All 7 Lord Rennard contributions to the Health and Care Act 2022

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Lord Rennard Excerpts
Lord Rennard Portrait Lord Rennard (LD)
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My Lords, last Friday, we had an excellent Second Reading debate on the Private Member’s Bill of the noble Lord, Lord Young of Cookham, on cigarette stick health warnings. As the noble Lord, Lord Kamall, said then, we have made progress over the past two decades, with a range of measures to help smokers quit and to prevent future generations using tobacco. But there is much more to be done. Smoking is responsible for the half the difference in life expectancy between the richest and the poorest in our society. There are still over six million smokers in the UK, and at current rates of decline we will miss the Smokefree 2030 deadline by five years nationally and by 17 years in the most deprived communities. So, further measures are necessary if we are to reduce health inequalities and increase healthy life expectancy, both of which are government manifesto commitments.

The detail of what is required is set out in the latest report from the All-Party Parliamentary Group on Smoking and Health, of which I am a member. I am pleased that the Government have committed to considering its recommendations for the forthcoming tobacco control plan. However, as the Minister told us on Friday that publication of the plan has been delayed from July 2021 to some time in 2022, amendments to this Bill are needed to accelerate progress in reducing smoking prevalence and to deliver the Government’s Smokefree 2030 ambition.

The Minister will not be surprised to hear that I and others will table amendments to this Bill to consult on the introduction of a “polluter pays” levy on tobacco manufacturers, to fund lifesaving measures to help smokers quit and prevent youth uptake, to close loopholes in existing regulations and to ratchet up regulation of tobacco through measures such as the proposal from the noble Lord, Lord Young, to put health warnings on cigarettes themselves.

In all debates about health and social care, we spend a great deal of time discussing the costs of the increasing demands upon the system, but probably too little agreeing measures to curb the rising level of those demands. Better education and greater information about health issues is vital, but funding for public health issues has not been protected in recent years in the same way as the costs for treating the consequences of illnesses. Personally, I wish there had been much better education about diet and greater understanding of the importance of physical education in my youth. I should have learned more about issues connected with diabetes before I was diagnosed with the condition.

Across the UK, the number of people diagnosed with diabetes has doubled in the last 15 years and it is estimated that the costs associated with it account for 10% of NHS expenditure. We need to support the provisions in the Bill on restricting the advertising of less healthy food and drink and recognise the importance of these measures in reducing the significant harms that can come from diabetes. People struggling with obesity and diabetic control, children especially, are not helped by the advertising of foods that are high in fat, sugar or salt. We need to strengthen nutrition labelling requirements.

For people with diabetes who need insulin, which includes all type 1 diabetics, we need to address the short-termism that denies many of them access to continuous glucose monitoring systems and technology such as insulin pumps that can help them to maintain good diabetic control. Complications from poor diabetic control can include heart attacks, strokes and amputations, as well as kidney damage, loss of eyesight and mental health problems.

In 2017, the report produced by the Medical Technology Group showed that

“80% of the cost of Type 1 diabetes is spent on treating complications—many of which are avoidable.”

We all know that the NHS is under many great pressures, but we can reduce those pressures by reducing the number of people in hospital and by looking to increase investment in technologies that help people with diabetes to improve their control.

Health and Care Bill

Lord Rennard Excerpts
Lord Bishop of Carlisle Portrait The Lord Bishop of Carlisle
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My Lords, I will speak on behalf of my noble friend the right reverend Prelate the Bishop of London. She has added her name to Amendment 65, and we on these Benches support the other amendments in this group that seek to reduce health inequalities. As we have heard, these amendments would help to ensure that the Bill does not forget the underserved and disadvantaged in our society, many of whom have been mentioned already.

In the Christian and Jewish faiths, there is a Biblical concept—shalom—which embodies a sense of flourishing, generosity and abundance. Shalom can be summarised as experiencing wholeness, or a state of being without gaps. This is reflected in the World Health Organization’s definition of health, which is about not only the absence of disease but mental, physical and social well-being. It is a vision for individuals and for the whole of society. Our efforts to design a more holistic health service are, in effect, aimed at achieving that sort of shalom. We see this clearly in the decision made to place 42 integrated care systems across the country. What is not yet apparent is the relationship of these systems and boards to the wider community.

This Bill must seek to involve local communities—and not just professionals—in the reduction of health inequalities. These amendments highlight the monitoring of both physical and mental inequalities, take account of the experiences of young people and children and place more emphasis on the strength of local interventions to help reduce and prevent health inequalities. I commend them wholeheartedly to your Lordships’ House and to the Minister.

Lord Rennard Portrait Lord Rennard (LD)
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My Lords, I rise in support of these amendments, in particular Amendment 66 in my name and those of the noble Lords, Lord Young of Cookham and Lord Faulkner of Worcester.

This amendment would expand the duties of integrated care boards. We want them to exercise their functions with respect to reducing inequalities relating to

“modifiable risk factors, such as smoking.”

Our aim is to help the Government achieve their manifesto commitments to reduce health inequality, level up and increase healthy life expectancy by five years by 2035. This amendment would mean that integrated care boards would have a responsibility to reduce inequalities in access to health services and the outcomes achieved. They would also be responsible, in consultation with partners such as local health and well-being boards, for drafting joint five-year plans to explain how they would discharge their responsibilities, including those to reduce inequalities.

At present, there are significant inequalities in both patient access to health services and in the outcomes achieved. The biggest causes of inequalities in health outcomes are behavioural risk factors, such as smoking, obesity and alcohol. As the noble Lord, Lord Young of Cookham, said, smoking alone is responsible for half the difference in life expectancy between the richest and poorest in society. It is a greater source of health inequality than social position and it remains the leading cause of premature death in this country.

We all hope that the integrated care systems will contribute significantly to reducing inequalities in smoking and other behavioural issues, but they are likely to succeed only if addressing such modifiable risk factors becomes a core function of the NHS, working in collaboration with local authorities. Amendment 66 would ensure this.

The difference in healthy life expectancy between those living in the most and least deprived areas of England is around 19 years for both men and women—in other words, almost two decades. Let us look at one place in particular. As measured by the index of multiple deprivation, Blackpool is, sadly, top of the table of the most deprived local districts in the country. Over the last decade it has consistently had one of the highest smoking rates in the country, at over 20%. Most distressingly, more than 20% of mothers in Blackpool are smokers at the time they give birth. So our amendment is needed because the recently published NHS inequalities strategy—which is impressive in parts—does not address the behavioural causes of health inequalities. In fact, it says nothing about them at all.

The Government’s inequality strategy sets out five clinical areas that are crucial to improving health outcomes for the poorest 20% in society. They are chronic respiratory disease, serious mental illness, early cancer diagnosis, maternity and—last but not least—identifying people with high blood pressure who need to be pre-treated to prevent heart attacks and strokes. In all these areas, behavioural factors such as smoking, obesity and alcohol very significantly increase the dangers to health. If appropriate action is taken, it can greatly improve patient outcomes and, at the same time, reduce pressure on our NHS.

To take just one example, chronic respiratory disease is caused primarily by smoking. It is estimated that smoking is responsible for 90% of chronic obstructive pulmonary disease, but one-third of patients diagnosed with COPD carry on smoking. There is nothing in the NHS England inequalities strategy about this, and no target for reducing smoking rates among those with chronic respiratory disease. Yet stopping smoking is the most effective and cost-effective treatment. Only by quitting smoking can those with COPD prevent further decline in lung function.

Smoking, obesity and alcohol are also causally linked to cancer and hypertension. People with mental health conditions die on average 10 to 20 years earlier than the general population. Smoking is the single largest factor in this shocking difference. The question we must therefore ask today is this: given that modifiable behaviour risk factors are core to all five identified clinical focus areas, why are they not included in the NHS England inequality strategy? Perhaps it is because the Government do not see addressing these population-level health risk factors as a core responsibility of the NHS.

Health and Care Bill

Lord Rennard Excerpts
Lord Rennard Portrait Lord Rennard (LD)
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My Lords, I draw the Committee’s attention to my registered interests in healthcare equipment. I have added my name to Amendment 50, moved by the noble Lord, Lord Black of Brentwood. The noble Lord, Lord Hunt of Kings Heath, demonstrated clearly, as have others, that it simply cannot be said that the amendment is unnecessary.

The recent report on fracture liaison services from the APPG on Osteoporosis and Bone Health makes important reading. It shows clearly that the health and independence of tens of thousands of older people who suffer from osteoporosis are threatened by great inconsistencies in accessing vital services and treatment. Far too many people are suffering multiple fractures before their condition is properly diagnosed. Much unnecessary pain is caused and more permanent disability results from failures to diagnose osteoporosis in thousands of cases. Those failures add significantly to the future costs of the NHS and care system than would have been the case with early diagnosis.

The Committee has already heard from the noble Lord, Lord Black, of the significant cost savings to the NHS where a fracture liaison service is in place. The Royal Osteoporosis Society estimates that extending fracture liaison service provision to cover the whole population would require a modest initial investment of about £27 million in England and £2 million in Wales. There should be much more long-term cost-benefit analysis of provision such as this, and it would more than justify those sums of expenditure.

There are many examples in preventive healthcare where focused interventions dramatically improve outcomes for patients and cut long-term costs. We need to raise awareness of conditions such as osteoporosis, provide more education and training for healthcare providers about diagnosing it and increase support for people who suffer from it. Osteoporosis is a long-term condition. It is more prevalent than many people realise and we should all recognise that a spinal or hip fracture is equivalent to a heart attack or stroke in terms of its clinical implications. Fractures are often preventable through use of pharmacological treatments supported by lifestyle modifications, which include appropriate exercise and smoking cessation as well as nutritional supplements such as calcium and vitamin D.

There needs to be much greater public awareness of how to maintain or improve bone health, particularly for the most at-risk populations. The introduction of integrated care boards will provide an opportunity to better co-ordinate and integrate fracture prevention and osteoporosis care. It is currently too dispersed across different parts of the system, as so often our short debate on this group of amendments has shown is the case. For fracture liaison services we need universal access. We need a clear mandate from government that the new boards have a specific responsibility to provide fracture liaison services for the whole population.

Health and Care Bill

Lord Rennard Excerpts
We need Amendment 72 in order to provide greater certainty for patients to be able to choose elective care providers, to reduce the enormous backlog of treatment and to send a message to NHS staff about the rights of patients. I hope that the Minister will accept these arguments and will be able to answer my questions. I beg to move.
Lord Rennard Portrait Lord Rennard (LD)
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My Lords, I support Amendments 109 and 226 in this group, both of which are in my name and that of the noble Lord, Lord Hunt of Kings Heath. I will address them from the perspective of people with diabetes and with the support of the Juvenile Diabetes Research Foundation and Diabetes UK.

It is just over 100 years since insulin was discovered. Before 1921, a type 1 diabetic would live for no more than a year or two from when the condition became discernible. In the 1920s, my father, a World War I veteran, developed diabetes, and he was very fortunate that this was the decade in which insulin was discovered. It was so successful that it enabled him to have a long and happy life—indeed, I was born when he was 71, and my younger brother was born when he was 73.

Much progress has been made in the treatment of diabetes over the last 100 years, but we are not making the most of technological developments relating to insulin use and diabetes management. I have struggled with these issues myself, and I have learned much about them since I became dependent on insulin in 1994. I personally have enormous reason to be grateful to the diabetic team at St Thomas’ Hospital, just over the river from us, but not everyone with diabetes gets that standard of care, and progress with the adoption of the most recent technology is simply too slow.

There have been great developments in wearable medical technology, such as insulin pumps, flash glucose monitoring and continuous glucose monitoring. We are making progress with such innovations and in NICE’s obtaining approval for them, but they are often not widely accessible. Access to technology, including linking a person’s insulin pump and a continuous glucose monitor, may help a person to self-manage their condition in the absence of routine NHS support. The long-term cost savings are demonstrated by the wider use of such technology in insurance-based systems, where the outlay must be justified by reducing the costs of later complications, which can be very considerable.

Diabetes probably now takes up 10% of the NHS budget, and 80% of the cost of diabetes relates to complications, with the largest costs arising from excess in-patient days, cardiovascular disease and damaged kidneys and nerves. The latest technology may enable parents of young people with type 1 diabetes to obtain a full night’s sleeping soundly, knowing that their child’s glucose monitor will issue an alarm and wake them up if they experience a severe high or low-glucose episode. New technology has been shown to support blood glucose stability and to lower average blood sugar levels, reducing potential health complications and hypos or hypers, which can lead to coma or even death if not treated. There are great benefits to physical and mental health from better long-term control of blood sugar levels.

Research by JDRF shows that barriers to the uptake of this technology include the fact that many clinicians are not trained in it and that the pressure on appointments means that there is often not time to discuss treatment options. Amendment 109 would require NHS England’s oversight framework for integrated care systems to include a metric on the percentage of diabetes patients in their area accessing diabetes technology. An embedded requirement that would better support the prescription of technology would incentivise better training for clinicians and encourage more time to be provided in appointments to discuss technological treatment options and any potential fears or concerns of the patient.

Amendment 226 concerns the promotion of self-management using the latest technologies. We need it in order to reduce the number of people with diabetes suffering from complications, which may include sight loss and problems with their feet, presently resulting in around 6,000 amputations per year. When in hospital, people with type 1 diabetes require five times more secondary care support than people without diabetes, so it is essential that the NHS invests in technology that can significantly reduce the instances of hospitalisation and adverse health outcomes for people with type 1 diabetes.

Lord Lansley Portrait Lord Lansley (Con)
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My Lords, I thought those were very interesting and helpful remarks from the noble Lord, Lord Rennard. They serve to remind us of the importance of self-management in securing the best possible outcomes for patients. I just add the thought that, when the Government promulgate regulations relating to patient choice, one of the things we want to include is shared decision-making between clinicians and patients. In my observed experience, that too can deliver better outcomes. I think we have made significant progress in recent years in encouraging shared decision-making, and I hope we will see that come forward.

In moving Amendment 72, the noble Lord, Lord Warner, touched on a range of issues. I will not go down one or two paths, but I highlight that we will need to think hard about the interconnections between the question of patient choice and how far patients continue to be given choice. We need to ensure that it is not just talked about in the constitution or in regulations that say it is generally a good thing. For choice to happen in practice, subsequent clauses in the Bill relating to procurement, such as Clause 70, need to enable a choice of providers. The noble Lord made that perfectly clear.

The clause relating to payment systems—Clause 68, if my memory serves me correctly—still needs to have a “money follows the patient” approach. It is not me saying that these are all good things; they were put in place by the Blair Government, not the coalition Government, who did not do away with them but entrenched them.

I am worried. I will just make this point about Clause 70, the effect of which is to repeal Section 75 of the 2012 legislation. Included within that was that one of the requirements of the procurement regulations would be to support the right to patient choice, and the Government are proposing to repeal that.

The Minister may well, perfectly correctly, say, “That may be so, but we have the power in this Bill to set regulations relating to patient choice”, but this is separate, and, in the event, we may find that the link is broken between procurement and payment and patient choice. The net effect would be that patient choice is vitiated. I am worried, for exactly the reasons that I think the noble Lord, Lord Warner, is worried, that what has been around for some 18 years in one form or another—the expectations on the part of patients that they can exercise choice—may not be able to be exercised in practice because the preference of the NHS in many of these localities is to operate as a monopoly and not to give any opportunities for that choice actually to function.

Our debate on this group would be far better and easier to have—and might not even be needed—if the Government published the regulations under Clause 68 in draft so that we can see what they are proposing to do. They have not done it; between now and Report they could do it. When we get to Report, we are going to have a very difficult—certainly from my own personal point of view—set of conversations about how patient choice is to be exercised, how the NHS is to get best value from its procurement, and how trusts and providers are to be paid appropriately, rather than simply go back to block budgets. How do we get out of that debate? The answer is: let us see what the regulations the Government are proposing—in this case relating to patient choice—actually look like, and let us see it before Report.

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Lord Rennard Excerpts
We have an industry that, along with other industries, is harmful to people to some degree, but we are talking about adults. In our society, adults can choose what they do. I do not gamble, but I am quite sure that some Members of this House do. That is equally addictive and is taxed. We should tread very carefully in treating our adults of 18 as if they were young children.
Lord Rennard Portrait Lord Rennard (LD)
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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 Portrait Lord Moylan (Con)
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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.

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Lord Rennard Excerpts
Lord Young of Cookham Portrait Lord Young of Cookham (Con)
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My Lords, it is a pleasure to follow the noble Lords Lord Crisp and Lord Faulkner in support of these amendments, which replicate the amendment I moved in Committee. They set out proposals for a statutory smoke-free 2030 fund, based on the polluter pays principles, to pay for measures to end smoking. We are grateful to both Ministers for the time that they spent with us on a Zoom call last week, when we sought to persuade them of the merits of these amendments, and time alone will tell whether those representations bore fruit.

In Committee, my noble friend Lord Naseby, whom I see in his place, suggested that these proposals had been consulted on in 2015, and that the Government had concluded they were not workable, a conclusion which he said had been reiterated by the Exchequer Secretary on 10 January 2022. While my noble friend was right to say that the Government consulted on the levy in 2015, they did not consult on the proposals before us today. What was consulted on then was an additional tax, and the decision was taken not to proceed because tobacco manufacturers and importers would pass the costs of a levy on to consumers; the Statement by the Treasury in January merely reiterated that conclusion. Back in 2015, the regulation of tobacco prices to prevent the costs of a levy being passed on to consumers was prohibited by the rules of the European Union. That is no longer the case, so the 2015 objection to the levy no longer holds true. The Government can now put the financial burden firmly where it belongs, on the polluter—the tobacco manufacturer— and not the polluted—the smoker.

Our scheme enables the Government to limit the ability of manufacturers to profit from smokers, while protecting government excise tax revenues, which is a win-win for the Government and for smokers. The scheme is modelled on the Pharmaceutical Price Regulation Scheme, the PPRS, which has been in operation for over 40 years and is overseen by the Department of Health and Social Care. It has teams of analysts who already have the skills to administer a scheme for cigarettes, a much simpler product to administer than pharmaceutical medicines.

Unlike corporate taxes, which are based on reported profits and can be—and indeed are—evaded, the levy would be based on sales volumes, as is the case in America, where a similar scheme already operates. Sales volumes are much easier for the Government to monitor and much harder for companies to misrepresent. Implementing a levy would not require a new quango to be set up, as the Department of Health and Social Care has all the expertise needed both to supervise the scheme and to allocate the funds raised. We would not be averse to the consultation mentioned in the amendment including other options, as long as it included careful consideration of our proposals.

The Government have said that they accept the polluter pays principle. My party has form in implementing that proposal through the landfill levy, the tax on sugar in soft drinks and requiring developers to pay for the costs of remediating building safety defects. Indeed, as we heard from the noble Lord, Lord Crisp, the Government promised to consider this approach to funding tobacco control nearly three years ago in the prevention Green Paper. Surely they should now welcome this opportunity to consider how it can be put into practice.

Lord Rennard Portrait Lord Rennard (LD)
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My Lords, I speak in support of these amendments, to which I have added my name, and which are in accordance with my party’s policy.

In Committee, there was almost universal support for dealing with health inequality issues, and there was widespread recognition that, as the noble Lord, Lord Crisp, said, half the difference in life expectancy between the richest and the poorest people in this country is caused by smoking. There are many ways in which we can further reduce the prevalence of smoking, and those of us who are members of the APPG on Smoking and Health set them out during the course of our debates.

However, we are concentrating today on just one key principle which is necessary if the Government’s target of reducing the prevalence of smoking to 5% or below is to be achieved by 2030. That principle is finding the funds to support smoking cessation and tobacco control measures through a levy on the tobacco companies. This would help to ameliorate the terrible damage done by their products, which includes shortening the lives of half the people who use them.

The funding for local authorities to pursue tobacco control policies such as smoking cessation services and enforcement and for national mass media campaigns has been cut significantly. Without the proposed levy, the NHS will face greater costs in future in dealing with the many issues, such as lung cancer and heart disease, which arise in part because of smoking tobacco.

Last month, together with other officers of the APPG on Smoking and Health, I had the pleasure of meeting Javed Khan, chair of the Government’s independent review into smoking. He listened carefully to all our proposals, particularly on the levy, and certainly understood the necessity of funding being found. The Government have asked him to say what the most impactful interventions that could be taken forward in the new tobacco control plan would be. He told us that if nothing different is done, the Government’s smoke-free target will not be met. He promised that his recommendations would be “bold and brave”, as I hope they will.

I expect that we will soon get some soothing words from the Minister. But before he replies to this debate, I ask him to consider how, in “Hamlet”, King Claudius has to admit that

“words without thoughts never to heaven go”.

I hope the Minister will give us not just warm words about tobacco control but confirm that the Government have thought about the tobacco levy and will undertake a formal consultation on it.

Lord Naseby Portrait Lord Naseby (Con)
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My Lords, I hasten to say to your Lordships that I do not smoke and have never smoked. In considering the amendments before us this afternoon, it is worth giving some of the official statistics rather than the aspirational ones. Smoking rates in England continue to decline year on year and that has been a trend for the last 30 years. According to the Office for National Statistics in 2021, smoking rates in England have declined significantly, from 20% in 2011 to 12% in 2020. The decline in the number of smokers has resulted in a reduction in the cost to the NHS of treating the impact of smoking. In 2015, Public Health England estimated that the total smoking-related cost to NHS England was £2.6 billion a year, when 18% of the population smoked. This figure and the corresponding cost to NHS England over the last five years have declined further, given the 12% smoking rate in England in 2020. According to NHS data published in 2019 on smoking, drinking and drug use among young people, the number of young people aged 11 to 15 smoking has declined dramatically, from 16% to just 5% in 2018. According to the Office for National Statistics in 2021, only 12% of 18 to 24 year-olds in Great Britain smoke, a major reduction from 26% in 2011 and the lowest smoking rate across all age groups except the over-65s.

By way of background, according to the most recent HMRC tax gap data, illegal smuggling and consumption of illicit tobacco cost Her Majesty’s Government £2.3 billion in lost revenue in 2019-20, a figure that remains unchanged from the fiscal year 2016-17, which reinforces the fact that the Government’s anti-illicit tobacco strategy is not working. It ought to be working, when you have a situation where a group of companies is working with the Department for Health and has done over many years. Frankly, it is a sad reflection on the status of HMRC that this illicit tobacco importation is increasing. You have only to look at what is happening in Dover or any of our other ports today to see why it is increasing. It is a pathetic and embarrassing performance at Dover at the moment, the net result being not just tobacco but illegal alcohol and so on coming in.

Now we look at the idea of a levy, something that has never been in the manifesto of a Conservative Government to the best of my knowledge. A levy on any company prescribed by government, even companies trading locally, certainly does not fit into the basic elements of our financial and economic strategy. If it was just a levy on cigarettes, there might be half a case, but this is on anything to do with tobacco. Most of all those other products have no effect on people’s health—they are a matter of enjoyment—but this idea goes across the whole lot. It has not been thought through.

It is all very well my noble friend Lord Young on the Back Benches saying that there was a consultation in 2015 on a levy on tobacco manufacturers’ profits and the Government concluded that it would be unworkable, but that was because we were in the EU so it has all changed now. I say to my noble friend on the Front Bench: I would have thought he had enough on his hands without introducing a complicated levy, but that is my personal view. There was an exchange between the Exchequer Secretary and the then shadow Exchequer Secretary, confirming

“that our position regarding the 2015 consultation stands. A levy would be a complex”—

this is not going to change—

“and costly way of raising money to fund tobacco control measures and would be unlikely to provide a stable revenue stream.”

I say to my noble friends on all sides of the House that tobacco manufacturers already invest hundreds of millions of pounds every year in R&D and highly skilled jobs to bring to market alternative smoke-free nicotine products. Some of your Lordships may use e-cigarettes, nicotine pouches or heated tobacco products. Further tax increases on manufacturers as a whole will have the effect of reducing that investment, which is not a very clever way forward.

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Baroness Fox of Buckley Portrait Baroness Fox of Buckley (Non-Afl)
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Well, good. I have got a few “hear, hears”.

Lord Rennard Portrait Lord Rennard (LD)
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Does the noble Baroness accept that a crucial difference is that organisations such as ASH are funded by organisations concerned with public health, including Cancer Research UK and people who deal with trying to save lives, while FOREST is funded by the tobacco industry, which kills half its customers?

Baroness Fox of Buckley Portrait Baroness Fox of Buckley (Non-Afl)
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I was coming on to that point. I would really appreciate a dose of honesty in this House. If those people who are so hostile to smoking a legal product believe that it is the killer they allege, they should call for smoking to be made illegal and be done with it. At the moment, tobacco companies are legal companies. People talk about them with such distaste, as though they should be abolished. It would be better and more heartfelt if they argued that tobacco should be illegal; then we would have a different debate. Public health is not always neutral when you talk about public health lobbyists, in my opinion. The freedom to choose to do something that is bad for your health is still allowed in a free society, despite some people wishing it was not.

Health and Care Bill

Lord Rennard Excerpts
Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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My Lords, I, too, support the noble Lord, Lord Crisp, in his amendment. My noble friend Lord Faulkner would of course have been in his place to speak in favour, but he is unable to be here, so perhaps I may make a few remarks which I think he might have made.

Going back to Report, the Minister suggested that the tobacco industry is already required to make a significant contribution to public finances through tobacco duty, VAT and corporation tax. But I do not think that states the case as accurately as possible, because we know that tobacco manufacturers are skilled at minimising the amount they pay. For example, between 2009 and 2016, Imperial Brands, the British company that is market leader in the UK, received £35 million more in corporation tax refund credits than it paid in tax. The largest amount of tax collected by the Government comes from excise tax and VAT. This, of course, is not paid by the manufacturer; it is passed on to the consumer. That was a point HM Treasury made in 2015, when the Government consulted but, alas, decided not to put an additional tax on tobacco products to pay for tobacco control.

My understanding is that, in total, smokers spend nearly £11 billion on tax-paid tobacco products, more than three-quarters of which goes to the Government in taxes. We know that the majority of smokers are not well off; they often suffer multiple disadvantages. We must compare that huge tax take with the pitiful amount that is actually spent by the Government encouraging people to stop smoking. It is certainly not enough to make England smoke-free by 2030.

I listened carefully to the Minister’s introductory remarks. The noble Lord, Lord Kamall, objected to the terms of the amendment of the noble Lord, Lord Crisp, because, he said, the independent review had not yet reported and therefore we were seeking to pre-empt what the review will say. I thought the noble Lord, Lord Crisp, responded to that incredibly well. I do not think he is seeking to pre-empt the review; his amendment asks the Government to consult on recommendations in the review if the Secretary of State thinks that it is required. It is left entirely in the Secretary of State’s hands to act according to whether he or she considers that the recommendations should be consulted on.

This is a sensible amendment, it points us in the right direction, and I hope that, even at this late stage, Ministers may be sympathetic.

Lord Rennard Portrait Lord Rennard (LD)
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My Lords, if I understood the Minister correctly in his introductory remarks, he was saying that the Government’s case against the amendment is that they do not want to consult on something to which they are not already committed. So what is the point of consultations if they are only on things to which the Government are already committed? Should the Government not consult on what they might do, and take into account the opinions of experts and others?

Amendment 85B, in the name of the noble Lord, Lord Crisp, has the support of these Benches. It is in accordance with my party’s policy but, more importantly, it is essential to the Government’s stated objective of reducing the prevalence of smoking to below 5% by 2030. The amendment does not require the Government to do anything that they do not want to do; it just asks them to consult on something which they have said that they would consider—namely, to make tobacco companies pay more towards helping save and prolong the lives of their customers.

Last year, I found myself outside the HQ of British American Tobacco. It is an enormous headquarters: it looked like a palace of which any Russian oligarch would be proud. This company makes huge profits that could be diverted towards ameliorating the damage done by its products. The amendment would mean taking action to help people live longer and more healthily, with fewer families living in poverty because of smoking.

I expect we will have more warm words from the Minister and from the Department of Health and Social Care, but I believe that Parliament wants to adopt the polluter pays principle in relation to tobacco. So I end with a quote from a great parliamentarian, John Pym, who, in 1628—I am sorry that I do not have the Hansard reference—said: “Actions are more precious than words”.