Health and Care Bill

Lord Moylan Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Moylan (Con)]

My Lords, as a fellow Brummie by origin, I congratulate the noble Lord, Lord Stevens of Birmingham, on his maiden speech. I also express my very strong agreement and support for my noble friends Lord Sandhurst and Lord Shinkwin in the emphasis they have placed on Clause 4 and the importance of improving cancer outcomes.

With regard to the speech by my noble friend Lord Naseby, I will say how remarkable it is that we seem to have accepted, almost without dispute or protest, the transformation in GP services in this country, which are no longer delivering what we have traditionally expected them to deliver. That is perhaps something that can be explored further as this debate continues, because it seems to pass by with nobody commenting, as if it would be rather rude or impertinent to say something about it. But it is a real phenomenon, which is being deeply experienced.

I generally support this Bill—it is a very good Bill —but I would like to make three points. First, we take it for granted nowadays that Nye Bevan was right to insist on a topdown centralised National Health Service. But that view was contested at the time, and by no less a person than Herbert Morrison, with his long service in local government.

I am grateful to the Library for finding for me a rather fiery Cabinet minute from Morrison arguing for local authorities to keep their role in healthcare provision. That did not happen, but perhaps if it had happened, we would have had a less troublesome bifurcation between the health service and social care that we have spent so much time since trying to address. We are back here now trying to do something to fix and amend that relationship.

My concern, with my experience of local government, is simply this: that the new statutory integrated care partnerships must maintain a proper balance between the National Health Service and local government and respect the democratic and local character of the latter. As was said, I think, by the noble Baroness, Lady Murphy, there must be the threat that when you have such a large shark in the room, some of the minnows get squashed. That might not be an exact analogy, but the drift is clear.

My second point is that I will be supporting my noble friend Lady Morgan of Cotes in her proposals for the collection of UK-wide health outcome data on an interoperable basis. The pandemic has shown that everyone in the UK is entitled to the same high health outcomes from our National Health Service. To achieve that, we must have comparable data and appropriate mechanisms.

My third and final point—I am sure that at least some noble Lords will recognise this, which the pandemic has brought to the fore—is that health policy is increasingly seen as the new form of social control. One hears calls for non-medical conditions such as gambling addiction to be treated as a medical problem. The phrase “public health approach” to a problem is the new code for policies designed to coerce, tax and nudge people into doing what is thought best for them.

This Bill gives us fluoridation. It gives us an advertising restriction on what are thought of as unhealthy foods, but even government figures, despite the catching enthusiasm of the noble Lord, Lord Rooker, show that this would result in a trivial reduction in annual calorific intake. In Committee, as the noble Lord, Lord Rennard, has already told us, we can expect a raft of further amendments of an illiberal character. I will end by saying that these will not be uncontroversial, nor should they be.

Health and Care Bill

Lord Moylan Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Mackay of Clashfern (Con)]

Exactly. A draft Bill is preliminary to a Bill; it is not there for the purpose of not being considered. A draft Bill is for making a proposal the subject of an ordinary parliamentary Bill, which has the same authority as a government Bill. All Bills are produced in draft; some are considered in draft in pre-legislative scrutiny. A Bill has to be in draft at some stage, but the object of producing this Bill is not that it should remain in draft but that it should be considered. The amendment does not say how long it should be allowed, but that is another matter. The point is that there is already a procedure by which government help can be obtained if it is asked for in the proper situation of Private Members’ Bills.

I think it is wrong in principle to consider the merits of this matter tonight. Some remarks have been made about that, and I refrain from making any remarks about it because I do not think that that is what is needed here. I submit that it is a view well founded on the rules that Private Members’ Bills are drafted by the private Member, are submitted and then are subject to procedure in the Private Members’ Bills system, including if the Government think it is right that they give additional time.

It is also questionable whether this Motion is in order, since the matter has already been discussed in this Session. There is a question about whether having have a separate procedure raising the issue in much the same form as it was considered some weeks ago is in proper order.

But my main point is about the procedure for dealing with Private Members’ Bills in our Parliament—we are not in the Scottish Parliament at the moment, and there may be some question as to whether my noble friend would like to be—and we have to apply the rules in this Parliament. In my submission, applying the rules of this Parliament, if we want help from the Government, it is to be asked for in the Private Members’ Bill procedures and the Government may, for all I know, be prepared to do something along the lines that my noble friend has suggested.

[Lord Moylan (Con)]

My Lords, I wish primarily to speak to the amendment standing in the name of the noble Baroness, Lady Meacher, but, before I do so, may I just reply, without any hint of rancour, to the comments made by the noble Baroness, Lady Hayter? She repeatedly described the amendments tabled to the Assisted Dying Bill as “wrecking amendments”. Certainly, my amendments are not intended to be wrecking amendments; the Bill raises very important consequences for the National Health Service, and my amendments are primarily about the effect on the relationship between doctors and patients. These are important considerations, and to call them wrecking amendments is a little unfair. I say that without any rancour at all.

Health and Care Bill

Lord Moylan Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

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

My Lords, I will also be moving Amendments 225B and 225C in due course. Clause 4 sets a requirement for the Secretary of State to include objectives relating to cancer outcomes in the mandate to NHS England, and for these objectives to have priority over other objectives relating specifically to cancer.

I first thank John Baron MP in the other place, who introduced this clause, and noble Lords for their support in ensuring that the Bill best delivers on our shared intention of improving outcomes for cancer patients. I also thank the cancer charities that have contacted me to express their views, and the noble Baroness, Lady Morgan of Drefelin, for her engagement. The Government have worked with Mr Baron, NHS England and stakeholders to ensure that we deliver the greatest benefits for cancer patients while minimising the risk of unintended consequences. Amendments 225A, 225B and 225C, tabled in my name, have the full support of Mr Baron, and I strongly encourage your Lordships to support them.

In recognition of the range of services offered to cancer patients, Amendment 225A will ensure that the scope of possible outcomes-driven objectives is broad enough to capture all cancer interventions, such as screening programmes or targeted lung health checks, not just those relating specifically to treatment. Connected to this, Amendment 225C will ensure that these objectives have priority over any other objectives relating to cancer, not just those relating to cancer treatment.

Amendment 225B, meanwhile, makes it clear that the objectives over which the cancer outcomes objectives have priority are those which relate specifically to cancer. When it comes to setting priorities for NHS England, including on cancer, it is vital to consider the outcomes that they should be directing the NHS to achieve. Improving outcomes means boosting survival rates—that remains our overriding aim. But the outcomes that matter to cancer patients are not limited to survival. They also include improving the quality of life for those living with cancer and the patient experience of those being treated.

We want to make sure the objectives we set benefit the outcomes of all cancer patients, whether the objectives relate to screening, early diagnosis or treatment. This is crucial as screening and early diagnosis interventions are one of the most effective ways of improving outcomes and chances of survival. I hope your Lordships can support these amendments.

[Lord Moylan (Con)]

My Lords, I greatly welcome the amendments proposed by my noble friend. In fact, I put my name to the equivalent amendments earlier, proposed by my noble friend Lady Morgan of Cotes. I rise to speak to my Amendment 294, the purpose of which is to draw attention to the dire state of the services and treatment offered to people suffering from cancer of the pancreas—although I could also say that there are other, equally forgotten and equally deadly cancers, such as bile duct cancer, that deserve a debate as well. I am grateful to my noble friend Lord Vaizey of Didcot and to the noble Lords, Lord Patel and Lord Aberdare, for their support of the amendment.

Many of us have seen family members and friends fall prey to this disease. Pancreatic cancer is the deadliest common cancer. It affects 10,000 people a year across the UK, and more than half will die within three months. Three in four will die within a year. Vague symptoms, lack of a simple early test, and low symptom awareness among both the public and primary care professionals result in three in five people with pancreatic cancer being diagnosed at a late stage, when curative treatment and life-saving surgery are no longer possible.

Research into pancreatic cancer has been underfunded for decades: it receives only 3% of the UK cancer research budget, despite being the deadliest common cancer. The result is that pancreatic cancer has the lowest survival rate of all common cancers, with five-year survival rates less than 7%. Five-year survival in the UK lags behind the rest of the world, with the UK ranking 29th out of 33 countries with comparable data. These survival statistics have barely improved in decades.

In addition, there is an unacceptable variability of services for pancreatic cancer sufferers, depending in part on geography, with those living near the few specialist centres able to access some services barely available elsewhere.

I wrote last year to my noble friend Lord Bethell with a particular suggestion being promoted by the small but excellent charity Pancreatic Cancer UK. In due course, on 1 December, I received a reply from my honourable friend Maria Caulfield, who said that NHS England and NHS Improvement had launched an audit of pancreatic cancer services with a view to reducing variations in treatment and improving outcomes. That is wholly welcome. The information we have nationally on pancreatic cancer treatment in the NHS is woefully poor. An audit is a good place to start. But she went on to say that the first data were expected in 2023—not the report, not the action plan that we need, and not the funding allocation, merely the first data.

My amendment seeks to impose certain reporting obligations on the Secretary of State, but its real purpose, and the real purpose of this debate, is to inject some urgency into the Government and the NHS. We cannot afford to wait years just to begin to understand the state of pancreatic cancer treatment and care, let alone to take action to improve outcomes. Pursuing the audit with urgency and dispatch should be a top government priority.

There is one thing the Government could do right away that would at least alleviate the suffering of pancreatic cancer patients—and this indeed is the subject I wrote to my noble friend Lord Bethell about at the urging of Pancreatic Cancer UK. The symptoms caused by pancreatic cancer have a very distressing impact. In particular, people are often unable to digest their food, ultimately starving the body of nutrients and calories, leading to rapid weight loss, malnutrition and loss of muscle mass.

The solution to these symptoms is pancreatic enzyme replacement therapy—PERT. PERT comes in tablet form; you take it with your food. It replaces the digestive enzymes that many people with pancreatic cancer can no longer produce. Taking the tablet helps food to be digested and absorbed by the body, and can vastly improve people’s quality of life. It can also, crucially, help them to gain the strength needed to undergo treatment. If people have lost weight and are too weak, they are sometimes not able to have surgery for that reason. NICE guidelines clearly recommend PERT for people with pancreatic cancer, whether the cancer is operable or inoperable, and there is widespread clinical consensus on its effectiveness. It is widely available and is cost-effective: it costs the NHS just £7 per day per patient.

However, a recent study has shown that only half the people with pancreatic cancer across the UK are prescribed PERT. The May 2021 RICOCHET study, undertaken by the West Midlands Research Collaborative, found that 50% of pancreatic cancer patients were not being prescribed the tablet they needed to digest food. The key reason people are not being prescribed PERT currently is a lack of dissemination of specialist knowledge about pancreatic cancer and the benefits of PERT to general healthcare settings. PERT is more likely to be prescribed in specialist surgical centres than in general hospitals, meaning that people whose cancer is operable are more likely to be prescribed PERT than those whose cancer is inoperable, because people whose cancer is operable are more likely to be moved to a specialist setting.

However, three in five people with pancreatic cancer are not diagnosed until their cancer is at an advanced stage and no longer operable, so they will tend to be treated with palliative care in a non-specialist setting. This means they will be far less likely to be prescribed PERT than if they had been diagnosed early.

What I would hope to hear my noble friend the Minister say this evening is that without waiting for the results of the audit, he will immediately set a national priority that PERT should be routinely prescribed as a feature of pancreatic cancer care. Without setting this focus and without corresponding leadership from national and local health bodies, knowledge and expertise will continue to spread far too slowly for the people with the quickest-killing cancer.

[Baroness Morgan of Drefelin (CB)]

My Lords, I am delighted to rise in support of the Minister’s amendments to Clause 4, and I would like to declare my interest as chief executive of Breast Cancer Now. I am also absolutely delighted to pay tribute to the honourable member John Baron, from the other place, for his incredible leadership as chair of the All-Party Group on Cancer, his tireless campaigning for the interests of cancer patients and his relentless demands around prioritising improvement in cancer outcomes—hence the origin of this new clause.

For me and for those listening to this debate, it is extremely important that the Minister has been able to clarify that the wide range of outcomes covered by this new clause will include, for example, early diagnosis, objectives around end-of-life care, the importance of measuring quality of life as an outcome, and timeliness of care, as well as survival, because we know that all those factors lead to improved quality of life but also improved survival. We do not have the time to wait five or 10 years to see whether improvements in survival are occurring—we need to see them today, next month. We need to see, for example, that PERT is getting through to all patients with pancreatic cancer, rather than waiting for the longer-term survival results.

I am very pleased that these amendments have been tabled and that the Minister has confirmed that a wide range of metrics will be used to ensure a tight grip on keeping track of the system’s performance, identifying emerging problems and backlogs as they arise, because we do not have the time to wait to find out if the system is off-track. I am very pleased that we have some clarity around what is included in these objectives. I will read the Minister’s remarks properly—when it is not quarter to 10 at night—and reflect. I am very grateful for them.

Also, what a tremendous amendment we have on pancreatic cancer, which is, as we have heard, such a pernicious disease. The audit will be very powerful when it really gets to work on what is going on locally to unearth thoughtful ideas about how the system can be improved. So much good work goes on in these audits, not just on pancreatic cancer but other diseases too. Making sure that those improvements are put into practice as quickly as possible has got to be a really good thing that this House will care about very much.

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With these amendments, the Secretary of State would continue to set objectives relating to outcomes for cancer patients in future mandates, to reflect the priorities that the elected Government of the day have for NHS England, but working in partnership with the cancer charities and cancer experts.

[Lord Moylan (Con)]

My Lords, before my noble friend sits down, on behalf of people who are currently suffering from pancreatic cancer or who might be diagnosed with it in the next few months, is anything going to happen faster in relation to dissemination of knowledge and prescription of PERT as a result of this debate than would have been the case had we not raised this with him?

[Lord Kamall (Con)]

I am afraid that I am not entirely sure of the answer to that, but I hope that we have raised awareness. I am very happy to have a conversation with my noble friend to see what more can be done, if anything.

Health and Care Bill

Lord Moylan Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

I felt strongly about this issue for many years, because I have seen it slowly trundle down the track—the train leaving the station. I want to reach out a hand and say I have enormous admiration for some very close friends who campaign vigorously on obesity, and who sent me some very rude emails last night after reading the editorial in the Grocer. I understand why they are passionate about the ban as a great signal that progress is being made on obesity. But since 1997, successive Governments have come up with a total of 640 obesity strategies and none of them has been implemented or worked. This is an excuse for an obesity strategy. If noble Lords support my amendments, we can force the Government to go back and to come up with something that will actually work—which, in my opinion, is education for children and great nutrition in schools.

[Lord Moylan (Con)]

My Lords, it is a great pleasure to follow my noble friend Lord Vaizey of Didcot. Might I say, before I get into my stride, that certain noble Lords may have received an email that emanated a week or so ago from what I call the “cold dip” wing of the Conservative Party. Essentially, the message was, “Those rotters Vaizey and Moylan are out to spoil our whizzo scheme”. This is not true, in my case. Unlike other speakers, I declare that I have no interests to declare. I am not aligned with the food industry, the advertising industry, the broadcasting industry or any of the charities that wish to restrict, ban or control various foods and drinks. That seemed to cause a little upset to the noble Baroness, Lady Boycott, who seemed to think that because I could speak in a disinterested fashion I was somehow precluded from taking part in the debate, but I hope noble Lords will not agree that is the case.

I have put my name to a number of amendments in the name of the noble Lord, Lord Vaizey. The ones I have signed up to are essentially to do with giving enough time to implement the ban, if it is brought into effect, and I hope that they are accepted. I note that the Government have brought forward amendments of a similar character; they improve the Bill, but they do not go as far as they should. But it is a good sign, and it shows that what we are engaged in here is improving the Bill, not trying to destroy it.

I will add a particular word in support of my noble friend’s Amendment 247A, which seeks to make the identification of HFSS food a matter that would be subject to parliamentary scrutiny. In effect, what the Government are seeking through this schedule is a power to make binding law—with all the apparatus of fines and other enforcement—by way of mandatory guidance that will not be subject to parliamentary scrutiny. Instead, business planning and investment will always be at the whim of civil servants with no recourse to Parliament. That is not a situation that, in other circumstances, your Lordships’ House would feel comfortable with. We should apply the same standards here and insist that, with Amendment 247A, parliamentary approval is required before these punitive measures can be amended.

The other amendments in this group in my name cover a wide range of issues, but all of them are aimed at helping business plan for and implement the bans that the Government contemplate. That said, I noted last Friday that “Red Box” in the Times was reporting a change of heart by the Prime Minister on the whole policy of introducing the advertising and promotions ban. If this is true, we can happily move on and ignore Schedule 17, since all the evidence—including the Government’s own impact assessment—shows that the policy will, as my noble friend said, have a minuscule effect. The Government’s own assessment suggests that there will be a reduction of fewer than three calories a day. I ask my noble friend the Minister to confirm, when he wraps up, whether or not this planned change of policy is in hand.

Amendments 247, 250A and 253A in my name deal with the question of whether the ban applies to brand advertising and sponsorship—already mentioned by the noble Baroness, Lady Boycott, and my noble friend Lord Vaizey. This concerns advertising when no product of an unhealthy character is included in the advertisement or sponsorship statement. Putting the brand advertising exemption into the Bill is important for business—businesses which are looking for certainty as they are already planning advertising campaigns which will run after 2023.

The exemption for brand advertising was confirmed in Committee in the other place when the Minister there said:

“Products are deemed identifiable if a person could reasonably be expected to identify the advertisements as being for that product. This means that brand advertising is not in scope of the restrictions, as the purpose of the restrictions is to prohibit identifiable products.”—[Official Report, Commons, Health and Care Bill Committee, 26/10/21; col. 676.]


He made similar remarks on Report. This is helpful but putting the exemption into the Bill—alongside the other exemptions—would mean, should the Government wish to revisit this exemption in the future, that they would be obliged to return to Parliament to set out their reasons for doing so and seek the consent of both Houses.

The noble Baroness, Lady Boycott, commenting on this, seemed to say “Why do we need all this paraphernalia? Let’s just trust the Government and go with what they say”. I almost fell off my Bench when I heard her say that. So often in this House we are saying quite the reverse; we are saying let us not trust the Government and insist that, if we want something to happen, it should be on the face of the Bill. That is all I am saying. I believe the Government of course, and in my own small way I trust the Government—but Governments change. If we believe in this, let us see the Government put it on the face of the Bill. This has been called for by the Delegated Powers and Regulatory Reform Committee and the Constitution Committee, which have signalled their dissatisfaction with this way of proceeding.

I turn to Amendments 249A, 252A and 257A in my name, which concern how the Government will assess the effectiveness of the ban. I am assuming, perhaps optimistically, that all noble Lords will agree that the restriction on freedom of expression involved in the Government’s policy should be continued only if it is seen to be effective in its purpose of reducing calorific intake. Indeed, that is the Government’s view, because the Bill contains a five-year review of the effectiveness of the restrictions, in line with better regulation principles, but it is not clear how “effectiveness” will be judged.

The purpose of my amendments is to seek some clarity on the issue now, as we adopt the new rules, so that the effectiveness criteria are not shaped retrospectively in five years’ time. This needs to be done now, in the interests of transparency and to enable the collection of data. It also needs to be done if the industry is to respond by changing its product mix—something which the noble Baroness, Lady Boycott, said she hoped for and looked forward to, and said there was evidence of its having done so in advance. But unless it understands in advance the criteria by which the ban will be judged effective, how can it possibly begin the process of changing the product mix to meet those criteria? The lack of impact of the ban is clear, but the criteria judging how it will be assessed effectively need to be addressed right at the outset.

There is also the question of what the Government will take into account in assessing those criteria. Their impact assessment envisages that the policy will likely reduce calorie consumption by around three calories a day, which is roughly equivalent to half a gram of butter, or one-five-hundredth of a standard pack of butter. This is so small as to be insignificant in terms of health benefits, yet the policy will undoubtedly have wider economic benefits, including on competition, innovation, prices, media revenues, advertising and the wider creative industries. Are the Government going to assess this wider picture?

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[Lord Rennard (LD)]

My Lords, for decades, all the various weak arguments associated with the tobacco industry, opposing tobacco regulation, have been comprehensively and completely disproved by the effectiveness of that regulation at reducing the prevalence of smoking rates. Tonight, we will argue why we need to go further with measures of tobacco regulation to further reduce the prevalence of tobacco smoking. I will speak briefly on Amendments 276, 277 and 278.

It is topical that, this week, mission seven of the Government’s Levelling Up White Paper committed

“to narrowing the gap in Healthy Life Expectancy … between local areas where it is highest and lowest by 2030”.

As Ministers regularly acknowledge, half of that gap is down to smoking, so real commitment to levelling up means that immediate action must be taken on these issues.

The tobacco-related amendments in this group will assist the Government in their stated aim to reduce the prevalence of tobacco smoking to below 5% by 2030. Amendment 276 requires the Secretary of State to introduce health warnings on cigarette sticks and rolling papers, in addition to the existing pack warnings. The claim that there is not yet sufficient evidence to justify the policy is a very weak excuse for inaction, and similar claims were made before the introduction of health warnings on cigarette packs. That is why the tobacco industry opposed them so strongly. These warnings on the packs are proven to be effective in reducing the prevalence of smoking tobacco, saving the lives of some of the people who were addicted to tobacco.

What is effective on the pack must be effective on the product, and 29 different studies have concluded that this would be the case. Other countries are considering this measure, and there is no reason why this country should not again lead the way.

Amendment 277 requires the Secretary of State to mandate pack inserts advising smokers about how to quit, and we know that very many smokers do want to quit. When the Government announced their smoke-free ambition in 2019, they said they believed that there was a “positive role” for such inserts, which they would consider as part of their review of regulations on exiting the EU. But the Government have inexcusably held back so far, making the lame excuse that

“further research”

is supposedly required to

“establish the public health benefit”—[Official Report, Commons, Health and Care Bill Committee, 28/10/21; col. 813.]

before proceeding.

The best research would be to introduce the inserts—at worst a harmless policy and something the tobacco companies could easily pay for from the huge profits they make from shortening the lives of half their customers. As the noble Baroness, Lady Masham, said, pack inserts have been mandatory in Canada for two decades. They have been shown to enhance motivation to quit, increase quit attempts and sustain quitting tobacco.

Amendment 278 would close a loophole in current legislation. In May 2020, it was rightly recognised that menthol can hide the harsh taste of tobacco and make cigarettes easier to smoke and more appealing to children; that is why it was banned. However, a massive loophole allowed flavouring to continue. The Government’s response on this issue in the other place was that

“it is not clear how a ban on flavours would be enforced in practice, as it would include a ban on flavours that do not give a noticeable flavour to the product.”––[Official Report, Commons, Health and Care Bill Committee, 28/10/21; col. 815.]

However, this has not been a problem in either the Canadian provinces or our European neighbours, such as Germany and Finland, which have successfully implemented a complete ban on flavourings.

In the year after the ban on menthol cigarettes came into force, Japan Tobacco made more than £90 million in profits from selling 100 million packs of its so-called “menthol reimagined” brands, which, it argued, were entirely legal. The loophole must be closed. I hope that the Minister will confirm that the Government plan urgently to step up a gear on tobacco regulation and support the tobacco-related amendments in this group.

[Lord Moylan (Con)]

My Lords, I am aware that, in your Lordships’ House, any lack of zeal for persecuting smokers marks one out as an aberration, but some realism has to be brought to this debate. It is my understanding that the Government will rightly resist these amendments so, in the interest of brevity, I will leave it to my noble friend the Minister to give a detailed rebuttal of each of them. However, I have a few things to say.

Unless smoking tobacco is made illegal, which would only bring with it all the organised-crime consequences associated with illegal drugs, the UK will not be smoke-free by 2030 or any other foreseeable date. There is likely to be an irreducible demand for smoking among both a small core of regular smokers and a wider population of people who enjoy the occasional cigarette. A sensible policy would recognise this and seek to accommodate it. There are widely understood risks to health associated with smoking, of course, but, as we have heard in this Committee, so there are with fat, salt, sugar and even fluoride. Despite all that, we have the constant efforts of well-funded zealots to bully and humiliate smokers and place burdens in the path of businesses engaged in the manufacture and distribution of this lawful leisure product.

Each of these amendments falls into one of those categories in one way or another, despite the smoothly expressed words of those who tabled them about increasing public information and the like. The public are already better informed about the risks of smoking than about almost any other topic. The UK is already highly regarded globally for its success in reducing the number of smokers. Those who wish to give up smoking deserve some modest help from public authorities, I agree, but they can be helped in other ways—for example, by diverting into products with much lower health risks. However, the campaigners against smoking cigarettes have been almost as determined to kill vaping as an alternative—although, as was indicated by the speech of the noble Baroness, Lady Northover, even public health officials are now beginning to question whether the initial blanket opposition to vaping is preventing some people making the transition from smoking cigarettes.

A similar question arises now as non-combustible tobacco products increasingly come on to the market. These contain tobacco but it is not heated to the point of combustion, although they still deliver nicotine to the user. Most of the harmful effects of smoking come not from the nicotine as such but from the smoke. Non-combustible tobacco products do not give rise to any smoke. The Government should be able to say, and make clear in their tobacco control policy, whether there should not be distinct regulations covering, separately, combustible and non-combustible tobacco products. I hope that my noble friend the Minister will be able to assure me that this will be so on sound public health grounds.

Health and Care Bill

Lord Moylan Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I added my name to Amendment 287, and I thank my noble friend for tabling Charlie’s law. Charlie Gard’s case was painful for all involved, including his parents and the doctors at the hospital where he was receiving treatment. Protracted disagreements can have far-reaching effects, particularly when they are played out in public, as has happened in a small number of cases. For the child, it can mean a delay in a decision about their care and treatment. For the parents and family of the child, there can be enormous distress, feelings of loss of control, and financial strain. Healthcare staff can also experience stress and anxiety, and they might be subjected to intimidation.

The parents of Charlie Gard, Alta Fixler, Alfie Evans, Tafida Raqeeb, and many others, wanted to do what any parent would do to try to improve their child’s condition and alleviate their child’s suffering. However, it is evident that the parents in such cases do not feel adequately heard and listen to when discussing options about their child’s treatment. This results in the devastating conflicts that lead to litigation. With this amendment, parents would be given the chance to discuss their views openly with the clinicians and hear the views of those clinicians, too.

Too often in my career, I have heard distressed parents described as “difficult” and “impossible to work with—nobody can work with them”. These are grieving parents who are looking for someone they can trust to help them. Mediation can sometimes help parents, and professionals to acknowledge that the consequence of conflict has been to shift focus away from the needs and welfare of the child. An independent mediation process can help to facilitate less confrontational conversation while supporting both parties. Thus, it provides support for both. Mediation across England is inconsistent. It needs to be available in every NHS hospital where conflict emerges, and at an early stage, so that the lives of very sick children such as Charlie are less likely to escalate to court.

In the rare event that a child’s case escalates to court, the amendment seeks to provide access to legal aid to ensure that families are not burdened with the financial strain of legal representation. Currently, families in this position are effectively punished, both financially and emotionally, through litigation for simply doing what they strongly believe is in their child’s best interest. Although this amendment makes provision for legal aid, the main purpose is to keep cases such as Charlie’s out of court, rather than arming everyone to be prepared to enter into long-winded and expensive legal disputes. Parents would not automatically win the right for their children to be given novel treatment, but the amendment would rebalance the dialogue towards resolution, rather than towards costly and distressing legal battles that do nothing to help the parents’ grief.

I also strongly support the introduction of the significant harm test. This legal test would focus on whether an alternative credible medical treatment could cause a child “disproportionate risk of significant harm” when deciding whether a parent can seek that treatment for their child. A key point here is that no medical professional would ever be required to give care or treatment that they did not view as in the best interests of the child. The legal test is already widely used under the Children Act 1989 and should be applied to cases such as Charlie’s in the future. I am strongly in support of this amendment and commend it. It is a just and necessary package to support parents and doctors, and I hope the Minister will be in a position to welcome it.

[Lord Moylan (Con)]

My Lords, I have also put my name to this amendment. I congratulate the noble Baroness, Lady Finlay of Llandaff, on bringing it forward.

We need a broad debate on the balance of responsibility for children as between parents and the various arms of the state. Sadly, these have come to include the medical profession. Today is not the day for that debate, but this amendment does something to give a voice to parents who find themselves in dispute with doctors, often unaided, unsupported and dependent on voluntary contributions, so that they have at least a voice and a status in decisions about their sick child. I very much hope that the Government will be able to support this.

[Baroness Stowell of Beeston (Con)]

My Lords, I do not very often become involved in health matters, so I hope that your Lordships will indulge me on this occasion.

Five years ago, when Charlie Gard’s parents were doing everything they could to fight for his life, I, like everyone else, was moved by their determination. Even so, my instincts were to accept what the Great Ormond Street hospital doctors were advising and what the judge decided was in Charlie’s best interests. I fall into the camp which believes that, in such an unimaginable, heartbreaking situation, the objective and dispassionate professionals are best placed to make a decision that no parent would ever want to have to make for themselves. When Charlie sadly died, I was moved by his parents’ dignity in coping with their heartbreak in the midst of a legal battle and in the full glare of publicity. Probably like many others who felt so sorry for their loss, I soon moved on and thought little more about this tragic case.

Then, just over a year ago, during the Christmas lockdown, when I was out on my daily walk, I heard an interview that Charlie’s mother, Connie Yates, gave to Andy Coulson on his podcast, “Crisis What Crisis?” For well over an hour, I listened to Connie tell her story. She spoke clearly, intelligently and reasonably about their experience as a family during the year in which Charlie lived, and about all that she and her partner, Chris, went through in their fight to be heard and taken seriously by doctors and lawyers. From listening to Connie, I learned that their expectations were well-informed and reasonable but that as the dispute continued, the situation became increasingly fraught and distressing —to the point where their efforts to be heard as parents made them feel that others believed they were guilty of not wanting the best for their baby. Even so, she was at pains to praise all the medical staff who had cared for Charlie at Great Ormond Street.

Towards the end of the interview, Connie told Andy Coulson that a Private Member’s Bill was being sponsored by the noble Baroness, Lady Finlay, that would bring to life what she called “Charlie’s law”. The noble Baroness has described this law. When Connie talked about it, I was struck by how modest and reasonable it is to create a legal framework to allow for resolution, without the added stress and trauma that they had faced during the time when they were fighting for Charlie. It also struck me very powerfully that, in developing this framework, Connie had taken the time to contact and listen to the doctors who had opposed her, so that she could better understand them and their position. That is worth emphasising again: this young woman is so reasonable that she wanted to create a law that would work for the benefit of the medical profession, not just parents.

As I finished listening to Connie, I vowed that I would support that Bill whenever it appeared. But as we know, Amendment 287 is here in lieu of that Private Member’s Bill, and arguably is a better way to introduce this measure, rather than having to battle with the usual procedural risks that are associated with private Members’ legislation. I am delighted to lend my support to this amendment. I am sure there are technical matters within the amendment which might require discussion between the noble Baroness and the Minister, but I urge my noble friend to take this seriously.

Given the ordeal that Charlie’s family faced a few years ago, when no one in authority listened to them, I am sure it would bring them a huge amount of comfort to know that they are being heard now. That is my main point and motivation today. Of all the things we must do if we are to level up this country, listening and taking seriously people who feel ignored or misunderstood is the most important aspect of that agenda, and in this context it costs us nothing.

I also say to Connie Yates, should she be listening today or read the record subsequently, that she is one impressive woman. When I heard her speak, and listened to what she had to say, she changed my mind and made me realise I had been wrong not to listen more carefully a few years ago.

Health and Care Bill

Lord Moylan Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Baroness Smith of Newnham (LD)]

My Lords, I will speak to Amendment 108, while supporting the other two amendments introduced so powerfully by the noble Lord, Lord Hunt, and my noble friend Lady Northover, and to which the noble Baroness, Lady Finlay, spoke so eloquently.

I am completely in support of those amendments, but I wish to speak briefly to the genocide amendment today. On various occasions during the Covid pandemic questions were asked of the then Health Minister about the procurement of PPE. He was not able to give me a straight answer to say, “We can guarantee that no PPE procured could have had anything to do with slave labour or could have come from Xinjiang.”

The NHS seeks to be world leading. We all support it and want it to be able to deliver for every citizen in this country. But that should not be at the expense of the lives of those in other parts of the world. It is not good enough to say that we have the Modern Slavery Act if that will not lead to a change in practices. It is absolutely essential that our supply chains do not include anything that comes from forced labour.

If one looks at what is going on in Xinjiang, it is possible to barter to get numbers of people, just as it was 200 years ago during the slave trade. That is not acceptable. It may be the case that, as the noble Baroness, Lady Kennedy of The Shaws, pointed out, we will be told, “This is not the right piece of legislation.” If it is not, what will the Government bring forward that will mean that every point of our supply chain—every part of government procurement—ensures that we are not procuring things that have been made using slave labour?

We must not be complicit. This House should support the amendments, and if the Minister is not able to support the amendment, perhaps he could come back with a revised and better version of the amendment that will do what we all seek to achieve.

[Lord Moylan (Con)]

My Lords, I will speak briefly only to Amendment 108, which I understand the Government are likely to resist when my noble friend the Minister comes to speak. I say simply, very briefly, that to be persuasive, my noble friend has to explain how through administrative measures the National Health Service will achieve the effects of this amendment. He has to explain that in a credible way and that the effects will be rapid and comprehensive. Any idea that this will be kicked into a long review that ambles on and may or may not produce the effects required by at least the first two proposed new subsections of the amendment will lack credibility; I am less concerned about the chairman of the Select Committee part that comes in the third one. I would like my noble friend to know before he speaks that that is what I think we all want to hear.

Health and Care Bill

Lord Moylan Excerpts

Lords Hansard - Part 2 & Report stage
Monday 7th March 2022 Lords Chamber

Moved by

[Lord Moylan]

148: Schedule 18, page 254, line 34, after “State” insert “which may not include products containing more than 20% of their calorific value by way of protein and not more than 5 grams of sugar per 100 grams in their composition”
Member’s explanatory statement
This amendment, along with others to Schedule 18, ensures that foods that can be advertised as “low sugar” and “high protein” under Regulation (EC) No 1924/2006 of the European Parliament and of the Council of 20 December 2006 on nutrition and health claims made on foods are exempt from the restrictions on advertising proposed in that Schedule.

[Lord Moylan (Con)]

My Lords, in moving Amendment 148, I will also speak to Amendments 150 and 152 in my name. There are a number of interesting amendments in this group but I intend to stick to my last, broadly, and speak only to the ones in my name.

I had a number of amendments to this schedule—it has been renumbered; it was Schedule 17 but is now Schedule 18—in Committee, but I have decided to stick with just these three. I apologise that there are three; there is only really one, of course, but the schedule is drafted in such a way that everything has to be said three times. This amendment effectively relates to high-protein, low-sugar bars. Noble Lords may wonder why I have developed an interest in such bars; to answer that, I will tell them a story. That is all I am going to do. I will tell noble Lords a story about a real business; I will then ask my noble friend the Minister a question.

--- Later in debate ---

Therefore, I hope that my noble friend can withdraw his amendment, and that other noble Lords will not move theirs when they are reached.

[Lord Moylan (Con)]

My Lords, especially at this time of night, it is very taxing to try to summarise what is a complex debate raging across a number of issues, and in particular to thank everyone who has spoken. If I fail to thank everybody by name, I hope I will be forgiven in the interests of brevity, but I thank my noble friend the Minister again, not only for her remarks but for the attention, care and hard work she has put into addressing all these issues with me and many other noble Lords who have spoken on the various topics we are addressing.

I have to thank one or two other noble Lords. In particular, I express my gratitude to the noble Lord, Lord Krebs, who went out, no doubt at considerable personal risk and with some arduousness, to purchase an example of the Grenade Carb Killa. I had never seen one in captivity or in nature until he produced it in the Chamber today. That in itself is something I am very grateful for. He chose the one that I think is called “white chocolate” or something like that.

Here the noble Lord, Lord Krebs, has been helpful to me. I believe there are 14 different flavours of Grenade Carb Killa. It is the view of the confectioner that manufactures them that some will comply with the profiling model while others will not. Perhaps next time the noble Lord could try a different flavour and have it tested in Liverpool, I think it was, and that would generally help to advance things. The difficulty for the company, though, is that this is not a game. It needs to know which of these products has to be reformulated and how for it to remain compliant and stay in business. This was a very helpful illustration of the difficulties.

One other noble Lord I will mention is my noble friend Lord Bethell, who referred to the tobacco advertising ban as if it were some sort of comparison. There is no comparison. Nobody had to carry out a profiling exercise to decide whether something was a cigarette: it was a cigarette or it was not. There was no question of putting it through a model to discover it was a cigarette. Nobody in the cigarette manufacturing business had to reformulate their product and market test it to make it compliant with regulations. What you can do with a tobacco ban very quickly is simply irrelevant to the hurdles the Government are setting in front of businesses.

Apart from that, the many noble Lords who spoke on other aspects of the Bill, some with great knowledge and experience, have illustrated something that I hope everyone in the House can agree on, with the possible exception of my noble friends on the Front Bench: it really is a crying shame that issues of such importance and complexity should be rammed into a major Bill in a schedule when in fact it must be clear to us all now that this schedule should really have been a Bill in its own right, and should have received the attention and scrutiny these complex commercial and nutritional issues deserve. With that, I beg leave to withdraw my amendment.

Amendment 148 withdrawn.

Health and Care Bill

Lord Moylan Excerpts

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

Moved by

[Lord Moylan]

166: After Clause 164, insert the following new Clause—
“Guidance on Pancreatic Enzyme Replacement Therapy
(1) The Secretary of State must, within six months of this Act being passed, publish national guidance making the appropriate prescription of Pancreatic Enzyme Replacement Therapy a priority within pancreatic cancer care in the NHS through the implementation of national targets.(2) The Secretary of State must, within a year of this Act being passed and every year thereafter, publish data on the prescription of Pancreatic Enzyme Replacement Therapy for pancreatic cancer patients.”

[Lord Moylan (Con)]

My Lords, pancreatic cancer is a terrible disease, as noble Lords know: 10,500 people in the UK a year are diagnosed with it, 9,000 people a year die from it and five-year survival rates in the UK rank us 29th out of 33 countries with comparable data. The Government recognise that this is not good enough, so they are commissioning an audit of existing services as a first step to improvement. That is wholly welcome but it is turning out to be a very slow business, with the first data expected in 2023 and no timetable for action to follow.

Amendment 167 in my name is intended to add a sense of urgency to that. I am grateful for the support it has received from the noble Lords, Lord Aberdare and Lord Patel, and the noble Baroness, Lady Hayman of Ullock. However, I turn my attention this evening principally to Amendment 166 in my name, which is also supported by the noble Baroness, Lady Finlay of Llandaff. It relates to improving the treatment of those diagnosed with pancreatic cancer and can be delivered immediately.

The end-of-life experience of pancreatic cancer sufferers includes huge difficulties in eating and digesting food, because of the lack of an enzyme normally produced by a healthy pancreas. Pancreatic enzyme replacement therapy, or PERT, is a simple tablet costing only £7 a day. It is fully approved by NICE and allows sufferers to eat, but it reaches only about 50% of pancreatic cancer sufferers. Why is that? The truth is that we do not know exactly and, pending the audit, may not be able to say exactly. But a likely reason is that diagnosis of pancreatic cancer occurs so late because the symptoms present so late that a prompt decision has to be made about those who might be saved by surgery and those for whom nothing can be done. The former go to specialists, who tend to be aware of PERT and prescribe it. The latter, on the whole, move into more general palliative settings, where it seems that knowledge and understanding of PERT is less widespread.

Amendment 166 obliges the Government to make increasing prescription rates for PERT a national priority, without waiting for the outcome of the current audit. It was tabled in Committee and got a somewhat dusty answer from the Government Front Bench, hence its return today. To say that emphasising PERT should await the outcome of the audit would be to condemn literally tens of thousands of people to unnecessary suffering at end of life so I think these amendments, especially Amendment 166, will find general support across the House. Happily, I understand that my noble friend the Minister will be able to offer certain assurances when he speaks that would make any such Division unnecessary.

Before I conclude, there is one extra step that the Government could make early progress on that would be welcome. It is in disaggregating the data about the prescription of PERT, which can be prescribed for conditions other than pancreatic cancer. While the Government and the National Health Service are able to point to figures showing slowly increasing PERT prescription rates, what they cannot do at the moment is to say whether it is being prescribed for pancreatic cancer or some other condition. Disaggregating that data will be an important job for the Government to do, even to make progress with their own audit. Some comments on that today would also be welcome so, for the moment, I beg to move.

[Lord Aberdare (CB)]

My Lords, I am pleased to speak in support of Amendments 166 and 167 in the name of the noble Lord, Lord Moylan, addressing pancreatic cancer, to which I have added my name. I shall be brief as he has already made the case for these amendments so strongly. Both amendments include deadlines: for guidance on pancreatic enzyme replacement therapy to be published within six months; for data on PERT prescription to be published within a year, and yearly thereafter; and for a report on the audit of pancreatic cancer services to be laid before Parliament within six months and updated six-monthly. The reason for these deadlines comes down to a single word: urgency.

On average, pancreatic cancer sufferers live for only six months following diagnosis and more than half of the 10,000 a year will die within three months. That is hardly enough time for them to say proper goodbyes to their family and close friends, let alone to put their financial and other affairs in order, so the usual government timescales of “in due course” or even “shortly” are nowhere near fast enough for action to improve their treatment. I hope we may hear something more encouraging from the Minister.

Some such improvements may help extend their lives, even if only by a matter of months, but others equally important, such as PERT, may make a significant difference to the quality of the time remaining to them, however short. PERT enables pancreatic sufferers to digest their food; in some cases, it may even help them to gain the strength needed to undergo life-saving surgery. It is recommended by NICE and widely available. It costs just £7 a day per patient. I find it shocking that, as the noble Lord told us, half of patients who need PERT are not being prescribed it, mainly because of lack of awareness among non-specialist staff. Surely the Government can and should investigate and address this with urgency, as required by Amendment 166.

--- Later in debate ---

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

I thank noble Lords for bringing forward this further debate on the subject of pancreatic cancer services. I begin by confirming that the pancreatic cancer audit is included in the national cancer audit collaborating centre tender, which is currently live. Reporting timelines are included in the specification for this audit, developed in partnership with NHS England and NHS Improvement. However, I hope noble Lords will understand that, during a live tender, the document is commercially sensitive and cannot be shared beyond the commissioning team, as this would risk jeopardising the procurement process. While I recognise that it may be disappointing that I am unable to confirm the timeline for the pancreatic cancer audit until the procurement process is completed, I can say that the future contract to follow the procurement process in relation to the clinical audits is anticipated to start this autumn.

The normal process for a new national audit is a year of development and set-up, followed by data collection and analysis. The publication of the data would then follow. However, on a more positive note—and I hope my noble friend Lord Moylan considers this response less dusty—I can confirm that, alongside the audit of cancer services, important actions are being taken to ensure that clinicians are able to take informed decisions. NHS England and NHS Improvement have ensured that guidance on pancreatic enzyme replacement therapy is shared with cancer alliances to disseminate to clinical teams in their area. NHS England and NHS Improvement will also continue to work with Pancreatic Cancer UK to raise awareness among the clinical community about the value of PERT for many patients with pancreatic cancer.

Noble Lords will be aware that NICE has a clinical guideline, NG85, recommending that PERT should be offered to patients with inoperable pancreatic cancer, and that NICE has also included PERT in its quality standard on pancreatic cancer. NICE clinical guidelines are developed by experts based on a thorough assessment of the available evidence, but they do not replace the judgment of healthcare professionals. They are not mandatory, but they represent best practice. The NHS is expected to take them fully into account in ensuring that services meet the needs of patients. Ultimately, the use of PERT in individual cases is for clinical decision-making, following a discussion between doctor and patient. As such, national targets would not be appropriate.

My noble friend asked another question on data. PERT prescription data is already published online through the English prescribing dataset. This shows that levels of prescription have been rising. The data does not currently differentiate between prescription for pancreatic cancer patients and for people with other conditions. However, NHS England and NHS Improvement will consider PERT prescription data during the scoping of the pancreatic cancer audit.

I end by thanking my noble friend Lord Moylan for his constructive engagement and for pushing the Government on this. But I hope that the reassurances I have given are sufficient to persuade him to withdraw his amendment.

[Lord Moylan (Con)]

My Lords, I am very grateful to noble Lords who have spoken, particularly the noble Lord, Lord Aberdare, and the noble Baronesses, Lady Finlay of Llandaff, Lady Walmsley and Lady Thornton. I know that support for the principle behind these amendments is widespread throughout the House. The Minister has also taken that on board, and I am grateful to him not only for his engagement before this short debate but for the words he uttered from the Dispatch Box. He will be in no doubt that noble Lords will be paying attention to these prescribing rates in the future, carefully following what is happening, monitoring and asking questions to ensure that the information is getting to clinicians and that the medicines are getting to the patients who will benefit from them.

Before I sit down, I want to say a word of thanks to the excellent charity Pancreatic Cancer UK, with which I have worked on this and which I know also works with officials at the department to improve treatment for pancreatic cancer patients. I will test my licence a little further by saying that it is not only pancreatic cancer; there are also conditions such as bile duct cancer, which are just as devastating and which we, as a nation and a National Health Service, need to bring to the fore so that people get better treatment, better care and early diagnosis. We really can do this.

With that, I express gratitude to my noble friend the Minister and the other noble Lords who have spoken. I beg leave to withdraw the amendment.

Amendment 166 withdrawn.

Health and Care Bill

Lord Moylan Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

[Lord Moylan (Con)]

My Lords, I rise briefly to support the amendment in the name of my noble friend Lady Eaton. I listened very carefully to what my noble friend the Minister said about protections and safeguards offered by the NHS, and the system of abortion provision to young people. But it seemed to me that those safeguards related principally to pregnant children up to the age of 16. There is a gap here, because the age of 18 is important in this debate, and it does not seem to be covered. As the noble Lord, Lord Morrow, said, it was only last night that an opposition amendment said that, in the case of child refugees, the Government must give priority to the best interests of the child—and, as I recall, that amendment was passed and is now back in the Bill. But “child” was defined in the amendment as a person under the age of not 16 but 18. So the best interests of the refugee child must take priority but the best interests of the pregnant child are not even mentioned anywhere in the amendment.

If I recall correctly, only last week we were debating a Private Member’s Bill—but one which I believe had government support—which would raise the permitted age of marriage to 18. Marriage is a natural law right, and also arguably a convention right, because there is a right to a family life, but, correctly, we are allowed to moderate how that right is implemented and affected by putting age restrictions on it. We may decide that 16 is an appropriate age or that 18 is an appropriate age; these are all perfectly legitimate decisions to make. But if our movement is in the direction of saying that 18 is the age at which you should be allowed to marry, it seems to me that there is a huge gap in the amendment in Motion N, which my noble friend Lady Eaton is doing her best to correct.

I regret that my noble friend has said that she is not going to move to a vote, so I am left to ask my noble friend the Minister whether he can explain to me, when he replies, what it is that the Government see as being the means of safeguarding pregnant children between the ages of 16 and 18, who are regarded so carefully in relation to other types of protection that are debated in this House and command widespread cross-party support but seem to have fallen through the traps here.

[Baroness Thornton (Lab)]

I shall be very brief, because it is time we draw this ping-pong session to an end. First, I congratulate the Minister on his introduction to the tele-abortion amendment, and on the reassurance that he gave to the House and the noble Baroness, Lady Eaton. The issue has been expressed very eloquently by the noble Baronesses, Lady Sugg and Lady Barker, and I have no intention of going into detail.

The only other matter before us right now on which we need to take a decision is that of the amendment put by the noble Lord, Lord Crisp. From these Benches, I need to say that we absolutely support the noble Lord in his amendment, and we will vote with him, if he divides the House.