Health and Care Bill

Philippa Whitford Excerpts

Report stage
Monday 22nd November 2021 Commons Chamber

[Mary Kelly Foy]

Again, I could not agree more.

In Committee, the Minister said that the Department could already legislate under the Children and Families Act 2014 to require the insertion of such information messages. In that case, why do the Government not commit themselves to doing so now?

New clauses 4 to 6 address loopholes in current legislation. Now that those loopholes have been identified to the Government, they should be fixed without delay, and today we have the opportunity to do so. New clause 4 would give the Secretary of State powers to remove child-friendly branding elements from nicotine products. There are e-liquids on the market that are given sweet names, such as “gummy bears”, and that have branding that is in garish colours and features cartoon characters. Surely more evidence is not necessary to prove that such branding risks attracting children.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Is this not one of the most important of the hon. Lady’s new clauses? As people age and die—events often driven by cigarettes—or perhaps manage to give up, the tobacco companies must recruit the young, with the indefensible aim of persuading them to start smoking.

[Mary Kelly Foy]

I entirely agree. Tobacco is the only legal product that kills one in two of those who use it, and most people start smoking at a young age. These new clauses are therefore extremely important, because they would tackle that problem.

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[Richard Fuller]

It is a great pleasure to follow the hon. Member for Nottingham North (Alex Norris). I will speak to new clause 14 and the other amendments in my name. I am grateful for the Opposition’s support for amendments 6, 7 and 8 and for an industry-led alternative—in spirit, if not necessarily in voting. I think the hon. Gentleman, as well as many of my hon. Friends, will be wanting to hear something from the Minister to show that he has been listening to concerns that have been raised across the House.

I was surprised and delighted to see on some of my amendments the name of the hon. Member for Central Ayrshire (Dr Whitford), but she advised me that that was an error, so I am sorry that the potential amity between me and those on the Scottish National party Benches will have to wait for another day.

[Dr Whitford]

I am grateful to the hon. Gentleman because that has saved me from having to put a disclaimer at the start of my speech, as I was rather shocked to find my name on his amendments. I just reiterate the point made by the hon. Member for Nottingham North (Alex Norris). It is a concern that the names of companies, as we saw in F1 racing and other things, simply promote certain types of food and drink and you cannot separate the brand from the product.

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[Richard Fuller]

I absolutely do not agree. The reason why the Opposition Front-Bench team are probing on this is that we are not harnessing all the talents to come up with the solution. As the hon. Member for Nottingham North said, he does not have, or want, any objection to the objective—he just feels that there may be better ways to do it. That is what my amendments are trying to create. They would introduce a better way, working with established principles and with the industry—let us face it, it has the experts in this—rather than undermining issues to do with how the Advertising Standards Authority has managed how products are advertised and rather than bulldozing through the industry, which is the current process that the Government, or this Department anyway, are proposing.

Let us just remember that this pressure on our food and drink manufacturers is part of a wider effort of social responsibility that we are putting on them. The proposal does not sit alone, but with other things, in particular around environmental protection. The Food and Drink Federation has calculated that the cost of the UK Government’s proposed environmental health policies is at least £8 billion. That is equivalent to £160 a year on household food bills that we are asking the industry to take on.

It is estimated that the introduction of this policy will cost £833 million, but the Government’s own impact assessment estimates that the benefits are likely to be in the order of only £118 million. That is a real dead loss that we will be putting, let us face it, on food bills, primarily of those in lower income brackets. Members on all sides should take a moment to consider whether this is the right time and the right process for doing that. As the Government’s own assessment shows, the actual effect on diet for those who are targeted is estimated to be 1.7 calories a day, so it is a lot of effort and cost, but not very much impact.

New clause 14 proposes an alternative that would require the regulator to implement an alternative set of increased restrictions for online, but developed through the industry by the Committee of Advertising Practice. The new clause would legislate for a three-step filtering process drawn up by the industry to appropriately manage the targeting of online ad campaigns.

Another of my amendments would introduce brand exemptions. I take a different view from the hon. Member for Central Ayrshire, who said that brands are intrinsically tied to their product. The truth of the matter is that Coca Cola is made by Coke and Coke Zero is made by Coke. Coke Zero is advertised with the word “Coke” on it. This issue is not necessarily covered by the legislation, but Coke is not tied to one thing. Brands are extraordinarily flexible in how they can assist progress in achieving some social means. The Minister should consider looking again at this area.

Finally, on the nutritional profile, the issue is consultation. I can see that the Secretary of State has tabled some amendments on that, and perhaps the Minister can talk about that. They do not seem to make the changes I would like to see, but I would be interested to hear what he has to say.

It is worrying that the Government have undermined the Advertising Standards Authority with their approach. One of the other things is targeted advertising. I am sure it has struck hon. Members here as it has me that the tech revolution of the dotcom era was 20 years ago, and two decades of technical expertise in understanding how adverts are targeted is being swept away or ignored by the Department of Health and Social Care, which would much rather have “nanny knows what’s best”. The truth of the matter is that, by harnessing technology, the Government could get a better outcome than this official ban. As my hon. Friend the Member for Buckingham said, there are plenty of other ways to do it that would be hard for advertisers to get around.

I say to the Minister that I am trying to be helpful, as always, and, to be serious, as are the Opposition. The Government have made a slight misstep by adopting a top-down, state-driven model. I say to the Minister that the path of good intentions is littered with unintended consequences. The essence of conservatism is not to use the state to bully or, as perhaps the advisers in the various Departments say in modern parlance, to nudge. It amounts to one and the same thing. The Department’s attempt to censor products such as these is profoundly un-Conservative. Our party believes in individual responsibility and that families are the foundation of society where choices and power in society most naturally lie. Nowhere is that more important than in health matters, yet these proposals extend the role of the state and undermine parental responsibilities.

The measures make the Department of Health and Social Care look like a new outpost of cancel culture that denies free speech and has a predisposition that individuals should conform to what the state determines, rather than enabling informed free choice. It is desperately sad to see them being pushed through by a Conservative Administration. I say to my colleagues on the Back Benches: when will we wake up and realise that we need a Government who support free enterprise and individual responsibility, and who understand that the way to create growth in the economy is through enabling people to make free choices, rather than expecting the state to be the answer to every problem? With that question, I will wait to listen to what the Minister has to say.

[Dr Whitford]

I thank the hon. Member for North East Bedfordshire (Richard Fuller) for clarifying that I had not voluntarily added my name to his amendment.

Whenever we talk about such subjects, we hear a lot about the nanny state. As a surgeon working in A&E in general surgery, however, the difference when seatbelts, airbags and speed limits came in was night and day in how much time I spent dealing with people in operating theatres who had been involved in car crashes. Sometimes the state has to take action to protect people’s health and wellbeing.

The Bill focuses largely on reversing some of the most egregious aspects of the Health and Social Care Act 2012, which I welcome, but these measures focus on improving public health. There is no question that obesity, type 2 diabetes and other diseases associated with obesity pose not just a real threat to individual health but a threat that will overwhelm national health services in future. When I looked at the original Bill, however, I was surprised that, apart from the measures around obesity, there was little in the way of public health policy to improve and promote health, and there is also little enough about care.

It is not the national health service that delivers health. I have often said that it would be more appropriate to call it the national illness service, but who would want to work somewhere called that? The NHS spends most of its time catching people when they fall. Health comes from a decent start in life, a warm dry home, enough to eat and a decent education. Those are the things that deliver health, but there is nothing like them in the Bill.

Particularly, and surprisingly, there is nothing in the Bill on reducing harm from tobacco products and alcohol, which is why I rise to speak in support of new clauses 2 to 4, which seek to strengthen the health warnings on all tobacco products; new clauses 7 to 10, which seek to allow regulation of tobacco pricing; and particularly new clause 6, because the use of sweet flavourings to entice children and young people to take up smoking is indefensible.

[Barry Gardiner]

I heartily commend the hon. Lady for her comments. Does she experience in her constituency, as I do in mine, that smoking cessation services are diminishing and becoming less successful? As the tobacco industry concentrates on a core group of existing addicts, it is desperate to move down the age range and encourage new addicts. That is why that element of the new clause is important.

[Dr Whitford]

I agree that new clause 6 is the most important of the new clauses, because tobacco companies are driven to recruit new victims—as I would have to call them, as a doctor—and they are recruiting them from young people.

Public health is devolved, so we have not had the cuts in public health funding that we have unfortunately seen in England since 2016. Therefore, we have not had the cuts to smoking cessation and sexual health services that many local authorities experienced across England when public health moved into local government.

Smoking does not just cause respiratory problems such as chronic obstructive airway disease, but affects all the blood vessels causing peripheral vascular disease, vascular dementia, strokes, heart attacks and many forms of cancer, not just lung cancer. Stopping smoking is the best favour anyone can do themselves, but many people require the very smoking cessation services that the hon. Gentleman mentioned.

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[Christian Wakeford]

Obviously, as the chairman of the all-party parliamentary group on alcohol harm, I know that part of the issue with treatment—I am thinking in particular of new clause 16—is the stigma behind alcohol dependency and its still being seen as a personal choice. While we need to overcome the stigma of addiction, we first need to be having a conversation about alcohol. Does the hon. Member agree that, as part of the treatment, we need to be having this conversation on a national level?

[Dr Whitford]

I would say that really no one who has a health problem should be stigmatised. Having dealt over 33 years in the NHS with many people who were problem drinkers, I know that the public image of someone who abuses alcohol is quite a caricature. There will be many people across this House who drink more than is healthy for them and I have met many people as patients from the middle and upper classes who had serious alcohol problems, so we should get away from the stigma and the caricature. We will not spot everyone who needs to deal with alcohol just by looking at them.

[Catherine West]

I commend the work of my hon. Friend the Member for Liverpool, Walton (Dan Carden) in this regard. Does the hon. Lady agree with me that the whys and wherefores are all very well in this debate, but in the end the cuts to local government, which would primarily be providing services in relation to alcohol abuse, have been most disgraceful, and that is why we are seeing the huge increase in the number of people who have passed away from alcohol disease in the last couple of years following covid?

[Dr Whitford]

There is no question but that, after public health moved into local government—we can absolutely defend that because, as I have said, health is often delivered by things that are nothing to do with the NHS—the problem was that the budget was then cut, so the potential benefit of putting public health into local government was lost due to the cuts to services.

On alcohol not being classed as a less healthy food, with this Government I find it hard not to ask: why not, and what or who may have influenced that decision? I certainly support amendments 11 to 13 from the hon. Member for Liverpool, Walton (Dan Carden), which would include alcohol, particularly the medium and high-strength alcohols, under less healthy foods, so that alcohol is covered by advertising regulations. I also support his new clause 15, which would mandate much clearer labelling of alcohol units, or whatever measure, on labels. It is no good just saying “Drink aware” or “Drink Responsibly” when the consumer has not actually been given the tools on the product to make a proper choice, such as by asking, “How much is in this?” Why not agree to use a simple, straightforward approach? A lot of public health advice is in units, so why not actually use them? People would then learn to be aware and ask, “How many units have I already drunk today?” or “How many units have I already drunk this week?”

New clause 17 calls on the UK Government to follow Scotland, and now Wales, by introducing a minimum unit price for alcohol. The UK Government have the advantage in that they can do that by setting alcohol duty based on unit, instead of on classes of drink. In every Budget we hear about a penny on a pint of beer, or so much on spirits, but why not do it by unit? It is much more accurate, and it would still allow the raising of taxation to help fund alcohol services, as well as those public services most hit by alcohol abuse, such as healthcare and policing. Under devolution the Scottish Government, and now the Welsh Government, did not have that power.

Over the past year and a half of the pandemic we have, unfortunately, seen a big increase in both smoking and alcohol consumption, as people struggled to cope with the loneliness and boredom associated with lockdowns and pandemic restrictions. However, the initial valuation of minimum unit pricing in Scotland showed that alcohol sales fell, for the first time in many years, by more than 7% in Scotland, compared with a continued rise in England and Wales. It was not possible to demonstrate a reduction in overall alcohol-associated admissions to hospital, which may include car accidents, violence and so on, but there was a drop in admissions due to alcoholic liver disease, suggesting that the policy was working. More evaluation after the pandemic will be required, but an immediate impact was an almost three-quarters drop in the sales of cheap white cider. That product is cheaper than soft drinks, and predominantly used by young—indeed, often under-age—drinkers, who purchase it, or get someone else to purchase it, so that they can drink it at home. However, that sector is literally disappearing overnight.

It will be important to review and maintain the pressure of the unit price on a regular basis, because young drinkers also drink many other products—this is the same issue as young smokers; more people are being recruited, often into problem drinking and problem products. Minimum unit pricing does not affect good wine, high-end spirits, or what is sold in a pub, but it does affect what someone can buy in a small shop to then hang out with their mates in their bedroom. Some of those products are not affected by the 50p unit price, and that must be kept under review.

I was disappointed that new clause 30, which is listed for discussion tomorrow, was not included in this group. It calls on the Government to reform the out-of-date Misuse of Drugs Act 1971, and to devolve it so to allow the devolved nations to take a public health approach to tackling drug addiction, in the same way as we take a public health approach to dealing with alcohol. Such an approach has already been demonstrated in many countries across the world, yet the Government keep sticking their head in the sand.

[Hywel Williams]

I am grateful to the hon. Lady for mentioning new clause 30, which I still hope against hope we might be able to discuss tomorrow. I am sure she will agree that problematic drug abuse is an illness and a social ill, not a crime, and our emphasis must be on harm reduction, treatment, and support for the problematic drug user.

[Dr Whitford]

That is the policy of the Scottish Government, and we would absolutely support the new clause if it is voted on tomorrow.

As Opposition Members have said, key to improving public health would be restoring the non-covid related public health budget in England. We cannot hide behind covid funding, because that is used up by the pandemic and does not help us with smoking, alcohol, or drug addiction. The biggest contribution the Government could make would be to abandon their plans for yet another decade of austerity. We hear the slogan all the time—levelling up—but it rings hollow after taking away £1,000 a year from the poorest families and most vulnerable households. Over the past decade, cuts to social security have caused a rise in poverty among pensioners, disabled people, and particularly children. Sir Michael Marmot was mentioned earlier, and his research was clear: poverty is the biggest single driver of ill health, and the biggest driver of poverty is Tory austerity.

[Bob Blackman (Harrow East) (Con)]

It is a pleasure to follow the hon. Member for Central Ayrshire (Dr Whitford), who brings her knowledge of the medical profession to this House on every occasion. I agreed with almost everything she had to say, apart from the last comment.

I declare my interest as chair of the all-party group on smoking and health, and I support all the new clauses tabled in the name of the hon. Member for City of Durham (Mary Kelly Foy). These comprehensive proposals are complementary and can be picked up by the Government. The new clauses were tabled in a different form in Committee. They were discussed and debated, and I think Ministers said they would take them away and have a further look. We have refined the proposals on the basis of the debate in Committee, strengthened them, and brought them back again, and they address the loopholes in current legislation. They strengthen the regulation of tobacco products still further, and they provide funding for the tobacco control measures that are so desperately needed if we are to deliver the Government’s Smokefree 2030 ambition.

We had an excellent debate in Westminster Hall last week, to which the new Under-Secretary of State for Health and Social Care (Maggie Throup) responded. Questions were posed to the Government from across the Chamber about when we will see the long-promised tobacco control plan, which is presumably due to be delivered by 31 December this year. We got no firm commitment on when we will see it, and I would like my hon. Friend the Minister to bring that forward as soon as possible. We can then measure what will happen.

The problem we have with tobacco control right now is that if we do nothing and none of these measures is introduced, the risk is that, as the hon. Member for City of Durham rightly articulated, we will miss the target by seven years. For those on low incomes and in deprived circumstances, it will be 14 years. We must consider how many people will die from smoking-related diseases as a direct result of the Government’s failure to achieve their Smokefree 2030 ambition. It is clear that we need to take further action, and I urge the Minister, who I know is a doughty campaigner for public health, to make sure that we deliver on the proposals.

My main focus is obviously on the new clauses that seek to provide funding for tobacco control. We all accept that not only can we implement measures, but we have somehow to fund them. That is critical. We must also consider raising the age of sale, as that, unfortunately, is a key proponent in encouraging young people to start smoking. The spending review failed to address the 25% real-terms cut to public health funding since 2015. Reductions in spending on tobacco control have bitten even deeper, by a third, since 2015. We need new sources of funding.

The Government promised to consider a polluter pays levy in the 2019 Prevention Green Paper, when they announced the Smokefree 2030 ambition. The all-party group on smoking and health has done the analysis, and we estimate that in the first year alone of a polluter pays levy, £700 million could be raised. That would benefit not only England, but the whole United Kingdom. It is more than twice the estimated cost of the tobacco control measures that we are proposing tonight, and that would then leave the Government with further funding to spend on other health priorities. The proposal is for a user fee, along United States lines, rather than an additional tax. Now that we have exited the European Union and can set our own rules, EU tobacco manufacturers’ profits can be controlled. They cannot pass the cost on to the consumer, but we can control their profits and use those for preventing people from smoking in the first place. It is quite justified that we should tax the manufacturers’ profits. This is the most highly addictive product that is legally available, and it kills those who use it for the purpose for which it was intended.

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[Jeremy Hunt]

I am happy to do that, because I know my hon. Friend has a great interest in social care issues. I feel conflicted by new clause 49. I think that what we will end up with after this measure will be a whole lot better for people on low incomes than what we had, because the means-test threshold will be raised from £23,000 to £100,000, and that is a very significant improvement. However, I have to be honest and say that it is nothing like as progressive as we had hoped, but it is a step forward. My concern when it comes to social care is that our entire debate is focusing on what does and does not contribute to the cap, when the fundamental problem in social care is the core funding to local authorities; that, though not a matter for this Bill, has a direct impact on the care received by our constituents.

I conclude by thanking the Government for their support for amendment 114. I will move it formally later, but I am not expecting to divide the House on it.

[Dr Whitford]

I initially want to touch on new clause 49. Like other members of the Bill Committee, I sat through hours and hours from September to November, and the Government have suddenly pounced on us with this at the last minute. It is such a complicated new clause, but it has not been interrogated.

It is quite clear that the Government’s original spin that no one would pay more than £86,000 for social care and no one would have to sell their house is completely misleading. All the accommodation costs are on top of this. As has been highlighted in the media and by Members in the Chamber, those with assets of about £100,000 will not see any real gain from this policy, while those sitting on assets of £500,000 or more will keep a lot of their wealth. That means it exacerbates the differences, and penalises those in the north of England and areas where house values are not so high. Basically, it is feeding the frenzy down here of people sitting on over-inflated house prices. As has been said, this is not levelling up, just doubling down.

The cap applies only to personal care, which means things like washing and dressing. That has been provided free in Scotland both within the care home and in home care since 2002. It was expanded in 2011 to provide more hours so that people with greater need could stay at home longer, and it was extended to those under 65 with care needs in April 2019. Scotland is the only UK nation that provides free personal care, and we see it as an investment. It is an investment that we spend 43% more per head on social care in Scotland, but it is an investment in people’s independence and their inclusion in society. The problem is that we spend far too much time talking about social care just as a burden, instead of actually seeing it from the point of view of the user.

The Scottish Government have already added an extra penny on taxation for medium and high earners to cover things such as our wellbeing policies, health or social care, but this Government’s plan to increase national insurance contributions will disproportionately hit low-paid workers and young workers. I would say that the biggest weakness of all, as we know from the original debate on the national insurance change, is that the funding is not going to go to social care initially; it is going to go to the NHS, yet it is social care that is in crisis. This is what is causing the pressure in accident and emergency, because people who are ready to be discharged simply cannot be, as the care support is not there. I do not think that this fixes the problem. There will actually be very little money, because a lot of it is going to go on capping the overall payment. I do not see social care benefiting from this at all, yet it is social care that needs investment more than anything else.

Turning to the main substance of the Bill, which is meant to some extent to unpick the damage and fragmentation of the Health and Social Care Act less than a decade on, I wish to express support for amendments 9 and 72. Many in the NHS, including me, will be glad to see the back of section 75 enforced tendering. Others in the Chamber know that it was the Health and Social Care Act that brought me into politics, as I just could not believe anybody thought what they were doing was a good idea. It is still clear from the pandemic that this Government are absolutely wedded to outsourcing services to private companies, and to the flawed notion that financial competition somehow drives up clinical quality. I am sorry, but that simply is not the case. As the Chair of the Health and Social Care Committee has highlighted, we have to focus on safety, on clinical audit, and on peer review if we want to drive up care quality for patients, not just on the money in the system.

The Government appear to have conceded that integrated care boards should be statutory bodies, as health boards have always been in Scotland, but partnership boards can include private providers, such as with Virgin Care in Bath. As the partnership boards will be involved in devising the local strategy for health services, that is likely to lead to a blatant conflict of interest, and I do not see a resolution to that. The NHS simply should be the presumed provider of health services. That is not just, as the shadow Health Minister said, because the NHS is in it for the long term, or for a quick contract, but because the NHS provides the training to nurses and doctors who are the vital workforce of the future. Private providers do not do that; private providers largely live off the NHS. As well as not training staff, where there are major problems or complications, patients inevitably end up in the intensive care unit of an NHS hospital.

In conclusion, for all the size of the Bill, and the scale that the reorganisation will involve for staff in the NHS, who we all know are frankly exhausted, the Government have failed to take the opportunity to repair fully the damage of the Health and Social Care Act 2012, and to recreate in England a unified public health system, such as the one we are lucky enough still to have in Scotland.