The Long-term Sustainability of the NHS and Adult Social Care

Lord Ribeiro Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, as a member of the committee I join others who have expressed their thanks to the noble Lord, Lord Patel, for producing the report and getting us to where we are today. It is a landmark report and a wake-up call to government to take notice and to act.

When I introduced my Private Member’s Bill on banning smoking in cars with children present, I was accused of invoking the nanny state. We have heard about that today. The Children and Families Act became law in 2014, and the regulations included penalties for the offence. The Mirror newspaper last year branded the ban an absolute failure because of only one conviction in two years. The DoH response was:

“The measure of success is the change of behaviour, not the number of convictions”.


I agree with that.

Recommendation 29 of our report asks the Government to mount a nationwide campaign on obesity and to highlight the many complications that arise from it and its links to chronic disease. It should include the selling of food and drinks and the advertising of junk food before the 9 pm watershed to protect children and support parents.

I will focus on the public health and prevention aspects of our report. The WHO identifies the four most important risk factors for non-communicable diseases as tobacco use, physical activity, the harmful use of alcohol and unhealthy eating. My noble friend Lord McColl will have dealt with obesity, as he has been a champion of this cause for many years. I hope that in his absence I can say a little on obesity and the surgical treatment of the condition. I will also speak on the impact of smoking, despite its falling prevalence, which was estimated in 2015 to cost the NHS £2.6 billion and is a major cause of preventable premature death, with some 80,000 deaths a year. I will end with alcohol which, with obesity, causes significant liver disease.

The Government are to be congratulated on introducing the soft drinks industry levy, or sugar tax, this month. This is a success story that they should be proud to claim. It was estimated that £520 million in tax revenue would result. However, since its announcement in 2016, 50% of manufacturers have reformulated their products to avoid the levy and the current estimate is £240 million. No matter—it has had the desired effect and goaded industry into action to reduce sugar in its products. There can be only one winner, and that is our children and grandchildren. That is what I call a “nanny state” at work—and, ironically, a Conservative nanny state.

It is estimated that, in England alone, a third of our children are obese or overweight when they leave primary school, and it gets worse as they progress through senior school, where there is evidence that 80% of obese children will become obese adults. Obesity is associated with 10 types of cancer, of which breast and bowel cancer are top of the list. So it is not just about size but about the metabolic health problems that lie in store for obese children.

Soft drinks levies work: they have done so in France, Denmark, Finland and Hungary—even though people remain sceptical about its effects in Mexico, where it was introduced in 2014 and has not affected the poor there as much as was expected.

We have the second-largest obesity epidemic in Europe, and the sixth-largest globally. A Cochrane review of 22 randomised controlled trials of bariatric surgery found it to be more effective and cost effective for treating severe obesity than non-surgical methods after two years. Long-term trials favour surgery. So why are others in Europe doing more as we do less? We are 13th out of 17 in EU countries and sixth in G8 countries for performing bariatric surgery. France, with a similar population to that of the UK, does 37,000 cases a year. Belgium, with a population of 11.3 million, does 12,000 per year. The UK does 5,000.

Surveys by the Royal College of Surgeons and the Metabolic Surgery Society suggest that some CCGs are not commissioning surgery unless a patient’s BMI is more than 50. This is unsafe and puts patients at risk when they finally earn their surgery. About 2.6 million people in the UK meet the NICE criteria for bariatric surgery. We cannot operate on them all, so the NHS must target patients with high BMIs and those with type 2 diabetes. What are the Government doing to increase the rate of bariatric surgery and to reduce the variation in access across the UK?

Another area touched on earlier is the effect of the sugar tax on the nation’s teeth and, in particular, on our children’s teeth. I spoke in the debate on the Queen’s Speech on the staggering amount of sugar—practically their own body weight—that children can consume in a year. It is time that something was done. To protect our children, the money from the sugar tax should go to nurseries, schools and breakfast clubs to help children brush their teeth and look after them. This is because Public Health England has shown that 141 children a day have their teeth removed in hospital due to dental decay. We should encourage schools to go sugar free, perhaps excluding special occasions such as birthdays.

On alcohol, policies should tackle affordability—hence the need for minimum unit pricing; availability, especially where minors are concerned; and marketing and distribution. A minimum unit price of 50p would have a major effect on white drinks—the cheapest alcohol products which cause the most harm, such as cider—without impacting on the price of drinks usually served in bars and restaurants. The health effects of alcohol abuse cost the NHS £3.5 billion per year. It is possible to exceed the guidance of 14 units per week for less than £2.50. There were 1.1 million alcohol-related admissions to hospitals in England in 2016.

This debate is limited in time. I had prepared something a little bit longer, so I will have to draw it to a close. With alcohol, it is important to focus on reducing demand rather than merely increasing NHS funding. This applies in areas that I have discussed, such as obesity, alcohol and smoking.

Finally, on the matter of public health and prevention, it is important to consider how future generations can take responsibility for their own health and contribute financially to their long-term care. The Prime Minister at PMQs in February 2017 said that,

“we do need to find a long-term, sustainable solution for social care in this country”.—[Official Report, Commons, 8/2/17; col. 420-21.]

As the Secretary of State said in his evidence to us:

“The reality is that putting in place longer-term incentives so that people save more for their social care costs will not make a material difference for decades, but it is still the right thing to do”.


I believe that he is right. Mention has been made of the Japanese and German schemes, and we referred to them in our recommendation 23. I passionately believe that those over the age of 40 should make some contribution to their long-term care.

As a colorectal surgeon, I relied on bowel cancer screening and colonoscopy to detect early colonic and rectal carcinomas. Sadly, far too many patients presented late, with evidence of disease in other organs, making surgery palliative at best. We need more cancer specialists, colonoscopists and pathologists to screen our growing elderly population. The noble Baroness, Lady Redfern, referred to faecal immunochemical testing for bowel cancer. When is that likely to be introduced UK-wide, as it was meant to be this month?

The Government are to be congratulated on introducing the sugar tax to deal with obesity and dental cavities, and the smoking regulations to protect our children from second-hand smoke. Now they must do more to tackle alcohol abuse and, in particular, cheap alcohol by introducing a minimum unit price.