Health and Care Bill

Lord Young of Cookham Excerpts

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

The Government so far have argued that addressing inequalities is already implicit in the first aspect of the triple aim—the requirement to consider the effects of decisions on the health and well-being of the population. It has clearly not been obvious to many experts and charities scrutinising the Bill. However, if it is the Government’s intention to ensure that the reduction of inequalities is prioritised, they should make this explicit in the Bill.

[Lord Young of Cookham (Con)]

My Lords, this is my first contribution to the debate on the Bill and, listening to earlier exchanges, it struck me how many were being made by those who had either run the NHS as administrators or, indeed, as Ministers. I can join that happy band. I was a Health Minister in 1979 and put on the statute book the Health Services Act 1980, abolishing area health authorities. Nostalgia has overcome me, as phrases I used 40 years ago about streamlining the structure and making it more efficient have been recycled in debates on this Bill.

My first piece of health legislation followed the appointment of commissioners to run the Lambeth, Southwark and Lewisham Area Health Authority which was breaking its cash limits and behaving illegally. Unfortunately, our suspension was also illegal, and I had to pilot through the other place the National Health Service (Invalid Direction) Bill, with much hilarity at my expense from the Opposition. So, more than 40 years later, it is good to join in another debate about NHS reorganisation. Today’s debate about inequality was actually raised 40 years ago: noble Lords may remember the Black report on inequalities in health. I was rereading it last night and it struck me how many of the 37 recommendations made 40 years ago are still relevant today.

Mine is the lead name on four amendments, but I plan to say very little on Amendment 66 and leave it to the noble Lords, Lord Rennard and Lord Faulkner, to make the case for a specific reference to smoking as a key factor in reducing health inequalities.

As we have heard, the Bill gives integrated care boards a responsibility to reduce inequalities in access to health services and in health service outcomes. The biggest cause of inequalities are factors such as smoking, obesity and alcohol, particularly smoking, which is responsible for half the difference in life expectancy between the richest and poorest in society—an issue that was raised an hour ago during Oral Questions. Others will say more about the imperatives of tackling these hazards to health.

I will focus instead on Amendment 152 in my name and will also speak briefly to Amendments 156 and 157. These amendments are supported by the noble Lord, Lord Shipley, who will focus on housing and why legislation is necessary, and by the noble Baronesses, Lady Neuberger and Lady Watkins. I am grateful to Crisis, the homeless charity, for its briefing.

I commend the Government’s welcome commitment to tackle health inequalities and hope the forthcoming White Paper on levelling up will have a strong section on this, following the recent report of the Public Services Select Committee, chaired by the noble Baroness, Lady Armstrong. I hope that will put flesh on the bone of what risks becoming more of a slogan rather than a policy, meaning different things to different people. I hope the levelling up White Paper will directly address inequalities in health.

As the Secretary of State for Health has said recently, we must tackle the “disease of disparity”, and these amendments highlight the experiences of those groups who are undoubtedly at the worst end of that disease. In current NHS policy and documents, these groups are referred to as “inclusion health populations”—a term used to highlight the need for health services to overcome the social exclusion and marginalisation that many people face, resulting in dire consequences for their health. That group includes rough sleepers, Gypsy, Roma and Traveller communities, vulnerable non-UK nationals and people with substance misuse issues.

These people develop health conditions usually seen in people in their 70s and 80s up to 40 years earlier, and often die from them. Tragically, the average age of death among people experiencing homelessness is 46 for men and 42 for women. Clearly, these are not health outcomes we should accept for anyone. The solutions exist, and chime very well with what the Health and Care Bill seeks to do. However, it currently does not go far enough.

The Bill places a welcome emphasis on integrated services. To tackle the health injustices for people who are socially excluded, we need holistic, integrated health services to meet their needs, and we need them everywhere. They do exist in some places; they are also referred to as “inclusion health services” and they have a significantly positive impact. For example, Pathway, the leading health charity for inclusion health, has helped 11 hospitals in the UK create multidisciplinary teams of doctors, nurses, social care professionals and housing workers. These teams support over 4,000 patients every year who are homeless, with very positive outcomes. An audit of Pathway’s services in 2017 showed a 37% reduction in A&E attendances, a 66% reduction in hospital admissions and an 11% reduction in bed days. However, despite these successful services, inclusion health services are not currently commissioned at the scale required, and access to them is a postcode lottery. King’s College London found that 56.5% of homelessness projects in England do not have a specialist GP inclusion health service in their area—hence the amendments on best practice.

During my time as a Housing Minister, I saw the impact of social exclusion on people, including how not having a stable home to live in is devastating for people’s physical and mental health. Therefore, working closely with expert organisations across these sectors including Crisis, Pathway, St Mungo’s and many others, we want to amend the Bill to ensure a strategic focus in the new systems being set up to help the most socially excluded in our society.

The amendments introduce two important and necessary changes. The first would place a duty on integrated care partnerships to have due regard to the need to improve health outcomes for inclusion health populations when they create their healthcare strategies. Placing a duty on partnerships will make it clear that inclusion health is a strategic focus, and that should follow through and be reflected in the resourcing and commissioning decisions of integrated care boards. I do not regard the requirement to “have regard to” as an onerous imposition.

The second change would make clear the importance on health outcomes of having a stable home. It would mean that, in addition to the partnership having to consider health and social care in its strategic integration arrangements, it would also need to consider housing. This possible change would make clear that housing is on a par with health and social care services. The noble Lord, Lord Shipley, will say more about this.

With the advent of the Everyone In scheme in March last year, which sought to provide safe accommodation for those who without it would have continued to sleep rough, we saw how critical it is for people to have a place of their own. We need to build on that success and prevent rough sleepers drifting back on to our streets. My amendment legislates to ensure that health, social care and housing services continue to work more closely together to consistently support people who too often fall through the gaps between these services.

These amendments are firmly within the scope of the Bill. They will complement and strengthen its welcome aims to integrate health services across the whole system and tackle health inequalities. The amendments are neither overly prescriptive nor bureaucratic; their aims are simple. I look forward to my noble friend the Minister’s reply.

Health and Care Bill

Lord Young of Cookham Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Hollins (CB)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Pitkeathley, and her powerful speech. I support the amendments in this group and will speak to my Amendment 225. First, I declare an interest as an unpaid carer myself, who has had to take on considerable additional caring responsibilities as a result of the pandemic. I enjoyed the description of the noble Lord, Lord Howarth, of the use of poetry, because it is certainly a new hobby of mine, which I found very helpful during those long months of caring.

Mencap’s survey from the first wave of the pandemic in 2020 found that four in five carers of people with learning disabilities were taking on much more care of such people in their families because of the loss of paid support and daily activities for their family members. For many, it will take many months, even years, to return to pre-Covid levels of paid support to support those carers.

During the pandemic, care and carers were often spoken about as synonymous with care homes. I found it very discouraging as an unpaid carer myself to think that it was so little understood in government communications about the pandemic. I tabled this amendment to ensure clarity regarding to whom the Bill refers when it uses the term “carers”. As the noble Baroness, Lady Pitkeathley, explained, it does this by providing existing definitions of carers that are present in related legislation. I too thank Carers UK for its helpful briefing and support.

The amendment is necessary because there is so much confusion about the term “carers”. It is used to describe paid care workers, who I prefer to describe as support workers, or perhaps carer support workers, but that is not the same as caring for a family member and caring about a family member, which is a central part of the role.

The amendment is necessary for another reason: the inclusion of parent carers and young carers more systematically, where appropriate, in the Bill’s consultation and involvement provisions. This should drive better practice and outcomes for all concerned as well as providing clarity.

The provisions in the Bill relating to carers to which this amendment refers do not mean that all groups of carers defined here must be consulted or involved for all services, but only where appropriate. It does, however, provide clarity. The Health and Social Care Act 2012, on which the legislation builds, did not define carers either, which in hindsight it probably should have. This is therefore an opportunity to refine the legislation based on this experience.

Carers UK’s view is that this amendment would improve the clarity and delivery of policy and practice. Family and friends who provide care often put their needs at the back of the queue, and yet the NHS would collapse without them. As already set out, young carers face particular health inequalities and challenges in caring. Evidence from the Children’s Society shows that one in three young carers has a mental health issue and 80% of young carers felt more isolated during the pandemic.

The amendment has the broad support of a variety of different organisations that deliver services and support to carers, and which would welcome this clarity. As well as Carers UK, this includes the Patients Association, MS Society and many local carers’ organisations. As they are the organisations which will be implementing the legislation, supporting and informing carers and providing clarity is essential.

When this issue was raised in Committee in the House of Commons, the Minister said that “carer” should be defined in its everyday sense as unpaid carer. However, we already have sound legislation, which can be referred to, that defines carers. We need to ensure that the muddle of terms created during the pandemic is undone. I ask the Minister to define carers clearly in the Bill by accepting this amendment and to recognise the hugely invaluable role that carers play in our society.

[Lord Young of Cookham (Con)]

My Lords, it is a pleasure to follow my new room-mate, the noble Baroness, Lady Hollins, and I agree with every word that she has just said. I also agree with the other speeches that we have heard in favour of the various amendments. I pay particular tribute to the noble Baroness, Lady Pitkeathley, for her tireless campaign over 40 years on behalf of carers.

I have added my name to Amendment 219 but I will focus on my Amendment 269, which focuses on young carers. I am grateful to the three noble Baronesses who have added their names. Might I be allowed a word on one line in Clause 80, whose future I thought we were debating in this group but which has now been incorporated into the Bill? The line is:

“The Community Care (Delayed Discharges etc) Act 2003 is repealed”.


Noble Lords with long memories may remember that Bill. At the time, I said it was the worst I had seen in 30 years. Instead of doing what this Bill seeks to do —to bring together health and social care to facilitate closer co-operation—it established an antagonistic relationship between the NHS on the one hand and social services on the other by enabling one part of the public sector unilaterally to fine another part. It was a friendless piece of legislation, heavily criticised in your Lordships’ House, as the noble Lord, Lord Hunt of Kings Heath, who had the misfortune to pilot it through, will doubtless confirm.

At the end, my noble friend Lord Howe said, nearly 20 years ago:

“On a more philosophical level, we need to ask ourselves whether this system of financially driven imperatives is what we want to see pervading the fabric of our public services wherever the NHS and social services interact. I am clear that it should not”.—[Official Report, 17/2/03; col. 929.]


How appropriate that, 20 years later, my noble friend helps to put the final nail in the coffin of that Bill. However, it had one redeeming feature: the obligation to assess prior to discharging a patient from hospital. However, as drafted, as other noble Lords have said, the proposals could have the unintended consequence of weakening protections for children who look after adult relatives.

My amendment is about young carers and is shaped by my experience when in another place of working with Andover Young Carers. Children barely in their teens were combining education with caring for disabled parents. The organisation was based in a small bungalow on a local authority estate, and it did heroic work, forging closer links with schools and children’s services. Some of the children spent more than 30 hours each week looking after parents and elderly relatives—almost the equivalent of a full-time job—as well as often having caring responsibilities for younger siblings. They cooked, did the housework, shopped, collected prescriptions, leaving little or no time to enjoy their childhood. The noble Lord, Lord Howarth of Newport, spoke movingly about the work of young carers in Kingston.

According to research from 2018, as the noble Baroness, Lady Wheeler, told us, there are more than 800,000 young carers in the UK. Recent figures show that 180,000 children in England who care for an ill or disabled relative are missing out on support, simply because they are not known to their local authority. Hence the need for this amendment which ensures that young carers are identified before adults are sent home from hospital to be looked after by them. If contact with adult carers is necessary, as we have heard, it is doubly necessary for young carers.

This is because we have clear evidence from Barnardo’s—I am grateful for its briefing—which shows that adults are being discharged from hospital into the care of children, without first making sure that these children are aware of their new responsibilities and that they have the support necessary to enable them to discharge them. I fear this is set to only get worse, placing more caring responsibilities on small shoulders, unless the Bill as currently drafted is amended.

The Care Act 2014 gave a young carer under the age of 18 the right to a needs assessment and placed a duty on local authorities to take reasonable steps to identify young carers in their area who may need support. Yet, in its report Still Hidden, Still Ignored, Barnardo’s found that young carers were still slipping through the net. Its finding is reinforced by the latest CQC survey, which found that 21% of people did not have their family or home situation taken into account when staff prepared them for discharge, a point referred to in the excellent paper which many noble Lords received today from Dr Moore at the University of Manchester.

This amendment places an obligation on the NHS to ascertain whether a patient will be cared for primarily by a young carer and, if so, to contact the local authority concerned for an assessment and the necessary support. This will not delay discharge but would ensure that hospital staff ask if a child under 18 will be the primary carer. If the answer is yes, the hospital should contact the relevant local authority which will ensure that a needs assessment is carried out.

I know the Government have made positive steps to ensure that the needs of young carers are recognised in the guidance which will accompany this Bill, and for that I am grateful. However, without a clear duty on hospitals to establish whether a patient is being discharged into the care of a child, the current situation is likely to continue. Guidance is worthy, but sadly not definitive. Therefore, the pathway for young carers to get the local authority assessment they are entitled to needs to be strengthened and here the health service is the key missing link. I speak to this amendment today because young people who care carry huge responsibilities and we must, as a society, do more to ensure they can live the flourishing lives they deserve.

[Lord Warner (CB)]

My Lords, I strongly support all the amendments in this group. The noble Lord, Lord Young, has been so persuasive and I endorse what he said about young carers. As someone who has been involved with carers for almost as long as the noble Baroness, Lady Pitkeathley—I now regard her as my general in these matters—I want to focus on Amendment 221, to which I have added my name.

It is worth remembering that this Bill is being considered in the context of adult social care funding having been starved, in my view, by three successive Governments. Even when huge sums of money are being raised for health and care through a national insurance levy, social care has to wait its turn. A bit like Oliver Twist, it is at the end of the queue—hopefully there will be some money left in the coffers after the NHS has removed a substantial part of it. That context is very important.

In that context, I find it surprising that somebody somewhere in the Department of Health and Social Care thinks it is a good idea, as the noble Baroness, Lady Pitkeathley, said, to weaken the protections for carers. It is worth bearing in mind that one in five carers now waits over six months for an assessment. In a survey from last November, only 24% of carers had received a carers’ assessment or reassessment in the past year. This is the context in which officialdom and Ministers have thought it a good idea to weaken the protections provided in the 2003 Act. There may have been some weaknesses in that Act, but this was not one of them, as it provided for the NHS to undertake these assessments before people were withdrawn. The noble Lord, Lord Hunt of Kings Heath, is not in his place, but he was the person who took that Bill through and achieved support for that protection for carers.

Health and Care Bill

Lord Young of Cookham Excerpts

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

So this is about not mass medicating without consent. It is about trust, decision-making and being democratic. This is one more area in the Bill where the Government should think again.

[Lord Young of Cookham (Con)]

My Lords, I shall respond to the injunction from the Front Bench and speak for less than two minutes. I had not planned to intervene in this debate, but I was provoked by my noble friend Lord Reay, with whom I find myself in respectful disagreement, and further provoked by the noble Baroness, Lady Bennett.

Listening to my noble friend’s speech took me back 42 years. It was like Groundhog Day, because in March 1980 I had to sit through a speech lasting more than one hour by Ivan Lawrence on fluoridation. I was lucky because in 1985 he set a new record by speaking from 5.12 am until 9.35 am. I was refreshing my memory about what I said in response to the debate 42 years ago in just two paragraphs—I should explain that I was the Minister responsible at the time, when I said:

“I think I should first explain that fluoride occurs naturally in most water supplies, sometimes at a satisfactory level for the prevention of dental decay. Fluoridation consists merely of the adjustment to the optimum level for dental protection—one part per million in temperate climes—of the fluoride content of those water supplies that are deficient in it naturally. When water containing the optimum level of fluoride is consumed during the years of tooth formation, the protection conferred in childhood continues during adult life.”—[Official Report, Commons, 6/3/1980; col. 792.]


I wound up:

“Finally, as my right hon. Friend indicated last January”—


that was January 1980—

“it remains the Government's view—like that of their predecessors for many years—that extensive trials throughout the world have shown that fluoridation safely and effectively reduces the prevalence of dental caries—one of the commonest diseases and one which has lifetime consequences for general and dental health.”—[Official Report, Commons, 6/3/1980; col. 799.]

Since that time, government policy has not been delivered, as the noble Lord, Lord Hunt, explained. Initially it was the area health authorities that did not do it, and now it is local authorities. It is now imperative that government policy is delivered, and that is why I wholeheartedly support these clauses in the Bill.

[Lord Storey (LD)]

My Lords, I shall speak briefly on Amendments 224 and 261 and share my views on fluoridisation. I agree with the noble Lord, Lord Reay, that it is a pity we did not have a proper full debate on this matter.

There is a real problem among young children, particularly those in deprived communities, who have increasing levels of bad teeth—dental decay. You would think that as a result of that situation we would be trying to do something more practical about it, yet we see dental inspections in schools decreasing. When I was first a head teacher, the dental services would come in twice a year to inspect children’s teeth and would give a little note to the parents so they could go to their dentist. The second problem we face is that, as we heard from the noble Lord, Lord Hunt, you cannot find an NHS dentist, particularly in a deprived area, for love nor money. That is a problem for families that cannot afford to use a private dentist, even if one was available.

When I was leader of the council in Liverpool, all political parties together—I have to tell my colleagues—decided against fluoridation, so we took the view that perhaps there was a different way of doing it. We were setting up the network of children’s centres in the early 2000s. We therefore made dental health in the nought to five age group one of the highest priorities in the city council’s strategic plan. We also issued additional guidance to our primary schools, asking them to make encouraging better dental health a higher priority. As a result, 10 years later in 2013, the British Dental Association’s 10-yearly survey showed that a reduction of 28% in caries had been achieved in Liverpool’s schools. The targeted approach achieved an outcome double that identified in the York review as the average caries reduction from fluoridation. We will also have helped many children to develop lifelong good personal dental hygiene habits, which is a crucial part of the strategy.

Whether we have fluoridation or not, we need to be absolutely sure that the journey we are going on is correct. In the meantime, we should look at other ways. We should also look at what our colleagues in Scotland have been doing with their Childsmile project, which has been shown to be safer, less wasteful and more effective, and better value for money. I hope that at some stage we will revisit this issue and have a much longer and more considered debate.

Health and Care Bill

Lord Young of Cookham Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I declare an interest as a former chair of the Professional Standards Authority. I was happy to go down memory lane with my noble friend on the Front Bench.

When thinking about professional regulation, we always have to bear in mind—I hope the Minister will be able to convince the House that this is what the Government bear in mind—the protection of the public. It is never about the glorification or protection of a profession; it is always about the protection of patients and the public.

The Professional Standards Authority developed the concept of right-touch regulation, whereby you identify the problem before the solution, quantify and qualify the risks, get as close to the problem as possible, focus on the outcome and use regulation only where necessary. I draw the House’s attention to the very successful project of accredited registers, which the Professional Standards Authority has developed in order to have, as it were, regulation at a lesser level than the very tight regulation that is necessary for some professions. You should keep it simple; the system is far too complex at present. You should check—as we always must with legislation, but it seems to me that we do it far too seldom—for unintended consequences. You should also review and respond to change, and the Government are doing just that with the proposals.

However, I must echo the caution of my noble friend on the Front Bench regarding the new powers for the Secretary of State to deregulate as well as regulate professions. We know that the risk profile for different occupations changes over time and a more agile method of responding is sometimes necessary. I hope that is what the Government have in mind. However, I emphasise, and I hope the Minister will reassure me on this, that a commitment to keeping patients safe must guide any decisions made to deregulate professions. There must be a robust and independent process to ensure that decisions are made after a clear assessment of risk—and I emphasise “independent”.

If the Secretary of State has the power to abolish regulators by secondary legislation, will there not be a threat to the independence of the regulators? If they know that the Secretary of State can abolish them at a stroke, as it were, might they become too focused on pleasing—or, rather, on not antagonising— whichever Government are in power, instead of, as I have stressed, working always and solely in the public interest? I hope the Minister will assure the House that that is the Government’s intention.

[Lord Young of Cookham (Con)]

My Lords, Clause 142, which comes under the heading “Professional regulation”, deals with the regulation of healthcare and associated professions. One of the objectives of the Bill is to integrate health and social care, and I very much hope that under the heading “associated professions” it will be possible to look at the registration and regulation of social care as well as those who work for healthcare.

Noble Lords may remember a brief exchange three weeks ago at Question Time when I asked the Government what plans they had to regulate and register social care. I was grateful for the reply, which outlined the welcome support being extended to the social care workforce. It also mentioned a skills passport, but the Minister was silent on the issue of a register.

I pressed the Minister and pointed out that Scotland, Wales and Northern Ireland already have a registration scheme for their social care workforce, and that if we are truly to integrate health and social care, as the Bill seeks to do, we need to have parity of esteem between health staff and social healthcare staff with improved pay, working conditions and career opportunities—much of which was mentioned in the debate we have just had. A registration scheme could facilitate the professionalisation of the social care workforce.

We then had an interesting exchange, in which the Minister mentioned a voluntary register and the need to assess the skills of the existing workforce, 56% of which has no qualifications. He said that he was consulting on whether registration should be mandatory and was concerned that mandatory registration might cause people to leave the sector. However, I do not believe that that has been the experience in other parts of the UK.

--- Later in debate ---

[Baroness Masham of Ilton (CB) [V]]

My Lords, I support all these amendments but will speak to Amendments 276 and 277, to which my name is attached, requiring health warnings on cigarettes and inserts in cigarette packs containing quitting advice.

My father used to smoke, as very many people did in the war. At the age of 52, he died of coronary thrombosis; I always felt that smoking caused his death. In addition, one of my best friends who smoked died early. At this very time, my housekeeper is in St James’s University Hospital in Leeds receiving treatment for cancer. The other day, she scolded herself for having smoked. Smoking causes serious disability as well as premature death; far too many people have died because of smoking.

I strongly support the Government’s Smokefree 2030 ambition. The measures in the amendments will help put us on track; they are well-evidenced, cheap to implement and easy to enforce. Health warnings on cigarette packs have progressively increased in size over time and, most recently, their impact has been enhanced by the removal of colourful banding. Warnings on cigarettes is the logical next step, and it will have particular impact in preventing children and young people starting to smoke. Hundreds of children start smoking every day in the UK. Children are much more likely to have access to individual cigarettes than full packs, meaning that warnings on cigarettes are likely to be particularly effective in preventing youth uptake. This measure has strong public support. Adding health warnings to cigarettes and cigarette papers is a simple measure with minimal cost which would help deliver the Government’s Smokefree 2030 ambition.

Amendment 277 would give the Government powers to require that health information messages be inserted in cigarette packs. This is not a novel idea; it has been a legal requirement in Canada since 2000. They are proven to work, and there is already good evidence from Canada on which messages are most effective. If the Government could give an assurance today regarding the increased use of health warning inserts—they already have the power to do this—these amendments might not be necessary and we could save time on Report. If not, Amendments 276 and 277, which are by no means the only measures needed to address this terrible addiction, would be a small and significant step in the right direction. I commend them to the Committee.

[Lord Young of Cookham (Con)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Masham, who spoke in favour of Amendment 276, which replicates a Private Member’s Bill I am endeavouring to pilot through Parliament; we will see which of us has the fastest track towards the statute book. It is also a pleasure to follow the noble Lord, Lord Faulkner, who has campaigned against the damage done by tobacco for as long as I have known him, and I agree with every word he said.

I will speak to Amendments 272 to 275, which are in my name but supported by all parties. They apply the polluter pays principle to tobacco manufacturers. In view of the lateness of the hour, I will curtail my remarks as much as I can. The principle that the polluter should pay has been accepted by Conservative Governments for over 30 years, starting with the landfill levy to promote recycling, running through the sugar tax on soft drinks to tackle obesity, and referred to only on Wednesday this week by my noble friend Lord Greenhalgh in the debate on building safety, advocating a levy on the construction industry to finance remediation.

Health and Care Bill

Lord Young of Cookham Excerpts

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

We agree, but the funding must be found, and the best and most realistic option is for the polluter—that is, the tobacco companies—to be made to pay. I support these amendments.

[Lord Young of Cookham (Con)]

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 (LD)]

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.

Health and Care Bill

Lord Young of Cookham Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

[Lord Young of Cookham (Con)]

My Lords, I rise briefly to support Amendment J1, so ably moved by the noble Lord, Lord Crisp. I also join him in thanking my noble friends Lord Howe and Lord Kamall, the two Ministers involved, for their engagement with movers of the amendment on Report and for the genuine attempt they made to seek agreement to narrow the small gap between the Government’s position and ours—an attempt which, I fear, was blocked by HM Treasury.

On this subject, on Report, my noble friend Lord Howe said:

“Our strong preference is to continue with high tobacco taxation and excise as the best means and the most efficient process through which to generate revenue that can be put back into public services.”


I wish I shared his optimism, given the current pressure on the public purse and the recent experience with the levelling-up White Paper, published in February. The Institute for Fiscal Studies said that

“the White Paper contains no new funding; instead, departments will be expected to deliver on these missions from within the cash budgets set out in last autumn’s Spending Review. Departments and public service leaders might reasonably ask whether those plans match up to the scale of the government’s newfound ambition—particularly in the face of higher inflation.”

The same is true for tobacco control. Even before the rise in inflation, budgets for tobacco control and smoking cessation had been cut by a third since 2015. Already by 2019, it was clear that the Treasury’s claim that the tax system would provide funding for tobacco control was misplaced. That is why, when the Government announced the smoke-free 2030 ambition in 2019, they also promised to consider a polluter pays approach to funding tobacco control and smoking cessation, which is the substance of the amendment before your Lordships this evening.

On Report, my noble friend Lord Howe said:

“The proposal may look simple on the surface but it is complex to implement. It may also take several years to materialise.”


Our proposals build on the pharmaceutical pricing scheme operated by the Department of Health, which is a far more complex industry with far more complex products. If the Department of Health can successfully run a scheme for pharmaceutical products—an industry and set of products that are complex and evolving—I fail to see why it cannot operate such a scheme for cigarettes. These are simple, commodity products produced by an oligopolistic industry, with four main manufacturers responsible for more than 95% of sales.

The noble Lord, Lord Stevens of Birmingham, who I am pleased to see in his place, said on Report that

“if it is deemed appropriate to have a form of price and profit regulation for the medicines industry, which delivers products that are essential and life-saving, it does not seem too far a stretch to think that an equivalent mechanism might be used for an industry whose products are discretionary and life-destroying.”—[Official Report, 16/3/22; cols. 294-98.]

I agree. However, I also accept that further investigation of our proposals would be needed, which is precisely why a consultation without commitment is the appropriate way forward, as the all-party parliamentary group’s amendment proposes.

I hope that, even at this late stage, my noble friend might demonstrate some flexibility in order to try to bridge the narrow gap between the Government’s position and that in the amendment.

[Lord Hunt of Kings Heath (Lab)]

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.