greater impact on life expectancy than a person’s social position in society.

This is a fundamental health issue—and there are costs. There are costs to the individual: it is estimated that the average smoker spends about £2,000 a year on smoking; and half a million households, a third of a million children and 183,000 pensioners are living in poverty because of the costs of smoking. There are also costs to the system. It is not just about mortality; it is very much about morbidity. We know, for example, that smokers are more than five times as likely as non-smokers to have microbiologically confirmed influenza and twice as likely to develop pneumonia. Similarly, we know that smokers who quit smoking have better treatment outcomes from day one for everything from cancer to cardiovascular disease, diabetes to dementia, maternity to mental health, stroke to surgery—to the benefit not just of those smokers, but the NHS that provides the service and, frankly, the economy by ensuring that people of working age can be more productive and not take so many days off sick.

Finally, in talking about the impact, I note that there is now enormous public support for these measures. In a recent survey, some 77% of the public supported making tobacco manufacturers pay a levy or licence fee to government for measures to help smokers quit and prevent young people taking up smoking. Nobody in your Lordships’ House will be surprised to know that a levy on tobacco manufacturers has also been endorsed by around 50 health organisations of many different sorts.

As I said at the beginning, there are arguments for these amendments that are about the impact of smoking, which are compelling in themselves. There are arguments that this is fundamentally in line with government policy and that the smoking target will not be hit in 2030 without something of this sort. There is also the very pragmatic argument that in a time of financial difficulty such as this, it is very often the longer-term measures that get cut. There is nothing longer term than making sure that we stop children smoking at an early age. We have, therefore, in this levy a very practical way forward. I beg to move.

[Lord Faulkner of Worcester (Lab)]

My Lords, I support Amendment 158 and the others in this group, to which I have added my name. Last Wednesday was national No Smoking Day, and there was an excellent event in a Commons dining room hosted by the All-Party Parliamentary Group on Smoking and Health—I declare an interest as an officer of that group—to celebrate the 50th anniversary of ASH. The star speaker was the Public Health Minister, Maggie Throup. She reaffirmed the Government’s commitment to achieving a smoke-free England by 2030 and rightly said that stop-smoking services would be at the centre of the forthcoming tobacco control plan.

NICE has estimated that, for every £1 invested in stop-smoking services, £2.37 will be saved on treating smoking-related diseases and reduced productivity. However, cuts to local public health budgets have disproportionately hit stop-smoking services. They have lost a third of their funding in real terms since 2015, accompanied by a decline in the number of smokers setting quit dates.