I beg to move, That the Bill be now read a Second time.
As first days in a new job go, there must have been easier ones than this, but it is very good to be back and to be supported by an excellent new or nearly new team, in time to bring to the House a Bill that I can modestly claim to have had some hand in creating.
First, let me summarise what I think the Bill does. Building on last year’s 60th anniversary celebrations, it begins a new era in the national health service, in which quality becomes the focus of everything that the NHS does; the drive for quality is predominantly locally and staff led rather than dropped from on high; patients have more rights, choice and control over their care; prevention and health promotion truly come to the fore; and further reform can take place against the knowledge that NHS principles and values are secure and that the NHS will endure as the preferred British model throughout the century.
We build on a position of strength, banking the huge progress that the NHS has made in the past decade, but setting out a new direction for continued improvement in the next. By way of context, let me remind the House of some of the key developments of recent years.
In the past 12 years, the NHS estate has been transformed, with 100 new hospitals. NHS finances are secure, with more than a £1.7 billion surplus and only six trusts in deficit. Hospital-acquired infections are being tackled, with MRSA rates down 65 per cent. on 2003 figures. We now have the shortest waits in the history of the NHS, moving from the scandal of 18-month waits for operations to the landmark pledge that all patients are now seen in 18 weeks. On average, patients now wait only eight weeks for treatment and are seen by a specialist in two weeks if cancer is suspected.
Public satisfaction with the NHS is at a record high. The Care Quality Commission’s adult in-patient survey found that 93 per cent. of patients rated their overall care as good or better. That is conclusive proof that the NHS is Labour’s great achievement, and its revival in the past decade is arguably the Government’s greatest success story, which I intend to tell with pride and energy every day that I do the job.
May I be the first to congratulate my right hon. Friend on his new post? I am sure that he will do a splendid job, building on the amazing work that has already happened in the health service. Far from 18 weeks being the target, many people in my area are seen well before that. When I, as a practising GP, see somebody with suspected cancer, I can often get them seen in a few days. That was unthinkable five years ago. I therefore congratulate my right hon. Friend and the whole team on such a remarkable achievement.
I always bow to the wisdom of my hon. Friend. When I occupied the Minister of State position in the Department, I often talked about the 18-week commitment as the end of waiting lists. Conservative Members greeted that with derision, but that has happened, and my hon. Friend knows that better than anybody.
That success and the others that I listed are due in no small part to the skill of my right hon. Friend the Member for Kingston upon Hull, West and Hessle (Alan Johnson), who—to paraphrase the hon. Member for South Cambridgeshire (Mr. Lansley)—is the postman who delivered. The Bill takes forward my right hon. Friend’s excellent work and that of my noble Friend Lord Darzi of Denham, providing the legal framework for the reforms proposed in the NHS next stage review, which was published almost a year ago.
May I be the first Conservative Member to congratulate the Secretary of State on his elevation? While revering his predecessor and his work in the Department, will he kindly undertake, as one of his first steps, a review of his predecessor’s decision in the past month to scrap the community hospital redevelopment fund building programme of some £500 million? It was announced to our strategic health authority, at great cost to the plans for redeveloping Ludlow community hospital.
I am sure that my right hon. Friend will be grateful for the hon. Gentleman’s reverence—I will be doing well if I get close to such praise. Obviously, I have not had time to examine that particular decision. I give the hon. Gentleman a commitment that I will do so and write to him.
The first chapter of the Bill relates to the NHS constitution and provides for further improving quality and giving patients greater say about their care. The Bill places a duty on all providers of NHS services to have regard to the first ever NHS constitution. It will also require the Secretary of State to review the constitution every 10 years and to report on its impact every three years.
The constitution is a landmark document. It sets out the rights and responsibilities of patients and staff, bringing together existing legal rights with commitments to deliver the standards of service that patients can expect from the national health service. However, the constitution is far more than a piece of paper. It provides three concrete legal rights for patients: first, the right to recommended vaccines under a national immunisation programme; secondly, the right to all National Institute for Health and Clinical Excellence-recommended drugs and treatments; and thirdly, the right to make choices about NHS care and the right to the information needed to make those choices.
The constitution belongs to every one of us. It reflects what people, patients and staff say they want to see in a 21st-century health service, and it commits the NHS to delivering on that promise, now and in the future. By placing a legal duty on all providers of NHS services to have regard to the constitution, we are reaffirming the right of patients to access the best possible treatment, while ensuring that the fundamental principles of the NHS are protected for future generations.
The proposal for an NHS constitution was the central recommendation of a report that I published for the then Secretary of State for Health, following a period of shadowing work at every level of the system. It is a pleasure to see the constitution as the centrepiece of the Bill, and I was encouraged by the wide welcome that it received when the Bill was in another place.
To improve the focus on quality, the Bill will place a legal duty on all NHS providers to provide annual quality accounts, in the same way that they are required to publish financial accounts. That information will be in the public domain, so that patients will have clear information on the quality of care provided by local health services. Lord Darzi’s definition of quality includes patient experience. The quality accounts will therefore cover not only the quality of clinical care, but whether patients feel that they have been treated with dignity and respect.
As Lord Darzi has pointed out, the NHS is good at invention, but it can be slow to adopt new technologies and treatments, and the spread of new ideas is variable. We are taking several measures to foster a more innovative culture in the NHS. NHS Evidence provides all the clinical and non-clinical evidence on new treatments and best practice in one place, through one easily accessible portal. The £220 million strategic health authority regional innovation funds will help front-line staff to develop, grow and spread new ideas, delivering genuine improvements in the quality of care that people receive. The Bill will provide further support for innovation by enabling the Secretary of State to make payments, as prizes, to promote innovation in health services. Innovation prizes will reward those front-line staff who have excelled and will encourage others to do likewise.
In order to give patients more choice and control over the care that they receive, the Bill brings forward measures that will enable the NHS to pilot direct payments, as part of a wider programme of piloting personal health budgets. Personal health budgets could work in many ways. The NHS is already setting up pilots where the personal budget is not physically held by the patient—rather, there is a notional amount—or where it is held by a third party on the patient’s behalf. However, where it makes sense, we also want to allow the option of direct cash payments to patients. The Bill provides powers for that, building on the experience of direct payments in social care, which have transformed the lives of many people over the past decade.
I congratulate the Secretary of State on his new post. Help the Aged, the British Medical Association and others have expressed concern about direct payments, which are to be piloted as part of the new personal health budget initiative. Will direct payments in any way remove patients’ human rights, and what happens to any underspend from them? Does it stay with the patient or does the patient pay it back to the NHS? There are genuine concerns about direct payments, so can we have a lot more meat on this bone?
I would say quite the reverse. The introduction of payments could help patients to secure their fundamental rights, particularly those that I mentioned earlier, as set out in the NHS constitution. I hear what the hon. Gentleman is saying, however, and there is a need to proceed cautiously. I looked at the issue when I was Minister of State in the Department, and I felt that although the idea had merit, there was a need to proceed cautiously. However, that is exactly what the Department is doing, with a programme of 70 pilots beginning next year. So we will listen carefully and work cautiously. The Minister of State, Department of Health, my hon. Friend the Member for Corby (Phil Hope) has done such good work in social care to unlock the benefits for patients of having more control over their care, and we now feel that there is merit in proceeding in this direction, especially when we can bring the two budgets together for people with particularly complex health and social care needs.
We are not being prescriptive nationally about how and where personal health budgets or direct payments should be used. Many of the primary care trusts that have applied to join the pilot programme believe that the arrangements could have the greatest impact for people with long-term conditions or mental health needs, but a range of innovative ideas is under consideration. However, we have set out a clear policy framework and guiding principles for how all types of personal budget will operate. Any budget should be spent on goods and services agreed in a care plan on which it is appropriate for the NHS to spend money, and there should be high quality advice and support to help people to manage their budgets properly. In the case of direct payments, the Bill and subsequent regulations will provide explicit safeguards. There will also be a robust evaluation to assess how personal budgets and direct payments can best improve the quality of care for patients.
While my right hon. Friend is on the subject of direct payments, will he clarify what would happen if a patient decided to spend their budget on a clinically ineffective regime that did not deliver the goods? Might not that result in a fall-back on the NHS, which would have to pick up the pieces or repair the damage caused by ineffective or harmful treatments?
My hon. Friend raises a reasonable point, but as I said a moment ago, authorisation for direct payments will be given only for services that NHS money is normally used for, and they will form part of a care plan that will have been signed off by a clinician or a health service manager. Actually, there must be a role for the GP in this—[Laughter.] My hon. Friend is always looking for work. Perhaps GPs will be able to play a guiding role in helping people to explore options that might not be readily available through mainstream care. Obviously, we shall want to tease out all these points and, as I said to the hon. Member for Castle Point (Bob Spink) a moment ago, we shall proceed cautiously in order to pick up precisely the kind of concern that my hon. Friend has just raised.
I also congratulate my right hon. Friend on his appointment at the Department of Health. He talked about the evaluation of the personal budget pilots. Will the outcomes of the evaluation be published before anything is rolled out across the NHS?
I am grateful to the Chairman of the Select Committee for his kind congratulations. This is an issue on which I have not yet taken a firm view. I have seen the list of pilot projects; I believe that they exist in every SHA region and in many primary care trust areas. I hear what my right hon. Friend says and I believe that there should be careful analysis of what the pilots tell us before there is any rush in this direction. It is also important to acknowledge at this point that different issues arise in respect of health care and of social care. Health care can often involve more specialised or complex services that might require a critical mass of patients to support their continuation, for example. These are precisely the kind of issues that the pilots will test, and I give him a commitment that we will proceed with caution and, wherever possible, publish information as we go along.
In the case of direct payments, the Bill and subsequent regulations will provide explicit safeguards. There will also be evaluation. The Bill will ensure that direct payments could be extended more widely only in the light of evaluation and with the active approval of Parliament. I hope that that will give my right hon. Friend further reassurance; Parliament would have to endorse any further development of direct payments.
The second part of the Bill establishes a new regime for NHS providers that have been performing badly despite interventions by primary care trusts, the strategic health authority or the appropriate regulatory body. The vast majority of trusts perform well, but in the rare instances where that is not the case, there must be transparent processes in place to deal with poor performance.
The Bill outlines the following measures, which would be taken only as a last resort and when other measures have failed. In such circumstances, the trust board would be immediately suspended and the Secretary of State would appoint an independent trust specialist administrator to review and consult patients, public and staff on the organisation’s future. Recommendations would be made to the Secretary of State, who would report to Parliament the final decision about the organisation’s future. These measures will provide protection against the possibility of allowing NHS providers that have consistently failed patients to continue indefinitely.
I congratulate the right hon. Gentleman on becoming Secretary of State for Health. Will he explain who would trigger the occurrence that he described? If, for instance, people disagreed fervently with a decision about a foundation hospital, who would trigger the decision about how to proceed? Would it have to be the Government or could the public be involved in it?
In the legal context, Monitor, as the authorising body of foundation trusts, would be responsible. The public could, of course, be involved and one hopes that a foundation trust would have developed better mechanisms for public engagement and consultation. Any information that came through that route would inform any decision that Monitor reached. As I say, Monitor is the decision maker in this context.
The administrator would review and consult patients and staff on the organisation’s future and then make recommendations to the Secretary of State. We believe these measures will provide protection against the possibility of NHS providers continuing indefinitely.
The National Health Service Act 2006 placed restrictions on the amount of income foundations trusts can earn from private patients. The private patient cap is automatically set at the proportion of private patient work a trust did in 2002-03. It was introduced because of the understandable concern that foundation trusts might expand private patient activity at the expense of the NHS. These concerns are still relevant today. Private care must not be delivered on NHS premises to the detriment of NHS patients, but the implementation of the cap has raised complex issues for some foundation trusts, which need to be resolved.
An amendment was tabled in the other place to give the Secretary of State the right to grant exceptions to the rule that limits the amount of income a foundation trust can generate from private work, but I do not believe that this is the right solution. Striking the right balance between protecting NHS services for NHS patients and allowing foundation trusts the flexibility they need to operate in the interests of patients is a complex issue. There is no quick fix to implement, particularly without widespread consultation with the NHS.
I add my congratulations to the right hon. Gentleman, and I hope that he enjoys his tenure until the end of this Parliament. He refers to the income that foundation trusts can receive from treating private patients. I have received some briefing material from the Foundation Trust Network, one of whose chairmen is my constituent. The briefing points out that there are some perverse impacts on foundation trusts stemming from the cap on private patient income, which effectively limits some of the Government’s own proposals for the health service. I do not want to get into a Committee stage debate, but will the Secretary of State provide an indication of what scope there will be to ensure that the cap no longer creates such perverse incentives?
I am grateful for the hon. Lady’s congratulations. I have some aspirations to stay beyond the next general election—who knows; we will see. She raises a very fair point and it is also fair to say that my predecessor had acknowledged that although we did not want to accept what we saw as a quick fix from the other place, we nevertheless believe that there is a case to review the operation of the cap and how it affects foundation trusts. We appreciate that many trusts are in very different positions in view of their case mix, and we would like to work with the Foundation Trust Network to explore those issues as part of the review. As I say, we are committed to looking again at the cap’s operation, but we think it would be better done through a wider process of consultation with the NHS rather than by simply accepting the amendment from the other place.
I join others in welcoming the Secretary of State to his new position. I shall say a bit more about that in a short while.
As a Back Bencher, the Secretary of State contributed to the debate on the private income cap during the Report stage of the Bill that became the Health and Social Care (Community Health and Standards) Act 2003. He therefore knows about this issue. He must be aware that the way in which the cap is biting on foundation trusts that are also mental health trusts, which have had virtually no private income, is preventing them from supplying services to, for example, the private companies that are acting as employment providers under the new deal. It is having potentially significant perverse effects.
I hope that the Secretary of State has noted that his noble Friend Lord Warner, who moved the relevant clause back in 2003, said in another place on 12 May this year:
“I was the Minister who moved the offending clause… I repent my sins.”—[Official Report, House of Lords, 12 May 2009; Vol. 710, c. 936.]
Will the Secretary of State at least tell the House now, on Second Reading, that he will not exclude the possibility of leaving the Bill as it is in this respect, so that Ministers can make the necessary regulations in the future? If he does not do that, he may close off the possibility of a change in the primary legislation.
I thank the shadow Secretary of State for his congratulations, and look forward to crossing swords with him once again. I have enjoyed many exchanges with him in television studios and across the Floor of the House, and I am sure that I shall do so again.
I did indeed read Lord Warner’s words in preparation for today’s debate, and they obviously carry considerable weight, given the position that he held in the Department and his role in the Bill’s passage. I am also aware of the particular position of mental health trusts, not just in terms of their relationship with bodies working for the Department for Work and Pensions or, as the hon. Gentleman said, with the new deal, but in terms of their relationship with local authorities and other parts of the public sector.
The hon. Gentleman is right to identify issues that need to be examined. That is why we set up the review. As his intervention demonstrated, this is a complex issue, and, especially given my recent arrival, I do not think that it would be wise for me to make a snap judgment today on whether to accept an amendment from the Lords. However, I give the hon. Gentleman a commitment to work through the issue, and I suspect that, with his engagement and that of the Foundation Trust Network, we shall be able to reach the right place.
May I express a counter-balancing view? I am not at all sure that my right hon. Friend will be able to “reach the right place”. I think that the fact that NHS institutions—foundation trusts—carry out private procedures is a distraction from their core business. I am saddened that they continue to do that, and extremely saddened that they now want to bust the cap—a bit like universities with top-up fees—and get away with charging more for private services. I urge my right hon. Friend to go in the other direction and ban the whole thing.
That intervention illustrates why I am not going to jump in feet first and say something that I might regret. It also illustrates that there are strong views on both sides of the debate. However, I think my hon. Friend would agree that we would not want the operation of the cap to stand in the way of improvement of NHS services if it could be demonstrated that that could be achieved, particularly where NHS trusts—especially mental health trusts—might wish to work in closer partnership with other parts of the public sector. Those are the issues that we shall have to tease out in the review. As I have said, it will be a thorough review, so that NHS and other key stakeholders can be properly consulted and we can ensure that any new proposals are workable and have broad support from managers, staff and patients.
The Bill also amends powers in relation to public appointments. The Secretary of State currently has powers to suspend chairs and non-executive directors of primary care and other NHS trusts. The Bill extends those powers to cover chairs and non-executive directors of strategic health authorities, relevant arm’s length bodies, and other bodies concerned with health. As with other responsibilities relating to public appointments that rest solely with the Secretary of State, this power will be delegated to the Appointments Commission.
The third part of the Bill reforms the process by which primary care trusts commission pharmaceutical services—I feel right away that the hon. Member for Romsey (Sandra Gidley) and I will be picking up a debate we had some time ago about how best to drive improvement in the pharmacy sector, and I respect the huge experience she has in the subject. It grants PCTs additional powers to deal with poor performers, including the right to issue remedial notices and to withhold payments from contractors who do not meet minimum standards. The Bill will also permit primary care trusts to provide pharmaceutical services themselves in an emergency such as a flu pandemic or where there is no suitable alternative.
The Bill also makes changes to the social care complaints system, enabling people who pay for their own care to refer any complaints to the local government ombudsman, just as those who receive free care from their local authority are currently able to do. I think the House will accept that that closes the long-standing loophole whereby self-funders have not been allowed to make complaints in the same way.
The Bill also gives a firmer legal footing to the transfer of anonymised data on doctors’ and dentists’ pay from Her Majesty’s Revenue and Customs to UK health departments. These data have been shared between HMRC and UK health departments for more than 20 years and form a vital part of the evidence that goes to the Doctors and Dentists Review Body on pay.
Let me turn to the final aspect of the Bill. It is becoming increasingly clear that the big challenges to the health of the nation are rooted in our lifestyles, and that if we want to build a sustainable NHS, we must now put as much focus on preventing illness as on treating it.
I am aware that this part of the Bill addresses tobacco control and protection for children in relation to tobacco, but is it not time that we looked at protecting children in other respects as well, because they are particularly at risk from both tattooists and piercers? Currently, there are no minimum age limits for children having piercing of their genitals, navels, nipples, mouth, nose, eyebrows and ears. There are also no minimum training qualifications and no skills qualifications for those who carry out such piercing. Should we not also be looking at the risks to children from such tattoos or piercing, which include the danger of infection, bleeding, complications and the need for plastic surgery? Should we not be updating the NHS to take account of such new risks to our young people?
I thank my hon. Friend for that contribution. I am always on the side of the argument that says we must give maximum protection to young people. I think I am correct in saying that there is currently a minimum age for having a tattoo, and I can assure my hon. Friend that I have no plans to change that. However, I know that she and other Members have raised the issue of piercing before, and I undertake to meet her to discuss her concerns more fully.
I congratulate the Secretary of State on his promotion. We all want people to live longer and to lead healthy lifestyles, but does he not share my concern that there might be an unintended consequence of particularly the health promotion aspect of the Bill in relation to tobacco advertising and the display of products, in that local convenience stores and small shops may well close? Of course the right balance must be struck and I agree that we need health promotion, but we must also bear it in mind that most small shop owners are responsible and undertake their duties in a lawful way, and that in order to survive they need to sell products and to provide products to the wider community.
I understand the hon. Gentleman’s point, and I can confirm that it would never be my intention to make it harder for small retailers to survive; I do not think anybody would want that. Nevertheless, we have to act to counter the fact that many young people still take up smoking, and if we in this House can take measures to reduce that, we have a responsibility to consider them. It is my judgment that this can be done without causing the effect on small businesses that the hon. Gentleman described, provided that we can find the right point of balance so that we do not put an unfair burden on small shops. I hope the hon. Gentleman will work with us to find that point, because we still have some way to go before we reduce smoking rates among young people to a level that we would find acceptable.
I, too, congratulate my right hon. Friend on his appointment; I am sure that he will make an excellent Secretary of State, and I hope that he also proves to be a tolerant one. Is he aware that in Canada, Iceland and Thailand, which are the only countries to have introduced a comprehensive retail display ban, there is no evidence to suggest that it has had any effect on youth smoking rates or consumption? Indeed, the Prime Minister of New Zealand has ruled out such a ban, stating:
“There’s no international evidence it actually works”.
On what basis is my right hon. Friend taking this measure forward?
I am grateful for my hon. Friend’s kind words of congratulation. I stand to be corrected, but what I read of the evidence over the weekend suggests to me that in both Iceland and Canada measures to restrict point of sale materials did have an effect on smoking prevalence among young people. In Iceland, the fall in smoking prevalence among 15 to 16-year-olds between 1999 and 2007 was most rapid in the period immediately following the display ban introduced in 2001—smoking prevalence for that age group fell by more than 40 per cent. during that period. I would argue that it is not correct to say that there is no evidence to demonstrate the effectiveness of this proposal, but I agree that it should be introduced in a way that does not make it even harder for small shops to trade. We all have concerns about the high streets in our constituencies, the community facilities and the community shops and services. It is not our intention to make those commercial pressures even greater; nevertheless there are steps we could take to reduce smoking among young people. Where there is evidence to suggest that things that we could do could have an effect, we are duty-bound to consider them.
In addition to that, will the Secretary of State try, whenever he can, to make the point to those who smoke that they should try never to be the first person to light up in any group and that they should try not to smoke in front of someone younger than them?
I join others in welcoming the Secretary of State to his new job—it is a very important one. The debate about how one prevents young people from becoming addicted to a harmful substance, be it tobacco, alcohol or another harmful drug, is difficult. While respecting the rights of adults to make choices about those products, will he give an undertaking that, first, everything he proposes will be evidence based and, secondly, that he will always seek all-party agreement, via the Select Committee and through other means, to ensure that we proceed with maximum consensus on such difficult issues? As we all know, young people can find ways around regulations as easily as anybody.
I am happy to give the hon. Gentleman that consideration, but what I ask in return is that if we give the evidence a thorough test in Committee and find that proof exists for certain action, the House does not then find other excuses not to take such action. Like me, I do not think that he is comfortable about the prevalence of smoking among young people in our constituencies. I think that there is more we can do to cut the number of young people smoking, and if that can be done, the effects on their standard of health will be huge. We must take this important issue incredibly seriously.
I congratulate my right hon. Friend on his new appointment. We must recognise how powerful and influential the tobacco lobby is. At every stage it challenges causation, manufactures uncertainty and hides behind third-party organisations—Save Our Shop is funded by the Tobacco Manufacturers Association. As the very last resort, it will drag its feet against the inevitable—what Philip Morris calls throwing grit into the gears of regulatory reform.
My hon. Friend makes an important point, which stresses the need—perhaps this goes back to what the hon. Member for North Southwark and Bermondsey (Simon Hughes) said—for us to examine the evidence and put aside some of the vested interests. I will argue strongly that if we can take steps to reduce the level of smoking among young people, we should always do so.
Smoking remains the leading cause of preventable death in this country. Although the number of people who smoke in England is at an all-time low, there are still too many young people taking up smoking.
I, too, congratulate the Secretary of State on his promotion. Will he think again about the ban on tobacco display, which is a triumph for the nanny state? The most recent evidence that the Department of Health itself commissioned on this subject showed that brand awareness was not a factor in influencing young people to smoke compared with other social, economic and family background factors. He said that he does not want to damage small businesses, and that is reassuring, but his Department says that it will cost at least £1,000 a store to implement this proposal. It is gesture politics of the worst kind: will he think about it again?
I will think about it, but I would just point out that during the life of this Government we have taken measures to restrict the promotion of tobacco and control exposure to it. At every point in that journey, the voices from the Opposition Benches have cried, “Nanny state!” Almost every time that a sensible measure has been proposed to tackle smoking, especially under-age smoking, we have heard those voices. If we had listened to them, we would not have reduced the proportion of people who smoke from 28 per cent. in 1997 to 21 per cent. in 2007. On this issue, the calls from the Opposition do not have credibility. Without those measures, we would not have had that progress—[Interruption.] The noise is rising from the Opposition, but we will stand firm on this issue.
The total number of deaths caused by smoking in this country is more than the number of deaths from diabetes, road traffic accidents, suicide and drug and alcohol related causes combined. Some 8.5 million adults still smoke, and some two thirds took up the habit when they were under the age of 18. Some 200,000 11 to 15-year-olds smoke, which is a major cause of health inequality. Children from disadvantaged backgrounds are much more likely to become smokers.
Since the tobacco advertising ban, the main conduit for marketing cigarettes to children is through retail displays in shops. There was a full and impassioned debate on this issue in the other place, where the full range of views was set out and discussed. Their lordships have thoroughly scrutinised evidence on the benefits and costs of our proposals, and their conclusion—by an overwhelming majority—is that we should act now in accordance with the measures set out in the Bill.
Will the Secretary of State confirm that the reduction in the prevalence of smoking was greater in the 1980s, under the Conservative Government, than it has been at any other time in the last 50 years, because of the impact of the increase in the price of cigarettes? The increase in prices in Iceland had the same impact.
We believe that evidence exists to support the proposition that we should ban tobacco vending machines in the public areas of licensed premises. Why are the Government resisting that suggestion?
On the hon. Gentleman’s first point, I do not wish to make a party political point—[Interruption.] I normally do, but not on this occasion. I remember the time of “The Health of the Nation” in the early 1990s, and progress was made in reducing smoking, but there was a real acceleration in 1997, with the introduction of smoking cessation courses and nicotine patches being made available to people. When tackling an issue of this magnitude, it gets harder and harder the lower we seek to go. The cut that I mentioned in the number of people smoking is a real and appreciable difference that will bring real health benefits to the people concerned and the national health service for years to come.
On the hon. Gentleman’s second point, I shall discuss vending machines shortly. If I pick up the drift of his question, he wants us to go even further than is proposed in the Bill. I hope that he will discuss with his colleagues the possible effect of that on small businesses, but let us have the debate.
People ask about the evidence. A study published in 2008 by Cancer Research UK reviewed two decades’ worth of research on the influence that point-of-sale displays have on smoking among young people. The collective conclusion of these studies is that point-of-sale displays not only encourage children who already smoke to make impulse purchases of cigarettes, but encourage children who have never smoked to take up the habit.
Research by leading academics at Stanford university’s school of medicine, published in 2004, showed that removing point-of-sale displays and advertising could reduce the likelihood of smoking among children and young people by as much as 50 per cent., even when other factors, such as parental smoking, are taken into account. Point-of-sale displays in the US are much more prominent than they are in the UK, but even if this legislation had only a 10th of the impact that it is estimated to have had in the US, it would still mean that 3,000 fewer children would become smokers each year—[Interruption.] I hear the muttering from the hon. Member for Shipley (Philip Davies). If he is talking of the nanny state and saying that it is not worth doing, then shame on him.
Will the Secretary of State give us his forecast of how many people might not become smokers if the point-of-sale measure goes through? What other measures is his Department considering in order to have even more success in reducing smoking?
The Department is considering a broader review of tobacco control policy later this year. We will be able to provide the right hon. Gentleman with a fuller answer then. I agree with the shadow Secretary of State that vending machines are an important part of the debate—we need to have that debate—but it is also important to act proportionately and to ensure that we consider the legitimate needs of small businesses when making any changes.
To give retailers time to prepare, the point-of-sale provisions will not come into force until October 2011 for larger businesses and 2013 for smaller shops. I hope that that responds to the concerns raised by the hon. Member for The Wrekin (Mark Pritchard). That will allow smaller retailers time to adjust, refit their shops when their old displays are due to be replaced anyway and limit as far as possible additional costs.
The Bill will also create powers to control the sale of cigarettes to children and young people through vending machines. Cigarette machines represent 1 per cent. of the overall cigarette market, but 17 per cent. of 11 to 15-year-olds describe them as their usual source of tobacco. Initially, we will introduce stricter controls to ensure that only adults can purchase cigarettes through vending machines, but if those restrictions fail to stop underage sales we will consider banning vending machines outright.
In conclusion, the NHS is both transformed and transforming as an institution. This journey of reform has seen our priorities evolve over time. There have been three phases of reform. In the wake of the 2000 NHS plan, when the focus was on building capacity and driving up core standards, we needed the discipline and focus that centrally agreed targets confer. Following that, the focus rightly switched from numbers to process, as we took steps to introduce greater diversity and flexibility into the system, pushing power down to local organisations and enabling the NHS to look outwards to the communities it serves rather than upwards to Whitehall. Now, with Ara Darzi’s “Next Stage Review” and this Bill, we are opening up a third era of reform for the NHS, one that is focused on people—patients and staff—and that empowers clinicians and staff as the driving force of reform. It will all be backed by an NHS constitution, securing the values and principles of our national health service for future generations. I commend the Bill to the House.
Once again, I welcome the Secretary of State to his new responsibilities. When he went to the Department for Culture, Media and Sport, he said that it was his dream job. I am sorry that we may turn his short tenure at the Department of Health into a bit more of a nightmare, but I hope that he will maintain the merit of consistency. As I noted in an intervention, the Secretary of State has already taken a consistent approach in trying to restrict foundation trusts from extending their private income cap.
The Secretary of State is consistent on a number of issues. When he first went to the Department for Culture, Media and Sport in February last year, he gave an interview to The Daily Telegraph. Surveying the artwork on the wall of his new office, he told the journalist:
“That’s very Purnell, and it’s going to have to go.”
The right hon. Gentleman has done it once, and now he is doing it again.
I welcome, too, the Ministers of State, the hon. and learned Member for North Warwickshire (Mr. O’Brien) and the hon. Member for Lincoln (Gillian Merron), to their new responsibilities. I wish the new Secretary of State for Culture, Media and Sport, the hon. Member for Exeter (Mr. Bradshaw), well in the Secretary of State for Health’s former dream job and I wish the Minister for Children, the right hon. Member for Bristol, South (Dawn Primarolo), well in her new responsibilities.
I am sure that he is far too busy to listen, but I say a fond farewell to the right hon. Member for Kingston upon Hull, West and Hessle (Alan Johnson), who has gone to the Home Office. Of course, Labour Members may be wishing that the new Home Secretary occupies his post for only a short period before he goes on to other things. When Kirsty Young asked the duly modest right hon. Gentleman whether he thought he had leadership potential, he said:
“I don’t think I would have been good enough, frankly. I don’t think I’ve got the capabilities.”
Just a word to the right hon. Gentleman: that did not seem to hold back the present incumbent, so why should it hold him back? Perhaps even before I sit down, others will be encouraging him.
I had not quite understood that the new Home Secretary was so in tune with what was happening in the national health service. So in tune was he that he must have noticed that the average tenure of a chief executive in the NHS is now 23 months. Lo and behold, 23 months after he took up his post at the Department of Health, he left to go elsewhere.
Yes, I must. The Secretary of State said that he sees the promotion of health and the prevention of disease as his top priority. The Opposition have been making suggestions to the Government for a long time, and they have accepted many of our proposals. May I make a proposal about something we have been on about for a long time? As Secretary of State, he should not make public health the responsibility of another Minister in his Department, but should make it his responsibility. Although I hope that his tenure as Secretary of State is short, he will realise that none the less there is an opportunity to do good if he takes public health into his own hands. There are certainly issues about the development of Change4Life and the public health programme that need to be pushed forward quickly if it is to have the success we all wish for it.
The Bill owes something to the Secretary of State’s past tenure at the Department of Health. He followed one of the proposals my right hon. Friend the Leader of the Opposition and I made about greater operational independence for the NHS and the need for it to have a constitution. He echoed those thoughts, and said that a constitution and more operational independence for the NHS would be a good thing.
Before the right hon. Gentleman interrupts, I should point out that he went on to differentiate operational independence from a constitution and ended up saying that a constitution would be a good thing but that although he wanted operational independence it did not seem to be such a good thing.
I found myself getting very frustrated on the many occasions when, while doing my dream job down the road, I heard the hon. Gentleman claim credit for the NHS constitution. If he looks at the record, he will see that I proposed it a long time before he first spoke of it. I would be grateful if he did not keep making the wrongful claim that he was the originator of the NHS constitution. If he looks back, I think that he will see that I first proposed it a good year before he did.
Let me agree this with the new Secretary of State: we will not have a debate about who proposed a constitution; we will just agree that there should be one, but let us agree that it ought to be a real constitution. The new Secretary of State embraces the thought that there should be a constitution, but what he has found in the Bill that he has inherited is not really a constitution at all but a declaratory statement. It simply declares that there are a range of legislative provisions and promises made by the Government that apply to the national health service, that those should be published in a document, and that the document should be called a constitution. As hon. Members will know, a constitution has to have certain characteristics. When the Government see a constitution in Europe, they deny that it is such a thing. When they see something that is not a constitution and it suits their political purposes to decree that it is a constitution, they do so.
What we are being offered in the Bill is not, in truth, a constitution, but that is what we ought to be offered. The new Secretary of State wanted greater operational independence for the NHS and believed that it would be important; it is precisely what he said was needed, but it is not enshrined in the constitution in the Bill. In effect, for the NHS, the constitution still enshrines the same principle of the legislative relationship between the NHS and the Secretary of State, which is that the NHS is at any moment whatever the Secretary of State chooses to make it. The Secretary of State can change the definition with the stroke of a pen—literally.
Does my hon. Friend agree that if hon. Members read the constitution to see whether their constituents will have any more rights under it—for example, more rights to high-quality service or faster or better treatment—they will see that it is all such weasel words that there is no enhancement of constituents’ rights to a decent service?
Yes, my right hon. Friend is quite right about that. Let us take one example: where in the constitution, if rights to treatment are so important, is the right of access to NHS dentistry? It does not exist. The Secretary of State says that there is a right of access to NHS treatments as recommended by the National Institute for Health and Clinical Excellence, but that is only precisely the same legislative provision that was put into a statutory instrument years ago, and it is a right that all our constituents have had breached time and again. There is nothing new whatever in the constitution that changes that statutory provision.
If one wants a constitution, it has to do what constitutions do: define the duties, responsibilities and accountabilities of the organisations within the NHS. I am afraid that that opportunity has not been taken in the Bill. In that sense, it is a clear wasted opportunity. We know that we will need to restore to patients the clear voice that was abolished when the community health councils were abolished, that was further undermined under patients forums, and that has not been restored under local involvement networks, or LINks, especially at a national level.
We will have to create the mechanisms by which commissioners and providers can be properly separated, because the legislation to do it is simply not there. We know that primary care trusts in parts of the country are trying to create a separation between their commissioning activities and their provider activities, but legislation prevents them from doing so. Have the Government created an opportunity in the Bill for that important constitutional change to be made? No, they have not. Have they put back into legislation what they took out in 1999—the opportunity for general practitioners on the front line to be able to exercise real commissioning responsibilities? No, they have not. They leave that with primary care trusts.
I am afraid that the Government’s approach in the Bill has not been to take the opportunity to entrench in constitutional form the kind of accountabilities and responsibilities that would go with the reform process that the NHS is really looking for. The new Secretary of State must remember his former boss, Tony Blair, making a speech about the character of what was required for reform in the national health service, because he became a Minister in the Department of Health at almost the same moment. If I recall correctly, that speech was made in June 2006, just when the Secretary of State took up his post as Minister. It was probably part of his instructions from No. 10 to go in and try to push the reform process. I think that was part of his responsibilities as a Minister. It was about accelerating patient choice, extending practice-based commissioning, completing the transfer of NHS trusts to foundation trusts, and stimulating additional capacity for the NHS through the independent sector. Those were the four drivers of reform that Tony Blair talked about.
What has happened? All four have stalled. The last Secretary of State did not deliver on patient choice. It went up by just 3 per cent. Only 3 per cent. more patients believed that they had patient choice. Most of the time, less than 50 per cent. of patients felt that they had choice when they were offered elective operations.
The Audit Commission has demonstrated that practice-based commissioning has stalled. I talk to GPs across the country who say that it is not happening. The primary care trusts, in effect, feel that they have been told by the Department of Health that they can take complete control of commissioning again and close GPs out of it. The NHS trusts were all supposed to have become foundation trusts by December 2008, but they are coming through only one at a time.
The independent sector has been dissuaded from additional investment because the recently departed Secretary of State told them that, as far as he was concerned, the issue was one of capacity, not of competition. The Government believed that in many parts of the country they had sufficient capacity in the hospital sector and therefore that they did not need the independent sector any more. They feel that they can turn the independent sector on and off like a tap.
The reform processes for which the new Secretary of State used to be responsible have all stalled. The Bill does nothing to drive any of them forward or to provide the drive, the pace and the institutional architecture that would help to entrench the reform process for the longer term.
I turn to what is in the Bill, as opposed to what should be but is not in it. On direct payments, if the new Secretary of State and I are debating who was in favour and who was not in favour of parts of the Bill, he will concede that in January 2006 the then Health Secretary, the right hon. Member for Leicester, West (Ms Hewitt), flatly rejected the possibility of extending direct payments from social care to embrace aspects of health care, which we were arguing for at the time. She said that that was inconsistent with the NHS principles and that it was revisiting the patient’s passport. The right hon. Gentleman says that as a Minister he considered direct payments—but presumably turned down the idea—so he was no doubt embracing that thought. I am glad that there has been a change of view on his part and that of the Government. We will support the proposal, but we must make sure that it is done well—not only cautiously, but well—and that the institutions in the health service that are charged with it do not try to frustrate it.
I am seriously worried that, in their commissioning of NHS continuing care and some of the joint purchasing of social care, PCTs are going through purchasing structures like reverse e-auctions, the effect of which is to deny those who enjoy personal budgets the possibility of using them in ways that are flexible and responsive to their needs, rather than precisely as predetermined by the primary care trust.
On quality accounts, the Secretary of State knows that we share the view that quality needs to drive the activities of the national health service, but we must be aware, as must the right hon. Gentleman, that too often commissioning in the NHS has been on the basis of cost and volume not quality. After his predecessor’s unhappy experiences with the Healthcare Commission’s reports on Maidstone and Tunbridge Wells and on the Mid Staffordshire Foundation Trust, it is clear that in both cases the primary care trust was pursuing an approach of commissioning for cost and volume, not for quality. Quality is very important.
It is difficult to be sure that quality accounts will, of themselves, deliver such quality. Let us take an example. In the case of the Mid Staffordshire Foundation Trust, we know that many organisations, including the Department of Health, treated compliance with a four-hour target as a measure of quality in the handling of admissions to the emergency department at Stafford general hospital. The Department and its fellow organisations, such as Monitor, published a document to tell us what quality accounts might look like. It is helpfully entitled, “The Sunnyview University Hospital Trust”. I have a copy.
In the Department’s lexicon of communications, if something is called the Sunnyview document, everybody will no doubt treat it as an optimistic document. Unfortunately, when one looks at the document to see what quality accounts on emergency care would mean, one sees that it focuses on targets. It says that the measure of quality is adherence to the four-hour target, but we know that that target is only one measure, and an insufficient measure in the experience of the Stafford general hospital, because the staff there said that in order to meet that measure, they had to compromise the quality of patient care—not support quality or deliver that care, but compromise it.
Has my hon. Friend noticed that there is now only one Labour Back Bencher in the Chamber for this important Bill on the Government’s flagship subject? Does he think that they are unaware that their Prime Minister would like them to be here supporting the new Secretary of State?
I am grateful to my right hon. Friend. I think Labour Members are more concerned with the health of their party than they are with the health of the population. That is a matter of regret. Let us recall that the Bill was meant to be a flagship piece of legislation, but they decided some time ago that it was not a flagship, but a rather small tender. [Laughter.] The silent one on the Government Bench found his voice.
When the Secretary of State was a Minister, he said that from 2009 there should be fewer national targets. One of the things that he could do, even in the space of the next few months, if he has so long, is dispense with those targets. If he believes, as he said in the past that he does, that people in the NHS felt frustrated by the weight of central top-down targets and bureaucracy, he should let go. Let him take away the four-hour target and see what can be arrived at by way of a series of measures of quality of emergency care in emergency departments agreed between commissioners and hospitals. Let us see whether the result is an improvement or a reduction in quality of care. My belief is that it would be an improvement.
Among other measures, the Secretary of State referred to trust special administrators. He will recall from the 2003 legislation that the Government promised to put in place a transparent failure regime. They have not done so. It was always clear that what was required was a failure regime that made transparent to those who were lending to the NHS and were the potential creditors of the NHS what would happen in the event of a financial failure. The Government have simply said that, in place of a presumption under existing legislation that all the protected assets of a foundation trust would be taken under control and the creditors left with virtually nothing, the whole of the foundation trust would be de-authorised, turned back into an NHS trust and taken back into the control of the NHS.
It is clear that we must protect the assets and services that are necessary for the delivery of NHS care. Alongside that, if there is to be an opportunity for foundation trusts to do as the Government originally intended and to behave with greater freedom and independence, a transparent failure regime is needed so that those who are creditors of foundation trusts will know that even if they do not have control of assets or services, they can at least be clear about the basis on which the liabilities to them are to be discharged in the event of the financial failure of the foundation trust.
I apologise to the hon. Gentleman for rewinding a little, but I should like to return to targets. He correctly quoted my remarks of a couple of years ago, but today let me say to him quite clearly that, where targets are superfluous, I shall look to get rid of them. When I was in my ministerial job and doing the work-shadowing exercise to which I referred, I spoke directly to staff in A and E who said that the four-hour target was a crucial part of making the whole system work—of moving people through the hospital.
When I did that job, I said on record many times that, once met, targets should become standards and points from which the NHS should not retreat. Did I really hear the hon. Gentleman correctly when he said that he would remove the four-hour A and E target? Would that not take us back to the A and E chaos and lack of hospital through-flow that we saw in the past?
The Secretary of State appears not to have remembered some of our exchanges, because I have been very clear about the matter: I would remove a central, top-down, four-hour process target. Commissioners and providers of service in the national health service need to arrive at a contract that makes clear the standards that they will meet. In emergency care and other aspects of care, however, the Government’s objective should be to move from targets to outcomes. He might like—[Interruption.] I shall explain the issue to the right hon. Gentleman, because, since he became Secretary of State, he will not have had the opportunity to read the latest—further—report by Dr. David Colin-Thomé, the national clinical director for primary care, on what happened at Stafford general hospital. He makes clear both the distinction between targets and outcomes and his belief that the Government’s and Department’s responsibility should be to focus on those outcomes.
The job from the centre is to specify the outcomes that we are trying to achieve, so, for example, emergency admissions for stroke might indeed embrace 30-day mortality. The quality of subsequent stroke care might include the proportion of patients who go on to live independently, and we can benchmark that against performance in other countries and determine, as we should, the quality of care in this country as compared with other countries. We cannot compare the four-hour target to other countries, however, because they do not define the quality of care that is provided by simply measuring how long people wait in an emergency department.
Processes, including the standards that support outcomes, must be determined between those who purchase services on behalf of patients and those who provide them. That might well include a question about the length of time that patients wait, but it would be negotiated and exist in a culture of continuous improvement. Some places would say “not 98 per cent. but less than 98 per cent.” Others would say, “more than 98 per cent.” If the Secretary of State talks to people in emergency departments, he will know that they might say, “Actually, we should have quite a different time in emergency departments for those who present with minor conditions as compared with major conditions.” In a contract with a hospital, one might quite properly have specified standards that set a much shorter waiting time for children than for adults.
There is a small benefit in having been in the job for almost six years.
Although the Minister has returned to the Department, having spent a year there previously, I am on my fourth Secretary of State and it is getting quite tiresome to have to explain endlessly to a succession of Secretaries of State that there is a real world out there, where people who want services contract for them in a culture of continuous improvement. The Government should focus on measuring the overall outcome.
I do respect the hon. Gentleman’s experience in the job, but he did not explain his policy when I was first in the Department and he has not done very well this time. He described a different standard for children and more serious cases, but there already is one in A and E departments. He seems to envisage a world of much more rigid, locally set standards, but the four-hour commitment is simply a cut-through standard—the minimum standard—that helps the whole system to work so that everybody knows where they stand. He is describing just basic, good clinical practice to bring through children and those in more serious need first. If he will forgive me, I do not think that he is putting forward a policy that will deliver clarity; it is a recipe for confusion.
Thank you, Mr. Deputy Speaker. I must confess that I prefer dialogue to monologue, but we are under your direction.
Let me at least make this point just one more time. What the Secretary of State said is simply not true. Patients who present with minor conditions and could be seen and treated are often not; they wait a long time. One Healthcare Commission report on emergency departments noted that that situation bears particularly on the elderly, who often wait almost four hours before they are discharged by the emergency department to avoid a breach. There is a range of such measures, and if, as he says, the proposal is already normal clinical practice, hospitals will have no difficulty building it into the structure of their performance measurement.
The Secretary of State made an interesting point, however, because I remember that Kettering general hospital was one of the original pilots of the four-hour target. The hospital said that the target helped it to deliver change in order to expedite the treatment of patients. I said, “Fine. Do you think therefore that you should go from 95 per cent. to 98 per cent?” The hospital said no. I then asked whether it thought it should go from four hours to three hours. The hospital said no.
Subsequent to my conversation with that hospital, which took place almost six years ago, the Government imposed the shift from 95 to 98 per cent., which the College of Emergency Medicine and many emergency medicine practitioners do not support. The Government did so in the belief that it was the right way to secure continuous improvement, but the right way to do so is to start performance management with the four-hour target and to move to an understanding that a range of quality metrics should be a part of the culture of continuous improvement. If it is not, we end up with 98 per cent. and four hours, and that is it. At Staffordshire general hospital and many others, it has become obvious that the focus on a single target for the delivery of emergency medicine leads to an immense range of distortions, many of which diminish the quality of care provided to patients.
We talked briefly about the exceptions to the private income cap. The Secretary of State should not listen to the siren voices, who have now left the Chamber, on the Government Benches. If one were to abolish the option to provide private medicine alongside NHS medicine, one would cripple hospitals such as the Royal Marsden. If anybody wants to see how being able to offer private health care alongside NHS care is to the benefit of NHS patients, they should go to the Royal Marsden hospital, because, with the Healthcare Commission’s ranking of double excellent year after year, it has demonstrated how it can reinvest the benefit of its private work in the NHS patients it looks after. The Opposition will be very critical if Ministers use a review as an excuse not to put into this Bill the opportunity for Ministers to introduce regulations to make exceptions to the private income cap. Ministers will know that Monitor feels that foundation trusts are highly constrained by the 2003 legislation. It can be changed only through this amending legislation; if it is not, the Government’s review will take place at some point in the summer or autumn—after the primary legislation opportunity has disappeared.
The Secretary of State talked about innovation, but, frankly, I am not sure whether we can give much credence to the way the Government have gone about innovation. The Darzi review, in an interim report in October 2007, said that there would be an innovation council. It met, but the Department’s website says that it last met in April 2008. The council seems to have disappeared since then. The fund that was supposed to be set up with the Wellcome Trust on a 50:50 basis—£50 million each—seems to have just disappeared, too. The provision is in the legislation simply so that the Secretary of State can give money to people who have already done something. However, he already has the power to incentivise people to do things in the future; he does not need legislation to do so.
I am sure that the hon. Member for Romsey (Sandra Gidley) will want to talk about pharmacy. The Government pursued dispensing doctors in an abortive attempt to remove some of their dispensing rights, and I worry that the Government are now seeing pharmaceutical needs assessment as a way, through primary care trusts, of arriving at a similar conclusion by a different route. We have to make sure that pharmaceutical needs assessments are real things that deliver real benefits, but the documentation that I have seen supporting such assessments simply says that primary care trusts should go away and work out what requirement there is for pharmacy services in their areas and commission according to that requirement. Where is the scope for patient choice, capacity building or a range of independent sector providers? Where is the freedom for pharmaceutical services to develop in response to need? We do not need primary care trusts to take to themselves more and more power over dispensing in their areas.
I come now to what I think will prove to be the most contentious issue in the Bill: I am thinking of the Government’s proposals on the point-of-sale display of tobacco. Time does not permit me to talk about the evidence at length, but I should say that my noble Friend Earl Howe and other Members of the House of Lords did a sterling job of considering the Bill and amending it in two important respects. They entrenched the constitutional principles of the NHS and put exceptions to the private income cap into the Bill.
My noble Friend set out at length the difficulties with some of the research evidence that is prayed in aid by the Government on point-of-sale tobacco display. In truth, comparisons between Canadian provinces such as Saskatchewan, which went down the route of a display ban, and other Canadian provinces, which have not had a display ban but have taken some of the other measures, show that the latter provinces have made similar progress—sometimes even greater progress.
I hope that we will have a substantial discussion in Committee on the subject. I hope that Government and Conservative Committee members will contrive to take evidence for that purpose, because our approach should be evidence-based and the evidence should be tested in Committee. When the Bill comes back here on Report, I hope that the Government, like us, will give Members a free vote. Hon. Members, including the right hon. Member for Rother Valley (Mr. Barron), the Chairman of the Health Committee, will well recall that, in itself, the giving of a free vote energised the debate about the ban on smoking in public places; in part, it led to the conclusion that we came to, rather than the one that would otherwise have been imposed by Ministers. I hope that, like us, the Labour party will give a free vote on these issues relating to public health and allow the evidence to determine Members’ views on the subject.
Although we will have a free vote, I should say that we on the Conservative health team strongly believe, like the Secretary of State, that smoking is still the greatest avoidable cause of premature mortality and that the rate of new smoking among young people is still far too high. We need to do whatever we can—if it is supported by the evidence—to ensure that as few young people as possible smoke. In that respect, we need to do more to combat smuggling and to act on nicotine replacement therapy, although those issues are not the subject of the Bill. We must ensure that the prescription and strength of NRT are optimised for the purposes of smoking cessation services.
Furthermore, we want two measures that could be in the Bill to be looked at. The first is the banning of tobacco vending machines from public areas of licensed premises; at the very least, we should structure the legislation so that we can ensure that young people do not have access to these machines in such areas. Secondly, there is an anomaly between the proxy purchasing of tobacco and the proxy purchasing of other products, alcohol in particular. If adults buy alcohol for children, that is a criminal offence, but the same does not apply to the purchase of tobacco. We see absolutely no grounds for such a perverse anomaly; it is important that adults should not give young people alcohol, but it is probably even more important that they do not give them cigarettes. We will press for the ban on proxy purchasing to extend to tobacco.
The Bill is a collection of measures that are not all bad; some are good. The incorporation of the principles of the NHS into legislation is a step forward, for which we have asked in the past. It has not been done precisely according to the NHS principles expressed in the NHS plan 2000; perhaps the Minister responding will explain why that is. Why has the principle that the NHS supports and values its staff been left out? That is rather curious. None the less, it is important that the principles are there.
The Bill is a missed opportunity to create a real constitution for the NHS. Most of all, however, it is a missed opportunity to entrench the reform process in a way that would show that the Government are committed to a vision of a health care system that is at least as good as that of any other country in the world. The system’s outcomes should be benchmarked against the outcomes of other countries’ systems, not against a small number of narrow process targets that distort the activity of the NHS.
We should create a framework that delivers reform and incentivises providers of NHS care to deliver a rise in productivity rather than the fall that we have seen in the past decade. We should see the delivery of real patient choice, with the information flows that make that happen. The Secretary of State said that there was a right to information in the constitution; actually, there is only a pledge that the NHS will strive to provide information—nowhere is it said that the information will be that which patients really need for choice to be supported.
Furthermore, there is no evidence that Ministers want to create the kind of information revolution and marketplace for information in health care that would deliver the real empowerment of patients. We want a structure in which decisions are increasingly made at the front line, but the Government are still trying to have it both ways. They talk about devolution in health care, but they are actually entrenching a structure that is all about top-down command and control; it is still all about command and control at the Department of Health. Health Ministers’ response to what I was saying about targets illustrated even more the fact that they cannot get their heads around the thought that their job is not to decide precisely what should happen to every patient who arrives at an emergency department.
The issue is about those who are responsible for care. [Interruption.] The Secretary of State says from a sedentary position that he remembers what it was like. The change in capacity and the increase in resources are important, but it is to traduce NHS staff to suppose that if the Government did not impose a four-hour or 18-week target, NHS staff would say, “Oh well, patients can wait any amount of time—it doesn’t really matter any more.” NHS staff care more than any of us about the quality of care that they provide patients. If they have the resources, freedom, opportunity and an incentive structure that helps to make it happen, they will be potentially capable of delivering the best health care in the world.
We know that the NHS is founded on the principle of equity, and we will not compromise on that principle; indeed, we need to do more to deliver it. However, in the past decade, under this Government, the NHS has become less efficient as productivity has fallen. It needs to become more efficient. Most of all, we must have excellence alongside equity. We will not achieve excellence in the NHS unless we focus on the outcomes and compare the health outcomes and health gain in this country with those of the very best health economies anywhere else in the world.
I conclude with a motto: “Nil satis, nisi optimum.” As the Secretary of State will know, it is the motto of Everton, his favourite football club. It means “Nothing but the best is good enough.” That is our motto for the national health service; I hope that, in the Secretary of State’s short tenure, it will also be his.
Could I first say—[Interruption.] I have to tell hon. Members on the Opposition Front Bench that I have got quite broad shoulders; I have had them for 26 years in this place, and they will remain.
Let me first say to my right hon. Friend the Secretary of State—I congratulate him on getting his new position on the Front Bench—that I support the Bill. It is quite wide-ranging and pulls a lot of things together, but not targets, which the hon. Member for South Cambridgeshire (Mr. Lansley) talked about. He mentioned an 18-week wait. Nowadays, everybody talks about patient choice in our national health service. In my local hospital, just five years ago, somebody wanting orthopaedic surgery was offered waits of months, if not years, for procedures on things such as knees and hips—or if they had a few thousand pounds, they could go to an independent hospital in Sheffield and have it done the following week by the same surgeon. Targets have got rid of that type of patient choice, which has been offered, wrongly, for very many years.
The hon. Gentleman says that we should not have such targets and we should let health professionals get on with it. With all due respect, some of them—a minority, I have to say—were getting on with it, and getting away with it, for years by using long waits in order to be able to increase their earnings in the independent sector. This Government have stopped that, not just in South Yorkshire but up and down the land. They should be congratulated by every Member of this House, in the knowledge that many of their constituents are not covered by health insurance. Many of those people discovered that if they wanted to get a better quality of life quicker, they would be asked to go and get bank loans or dip into savings. That situation has gone, and the waiting list target alone has done more than anything else to achieve that. Of course, there has also been increased capacity because of investment.
One of the aspects that I want to focus on is the national health service constitution. I know that that is, and will continue to be, a bit of a rolling programme. Nevertheless, having served on the Health Committee since the last general election, I know that many people up and down the land are frustrated when they see drugs going through the NICE process, whereby they are assessed and it is agreed that people should have them and it is accepted that they would be good clinically and cost-effective, and then those drugs are denied to them by the local purchasers—the primary care trusts. Through the constitution, people will have the right to a drug that has been through the NICE process; that is progress indeed.
NICE was set up many years ago—in my view, to get rid of so-called postcode prescribing. That is an inequitable system, because whether people can have drugs that have gone through the NICE process varies from one constituency, covered by one commissioner, to the next. This will be a major step towards introducing what it was intended that NICE should do—although I know that it does many other things as well.
I look forward to the Public Bill Committee’s reaction to this debate, although I should say to my right hon. Friend that I am not volunteering to serve on it; I have other things to do on a Thursday morning with the Health Committee. I look forward to seeing what the constitution is going to mean—not only to patients, although it does have an effect particularly in that respect, but to staff. It also covers rights and responsibilities. Rights are very important in our health care system, but so are responsibilities. What responsibilities do we have as individuals, or do patients have in terms of their health care? What will the NHS ask of them as regards what they have to do to contribute to their own good health, besides what the health service does for their ill health? I look forward to that debate.
My right hon. Friend will have heard me say on many occasions that in the 21st century the issues that will affect health care in this country, in particular, are not those that dominated public health in centuries and decades gone by. It is not about housing now, although we have to accept that there is still some poor housing around. It is certainly not about sanitation or fresh water supplies. I was one of those born into the first generation that could be immunised against many things that used to kill tens of thousands of people in previous generations. Now, at the beginning of the 21st century, we are immunising young women against cancer—just one type of cancer, I accept. That is an extraordinary step for medical science. The real threat to the health of the public in the 21st century will be about what the individual does or does not do—how much alcohol they drink, what food they eat and in what quantities, and whether they take exercise. Many things done by individuals will impact collectively on the health of the public. I look forward to the NHS constitution starting that important debate very early on in this century. It is the debate for the 21st century, come what may in terms of the health needs of the nation. It is no longer just about treating ill health, which the NHS has been doing very well for the past 60 years.
I am interested in the concept of the innovation prize. The hon. Member for South Cambridgeshire said that money is given to people who have achieved something. As I understand it, the innovation prize is about doing things differently from what happened in the past when money was given to people to carry out research within the NHS. Innovation is vital. It is the reason the NHS has improved, and continues to improve, the health of this nation in many respects, and it should be encouraged. However, we need to examine the idea that if someone makes an application and gets a pot of money to do research, it goes ahead, but if they make an application and do not get the pot of money, it does not go ahead.
I have here the Library research paper on the Bill, which discusses the innovation prize, saying that clause 14
“enables the Secretary of State to award prizes to promote innovation (including research) in the provision of health services in England, including prizes for work done before the Bill currently before Parliament becomes law. It also enables the Secretary of State to establish a committee to advise about awarding such prizes and to pay the committee’s members.”
My understanding—I hope that my hon. Friend the Minister of State will clarify this when he winds up—is that this is not just about reaffirming what happened in the NHS in years gone by, when getting a grant to do research was the only thing that ever happened. The paper continues:
“Debates in the House of Lords on innovation prizes were short; there was no debate at all on Report. There were no amendments in Grand Committee or on Report but on Third Reading, in response to arguments made in particular by Lord Walton and Lord Patel, the Government successfully introduced an amendment to clarify that innovation prizes would include research.”
I understand that that is to make the provisions consistent with the National Health Service Acts and what happened in the past.
If we are to improve the health care system and the NHS, we should recognise that one of the major quests that has been going on for the best part of 60 years is about how to spread best practice. I have always said, sometimes with my tongue in my cheek, that we tend to do that by wanting to reconfigure the NHS. We tend to say, “Well, if it’s not working in that shape, let’s look at another shape for it. Let’s look at another way to approach it.” In fact most reconfigurations, certainly in the past few years when I have been on the Health Committee and examined in detail what is happening in the health service, have been intended to spread best practice and get things working better in various parts of the NHS.
Instead of thinking of the prizes as structural changes, we should realise that they are about incentivising people to do things themselves. In the past, somebody would get a grant for research and then do it. I hope that my hon. Friend the Minister will tell me that the prizes are about using the high levels of skills that we have at all grades—not just among hospital nurses and doctors but in other, related professions—to ensure that innovation is encouraged in a more constructive and flexible way.
Various organisations have produced briefings for this debate and for the debates in the House of Lords, and I should like to read out some of their concerns. All of them represent the health professions at some level, and they ask questions about the innovation prizes. In a briefing for Second Reading in the other place, the British Medical Association stated:
“Doctors are at the forefront of innovation in the NHS and the Government’s continued commitment to encourage innovation is welcome. We would seek further clarity from the Government on its intention on possible membership of the committee that the Secretary of State may establish to advise on the form and allocation of innovation prizes.”
The NHS Confederation, in its briefing for Second Reading in the other place, stated:
“There is little detail in the bill about how the prizes would operate.”
That is absolutely true. It continued:
“We would welcome further clarification to the following questions: What will be the size of innovation prizes? Will prizes be awarded to individuals or organisations? Who will make up the committee and how will they be appointed?”
Those are typical questions in the NHS—“There is another committee. Who is going to be on it? Is this a chance for me? Can we get a representative on it?” It is typical of the structure and culture of the NHS.
The Royal College of Nursing, in a Second Reading briefing for this place, stated:
“Nurses are often at the forefront of innovation to improve the quality of patient care. The RCN welcomes the commitment to establish innovation prizes if these are transparent, fair and genuinely raise the morale of NHS staff. However, the way in which the schemes are implemented locally will be key in terms of assessing the practical impact the prizes will have on the NHS and those that work in it.”
I leave those thoughts with my hon. Friend the Minister, because it seems to me that we have an opportunity to bring innovation into the NHS by encouraging health professionals to do things that will get them the prize or whatever it is, including by spreading best practice in their workplace. I hope that the prizes are used sensibly and flexibly, so that we can further improve the NHS.
From what both Front Benchers said earlier, it seems that the part of the Bill that is likely to create debate during its passage is the provisions in part 3 on point-of-sale tobacco advertising and vending machines. I wish to say a few words about smoking and health inequalities. Members may know that in March, the Health Committee published a report on health inequalities. It addressed smoking, which is a major issue in health inequalities in this country and in other parts of the world.
The report showed clearly that the more deprived a person is, the more likely they are to smoke. Smoking is linked to almost every indicator of deprivation, including in income, education and housing tenure. There can be no question about that. Perhaps I ought to be saving part of my speech for another debate, because we have not yet had the opportunity to debate the Government’s response to the report. Other countries, particularly in northern Europe, classify deprivation and so on not by social class, as we do, but by education. There is no doubt that in countries not dissimilar to ours, there is more smoking among people whose education level is not high.
In turn, smoking drives health inequalities here in the UK. It accounts for half the gap in life expectancy between the richest and poorest in our society. There is clear evidence that quitting, or even better not starting, greatly reduces that gap. According to recent research by Dr. Laurence Gruer, the least affluent never-smokers have a much better survival rate than the most affluent smokers. Not smoking is a way of partly bridging the gap of health inequalities in this country.
In recent decades there have been great reductions in smoking rates, but they have been greatest among the most affluent. There is a danger that the poorest families could be left behind. I see that two members of the Select Committee are present for the debate, and one thing that we found was that although the health of the population is getting better, with life expectancy getting longer in every social class, the gap between the lower and higher social classes is widening. That is disturbing.
Just as smoking usually starts in childhood, so do the health inequalities that it brings. By protecting young people from tobacco marketing and reducing youth smoking rates, the Bill promises to reduce the health gap in future generations. That should not be considered lightly, because we are not talking about what is going to happen this year, next year or the year after. It is about what will happen in ill health and smoking maybe a generation down the line.
The measures in the Bill are proposed not in isolation but as part of a comprehensive strategy, most of which has gone through the House in recent years. It is especially important to have a proper plan for tobacco control, particularly if we believe that it is important to reduce health inequalities. When New York went smoke-free, it was not in isolation but as part of a five-point plan including taxation, cessation support, public education and evaluation. Smoking among New Yorkers fell by almost 20 per cent. in four years, and the greatest improvements were among disadvantaged and high-prevalence groups.
I wish to progress the health case against point-of-sale display. In its report on health inequalities, the Health Committee supported that aspect of the Bill. The hon. Member for South Cambridgeshire rightly mentioned tobacco smuggling, but the relevant recommendation in the report stated:
“Smoking remains one of the biggest causes of health inequalities; we welcome both the Government’s ban on smoking in public places, and its intention to ban point of sale tobacco advertising, as evidence indicates that both of these measures may have a positive impact on health inequalities.”
That is very important, and the last time the House legislated on smoking, when we had the big debate about smoking in public places in 2006, it was the recommendation of the Health Committee that carried the legislation through. I congratulate hon. Members of all parties, including the hon. Member for South Cambridgeshire, the hon. Member for Romsey (Sandra Gidley) and the hon. Member for Wyre Forest (Dr. Taylor), who supported that recommendation at the time. Considering the matter in detail and having the Select Committee take evidence and make recommendations made a major contribution to turning the proposal into the popular legislation that it is now. Up and down the land, people say that the smoking ban is the best thing that happened—I hear that all the time. It happened because the House examined the evidence, considered the problems in our society and reached the right conclusions.
I may be in a different Lobby from the hon. Member for South Cambridgeshire on Report, but the evidence shows that the Select Committee also got it right on this occasion.
I was a proud member of the Health Committee, but when we examined the evidence for the Government’s proposals, we rejected the Government’s attempts to cherry pick who would be protected by the legislation. We said, based on the evidence, that if we were to protect one, we needed to protect all. Such evidence is lacking for the provisions in the current Bill.
I agree with the hon. Gentleman’s first point. The first option—allowing smoking in public houses that did not serve food, but not in those that did—was not a public health measure. From a public health point of view, it was not the brightest proposed legislation. The amendment from the Health Committee probably changed minds about the free vote. None the less, the evidence was there.
The hon. Member for Hemel Hempstead (Mike Penning) suggests that there is no evidence to support the proposed ban on displaying tobacco products, but I shall make the case that there is evidence about the effect of such point-of-sale displays. Hon. Members can look through the many representations that we have received on the subject and they will see that the great majority that suggest that there is no evidence that the provisions will be effective come from those who make their living by manufacturing or selling tobacco products. [Interruption.] The hon. Gentleman can read this tomorrow if that is better, but I want to answer his question. The manufacturers or those who sell tobacco products question the evidence in support of the provisions.
By contrast, those who insist that the evidence is good are, for the most part, health professionals, health charities and researchers. The hon. Gentleman will have seen the letter that we received from Action on Smoking and Health—an organisation with which I have been involved for a long time. Nearly two pages contain the names of organisations that support the Bill, including eight royal colleges, cancer charities and other major charities. However, some people do not support the proposals, and I want to consider people’s motives either for supporting part 4 or for not supporting it.
Many hon. Members will have received standard letters from shopkeepers, who are genuinely concerned about the measure. Those letters simply say that there is no evidence that the provisions will be effective. It hardly seems likely that that opinion is based on first-hand reading of the published research. Indeed, we know that the message has been given to shopkeepers by an organisation that calls itself the Tobacco Retailers Alliance, which is funded by the big tobacco manufacturers through the Tobacco Manufacturers Association.
I have battled against the Tobacco Manufacturers Association and tried to influence the House on tobacco legislation since the early 1990s, when I promoted a private Member’s Bill. The Tobacco Manufacturers Association paid Members of Parliament to stay overnight on a Thursday to talk the Bill out on a Friday. Indeed, it was talked out. Its purpose was to ban tobacco advertising and promotion. It was eventually introduced in law by the Government, who should be congratulated on that.
The Tobacco Manufacturers Association has tried, through many different organisations, to buy influence in the Chamber for decades. The recent letter that we received from the Tobacco Retailers Alliance has many aspects worthy of note. At the end, it states that
“the Tobacco Retailers Alliance is funded by the TMA.”
So let us not forget who says that the provisions will not work.
We were sent four pages of questions in red, with accompanying answers. I shall read out only the first two. The first question and answer is:
“Why are shopkeepers so worried about hiding tobacco out of sight?
Because it may put them out of business. A tobacco display ban would be a huge financial and operational burden on small shops.”
The second question and answer is:
“Would shops be forced to close because of this?
Yes—we think so.”
Throughout the House’s history as a legislator on tobacco, going back to the late 1950s, when the late Sir Richard Doll found the connection between smoking and ill health, the tobacco companies have funded dubious research to oppose anybody who claimed that there was a direct connection between tobacco and ill health. They have got somebody to come along to say that small shops may be put out of business or that smoking “may” harm health. For decades, they have tried to undermine concrete evidence of the link between tobacco and ill health.
We must never forget that the Tobacco Manufacturers Association has influenced individual Members in this country for decades. Its aim is to protect at all costs a substance that leads to 50 per cent. of the people who use it dying a premature death. We should go further in our actions against the promotion of tobacco.
The right hon. Gentleman is clearly passionate about the subject. I may disagree with his line of thought, but will he go further and support any Liberal Democrat amendments to prevent the sale on of tobacco products by an 18-year-old to someone younger, as happens with alcohol?
I am happy to listen to the case for any amendments to improve people’s health and stop the selling of a substance that creates ill health and is addictive. I think that a member of the Conservative Government in the early 1990s said that if tobacco had been discovered and brought to this country today, it would be banned. I think that most people agree. However, it was discovered long ago and has not been banned.
When we examine suggestions of lack of evidence, we must remember where they come from. We do not rely only on the experience of Iceland and Canadian provinces, which show—in the real world—how putting an end to promotional displays reduces youth smoking. We also have a wealth of scientific evidence to show how that works.
Earlier this year, researchers in New Zealand published a systematic review of the evidence. Seven out of eight studies found a significant link between exposure to point-of-sale display and smoking initiation. Another study—this time of adults—found that even pictures of cigarette packs provoked cravings among smokers, and a third of recent ex-smokers reported urges to smoke after seeing tobacco displays.
That is, in miniature, a version of the debates that we had back in the early ’90s and late ’90s about billboards and posters in this country. Billboards did not even have to have tobacco products on them—all they needed was a bit of purple cloth, and most people with an inquiring mind would know exactly what they were about. The name of the product did not have to be there; people knew what was going on. That is how tobacco—and, for that matter, other products—have been promoted for decades in this country. Indeed, tobacco is still promoted in that form in places that retail it.
An even more recent study, which was published just last month, shows that tobacco promotional displays in the US are concentrated in low-income minority ethnic neighbourhoods. Interviews with shopkeepers reveal that contacts with tobacco companies left shopkeepers with little or no control over such displays. The tobacco companies make the decisions about where displays go, and if shopkeepers do not comply, they are penalised under incentive programmes. A study of tobacco displays in England conducted last summer also found evidence of similarly coercive relationships. That study found half of all displays within one metre of sweets displays, while one in five displays obscured the health warnings. One retailer explained:
“Display is owned by the tobacco company. When move briefs around by a deadline, trader has either star points or money donated…Tobacco company takes photos to prove briefs changed by deadline.”
The health and medical communities are united—I read the list of supporters out earlier. The research clearly shows that tobacco displays increase awareness of tobacco brands and prompt purchase among young people, and that jurisdictions that have put an end to such displays have seen youth smoking fall. There can be no question about that. No matter how one wants to dress it up or who pays for the research to do that, the peer-reviewed evidence is there for all to see. However, if the opinion of the leading researchers and health campaigners and the royal colleges were not enough, Channel 4’s FactCheck service concludes on its website that
“the evidence points pretty firmly the government’s way. And to say, as the opposition parties do, that there’s no evidence the ban will have an effect on smoking among young people seems pretty misleading.”
I say this to Opposition Members: go on FactCheck’s website and have a look at what it has found. The people at FactCheck are not supported by the TMA or the Government; they are people who have done open, individual research with our constituents about what should and should not happen.
Let me say a few words about the economic counter-arguments. Hon. Members will remember the mailbags filled with letters from the hospitality trade, which was genuinely alarmed by the effect that smoke-free legislation would have on its business. The tobacco industry told those businesses that the impact of such legislation would be devastating and they believed that, but it was not true. In the years following the introduction of smoke-free legislation, the number of premises licensed to sell alcohol in England increased by 5 per cent. Hon. Members will remember the claims sent to them about 39 pubs closing every week. However, that evidence, wherever it came from, was hardly independent and it cannot be verified. Such research does not say how many pubs closed before the legislation or how many new premises have opened since. Also, it often attributes changes entirely to the regulations, ignoring the recession, the long-term trends in the pub trade and—this relates to the Health Committee’s current inquiry—the pricing and availability of alcohol.
The British Beer and Pub Association sent all hon. Members evidence of where pubs had been closing. However, about three months ago I did a study of the borough of Rotherham—I am one of three hon. Members who represent it. I looked at the previous 12 months—the period for which the British Beer and Pub Association had sent us evidence—and found that there were actually four more pubs than there had been 12 months previously. I therefore find the idea of 39 pubs a day closing because of smoke-free legislation—or, for that matter, anything else—difficult to believe. I know that people in Rotherham like a drink, as I do now and again, but I do not think that the closure of 39 pubs a day is a real measure of what was happening. We must therefore always be careful when people send us briefs about proposed legislation.
Also, when shopkeepers say that the changeover will cost them £5,000 or £2,000, they are again quoting the tobacco industry. On closer examination, we realise that some of those costs include not only the cost of installing CCTV, but the cost of closing the shop to do so. That is hardly a truthful analysis of the cost of the changeover. The real costs would be much lower, with both Action on Smoking and Health and the Department of Health having been quoted a cost of around £200 by leading Canadian suppliers, who have some experience of such matters. Small shops will also have until 2013 to comply, whereas larger shops will have until, I think, 2011, so there will be a lot of experience around to help with any costs to the small tobacco retailers we have discussed. Vending machines are also covered in the Bill, although I am a little confused, because we are giving the Government powers to take action in respect of vending machines without knowing what action we would like taken. However, perhaps that is a good thing—that is fine; that is okay.
Hon. Members who are concerned about the future of local tobacco retailers should be particularly supportive of the provisions restricting vending machines. Vending machines compete with local retailers in the convenience tobacco market, taking just over £1 billion a year. That is quite a large sum. Unlike retailers, vending machines do not verify the age of the customer and are consequently a regular source of cigarettes for 17 per cent. of regular teenage smokers. Vending machines are also not popular with regular smokers, typically charging 20 per cent. more for 20 per cent. fewer cigarettes—that is, for packs of 16 cigarettes. One survey showed that only one regular smoker in 20 had used a vending machine once in the previous six months.
The other thing is that vending machines are found, by and large, in alcohol outlets—that is, in pubs. Relapse into smoking is strongly associated with alcohol. Situating vending machines in bars could trigger relapse among smokers trying to quit. Many years ago, when I stopped smoking, back in the 1970s, the one problem was going out at the weekend with my friends for a drink in pubs with smoky atmospheres. I am pleased that we have got rid of those atmospheres; I would like us now to remove the temptation to buy what is available over the bar or in more accessible places.
An end to tobacco vending machines would also end sales to children, transfer valuable business to more responsible retailers and support smokers trying to quit. The age check can be done by a retailer, but it cannot be done by a machine. There were some people saying in the media a few weeks ago, “Well, we wouldn’t let them put pound coins in it—they’d be able to get tokens for the vending machines,” but what a token has to do with the age of whoever puts it in a machine is completely beyond me.
The hon. Member for South Cambridgeshire talked about vending machines being banned from public areas—I assume that he was speaking on behalf of the Opposition Front Bench. When he said that, I was reminded a little of the argument that said, “We should ban smoking in public houses that serve food, but don’t ban it in public houses that don’t serve food,” but what happens if someone comes along with a sandwich or whatever? My view is that we should look seriously at banning vending machines full stop, so that there is no way that young people can access them. If we really want to help small retailers, that would be one way of doing so. I know that this proposal is not in the Bill, but I would be more than surprised if an amendment were not tabled on Report to ban vending machines altogether. There is no way that those machines can check anybody’s identification, whether they are in public places or elsewhere.
Does the right hon. Gentleman include in his comments nightclubs where there is a strict over-18s policy? Are not there some environments in which such machines could be placed? Does he think that there should be a blanket ban, or are there areas in which the machines could be properly policed?
That is a very good point. If there were a minimum age for admission to an establishment, that could be sufficient to prevent the under-age purchase of tobacco in those places.
We all know, however, that no one is asked their age before they use a cigarette vending machine. There is no ID check for anyone with a few pound coins who has access to a vending machine. On that basis, we ought seriously to look at their use. On the hon. Gentleman’s point, I will ask the powers that be in the Department whether an amendment could be made so that a ban did not cover all areas, but my instinct is that we will never be able to cover these machines with any form of licensing. Instead, we ought to consider banning them from public places.
I have asked the Minister a number of questions about how he sees the innovation prizes developing, and how much money would be involved. Perhaps he will tell us how they are going to encourage people in the national health service further to develop their skills to provide better services to our patients. I hope that the intentions behind the Bill will have the support of the House, although I think one or two matters will be contentious.
I would say to all Members that, if anyone sends them a briefing on any subject, telling them that something is right or not right, they should go to the source material to find out who is peddling these myths. We are all susceptible to getting a nice easy briefing from time to time and simply standing up and reading it out, but life is not like that, certainly when it comes to tobacco. Good evidence over many decades suggests that we need to treat with deep suspicion any briefings that support tobacco in one form or another.
It is a shame that the Secretary of State has had to leave the debate, although he apologised for doing so. I should like to put on record my congratulations to him on his appointment. When I first met him, we were on the Health Select Committee together. I originally thought that he was just new Labour voting fodder, but I soon realised that he was more than capable of making up his own mind on the issues. He is independently minded, and the only Minister I have ever been able to persuade to change a clause in a Bill. He does think things through.
The broad thrust of the Bill is welcome. We have heard the outline of what it includes: the NHS constitution; quality accounts; direct payments; and a range of measures following the next stage review. However, if the interventions during the Secretary of State’s speech are anything to go by, the measures that will attract the most attention are those that deal with tobacco. I see that Labour Members are now dribbling back into the Chamber, so I assume that their meeting has finished and they can now concentrate on the real issues.
Many areas of the Bill deserve our consideration, and I will start with tobacco. I want to put on record my personal baggage in this regard. My father died of lung cancer. He had never smoked in his life, but he was surrounded by smokers. He was also a newsagent. In thinking through these issues, I have looked carefully at all sides of the argument, but when it comes to a clampdown on smoking, I sometimes have to restrain myself from being a fag fascist—although I am as nothing compared with the Chairman of the Select Committee, the right hon. Member for Rother Valley (Mr. Barron).
I welcome some of the Government’s actions so far, although I query whether enough has been done. The increase in smoking-cessation programmes is welcome, although the quality and outcomes framework needs to be tightened up. It should not be enough for GPs simply to mention the need to stop smoking; there should be real evidence that that has happened. I am not entirely convinced that it is a measure of success that someone has quit smoking for four or six weeks, as is the case in some parts of the country. However, I congratulate the Government on eventually getting round to banning smoking in public places.
The Bill also contains a hotch-potch of further proposals. Our big regret is the complete absence of a comprehensive tobacco strategy. If the Government were to produce such a strategy, we might be able to get an indication of their thinking. Instead, we are faced with a fairly random set of initiatives. The big idea is the prohibition of the display of tobacco products at the point of sale. It is not being sold as something that will reduce sales in general, however. It is seemingly to be being touted as a measure to reduce sales to children, but the evidence that it would have that effect is weak. If there were strong evidence that that could be achieved, we would be tempted to support these moves. The Government seem to demand an evidence base for everything else that they do, but the evidence base for that proposal is very weak.
There is evidence that children are influenced by advertising and encouraged to smoke, which provided the motivation for the Tobacco Advertising and Promotion Act 2002. Many of us have seen pictures of displays of tobacco products in newsagents and supermarkets that push the boundaries of the Act. I was on the Bill Committee that looked into the fine detail of that legislation, and I should not have underestimated the creativity of the tobacco manufacturers. They have come up with a lot of display material that makes their products stand out to people going into a shop. We should do more to amend that legislation and to tighten up the law on what can be displayed, rather than going for the measures in the Bill. That would be honest and within the spirit of legislation that is widely supported on both sides of the House.
I am grateful to the hon. Lady for giving way, particularly as I have only just returned to the Chamber. She cites a lack of evidence in relation to point-of-sale displays and prevalent traits of smoking in young people, but studies of groups of as many as 25,000 people have shown that the 15-year-olds who are most exposed to point-of-sale displays are three times as likely to smoke as the rest of that age group, and that the effect of such exposure is even stronger than that of parental smoking in the family.
If the hon. Gentleman listens to the rest of my speech, perhaps he will rethink his argument. I do not think that the studies he cites are quite that large.
The bottom line is that, whatever we think about smoking, tobacco is a legal product that can be bought by consenting adults, yet we are planning to restrict its display even more than we restrict that of pornographic material. That seems to be a rather strange attitude to take. A compromise approach that would be worthy of consideration would involve the introduction of plain packaging, and we shall certainly table amendments on that in Committee.
If the aim of the proposed changes is really to reduce under-age smoking, the Bill is making the wrong proposals and missing a few tricks. For example, there should be greater penalties for shopkeepers who sell tobacco to under-age people, as the hon. Member for South Cambridgeshire (Mr. Lansley) suggested. It should also be an offence to buy cigarettes and pass them on to someone under the age of 18. It seems odd that the Government are proposing only one measure, when a whole basket of measures such as these would have a much greater effect. I do not understand the Government’s objection to such measures; it would be helpful if the Minister explained it in summing up.
The proposals on vending machines are weak. The Secretary of State said that if they did not work, the Government would consider a total ban. My hon. Friend the Member for Leeds, North-West (Greg Mulholland) mentioned places with a strict age restriction, and there may be a case for an exemption, but if we are serious about trying to stop under-age smokers gaining access to cigarettes, we should consider a ban on vending machines and restrict the sale of cigarettes in pubs to behind the bar.
The British Heart Foundation estimated that machines were the source of cigarettes for approximately 46,000 children in England and Wales, so if the Government were really committed to doing something about it, they would go a step further. Children are very clever in getting hold of tokens and other means of accessing the products. Other age-limited products can be bought only through a face-to-face, over-the-counter type of transaction, so why can we not have the same for tobacco products? I hope that the Government will consider the issue further. Many children obtain cigarettes from black-market sources, car boot sales and the like, so it is disappointing that the Government are not using the Bill to address smuggling, which would start to tackle some of the supply problems at source.
The concept of an NHS constitution has received widespread support from the British Medical Association and patient groups, and there even seems to be some agreement between the two main political parties. I agree with the comments of the hon. Member for South Cambridgeshire about whether the proposal really amounts to a constitution or whether much of it is new, but having all the rights and entitlements written down in one easily accessible format is helpful. The problem is how to prevent yet another motherhood and apple pie exercise and how to make the constitution meaningful so that it effectively becomes a bible of good practice for health professionals while commanding the trust and respect of patients.
It is important that we try in Committee to put some more meat on the bones. For example, it would be helpful to have further clarification of the duty to
“have regard to the NHS Constitution”
and of how it might be challenged. To give a simple example, a person has the right to be treated with dignity and respect. We all know that there is a widespread problem with mixed-sex wards; they were supposed to have been abolished years ago, but that has still not happened. Older people, who are often from a private generation, object to being in a mixed-sex ward and are much more against such wards than younger people. If treated in a mixed-sex ward, the patient could understandably become upset, but could the trust then say, “Well, we had regard to the NHS constitution and the rights in it, but the physical constraints gave us no other option”? It is not clear whether the constitution will act as a driver for change and improvement in that area. If it does so, that will be a very good thing, but it is not yet clear how much in the way of teeth the constitution will provide.
Does my hon. Friend agree that, as we are all committed to narrowing the artificial gap between social care and the NHS and we have created a NHS constitution, we now surely need a social care constitution alongside it? Otherwise, social care will be the poor relation once again. That is particularly important in view of the needs of elderly people.
My hon. Friend makes a very good point. In many cases, the dividing line between health and social care is very hard to identify, so some thought needs to be given to circumstances where the balance between health and social care is a very fine one and it is difficult to unpick which is which. It would be helpful to know whether the Government plan to extend the constitution in that direction, given that, as my hon. Friend says, the current mantra from most political parties seems to be that greater joining up of health and social care services would be good.
I want to move on to discuss discrimination and to raise a concern about whether some matters might fall between two political stools. The constitution states that people have
“the right not to be unlawfully discriminated against in the provision of NHS services”
on a number of grounds. Age is a particularly controversial criterion, but it is clear that the Government are also using the Equality Bill to try to provide some clarity. However, I am not clear about how the Equality Bill and the Health Bill will join up in practice or whether there is any capacity for some issues to be dealt with less than fully by either Bill. When the Minister responds, will he describe what conversations are going on between the various Bill teams working on aspects of the NHS constitution and equality issues to ensure that that cannot happen?
To provide one small example of the sort of problem I mean, the constitution also provides the same
“right not to be unlawfully discriminated against in the provision of NHS services”
on the grounds of disability. Research by the Royal National Institute of Blind People shows that many visually impaired people do not receive information in a form that they can read. Depending on which part of the NHS they want to access, anything from 69 per cent. to 81 per cent. of those people cannot read it. The RNIB tells me that a variety of Ministers have said that the Equality Bill provides the best opportunity to deal with the problem of making the information accessible, but a recent letter from the Solicitor-General stated:
“We are not persuaded of the case for making specific reference to the provision of information in alternative formats on the face of the legislation”.
It would thus be helpful to have some idea of how that issue will be dealt with and which legislation will enable people with visual impairments to access the relevant information.
I was intending to go on to deal with issues surrounding health and social care, but we have already covered that, so I will make one final point on the constitution. There were welcome moves in the other place to improve the reviewing of the constitution, but the patient voice seems to be lacking in the review process. There seems to be some resistance to the idea of involving patients and the public on the grounds that that might make the process too long-winded. That seems somewhat ironic, given that page 52 of the good old handbook on the NHS constitution gives patients the right to be involved in the planning of health care services. On one hand, we are giving people a right in a constitution, but on the other we are not giving anybody a right to be involved in its review, which seems to be a major omission.
We very much support the idea of direct payments for health care and we very much support the idea of pilot schemes, too. I have often been against pilot schemes in the past, because they seem to have been used as a mechanism for delaying the implementation of policies that have a good evidence base. In this case, the pitfalls are real, so it seems right to pilot the schemes. I welcome the commitment properly to scrutinise the pilot schemes before going a step further.
Direct payments are aimed at long-term medical conditions and I believe the pilots are going to start later this year. There is also great potential for such payment schemes in maternity care and mental health, so I hope we can pilot those areas, too. Women often have quite specific ideas about what maternity care they want for the birth, and it would help them if they were free to shop around a little more.
There are number of fundamental questions, however. The Secretary of State said earlier that the plan had to be signed off by the care manager. That struck me as potentially problematic. What if there is a disagreement? Many social care direct payments have given the recipients complete autonomy over the way in which the money is spent and the way in which they lead their lives. It seems to me that there ought to be approval of some kind. It could reasonably be argued that care managers should sign off the payments, because we would then know that approved treatments were being given, but that too would reduce patient choice.
I am not sure what benefit would be conferred by direct payments. What is the difference between deciding what people should do and giving them the money to do it, and deciding how patients are to be treated and making all the payments for them? I do not see much difference in either outcome or process or increase in flexibility. A legitimate question to be asked is “What will happen if patients underspend?” Will they be able to keep the money? I suspect that that is very unlikely. We should also ask what will happen if patients run out of money. The measure is intended to apply to long-term conditions, which are usually fairly stable. However, people may deteriorate. Another condition—a co-morbidity—may render the treatment of a patient much more complex. Will someone suffering from two or three long-term illnesses have to undergo three different assessments and add up the payments, or will that person be treated as a single patient? A number of answers will have to be teased out in Committee.
How will it be possible to calculate the amount that patients will need in order to receive the care that they want? We have all seen comparisons between the amounts spent by PCTs in different health areas, and we know that there are great differences. Will there eventually be a national tariff? Will there be some smoothing mechanism to ensure that people in PCTs that do not fund some services very well are not disadvantaged? The answers to those important questions may not be provided by the pilot schemes if they are conducted on a strategic health authority basis.
The Secretary of State said that if a patient chose a treatment that was not regarded as clinically effective, it would probably not be signed off. However, an equality issue arises as well. Is this a bit middle-class? Research shows that some demographic groups benefit from direct payments much more than others. Can the Minister assure me at this stage that equality will be a consideration in the evaluation, so that we can be sure that we are not hitting only certain sections of society?
All providers will be required to produce and publish quality accounts. I fear that the process will be time-consuming, and that the ultimate benefit will be limited. It reminds me of the time when standard assessment tests were introduced. My children were quite young then. I remember the headmaster saying “These are standard assessment tasks. There is no way they are tests, and there is no way they will ever be used to compare children or to compare schools.” When we consider what has happened to SATs, we have to worry about the way in which the quality account data will be used and analysed and the comparative purposes to which they could ultimately be put.
I did not intend to say much about pharmaceutical services, but I want to reassure the hon. Member for South Cambridgeshire. I am not sure whether he was involved in health at the time—he may have been involved in education—but at one stage the Office of Fair Trading proposed that pharmacies should be subject to a complete change in the control of entry regulations. There was a move to allow them to open anywhere, to allow a free-for-all and to see what happened after that. We ended up with a bit of a fudge, but a fair number of people argued at the time that pharmacies were not like sweet shops or toy shops, and that their provision should be planned as part of the primary health care service. The proposal was considered by the Select Committee, of which the Secretary of State was a member, and he seemed to be persuaded by the argument that control of entry could be used to ensure the provision of better services.
I must declare an interest as a fellow of the Royal Pharmaceutical Society, but I believe that if we are to advance the pharmacy agenda and ensure that the public are offered a greater range of pharmaceutical services, needs assessments are essential. That is not about preventing dispensing doctors from doing anything; it is more about giving the public more access to, for instance, smoking-cessation services. I hope that, in the long term, it will mean that when an application is made to open a new pharmacy, the primary care trust will have some control over what happens and will be able to insist that some extra services are provided. I hope that it will mean that we can move away from the supply side, and that people can expect a greater range of services from their pharmacies. I hope that the hon. Member for South Cambridgeshire will eventually see the proposal in a more positive light, because that is how I think it is intended.
My memory does not serve me well enough to recall how I was involved, but I think that the discussion of the impact of the control of entry regulations took place during our debates on the Bill that became the Health and Social Care (Community Health and Standards) Act 2003. If the hon. Lady consults the record, she will find that I questioned the then Secretary of State, the right hon. Member for Leicester, West (Ms Hewitt), on the subject. I said that while I did not oppose the liberalisation of control of entry, it must take place alongside proper measures providing for the Department to pay if it wished to have access to community pharmacy. If it was not willing to pay, there would have to be some compensating mechanism through control of entry.
The problem is that in the circumstances that the hon. Lady is describing, someone might wish to set up additional pharmacy premises to offer an additional service to the public. Why are we trying to prevent that from happening? The issue is not a pharmaceutical needs assessment preventing people from providing additional dispensing or pharmacy services; it is how to procure those services in places where there is a lack of community pharmacy. It is in that regard that the contract has not really done the job yet.
I think I am grateful to the hon. Gentleman for his comments, although they seem to be slightly at odds with what he said earlier. I am certainly grateful for his clarification of the way in which he sees the whole picture. His initial throw-away comment was that the pharmaceutical needs assessment seemed to be a backhand way of getting at dispensing doctors. That seemed to be his prime concern. It is a shame that he did not take the opportunity to say something a bit more positive then, but he has done so now, and I thank him for his intervention.
We shall have a greater opportunity to debate many of these matters in Committee. There are concerns about innovation, but they have already been mentioned. We shall probably want to return to the subject of asylum seekers. I appreciate the concessions made in the House of Lords, but I do not think that we have yet arrived at an optimum solution.
There is much to be recommended in the Bill, and also much to be improved. The Liberal Democrats do not plan to vote against it, and we look forward to working with all parties to try to improve it.
Before moving on to the main points I wish to make, I would like to talk about two issues that have taken up a lot of time in our debate. The first is the ban on in-store display material for cigarettes. Before I became a Member of Parliament, I worked in marketing and advertising for 17 years—indeed, at one point I worked with a cigarette brand—and I urge the Government to consider very carefully whether the proposals they are making today will have the outcomes they desire. I wholeheartedly agree that we need to manage very carefully the way in which cigarettes are marketed and sold to anybody, and particularly young people, but the Government are confusing the two issues of access to cigarettes and the attractiveness of cigarettes.
Simply stopping access to cigarettes, as the measure seeks, by hiding them under the counter in shops does not tackle the key issue, which is that youngsters find the idea of smoking cigarettes attractive; it is seen as part of their social life and as making them cool members of their community. Supermarkets have not been successful in marketing own-label cigarettes because they do not have the required brand cachet. Simply hiding cigarettes under the counter does not solve the problem that the Minister is trying to address, which is to stop so many young people in our community smoking. I wholeheartedly support him in that objective, but I am not sure he is using the right tools to achieve it, and I think he needs to do far more work with cigarette manufacturers to understand properly the key motivations and drivers that make people smoke. I do not think that can be achieved simply by getting rid of display material.
The second issue is to do with a point the Secretary of State made about the National Institute for Health and Clinical Excellence and the availability of recommended treatments. I am sure I do not need to remind the Minister that the Government have already intervened to change what NICE has said should be the desired amount of access to in vitro fertilisation treatment. NICE has firmly said women between the ages of 23 and 39 should have access to three cycles of IVF treatment. That is certainly not available in my constituency, my primary care trust area or my strategic health authority area. It is unavailable not because of any lack of desire to make this very important service accessible to my constituents, but because of a lack of money and funding. We need to prioritise funding. The Government have said today that it will be mandatory for all PCTs to make all NICE guidelines available to all our constituents, but the Government also need to address how that will be paid for, because it is unclear to me how they will square that circle in my area, and other Members may have the same problem.
The three main points I wish to make today are to do with three omissions from the Bill. One of them has already been touched on and Members in the other place have tried to rectify the problem, but the other two have not yet been covered. The Bill is wide-ranging, so it is surprising that it does not address any of them.
The Secretary of State brushed aside the deliberations of Members in the other place when he said he was not minded to allow the new clause 34 that they had inserted into the Bill to remain. The measure allows for exemptions to private patient caps for NHS foundation trusts to be made in regulations. That is particularly important in my constituency. Basingstoke and North Hampshire NHS Foundation Trust, which serves my constituents but is located in the constituency of my right hon. Friend the Member for North-West Hampshire (Sir George Young), provides excellent care, particularly in cancer treatment. It has an international reputation, which is extraordinary for what is a district hospital. It has that reputation because of the quality and calibre of its surgeons and cancer specialists and the ground-breaking work they do in rare abdominal cancer, liver cancer and colon cancer.
The hospital has the capacity to treat far more patients than it does at present, but because of the restrictions in place it is prohibited from doing so. It is therefore prohibited from expanding its work in a way that would benefit the people suffering from these chronic diseases—I am sure many Members’ will have constituents and family members who have suffered from some of them. Such development could boost the income of what is a very successful hospital. That income would be used to improve its ability to serve our local community and to improve the local NHS services that are already in place. I felt that the amendment in the other place gave the Government the opportunity to introduce regulations that would help my hospital and my community to get a better service. I was therefore disappointed that the Secretary of State was so quick to dismiss as merely a quick fix a measure that had been well thought-through and well debated in the other place.
Basingstoke residents already know the importance of having an internationally renowned hospital in our community, and the benefits of that. We have the Pelican cancer research centre and the ARK, a state-of-the-art teaching facility, and all because of the expertise in the community. We should be nurturing that expertise, not limiting it as the Government and some of the Secretary of State’s party colleagues, such as the hon. Member for Wolverhampton, South-West (Rob Marris), seem to suggest. I urge the Government to think again. I do not think they should consult too widely as that may well lead to the idea being kicked into the long grass, as currently happens to so many ideas in this place. Consultation is not necessarily the right way forward. The Government should talk to the hospitals that are being restricted and hampered. I know the management of my local hospital would be more than happy to talk to the Government on this matter.
I shall now move on to the other two measures that I am surprised were not included in the Bill. I echo the sentiments of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) that the Secretary of State should perhaps take on the role of public health Minister himself. The Government’s policy needs to put more emphasis on public health. It is disappointing that the amendment to include more detail in the constitution was not passed in the other place. Among other things, it gave more clarity of the central role public health should take in the NHS. Public health remains a Cinderella service in the NHS. The Minister needs to think very carefully about that, particularly the role of health visitors.
It is interesting that the Government have not taken the opportunity presented by the Bill to start to deliver on their pledge to implement Lord Laming’s recommendations after the recent and tragic death of baby P. The recommendations included highlighting the key role health visitors play in child protection and their function as a universal service, seeing all children in their home environment and with the potential to develop strong relationships with families. The Government missed the opportunity to put these recommendations in place and to put them into action.
The Government must live up to their promise to implement Lord Laming’s report in full. Many of the ideas contained in the report do not require legislation, but the Government know that taking health visitors off the statute book in 2001 had a significantly deleterious effect on the number of health visitors coming into the profession. There has been a 13 per cent. drop in the number of health visitors since the dedicated health visitor register was closed in 2004 and the Bill could have provided an opportunity for the Government to demonstrate the valuable role that health visitors can play. They could even have considered placing the role of health visitor back on a statutory footing. I know the profession is interested in talking to the Government about that. Unless the Committee picks this issue up in more detail, it will be another missed opportunity in the Bill.
I say that because the move towards using a mix of lower-skilled staff to replace qualified health visitors is not consistent with the Government’s undertaking to implement Lord Laming’s report in full; it is precisely the highly qualified and highly skilled nature of health visiting that he focused on in his report. The service is stretched to breaking point in too many parts of the country, leaving more than two out of three health visitors saying that they no longer have the resources to respond to the needs of even the most vulnerable children. I urge the Minister to consider in his response how he could weave this idea and, in particular, the implementation in full of recommendation 32 of Lord Laming’s report into the Bill, even at this late stage.
The third and final issue that I wish to raise relates to children’s trusts. Clause 2 contains a detailed analysis of the duty to have regard to the NHS constitution, yet the group of organisations that are to have such a duty does not include any mention of children’s trusts or Sure Start centres. To someone like me, who looks at these issues in some detail, it feels as though the Department of Health has put its head in the sand. The Apprenticeships, Skills, Children and Learning Bill establishes children’s trusts as statutory bodies that have an important, if not vital, role to play in the commissioning of services, including NHS services, for children in local communities. I find it interesting that the Department of Health does not appear to be talking to its colleagues in the Department for Children, Schools and Families in order to understand how this Bill and the NHS constitution will interact and link with children’s trusts, which its DCSF colleagues feel have such a pivotal role to play. Perhaps this is an oversight or something that the new ministerial group has not yet thought about, but I urge it to do so. If it does not, when the Bill is read by the people running our health services in our communities, such as the group of people I met in my constituency on Friday, who are doing all they can to weave together children’s services and make a better and more sustainable offer in Basingstoke, those people will be forgiven for thinking that the Department of Health still does not understand the importance of integrated working in the way it structures legislation.
As I said, I noticed that Sure Start children’s centres are also not an integral part of the Bill, despite their being a flagship policy of this Government—again the Department of Health does not seem to be getting a grip on that. Ministers are doubtless aware that the national evaluation of Sure Start undertook a study in 2007 on the effectiveness of Sure Start local programmes and demonstrated clearly that health-led Sure Start children’s centres are the most effective way of using the significant amount of public money involved. I realise that there are many new faces on the Treasury Bench and perhaps they need a little more time to get to grips with this part of their brief, but I urge them to look carefully at how they can work more effectively with their colleagues in the DCSF, because such working simply is not happening and that is not right for taxpayers’ money, for our constituents or for the people who work in the NHS and our children’s centres, and those who work in our children’s trust boards in future.
Underpinning this debate is the principle that smoking is an addiction of childhood—it is not an adult choice. Today, 1,000 under-16s will have started to smoke for the first time by trying a cigarette, and 80 per cent. of smokers start to smoke before they are 19. The tobacco industry needs to recruit more than 100,000 new smokers each year to replace those who die or who cease smoking. Smoking plays a huge role in perpetuating health inequalities and accounts for half the difference in life expectancy between social classes 1 and 5.
The Bill introduces two important measures that will protect children from smoking and help smokers who are trying to quit. It includes measures to restrict or prohibit cigarette vending machines and to put an end to the tobacco industry’s power wall promotional displays. Regrettably, it does not include a third measure: the requirement to sell tobacco products in plain packaging. Those measures are proposed not in isolation but as part of a comprehensive strategy; it is a proper plan to reduce the terrible burden of tobacco-related death and disease.
Campaigners on both sides of the argument have long been vocal, as we have heard in today’s debate. In one corner are those who would promote public health and in the other are those who would protect private profit. These are not equivalents. If the measures in the Bill would not work, health professionals would have nothing to gain from promoting them, but it is precisely because they will work that the tobacco industry is fighting so hard to defeat them.
I have mentioned vending machines, and the case against them is unanswerable; I was pleased to hear that Her Majesty’s Opposition will be pressing for the measures in the Bill to be toughened. Hon. Members who are still to speak, including the Minister, will doubtless make more detailed arguments, but, in short, mine is as follows: tobacco vending machines provide young smokers with about one in six, or 17 per cent., of the cigarettes they consume, whereas the figure for the entire population is about 1 per cent.; these young smokers use the machines as a ready supply of cigarettes because there is no real risk of their being asked for proof of age; those who profit by these illegal sales are almost never prosecuted—we must never forget that; and the machines are unpopular with regular smokers and are sited mostly where alcohol is sold and the resolve of smokers who are trying to quit will be at its weakest. I welcomed the Secretary of State in an intervention. I think he will be a superb Secretary of State, because he has the experience, track record and vision to make a success of the job. I urge him to draft, on behalf of the Government, the strongest regulations possible to introduce an immediate and total ban on tobacco vending machines.
I turn to the central feature of point-of-sale displays. Those who make and sell cigarettes hotly contest the evidence that point-of-sale displays increase youth smoking. However, very few smokers start smoking as adults and if we were to succeed in stopping under-age smoking, the industry would be bankrupt in a generation—that is self-evident. The Bill is against the tobacco industry’s interests, as we have seen in the furore and the campaign that it has mobilised, yet again, against any tobacco control measures. The more the industry tells the Government that they are off track, the more certain we and they can be that we are bang on target.
Saskatchewan was the first Canadian province to end point-of-sale display. At the time, its youth smoking rates were rising sharply, but when it put an end to tobacco displays those rates began to fall. The tobacco lobby had the ban suspended for a time, during which the youth smoking rate flatlined, but once the regulations were reintroduced the rates began to fall again—to me, that is proof positive that there is a strong link between the two. Overall, a rising trend had been reversed and the subsequent fall, despite the temporary suspension of regulations, was faster than the Canadian average.
Hon. Members listening to this debate should pay close attention if they receive briefings on this matter from the tobacco industry, as I am sure many have done. In the past, the industry sought to undermine the evidence—part of its modus operandi is always to muddy the evidence, challenge the science and breed uncertainty where something significant is going on—by referring to irrelevant adult smoking rates, by quoting an average decrease that starts years before the legislation came into effect and by comparing Saskatchewan not with the average Canadian province but only with those where youth smoking was falling fastest.
I move the discussion on 1,000 or 2,000 miles, to Iceland, which provides further evidence both of the effect of point-of-sale displays and the lengths to which the tobacco lobby will go to disguise it. In a long-term study that included almost all year 10 students in Iceland—those aged 15 to 16—smoking rates were seen to have fallen by a third, from about 20 per cent. two years before the ban to less than 14 per cent. two years later.
That figure is correct, but it is slightly complicated by the changes in taxation of tobacco products over that length of time. Can he elaborate on how that fits into the picture? I find it very difficult to tease out the details. For example, there was an increase in smoking rates after the taxation went down.
The hon. Lady is right to suggest that many factors influence smoking prevalence. Trying to control those factors, including for levels of taxation, and to identify and isolate what is happening at point of sale is difficult. The Tobacco Retailers Alliance certainly found doing that inconvenient and instead chose to use a small sub-sample of what was in essence a survey of adults. It continued to misrepresent the evidence until the Public Health Institute of Iceland, which was responsible for both studies, told it to stop doing so. I am pleased that the institute was moved to do that.
The health and medical communities are united in saying that tobacco displays increase awareness of tobacco brands and prompt purchase by young people. Jurisdictions that end such displays have seen the prevalence of youth smoking decline, and that is what this part of the Bill is about. If the opinion of leading researchers, health campaigners and royal colleges were not enough, Channel 4’s Fact-Check service concludes:
“The evidence points pretty firmly the government’s way. And to say, as the opposition parties do”—
by that it probably means opposition in the tobacco industry, rather than Opposition parties—
“that there’s no evidence the ban will have an effect on smoking among young people seems pretty misleading.”
We also have the economic counter-arguments, and we saw those in profusion when we considered the banning of smoking in workplaces and public places a couple of years ago. Members will remember that one of the main reasons given for opposing the smoke-free legislation was the harm that it was forecast to do to the hospitality trade. The tobacco industry understands that the only business that would really be harmed by smoke-free public places is its own, but it succeeded in alarming publicans who already felt under threat. Members may not be aware that in the year following smoke-free legislation the number of premises licensed to sell alcohol in England went up by 5 per cent.
The tobacco industry knows that it has lost any public sympathy it might once have had, so again it has identified a group of small businesses to manipulate as its front men to campaign on its behalf. The industry has suggested, for example—and the hon. Member for Shipley (Philip Davies) suggested this earlier—that compliance with the legislation could cost a small shop substantial sums of money, and figures have been quoted of up to £5,000. It has claimed that staff would be injured, thefts would increase and not only would smokers stop buying their cigarettes from small businesses, but they would stop coming into those shops altogether. I understand the alarm of some small shopkeepers, and we have all been to shops where tobacco is the heart of displays behind the counter.
The industry has claimed that in Quebec 12 corner stores closed every week. Like the claim that 40 pubs close every week in the UK, it is difficult independently to verify such statistics. It is never said how many shops closed before the legislation nor how many new premises opened since the legislation was implemented. The industry attributes the change entirely to the regulations, ignoring even the effect the global recession might have. It is almost as though some PR executive hit the “find and replace” button to recycle the old press releases that the industry used last time on smoke-free legislation.
The fundamental flaw in the industry’s argument is that it is simply not credible to suggest that there will be no change in smoking rates and, at the same time, that tobacco sales will fall. In truth, it will be several years before we see a major impact on tobacco sales to adults.
Tobacco packaging has become the industry’s most potent advertisement, especially when it comes to encouraging and recruiting young smokers. Traditional advertising is plainly a message from the manufacturer, but with packaging the customer becomes the message carrier. The hon. Member for Basingstoke (Mrs. Miller) mentioned the time when she had a tobacco company as a client and how the smoker who carries a particular brand is saying, “This is the brand for people like me.” That message is especially powerful to young people eager to fit in.
The Government have committed to fund further research into the effect of plain packs and to include a review of the evidence in the course of their promised tobacco strategy. That is to be welcomed. However, the evidence of how the industry attracts and deceives young smokers is growing and there is no time to waste. For example, manufacturers have long known that so called “mild” variants are as lethal as “full strength”. Only last month the appeal court in Washington ruled that some of the biggest tobacco companies in the world were guilty of racketeering and fraud by calling their products “light” or “mild”. In the words of the judges, manufacturers
“made the statements with the intent to deceive”.
Some people might think that advertising is a systematic attempt to deceive, but this was advertising at its worst.
In the UK, I am pleased to say, the terms “light” and “mild” to describe cigarette brands have been illegal since 2003. Not only that, it has been illegal to give the misleading impression that one tobacco product is less harmful than another. We have stopped the industry using those words, but it continues to send the same misleading message through the use of colour codes: red for full strength, gold for light and even silver for ultra light. Researchers have shown how smokers and young people read these “smoke signals” and fall for the fraud. It is the same low-tar lie—exploiting smokers’ health fears but keeping them hooked—only this time it is in code.
Branding is especially important to young people, whether for trainers, tracksuits or tobacco. A brand choice says a lot about how a smoker wants the world to see them. Most start before they are 18 and become brand-loyal, and the industry well understands that. But what if plain packs made smoking more attractive to young people? In fact, studies that gave young people a choice between plain packs and branded packs found they consistently favoured the branded packs. The tobacco industry depends on its ability to recruit 100,000 new smokers a year—300 a day and 12 or 13 in the hour since 7 pm. The industry insists that we cannot know that plain packaging will work until it is tried in the real world, but it opposes any country that dares try it.
The hidden hand of the tobacco industry is at work in all attempts made in democracies to introduce tobacco control and legislation. Those who make their money from the manufacture and sale of tobacco have been very active—as they are entitled to be—in lobbying this House. There may be nothing wrong with that as those who will be affected by regulations have the right to lobby about them, but we have a right to expect that those representations be honest and transparent. Much of what the tobacco lobby has offered us is neither.
Tobacco manufacturers and retailers are experts in tobacco marketing, but when they offer us their opinion on health, psychology and behaviour, we are bound to ask “Are they reliable, independent and expert?”, or are their vested interests so great that we must put their evidence aside. The tobacco industry has a long, long history of lobbying Government. Over the past 50 years, it used the same core tactics, in disputing whether smoking causes cancer—a point that was eventually conceded after a very long battle—and in fighting a rearguard action against smoke-free public places. I said to the Secretary of State, when he kindly allowed me to intervene, that the main planks of its campaigns are very similar. They manufacture uncertainty. One tobacco executive has even said:
“Doubt is our product, since it is the best means of competing with the ‘body of fact’ that exists in the mind of the general public. It is also the means of establishing a controversy.”
Members will have heard claims that compliance with the law will cost between £3,000 and £5,000, or that smuggling in Canada increased after point-of-sale regulations were introduced there. The campaigns manufacture uncertainty.
In the face of all the scientific evidence given by all the independent experts and research studies, the industry consistently challenges causation—the link between tobacco smoking and ill health. As much as 50 years ago, the industry was advised by its public relations experts always to dispute the signs. Its line was that cause and effect relationships have not been established in any way, that statistical data do not provide the answers and that much more research is needed. That is always the case. We can always procrastinate by saying that more research is needed—that we need to do pilot studies on this, and that we need to trial that. However, every year we hear that many tens of thousands of people die prematurely because of smoking. They cannot stand aside and wait for pilot research and yet more roll-out studies.
The third of the four tactics that the industry tries to use is to hide behind third-party advocates, which it does very successfully. We will all have received postcards from the “Save our Shop” campaign. Who funds that? An organisation called Responsible Retailers. Who funds that? The Tobacco Retailers Alliance. Who underpins that? The Tobacco Manufacturers Association. There is no surprise in any of those relationships. The Tobacco Manufacturers Association, as my neighbour the right hon. and learned Member for Rushcliffe (Mr. Clarke) would confirm, is a club made up of Imperial Tobacco, British American Tobacco and Japan Tobacco.
Having followed the current Chair of the Select Committee on Health as chair of the all-party group on smoking and health, I have received a good number of letters from the British Brands Group, which has a keen interest in tobacco policy but seems very shy about disclosing the involvement of BAT. Other Members might have heard Dave Bryans, the president of the Canadian Convenience Stores Association, who is often cited by the tobacco lobby, when he spoke at a meeting here in the spring. I doubt, however, whether he cited or they heard him mention that he was a former executive at Canada’s biggest tobacco manufacturer.
Finally, the fourth element of the strategy that the tobacco manufacturers and tobacco industry have rolled out every time that progress has been made on tobacco control legislation is, if all else fails, to seek to delay the inevitable. There are measures, among them plain packaging, which the tobacco industry considers inevitable. However, the longer those reforms can be prevented, the greater the industry’s profits will be. I said to the Secretary of State that Philip Morris had described that as throwing sand in the gears of regulatory reform.
When Members consider the evidence, they will need to be more than usually careful about the origin of that evidence. When they see the strong case for putting a stop to promotional displays and under-age sales from vending machines and in favour of plain packaging—as well as the case for the benefits to be gained from driving down yet further the rate of smoking among young people—they will realise that the social and health benefits will outweigh all the costs, all the angst and all the delays that we regularly endure when we face the tobacco industry over such measures.
It is a pleasure to follow the hon. Member for North-West Leicestershire (David Taylor), who is chairman of the all-party group on smoking and health, in which I am a humble spear carrier. Where he leads, I follow. I want to return in a moment to the points that he made about tobacco.
May I pick up on a point that my hon. Friend the Member for Basingstoke (Mrs. Miller) made about clause 34, which caps the private income that can be generated by a foundation trust? When the Bill setting up foundation trusts was going through the House of Commons, I remember objecting to that provision because it would freeze the activity of a hospital such as Basingstoke hospital at what had been its historic level. The whole thrust of the foundation hospital movement was to enable a hospital to develop its specialties, to expand in the areas in which it had a competitive advantage and to generate more income that it could then plough back into increasing its NHS activity. That is exactly what has happened in Basingstoke and I endorse the eloquent plea from my hon. Friend and neighbour that the clause should be allowed to stay in the Bill and should not be axed.
I welcome the Secretary of State to his new post. He could not have known five days ago that he was going to be moving the Second Reading of the Health Bill today and he did so with remarkable skill.
I want to touch briefly on two points, the first of which is chapter 3 and the provision for direct payments. I believe that the most radical element of this Bill is the provision for direct payments, and it has been touched on briefly in the debate by my other neighbour, the hon. Member for Romsey (Sandra Gidley). It is the manifestation within the NHS of a social policy that has already made good progress in adult services where it trades under the name of personal directed support. Direct payment potentially represents a very radical move from an inflexible, institutionalised response to a client’s or patient’s needs to a much more flexible, user-friendly response, and I welcome it. When we had a debate about this policy in the social care context, the Minister said that it would mean that people would have a life, rather than a set of services. Indeed, the Minister who said that might well have been the Minister of State, Department of Health, the hon. Member for Corby (Phil Hope), who is sitting on the Front Bench. In the social care context, that summed it up rather well.
I understand that the proposal is only for a pilot and that only a limited range of services can be funded by direct payments, but there are potentially enormous implications for the NHS. When services have been provided by a monopoly supplier, a new market for different suppliers is opened up. At the moment, the NHS is the funder, the prescriber or advocate, and the supplier. As direct payments come into play, the NHS will remain the funder, but the role of advocate and supplier will become available to others. For that to work in the social care context, independent advocacy services need to be available. As I looked through chapter 3, it was not absolutely clear to me who would provide that role for the NHS. If the NHS is the advocate, it is not clear that the patient will get the best value from direct payments because the patients might not be told what is available outside the NHS. If someone else is to do the advocacy, as they probably should, who will do it and who will pay for it? Will the cost of the advocacy have to come out of the direct payment?
I accept the point that choice is less of an issue in health than it is in social services, because it is by its very nature a more prescriptive service, but I think that patients want choice. Although they want choice, they do not want the hassle of contracts, of employing people, of insurance and all the rest. One reason why so few people took up direct payments in social services—initially, only 5.4 per cent. of those who were eligible did so—was the paperwork. We have to make it absolutely clear that the advocate or the NHS can handle the paperwork once the patient has decided on the package. The proposed new section 12A to the National Health Service Act 2006, which appears in chapter 3, makes provision for that, I think.
If direct payments are to work, the supply side of the health care market will have to respond and it might need some pump-priming. There will be demand for a totally different range of services as patients invest in packages of care that they have selected. Over time, the market might change as resources are shifted from institutionalised provision, on the one hand, to much more individualised provision on the other. There might be fewer block contracts, there will need to be much more transparency on costs and, crucially, we will need more trained providers who can provide the packages that people want.
The question of resources has been touched on. The issue of what I call calibration is crucial: how much money should be allocated for the direct payments or the individual budgets? There is a risk that the whole policy will not take off if unrealistic provision is made and people then find that they cannot buy the range of services that they need. At the moment, a PCT can prescribe through the GP or consultant a range of treatment and there is little transparency on cost—it will probably get lost in a block contract. With direct payments, however, the costs are of enormous importance and are very transparent. In some cases, experience with direct payments in social care was that the sum allocated simply was not enough to purchase the care that was needed, which may explain why take-up is low. We need realism in pricing if direct payments are to work.
We need to know how the direct payments policy set out in chapter 3 relates to the parallel policy of allowing primary care trusts to top up individual budgets from social services. For example, when a patient is also a social services client, will the PCT simply put the direct payment into that pot, or will it set up a separate one with its own NHS rules?
Top-ups are allowed in social care. I understand that, because they are means-tested, but apparently they will not be allowed under direct payments for the NHS. I cannot find a provision in the Bill that says top-ups are banned, but the King’s Fund briefing says that top-ups will not be allowed. There is a risk of confusion, because we are moving towards toleration of co-payments in the NHS—we had a debate about cancer drugs, for example—and if we are to allow people to top up their social care payments but not their NHS payments, and all the money is put in the same pot, I can see a philosophical problem. I hope the issue of top-up payments will be kept under review.
We have already heard about risk. How do we reconcile the right of an individual to determine how he or she spends the direct payment with the obligation of the PCT to ensure that public money is spent wisely and to discharge its responsibility to look after vulnerable people? We heard from the Secretary of State that there will be some safeguards, in that the PCT will have to validate the plan, but there will inevitably be an element of risk although I do not think it is necessarily a killer argument against going ahead. The same argument was deployed in the social care field, but in the event there has been little abuse of funds.
Finally on this point, I have a philosophical question. Why do the Government stop here? Does the logic of direct payments not imply that they could be extended elsewhere—to adult education or indeed to school-age provision? Perhaps the Minister who winds up the debate will explain the difference between an NHS direct payment and an education voucher. With that controversial question hanging in the air, I shall move to my second and final point, which relates to part 3 and the clauses on tobacco.
My first job as a Minister—30 years ago almost exactly to the day—was to renegotiate the voluntary agreement on advertising with the tobacco manufacturers. Because of my aggressive stance, I was transferred to another Department, but I have long taken an interest in measures that reduce the damage done to the nation’s health by smoking, so I welcome the Bill, which makes further progress in the right direction. However, I find myself a little ahead of my Front-Bench colleagues on the issue, and indeed of some of my other colleagues. I hope the Government will resist attempts to water down the Bill’s provisions.
The Bill includes two important measures that will help to protect children from smoking and help smokers who are trying to quit. It also includes measures to restrict or prohibit cigarette vending machines and to put an end to the tobacco industry’s power wall promotional displays. I agree with all those who say that the measures need to be seen in a broader context—as part of a comprehensive strategy to reduce the incidence of smoking and a proper plan to reduce the terrible burden of tobacco-related death and disease.
The measures in the Bill are wholly consistent with the ban on smoking in public places and the ban on advertising. They are trying to change the climate in which smoking was seen as a socially acceptable behaviour. As advertising was prohibited, so that changed the environment. As smoking in public places was prohibited, that too changed the environment and the measures in the Bill to restrict the display of tobacco packs will make a further change in the environment, to discourage the activity.
Very few smokers start as adults, and if the Government were to succeed in preventing under-age smoking, the tobacco industry would be out of business in a generation. The fact that the industry is so against what is in the Bill sends me the clear message that we must be on the right track and that the Bill must be good for public health.
The health and medical communities are united; the research clearly shows that tobacco displays increase awareness of brands and prompt purchases among young people. Jurisdictions that have put an end to such displays have seen youth smoking fall. A study of smokers published earlier this year shows that displays prompt sales where none has been planned and tempt smokers who are trying to quit. Indeed, one in four smokers say that a display ban would make it easier for them to quit.
I take the point that has been made about the impact on retailers of introducing these measures during a recession, but that is not what the Secretary of State is proposing. Whatever inconvenience small shopkeepers encounter will not occur for four years, by which time we will—we hope—be out of recession. Tobacco displays are typically replaced every three to five years, which would give ample opportunity to plan ahead for low-cost compliance.
The Secretary of State may have noticed that both speeches from the Government Back Benches advocated much faster action on vending machines, as have speeches by Opposition Members. I hope the Secretary of State gets the message that there is an appetite in the House for faster progress than is proposed. The tobacco vending machine market is worth £1 billion and is dominated by Sinclair Collis, a subsidiary of Imperial Tobacco. As has been said by a number of Members, the purchases are unsupervised, young smokers are rarely challenged and in some cases staff even offer assistance. Vending machines compete with small retailers, and a ban on them would help the smaller retailer because sales would be transferred to local retailers who are open all hours. An outright ban on vending machines would provide health gains but, as I have just said, it would also offer a benefit to hard-pressed small shopkeepers.
Smoking is the largest cause of preventable death and disease in the UK, causing more premature deaths than alcohol, obesity, road accidents and illegal drugs combined. The provisions could reduce those burdens on our children, so I hope the House will resist any attempt to water down the provisions and I hope Ministers will be encouraged by the debate so far to build on what is already in the Bill and take the argument and the debate a stage further.
It gives me great pleasure to follow the right hon. Member for North-West Hampshire (Sir George Young), who talks with great authority about smoking and comes up with extremely important points. As he rightly noted, he is well ahead of his Front-Bench colleagues on the issue, and all power to him. I am sure he will support the measures, as he has promised to do.
One of the advantages of a health Bill from my point of view is that it gives me the opportunity to rehearse a well-worn mantra the House has heard many times—“As a practising GP”. I do not say that lightly, because it is a serious point. I am proud to be an NHS general practitioner. I am very proud indeed to be on the front line, implementing some of the policies that I have helped my Government to pass over the past 10 years or more. That is an important point because it genuinely informs my work in the House—on the Health Committee, which my right hon. Friend the Member for Rother Valley (Mr. Barron) chairs so admirably; as chair of many all-party Back-Bench groups that do a lot of work behind the scenes; and in debates in the Chamber.
Ultimately, the proof of any Bill is in its implementation. Our debate and rhetoric in the House do not matter; what matters is how a Bill, when it becomes an Act, affects the lives of people out there. When a health Bill has been through all its stages in this and the other place and has become law and is implemented, I am in a position to judge at first hand how it affects the running of the health service and its direct impact on the health of my patients.
As we have heard, the Bill sets up an NHS constitution—an idea I thoroughly support—which will make a big improvement in the way patients engage with the NHS. I hope it will improve the way they use the NHS so that they get much more from the service, which of course they pay for.
Another aspect of the Bill is that it implements the parts of the NHS next stage review, so admirably run by Lord Darzi in the other place, that require primary legislation. They include provisions on the constitution, quality accounts and direct payments, as we have heard this evening. Despite great progress, the NHS still faces many pressures when it comes to achieving the goals set out in the NHS next stage review. We are a long way away from where we would like to be on the issue; we still have a considerable distance to travel. The next stage review makes it clear that to move forward, the NHS needs to spend time looking at how it can provide a more integrated service for its patients. For example, the review mentions piloting new “integrated care” organisations that bring together health and social care professionals from a wide range of organisations—community services, hospitals, local authorities and others—depending on local needs.
The review also said that stronger support will be given to practice-based commissioning by providing incentives for a wider range of clinicians to get involved. That is an important point. That would enable GPs to work alongside other community clinicians and specialists working in hospitals to develop more integrated care for patients. I strongly support that drive towards more collaboration between health care professionals. I have always believed in the effectiveness of the NHS, but it has been severely hampered over the years by the chronic inability or refusal of primary and secondary care professionals to work genuinely in partnership.
In the past, GPs and hospital specialists rarely engaged with each other in any meaningful way, while the relationship between GPs and community pharmacists was virtually non-existent in most parts of the country. Importantly, the new constitution emphasises the fact that the modern NHS is an integrated organisation that requires all its constituent parts to work in concert for the good of its patients, and that is long overdue. Although progress is being made in that area, it is clear that in parts of the NHS we still have a long way to go if we are to get the level of integration that we need.
One of the main challenges is information technology, and that, in the main, is what I want to talk about tonight. Connecting for Health, which started its life as the national programme for IT, has been mired in controversy since its very inception. Problems with software packages, and to do with access and security standards, together with the woeful failure of its commissioners to appreciate the complexity and scale of the undertaking, have caused severe delays in the roll-out of the NHS care records service, which, of course, is the centrepiece of the entire programme. Until we resolve that issue, we will never achieve the degree of integration that the next stage review envisages.
As someone who does some general practice, I have encountered my fair share of IT problems over the years. The much-vaunted choose-and-book system, which is designed to link 30,000 GPs with almost 300 hospitals across the country, is a case in point. When it works, it is wonderful. It allows me to search the entire NHS database for clinics that provide the service that my patients require. It allows the patient to sit with me and choose which of those clinics they wish to be referred to. They can trade off factors such as parking convenience, the knowledge of a particular consultant, particular specialties within a department, and the ability to visit a hospital near where their family lives. All those wonderful things, which in the past were virtually impossible, are now possible with choose and book. A patient could say, “I’d much rather be seen in Birmingham, doc, because my sister lives there”—not a problem. As long as the option comes up on the choose-and-book website and meets the tariff requirements, I can book an appointment in Birmingham for them. When the system works, it works marvellously well.
I spent 30-odd years, from the age of 19, working in the IT industry in the public sector before coming to this place in 1997. One of the problems in the public sector is that the outsourcing mania that there has been, particularly in the civil service, over a very long period has deprived and denuded Government structures of people who can act as intelligent clients. In other words, the Government are more susceptible to the wiles, charm and public relations of snake-oil salesmen, who are fairly common in the software industry. That is the problem. Intelligent clients can spot where the problems are, and the problems that my hon. Friend mentions were not spotted in the early days of Connecting for Health.
I bow to my hon. Friend’s great judgment on the issue. He is a real expert on IT, particularly in the public sector, and I defer to him. I sometimes wish that there was some more snake oil poured into my computer; it might then work a bit faster. As things are, it cranks along.
Things are not always straightforward, and I shall give some examples. Only about half of all services in my area are available on choose and book, and not all of the services that are supposed to be bookable can be booked. A couple of months ago I had a patient with a wrist problem, so I went on to choose and book. We found a hand and wrist service—ideal for the job—just down the road from my surgery. “Perfect,” one would think. However, the next day when the patient came back to see me I found out that the hand and wrist service did not do hands or wrists. I am not making that up; it actually happened. I had to start again from the beginning. It meant another wasted appointment, a baffled patient, and bemused staff. Eventually, we sorted the matter out with a different hospital.
The choose-and-book server has the interesting habit of throwing the user out at 5 o’clock on a Friday evening. That is not even outside core hours, let alone compatible with the concept of extended hours, which most GP practices across the country are now embracing. When, at 10 minutes past 5 o’clock, one says to a patient, “I’ll just book you a choose-and-book appointment,” only to find that the server has gone off and will not come back on again until Monday morning, it is, to say the least, irritating. I have never understood why it happens, but it happens very frequently—far too often to be just coincidence.
Even more seriously, it is apparent to me that some acute trusts have tried to get around the 18-week service target simply by saying to the patient, “There are no appointments available.” It is a great irritation when one has given the patient a print-out and told them to phone up for the appointment of their choice, for them to be told that there are no appointments whatever. The patient then comes back to see me the following day, which means another wasted appointment. It transpires that hospitals can manipulate the 18-week target if they simply stop offering any appointments. If they do not offer appointments, they cannot miss the target. That might be wonderful from the hospital accountants’ point of view, but it is pretty miserable from the point of view of the GP and the patient.
In some areas, however, choose and book has been a runaway success. In Barnsley, for example, about 75 per cent. of all GP referrals are made through choose and book. The key to Barnsley’s success is strong leadership from the local primary care trust, which has ironed out the technical glitches and professional resistance and persuaded the secondary care trust to get behind the service and make it patient-friendly. There is no reason why that should not be replicated across the country. There is no shortage of innovative care models involving communications technology that work at local level. In Sheffield, for example, trials are running of a virtual desktop that enables clinicians to access patient records using interactive bedside systems. That reduces the need for staff to keep logging in and out of computers, and cuts down on the endless administrative paper trail.
It is when we try to create IT systems that are capable of being used in more than one place by more than one type of health care professional that we run into problems. As chair of the all-party pharmacy group, one of my biggest frustrations—I am sure that it is shared by the hon. Member for Romsey (Sandra Gidley), who is also an officer of the group—is that pharmacists are not being given the IT resources that they need to allow them to make full use of the new responsibilities laid out in the new pharmacy White Paper. If they are not connected and integrated, they simply cannot maximise the use of their skills. That is a potentially dangerous problem.
If we are to expect pharmacists to prescribe as well as to provide front-line clinical services, as they should, it is absolute nonsense for them not to have read-write access to the patient clinical record. I shall give an example, because the problem is serious. This morning I did a surgery. I saw a patient with an infection and I wanted to prescribe her an antibiotic. I asked her if she had any allergies—“No, doc, I can take anything.” So I typed in the first antibiotic of my choice. A message popped up on the computer saying, “Warning. Patient allergic to this drug.” So I said to her, “It says on the computer that you’re allergic to this drug.” “Oh, yes,” she said. “That’s right.” I asked her if there were any other drugs that she was allergic to—penicillin, for example. “Oh, no, doctor, definitely not.” So I typed in “Penicillin”, and the message on the computer came up to tell me that she was allergic to penicillin. I said to her, “It says here that you’re allergic to penicillin.” “Am I, doc? Goodness me. Actually, come to think of it, there are quite a few drugs I can’t take,” which she had completely forgotten to tell me about a few minutes before.
Woe betide the hapless pharmacist who came across this lady and who might decide to prescribe antibiotics for her, having been told by her that she did not have any allergies, only to find out the hard way that she did. That is a mistake that should not happen. Had the pharmacist had access to the patient record, that would be easily dealt with. It is no longer credible to say that pharmacists cannot have access to the patient care record.
Pharmacists are doing medication use reviews in huge numbers. At present the reviews come back to the practice in paper form. Most of them are no longer handwritten. At least they are now computer-generated, but a piece of paper in the GP’s surgery is as much use as a chocolate Easter egg in hell. It is no use whatsoever, because the information on it has to be scanned, taken off that printed record and entered into the patient record, and in many cases that is not going to happen. So the usefulness of the MUR is severely hampered by the fact that if it is not in electronic form, it does not integrate into the patient record. It needs to do so.
I move on to the commissioning of services. Progress in commissioning of new providers has also been very mixed. Many PCTs have a great record when it comes to stimulating the market and commissioning services from community-based providers, such as pharmacists. I am therefore pleased that the Department of Health has taken steps to address this by encouraging PCTs to ensure that there is appropriate pharmacy input in PCT decisions. I hope that this will improve awareness within the PCT. However, it is also clear that the introduction of practice-based commissioning has helped to make more effective use of resources, and is bringing care closer to home for patients.
My patients, for example, are now able to take advantage of community cardiology services. This means that I, as a GP, can book a patient into a community cardiology service for a 24-hour ECG or an echocardiogram within a few days, which in the past would have taken several months. Now it can be done much more easily and quickly, with the patient travelling far less distance to receive that service. It has also reduced the cost by about 30 to 50 per cent. Similarly, those with muscular-skeletal conditions are now able to use a local access clinic, where the patient with a back, hip or knee problem can be triaged within a week or two and passed on to the appropriate consultant specialist without the need for extensive waiting and with a much more efficient service than we ever had before.
MRI scans are available to open access by general practitioners. This is a huge advantage. Not only can I now get an MRI scan for a patient within about two weeks of referral, but there are several other benefits. First, the patient does not have to travel, because it is a local service. The machine is mobile and can be moved from surgery to surgery. Secondly, the waiting time is extremely short—only a couple of weeks. Thirdly, GPs can maximise their own clinical skills by making much more use of investigations themselves, and fourthly and possibly more importantly for the NHS, that reduces the need to refer patients to a consultant. This means that there is less pressure on hospitals and gives them more opportunity to maximise the skills that hospitals can provide, which others cannot. It takes the pressure off them and allows them to get on with their job.
The challenge now is to ensure that these examples of best practice are replicated right across the country. I believe we can do that. I have provided many examples this evening to show that that can be done. I visited one of my pharmacy colleagues today, Bipin Patel, who runs a pharmacy in the middle of Bexleyheath, where my practice is based. I was talking to him about how we can reduce prescribing and dispensing errors, particularly in the light of an inquiry that the all-party pharmacy group is to carry out in the near future on dispensing errors. He read out to me a prescription with a very ambiguous message on it. He did not have access to the patient’s record, so he had to phone the GP and double check what the GP meant, causing delay and problems for the patient. That is another example in which access to the patient record would be a good thing.
The NHS constitution, which I thoroughly support, allows a review only after a 10-year period. However, it provides for the handbook to be considered every three years and the effects on patients and staff every three years. Perhaps my right hon. Friend will consider the matter in the course of his deliberations, or perhaps it could be discussed in Committee and on Report. Can we ensure that the NHS constitution is reviewed rather sooner than 10 years? That is too long a time. I would advocate that it be reviewed after three years, at the same time as the NHS constitution handbook and the effect on staff. Will my right hon. Friend address that point?
It gives me great pleasure to follow the only practising doctor in the House of Commons, the hon. Member for Dartford (Dr. Stoate). I have to admit that his speed of delivery sometimes leaves me feeling rather breathless, but I admire his turn of phrase.
I welcome the new Secretary of State to his position. I remember arriving in 2001 at exactly the same time, and sitting on the Health Committee for at least two years with him. Since then, his rise has been somewhat more meteoric than my own rather pedestrian progress from this very same Bench. However, I welcome him to his post and echo what the right hon. Member for North-West Hampshire (Sir George Young) said: to have mastered that brief in an extremely short time was pretty impressive.
First may I say, as I have said many times, that there have been great improvements in the NHS, particularly on waiting times and on cancer and cardiac services? However, in some respects, all is still not yet well. The results of patient satisfaction surveys, to which reference has been made, are impressive, but they miss out some matters on which the health service is not working quite so well, and I am afraid that I must draw the Secretary of State’s attention to one or two of them. We all know about Mid-Staffordshire, the failure of leadership and the failure of some staff to deliver quality or even safe care, but I have a horrible suspicion that that lack of quality, especially relating to dignity, compassion and communication, is more widespread. My hope is that the NHS constitution can address and alter the situation, but I shall give two examples of matters that have come across my desk recently. I referred to the first in a Westminster Hall debate on 14 May, but, as the Minister who heard me then is no longer in the same post, I shall repeat some of the points that I made on that occasion.
I read out a letter, in its entirety, from an elderly couple who had lost their only son at 31 years old. I shall not put the House through the whole letter, but I shall read one or two extracts just to demonstrate that things are not all well. Those elderly parents said:
“We would arrive to see him, to find him lying in a soaking wet bed, or worse.”
They went on:
“Our son had an infection under his nails and was unable to pick things up. This the staff knew about, so why were pills left in the little plastic cup…from the morning and lunch time. Maybe it was because he had no water jug or cup so he had nothing to drink.”
“Lots of working people have long stressful days, and I know people who went into nursing as a vocation but sadly those days have gone. When someone is training for this job, I’m sure they must learn what is expected from them, and the meaning of the word nurse means to take care of and hopefully give a person dignity, which sadly our son didn’t have at times.”
“We hope that if either of us should need to go into hospital in the future, that the cleaners do what they're supposed to do and our right to dignity is upheld.”
I saw that couple in my advice surgery last Friday. They are still so upset that they cannot face putting in a formal complaint or allowing me to name them. In my view, formal complaints are not much use; they lead just to apologies—not, very often, to any particular change. Even in Stafford, the Healthcare Commission upheld many complaints, but the board either took no notice or was not even aware of them.
In a second example, which was also raised in my advice surgery last Friday, a qualified nurse told me about her mother, who is 88 years old. She fell with a suspected hip fracture and was taken to an accident and emergency department at 7 o’clock. The family arrived at 10 o’clock, but she had not been assessed or seen. Eventually, she had X-rays and was admitted for review because no trauma and orthopaedics team was on duty until the next day.
The daughter, a nurse, felt that there could not be a fracture, because her mother was pain-free and had good movement. Nevertheless, she had to be admitted so that she could be seen by an expert. She had gone six hours without fluids, there were no beds and she remained on a couch in the accident and emergency department. The next day, surprise, surprise, there was no fracture, but she was confused and immobile. When her daughter asked for a glass to give her water, she was told that the tumblers were only for tea, not for water. But this really capped it, the daughter says:
“I was told by the staff nurse that she was dehydrated, confused and with a probable urine infection, but that it was not the nurses’ role to make her drink anything.”
The last straw came when the patient went to another hospital for rehabilitation; it was discovered that she had been having a large, wrong dose of a sedative in the morning instead of at night.
Those are two examples that show that all is not going well. I hope that the constitution can do something about such problems. Not that long ago, when I was walking to the railway station, I saw a member of staff picking up fag ends outside the station. He said that it was easy to change policies, but very difficult to change people. I thought that extraordinarily astute.
I turn to some of the rights under the NHS constitution. Under the heading “Respect, consent and confidentiality”, it states:
“You have the right to be treated with dignity and respect, in accordance with your human rights.”
Under the heading “Quality of care and environment” are the words:
“You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality. You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide.”
How will that be enforced? Somehow, Monitor let Stafford hospital through. I believe that Monitor could play a key role, and I hope that it will not let through other aspiring trusts that get the sort of complaints about basic quality of care that I am receiving.
I am bothered about the complaints process. The lack of an automatic independent review is a disaster. As the Secretary of State will be only too well aware, to get an automatic independent review, a person now has to go to the ombudsman, who will be completely swamped. Patients and families will lose the will to persevere that far.
It really is awful that a constitution should be needed to enforce such basic things. I am sure that at this time of year several of us go to mayors’ Sunday services in our own patches. I was at one in the little town of Bewdley at the weekend. One of the readings was the parable of the good samaritan, whose moral is “You shall love your neighbour as yourself.” We have forgotten the morals of such stories; we have forgotten some of the good parts of human nature. That takes me back to one of the things that we heard in New Zealand on our recent trip to look at the quality of care there. It was a question: “Will your hospital pass the granny test?” In other words, it asks whether a person would be happy for their granny to be treated at the hospital.
I am desperately concerned that we have lost some of the basic duties of the caring professions. The Royal College of Nursing is to be congratulated on its work on dignity. I would like to refer the Minister to an article in May’s Journal of the Royal Society of Medicine headed “Doctors and quality improvement”. It is by Hockey and Marshall, and is well worth reading. I have a completely different concern about the NHS constitution. I have learned about the difficulties of whistleblowers in various parts of the country, and unless I have missed it, the protection for whistleblowers is not spelt out in sufficient detail or emphasised enough in the Bill.
I turn briefly to the clauses on pharmacy. Unless I have missed something, they do not address most people’s major concern, which is prescription charges. I know that people with cancer have recently been exempted from paying them, and that is absolutely marvellous. There is also an inquiry, headed by the president of the Royal College of Physicians, into treatment charges for long-term conditions. I would like the Secretary of State to make absolutely sure that prescription charges are likely to be exempted in the case of HIV/AIDS, as that is now a long-term condition. I was amazed to talk to renal experts in the west midlands who did not realise that transplant patients are not exempted from prescription charges. Such an exemption is essential given that they have to take anti-rejection drugs.
A lot has already been said about smoking and the bits in the Bill relating to tobacco. As many Members have observed, as MPs we wear two hats. We are concerned about small businesses and corner shops, but we have a tremendous desire to stop the young taking up the smoking habit. The nanny state argument does not cut much ice with me. In the case of something like smoking in public places, which is so terribly bad for other people, not just the smoker, the nanny state does not come into it. I am afraid that some of these kids, who are starting to smoke at an amazingly young age, need the nannies of the nanny state to try to make them see sense. I have no objection to bans on advertising or on sales from vending machines. As other hon. Members have mentioned, covers are available which at the press of a button will obscure all the shelves with cigarettes on them, while the press of another button will expose everything, so without moving from the counter, the shop assistant can expose the products, get out the right thing, and then shut them up again. Cancer Research UK assures us that those covers cost only about £200. It would be a great help if small businesses could be given some sort of help with finding that £200—if it is true that it is only that much.
Why, in some places, and from some clinical staff, have we lost some of the best features of human nature—politeness and consideration for others? About 400 years ago, Montesquieu, a French political philosopher, wrote:
“The English are busy; they don’t have time to be polite.”
In some parts of the health service, people can claim that they do not have time to be polite, but that is absolutely no excuse. Webster’s dictionary has got it right: it says that politeness is
“marked by or exhibiting an appearance of consideration, tact, deference, courtesy or grace resulting sometimes from sincere consideration of others”.
If the NHS constitution had teeth and reminded all staff that common courtesy and politeness are absolutely necessary, it could achieve improvements in parts of the NHS that have not yet been reached.
I apologise to my right hon. Friend the Secretary of State and to Opposition Front Benchers for not being here at the beginning of the debate. It has been a busy day in the House, with a range of important meetings that I have attended—and enjoyed. In response to the hon. Member for Wyre Forest (Dr. Taylor), I am not an Englishman who is too busy, but I am a Scotsman who represents an English constituency, and I want to be busy on the issue of NHS reform and NHS investment. When I was a Member of this House in 1992, my first Front-Bench job was as Labour health spokesperson. My right hon. Friend the Member for Rother Valley (Mr. Barron) is here. We are where we are today only because he campaigned on issues such as smoking and preventive strategies in primary care and because of his commitment and engagement during that period, when the then Government refused to listen to any arguments about investing in the acute sector and in preventive strategies in primary care to improve health care, particularly in working class communities.
I welcome my right hon. Friend the Secretary of State to his new post. He and I share a borough, and we share a friendship; indeed, we live minutes away from each other. The fact that he has got this job is a breath of fresh air; that is not because the individual who had it before was not a breath of fresh air, but because ever since he was elected to this House and before, he has seen the importance of a preventive strategy in health care through investment in sport and sport-related issues. As Secretary of State for Culture, Media and Sport, he was the first Secretary of State to link the preventive strategy in health care with other strategies across Government, including sport.
As a consequence our local authority, Wigan council, was the first to introduce free swimming not just for young people but for every single person in the community. We now have thousands upon thousands of individuals taking up healthy pursuits, and the preventive strategy has improved their health due to the intervention of my right hon. Friend. If there had to be a reshuffle, I cannot think of anybody better to take on the portfolio, and I wish him and his colleagues the very best in their efforts to build on the success of the Labour Government’s record investment in health care.
May I ask a favour of my right hon. Friend? I will be leaving this House after 22 years for health reasons. I am probably the reason the NHS has had financial problems in the past few years. At least once in each of my 22 years in the House, I have been hospitalised. Because of the NHS, I am looking a very healthy ill person. But given my role as a patient in the NHS, my right hon. Friend could do me a favour if there is any work going after the next election and he is still Secretary of State, as I believe he will be. If he is looking for full-time NHS mystery shoppers, I am up for it.
This Bill and previous innovations in Bills like it are about empowering patients, and it is important that health care provision should not be a passive relationship between health care authorities, doctors, clinicians and other health care professionals. It should be about engagement with the patient, to maximise their opportunity to help manage both their illness and the process of improving from ill health to sustained good health in the years ahead. The Bill will assist in that process.
I have been in favour of direct payments for many years. In the case of social care, I argued the case in Government for direct payments, not to weaken public or community provision but to empower individuals to have a real say in their life as it relates to their health and social care. Yes, direct payments can be controversial, as many changes have been in the modernisation of NHS. My right hon. Friend should engage with trade unions and health care professionals, but he should do so on the basis of taking them on that journey. Direct payments, if well managed, well organised, accountable and in the context of NHS principles and the constitution, will benefit tens of thousands of individuals and their health care in the years ahead. I ask him to pursue that issue with vigour.
As we evolve and develop the role of NHS foundation trusts, it is important that we find ways to make them even more accountable to the local communities in which they operate. Whether a foundation trust is acute or non-acute, it is critical that the bureaucracy of establishing it does not create barriers to the community’s involvement in its management and decision making in a wider sense. That could include decisions on the professionalisation of the board memberships, or ensuring that individual communities—particularly working class communities, if Members do not mind my saying so—can engage in the decision-making process about the services that the trust provides. Trusts must reflect the priorities of the communities in which they reside.
As we establish foundation trusts, for which I argued in government, it is important that communities are engaged to the fullest extent. We must bring together local government and other partners to plan and provide services, and we must ensure that community groups and organisations are an integral part of the consultation process on the development and improvement of those services. Where it is appropriate, local community organisations should be involved in the delivery of those services as well.
I turn to the specific issue of children’s smoking. I do that not just because of the extensive work of my right hon. Friend the Member for Rother Valley—I was a supporting act to him when I was on the Front Bench in the 1990s—but because I represent a constituency in the north-west of England that has been devastated by the twin effects of poverty and smoking-related diseases. Literally thousands upon thousands of untimely deaths in the past decade can be attributed to smoking.
Smoking takes a heavy toll on the lives of the people in the communities of the north-west, with 14,000 deaths a year in our region. It exacerbates health inequalities and has a negative impact on children and young people. That is the history of the north-west of England. As a consequence of decisions in previous legislation, we now have the capacity to break that horrific cycle of smoking, poverty and inequality. However, there is a loophole, and I shall talk about that in a moment.
The prevalence of smoking in the north-west region is the highest in England, with 23 per cent. of the population smoking—25 per cent. of men and 22 per cent. of women. As many as 22 per cent. of 14 to 17-year-olds smoke in the north-west, despite the fact that it is now illegal to sell cigarettes to under-18s. In November 2007, leaders of local authorities, community groups, the NHS and young people’s organisations came together to set out a bold vision of a tobacco-free future for our children and young people in the region. In June 2008, local authorities and health service leaders throughout the region decided, on a non-party-political basis, to build on that initiative. They made a new pledge to
“make smoking history for the region’s children”
and agreed that a fully funded and effective national tobacco strategy needed to be developed.
There was a public consultation exercise, and 60,000 responses from people in the north-west accounted for around two thirds of the total 96,000 responses that the Department of Health received to its future of tobacco control strategy. That was a huge response from a community devastated by the effects of smoking.
The response is consistent with the findings of the survey conducted last June, with north-west residents expressing overwhelming support for further measures to protect children from tobacco. Smokers and non-smokers expressed such support. It is interesting that smokers themselves recognised the dangers to young people of either commencing or being encouraged to commence smoking and continuing to do that. The survey was not simply of people who are opposed to smoking in all circumstances. It included a huge proportion of smokers, who were encouraged to start smoking in their earlier years.
As a fellow north-west Member of Parliament, I know that some of the evidence that covers our region, in particular areas where there is a high prevalence of clubs and private premises, shows that the availability of vending machines is one of the main reasons for children’s early access to cigarettes. Is the right hon. Gentleman therefore moving towards supporting our approach on the relevant aspects of the Bill?
The hon. Gentleman needs to hear the rest of my speech. I will comment on that particular approach—I am not so sure that it is a Conservative party approach, although I welcome that party’s late conversion. It used to be a mouthpiece for the tobacco industry—[Interruption.] The hon. Member for South Cambridgeshire (Mr. Lansley) may say, “Oh no, he’s being partisan”, but I was here year after year, in debate after debate, for Queen’s Speech after Queen’s Speech, when Conservative Ministers refused to take action. Consequently, thousands of unnecessary deaths and illness occurred in the defence of the tobacco industry.
It was addicted to that, to the drinks industry and to anything that required defending the indefensible. However, I understand the point of the hon. Member for Eddisbury (Mr. O'Brien), whom I like. He has been very kind to me—indeed, he sometimes offers me lifts to the House. I have not been able to persuade him to vote Labour, but I have been trying to get him to stop smoking for years, and I hope that he has.
It just shows how much I notice on those journeys, but I welcome the fact.
The survey was interesting. Eighty-nine per cent. agreed with banning retailers from selling tobacco if convicted of selling to under-age smokers. The overwhelming majority took the position that if people continue to sell illegally, they should not be able to trade. Another significant figure is that 86 per cent. supported licensing retailers to sell tobacco, with licences being revoked if retailers sold to under-age smokers, while 81 per cent. agreed with the idea of a ban on smoking in cars with passengers aged under 18.
Some 79 per cent. would also support a crackdown on smuggling, which is a critical issue in the north-west, so perhaps we can discuss smuggling when the Bill comes back to the Floor of the House. Indeed, my right hon. Friend the Secretary of State may know this, but an anti-smuggling exercise has been conducted in our borough over the past few days that has led to a massive haul of illicit cigarettes and financial resources from organised crime networks. Around two thirds of respondents supported ending the sale of cigarettes through vending machines, stopping the sale of packs of 10 cigarettes and the removal of displays of tobacco on premises on which it is sold. Such surveys demonstrate a desire among smokers and non-smokers alike across the north-west to protect children from tobacco and its effects.
This excellent Bill has been through the other place, but clauses 22 and 23, which deal with the power to prohibit or restrict sales from cigarette vending machines, should go further and allow for a full ban from the outset. I accept that we should strike a balance, particularly in the current economic climate, between the rights of businesses to carry on legal trade and the need to stop children from purchasing cigarettes, but let us be quite clear. Tobacco is the only product that can be sold legally that kills its customers on a daily and recurrent basis. That is why the tobacco industry requires the fuel of publicity and investment to restrict the effects of legislation aimed at preventing people from taking up smoking in the first place. Given that the industry has that view of itself and given the disproportionate number of children using such machines, as compared with adult smokers, we should put children’s health first and ban such machines completely.
In 2006, one in six children in England who were regular smokers usually bought their cigarettes from vending machines. In contrast, in 2008, only one in 20 adult smokers said that they had bought cigarettes from vending machines over the previous six months. Vending machines are a convenience to get round bans and encourage young people to take up smoking, which will lead to premature death and, with absolute certainty, cause injuries to their hearts, lungs and other parts of their anatomy. The British Heart Foundation has estimated that machines are the source of cigarettes for around 46,000 children in England and Wales. We could fill up my right hon. Friend’s Everton ground with children who regularly use vending machines and still have 11,000 outside. Think about it, Madam Deputy Speaker: the whole of Goodison Park filled with children smoking their heads off who will not see Everton win the European cup 20 years from now—[Laughter]—this is a serious point—because they will fall ill prematurely and die, because they have been encouraged to take up smoking by the tobacco industry.
Calculations by the British Heart Foundation in 2006 suggested that around 45 million cigarettes were sold to 11 to 15-year-olds through cigarette vending machines. Think about it, Madam Deputy Speaker: that is equivalent to the size of a major European country, almost the total population of England. Think about it: children as young as 11 and under being able to buy cigarettes from vending machines. It does not seem feasible, but that is the reality. Would we allow children to seek access to vending machines for alcohol, fireworks or other products, such as glue? Of course we would not: they are dangerous to children. However, the most dangerous substance of all to children, with absolutely certainty, is tobacco, yet we allow them to purchase it in their thousands on a daily basis through vending machines.
That is why the British Heart Foundation, Cancer Research UK, Smokefree Northwest and other organisations have been campaigning for a ban. That is also why more than 110 Members have supported early-day motion 768, tabled by my hon. Friend the Member for Vale of Clwyd (Chris Ruane), which calls for such a ban. Imposing such a ban would close a loophole. I have said that it is hard to imagine the sale of solvents, alcohol, fireworks or knives in vending machines; if it is not right to sell those products in that way, it is certainly not right to sell tobacco in that way either.
The fact that cigarettes remain available in vending machines is an anomaly, and we need to tackle it in order to stop the harm being done to our children, and to prevent another generation from missing out on longevity and a healthy and safe lifestyle. We cannot simply leave this to an industry that needs to replenish its dying customer base on a daily basis by allowing our children to be undermined in this way. The only thing that our nation has to ensure its longevity is its younger generation. What we hand on to them must be different from and better than what was handed on to our generation. Yet, each year, we stand back and watch the undermining of the capacity of another generation of young British children to be the best that they can be, because we are doing nothing to prevent the tobacco industry and its allies from allowing our children to gain free access to tobacco products through vending machines.
Last week, I wrote to my right hon. Friend the Member for Kingston upon Hull, West and Hessle (Alan Johnson)—this shows how much I knew about the reshuffle—asking whether I could meet him and my right hon. Friend the Member for Bristol, South (Dawn Primarolo) to discuss the possibility of improving clause 22 and ensuring that we could achieve a total ban on cigarette vending machines. I feel extremely strongly about this, as do hon. Members on both sides of the House. I do not claim to feel more strongly about it than anyone else, but I am the grandfather of 10 grandchildren, and I want to ensure that every one of them—representing all children—lives to adulthood and becomes a grandparent and a great-grandparent.
I look around my constituency, and I see too many people in their 40s, and even in their 30s, dying of smoking-related diseases. They never go on to become the best that they could be. They never go on to become a grandparent or a great-grandparent. Some of them die a nasty, tobacco-related death just as their lives are coming to fruition and their relationship with the next generation of their family is just beginning. Why is it that someone in my constituency who is 40 years of age has only a 25 per cent. chance of survival following a smoking-related heart attack? Fifty per cent. of my constituents who have had a heart attack from tobacco-related heart disease die at home, before they even get access to the emergency services. Of the remaining 50 per cent., half die on their way to hospital. Only the remaining 25 per cent. have an opportunity to continue their lives, which might be saved through intervention and heart surgery. This is carnage on a grand scale, and it is unacceptable.
Clause 22 needs to be strengthened. If my right hon. Friend the Secretary of State cannot respond to my request for a ban this evening, will he please meet me and other hon. Members to discuss the matter? It is a matter of life and death. We have come so far and done so much in the teeth of great opposition. People said that the smoking ban would not work, yet it has received major public acceptance. It is not true to say that businesses have closed down as a result of the legislation. In the years to come, hundreds of thousands of our fellow citizens who might otherwise have suffered ill health and premature death will not now do so, because of the work that we have done in the House and the ban that we have imposed.
My proposal represents the final piece of the jigsaw. I implore my right hon. Friend, in his new post, to be brave and not to take heed of those who claim that this would be a regulation too far. I would introduce a thousand regulations if they saved a thousand children’s lives. I would introduce a million regulations if they would save a million lives. Over the next 20 years and beyond, the actions that we have already taken will save that number of lives, but we need to prevent young people from smoking in the first place, and ensure that we do not give them access to cigarettes for the convenience of an industry that wants to use vending machines to get round the existing legislation. We must close this loophole and save tens of thousands of children from illness and premature death in the years to come. Be brave—get the ban in!
I congratulate the Secretary of State on his promotion and wish him well.
I start by praising NHS staff—our doctors, nurses and all other staff—for the wonderful work that they do. That is worth putting on the record. I was proud to vote for the ban on smoking, and we have just heard an impassioned speech on that subject. I truly believe that voting for the ban is one of the best things that I have done since becoming an MP. I hope that the proposal to introduce a display ban is evidence-based. If I am convinced that it is, I will vote for it, but any legislation should take account of any losses to the businesses involved.
It is slightly hypocritical for some Labour Members to say that Conservative Members are addicted to smoking. Unless I am very much mistaken—it may be a selective memory loss—I rather think that the former Prime Minister might have had an addiction to Formula 1 and the advertising of smoking. Perhaps there is some addiction on both sides of the House. [Interruption.] I am pleased to hear that some Labour Members spoke against that.
I welcome the concept of an NHS constitution, but I am of the view that what the Bill proposes needs to go further. We need to stop any interference from Whitehall and the constitution needs to recognise that it should be left to professionals to control the day-to-day running of the national health service. Managers, doctors and other health care workers are frustrated by the one-size-fits-all system and structures imposed from the centre. It is time to set them free and to trust them to use their professional judgment.
Health care inequalities exist, so it is not sufficient to focus purely on treatment. The real priority must be recognising the causes that led to those problems. Poverty, family breakdowns and location all play a part. It is time to start fixing the problems. It is not just where we are born, however, as where we live can have the most devastating impacts on the care that we receive.
I welcome the fact that, according to the constitution, drugs approved by the National Institute for Health and Clinical Excellence will now be available to all who need them, but how can we explain a doctor having to tell a patient that they cannot have a drug that has not been recommended by NICE? We must look further at that problem. If a national health service is to mean anything, it must mean that treatment is prescribed on the basis of clinical need and not home address. Such key issues should be set out in the NHS constitution handbook only after the Secretary of State has guaranteed a wide consultation with interested bodies. Those involved at the sharp end deserve to have their views taken into account—they know best; far better than us. I believe that many of us would share the view expressed by Age Concern that dignity must be at the heart of the NHS. The constitution must provide a firm guarantee of the care that older patients can expect.
The constitution has some omissions. For example, where is the recognition of the vital role played by dedicated staff and the need to support them? Also absent is any move to give patients a meaningful say over their health care. The Government may say that they are determined to engage clinicians, but is it not true to say that the early drafts barely mentioned general practitioners? It is widely reported that the Royal College of General Practitioners had to fight to get GPs in the constitution. In fact, is it not also true to say that the constitution is, in its current stage, nothing more than engagement and window dressing? I say that without wearing any stiletto heels.
I move on to touch briefly on the issue of innovation prizes. I do not have a problem with rewarding staff, but I do have a problem with how it will be funded and carried out. Getting the NHS suspension policies absolutely right is vital. If we do not do so, we will end up unable to sack senior managers who have proved to be utterly hopeless—or we will see them walk away with huge payouts. The former chief executive of the Barking, Havering and Redbridge NHS Trust in my area walked away with a payoff after working up a £90 million deficit, which I personally find disgusting. I pay tribute to his successor, John Goulston, and his team for turning the situation round. Rewarding failure should no longer be an option. Failed managers should no longer be re-employed by the NHS as consultants and paid with public money.
The Bill also attempts to deal with the quality of provision, stating that quality accounts must be produced by all health care providers working for or on behalf of the NHS. I seek some reassurance from the Minister on the accuracy of those data. I am sure that I am not alone in asking whether those supplying the information would not be best served by predicting as rosy a picture as possible. There needs to be rigour. That means publishing only the unvarnished truth, including mortality rates and other key data. Patients will not be empowered unless they know the real story. We must stop talking only about patients’ rights. The facts must speak for themselves, so that patients can make up their own minds about where and by whom they want to be treated.
Two years ago, the new Secretary of State for Health told the Fabian Society that the next decade would be all about quality, not quantity. Why, then, is Labour still doggedly focused on targets? Even Tony Blair’s former adviser admits that they are inherently flawed. Perhaps if the Government had not failed to act on the advice of the new Secretary of State for Health to the Fabian Society, the families of those who have died in places such as Mid Staffordshire would not be grieving today. That is a classic example of the way in which clinical judgment suffers when targets are prioritised. Labour saw the problem—the fault line that threatened to rupture the foundations of its own policy—but, instead of being responsible and doing something about it, lumbered on without regard for the consequences. It is time to stop putting one’s own political survival first and to put patients first instead.
I want to make three brief points in the limited time available to me. Over the past three years, medical negligence payouts in the London region have totalled a quarter of a billion pounds, with the first amount going to the legal profession rather than the patients involved. That must be looked into as a matter of urgency. When accusations have been made against doctors—I refer not to malicious accusations, but to accusations with substance—those doctors must be suspended while investigations take place.
I also want to say something about the accuracy of checks on doctors’ qualifications. In my own trust, a Mr. Iwegbu, who used to call himself Professor Iwegbu, has now been told that he can no longer use that title. We do not yet know the reasons, but all qualifications of all doctors must be checked as a matter of principle to ensure that they are what they say they are, and to ensure that the patients on whom they operate know who is treating them.
Earlier, the Secretary of State spoke about what he described as the achievements that had been made over the lifetime of the Labour Government. All I can say is that this Labour Government may now be receiving life support.
I congratulate my hon. Friend the Member for Ilford, North (Mr. Scott) on his impassioned speech. I also thank the Secretary of State for his response to my intervention on his speech at the beginning of the debate, and apologise to him for not being able to be present for the whole of the opening speeches. It was not just the parliamentary Labour party that had other meetings to attend during the debate. I apologise to you, Madam Deputy Speaker, for the fact that I too had other things to do.
Before I comment on the details of the Bill, I want to return to the point that I made in my intervention. The Secretary of State has a large in-tray, and he has demonstrated today that he is getting on top of it quickly. One of the items he will find in it is the apparent disappearance of the community hospital development fund. I remind him that in 2005-06, when the NHS faced substantial deficits in trusts around the country, more than 82 community hospitals were threatened with closure. That caused a furore across the country.
When he took up his post, the Secretary of State’s predecessor, the right hon. Member for Kingston upon Hull, West and Hessle (Alan Johnson), sought to end the furore by magicking up a capital pot of money—some £750 million—for community hospital redevelopment. That was very welcome. The issue went away, and those campaigning to save their hospitals were able to divert that energy to seeking to improve their community hospitals. In the first full year, close to £250 million of the funds were allocated for community hospital rebuilding. It was a three-year programme of £250 million a year, and the first year’s sum was allocated.
One of three threatened hospitals in my constituency, Ludlow community hospital, was in dire need of investment. It was still operating in old Victorian workhouse premises as well as having facilities that had wards closed, and therefore the property was beginning to deteriorate and decay. The community got behind it and worked hard with the local authority to put together a base-case business plan for a renovation of the hospital, which, with the support of the primary care trust and the active support of the strategic health authority, turned into a bid for a significant sum for rebuilding the hospital.
It was an innovative project to co-locate the hospital and the GP surgeries in the town. The bid was supported as a top priority by West Midlands strategic health authority, or so we were told, and it went to the Department for approval. Having been encouraged to submit such a proposal, the PCT received a letter from the SHA less than a month ago saying that the funding had been put on hold and that no more funds would be made available, and that we would have to look elsewhere if we wished to fund the project going forward. The community is determined to do so and a great deal of work is continuing, but the sudden news that no money was available, our having been told that a further £500 million would be available, was immensely disappointing. I sincerely hope the Secretary of State will do his utmost to find out where that money has gone and to put it back on the table, and thereby allow communities throughout the country to access it. I look forward to his fulfilling the commitment to review that decision, which he gave at the beginning of the debate. That does, of course, square with the Government’s plans to bring forward public sector investment to help rejuvenate the economy from the recession, so it is in line with Treasury thinking.
I want to make two points about the Bill. First, I welcome clause 33 on the investigation of complaints about privately arranged or funded adult social care, which also has resonance for my constituents. My constituency has a significantly above-average elderly population. Some 24 per cent. of my constituents are above retirement age and the proportion of over-80s rises inexorably every year as both the standards of health care and longevity increase. As a consequence, there is an increasing need for adult social care provision and many of my constituents make contributions to their provision as they come to need it. At times, of course, problems arise with the arrangements for their adult social care and therefore a proper complaints procedure is required.
It is right that the Government are seeking to put in place an effective mechanism to allow for complaints to be dealt with, so that redress can be given for decisions affecting some of the most vulnerable elderly people in our community. They currently do not have much of a voice at that stage, but they will now be able to make appeals and, hopefully, secure redress where previously none existed. I look forward to seeing the detail that emerges in Committee to ensure that the system is effective, and that it is not merely window dressing so as to give a complaints procedure without teeth. Therefore, at least in principle, the proposal is to be applauded.
I am less keen on the proposals for the display ban on advertising, which has taken up a lot of time. I am no advocate for the tobacco industry, although it was suggested that some Conservative Members are. I suspect that almost every Member could bring to the attention of the House heart-rending tales of relatives, friends or constituents who have suffered the effects of a lifetime of smoking. My grandfather died from lung cancer. I have never smoked in my life—I have no intention of taking it up—and I encourage my children not to do so, but I firmly believe that if we are to introduce further measures to restrict the availability of tobacco to young people, it must be done on an evidential basis.
There is an illogicality in the Government’s approach. They use taxation as the main means of reducing smoking in this country—I have sat through enough Finance Bills to know the arguments in favour of that. This country has the second highest price of tobacco in the EU, at £5.85 for a packet of 20; only Ireland levies more tax than we do on tobacco products. The tax that the Government generate from every sale of duty-paid tobacco is greater than the retail price in every country in the EU save Ireland and France.
Taxation is, appropriately, the major mechanism used by the Government to restrict the consumption of tobacco, but many other measures have been introduced in recent years, most of which have yet to take effect. The proportion of young people taking up smoking has declined in this country year on year, which is to be applauded and welcomed. My concern is that some of the measures, in particular the display ban, will have perverse, unintended consequences and are unnecessary at this time for two reasons.
The first reason relates to the evidence base, to which reference has been made, in particular by the hon. Member for North-West Leicestershire (David Taylor). He made a powerful speech, but I fear that he has not captured the essence of the evidence—it is, at best, not clear-cut. We need to see clear-cut benefits—the reduction of young people’s smoking—before we embark on a display ban that will have significant ramifications for the people who will be most directly affected: the retailers, in particular the convenience store retailers, the corner shops and the confectioners, tobacconists and newsagents.
Every community in our country benefits from such shops. Some 48,000 or so outlets sell tobacco, the vast majority of which are community shops that serve their local communities and happen to sell tobacco as one of their products. Such shops are typically independently owned. Some may be part of a small family-owned chain. Few of them have the capital resources to invest significantly in fulfilling the requirements of the display ban and many of them generate a substantial proportion of their turnover from the sale of tobacco products. It has been estimated that close to 12 per cent. of them—more than 2,500 shops—would go from generating profit to generating loss as a result of the proposal, and that would put close to 2,500 communities out of touch with their local shop, which provides their convenience shopping and allows them to shop within their own community. That significant potential negative of introducing a display ban has not been adequately thought through in the economic impact assessment that the Government have undertaken in examining the measures. As a result, the proposal should be put on hold. We should wait to see the impact of some of the other legislation that the Government have put through—
I am about to finish, so I am not going to give way.
In particular, we should see the impact of measures that came into effect only on 1 April under the Criminal Justice and Immigration Act 2008, which specifically introduced the concept of negative licensing for retailers who are found to be selling tobacco to under-18s. That provision has been in force for two months and there has not been a single prosecution under it, because it requires three offences before a prosecution can be brought. Thus, it seems completely nonsensical to introduce additional legislation precisely to target that user group—the under-18s—and stop them smoking when there is legislation that will have an opportunity to be much more effective in directly addressing the Government’s concerns. We should see how that works before introducing this unnecessary and potentially very damaging measure.
If we needed any more evidence that this Government are a tad short of support, we only have to recall the notable absence of Labour Members from the debate on this so-called flagship Bill. There was a notable absence of almost every Labour Member between 6 pm and 7 pm, for some reason or another—[Interruption.] It is interesting that they do not want to be reminded of that.
The Bill’s 36 pages contain 10 policy areas that are completely inconsistent with each other. There is little vision for our NHS and much tinkering with legislation that the Government should have got right first time round. As with so many of this Government’s Bills, much of the substance lies in secondary legislation, for which drafts are not yet available, even though the Bill has already been through the other place and there has been plenty of time for the Department to prepare them. The Government probably would not provide time to debate them anyway. This is a wash-up Bill from a washed up Government.
Nevertheless, owing to the wide-ranging nature of the Bill we have had an interesting debate with contributions, in the end, from those on both sides of the House. I take this opportunity to welcome the right hon. Member for Leigh (Andy Burnham) back to our health debates, now as the Secretary of State. We will see whether his loss to the blue shirts at Goodison Park will be a gain to the blue scrubs of our hardworking NHS staff. Also, I congratulate the Minister of State, the hon. Member for Corby (Phil Hope), on retaining his post and I welcome the Minister of State, the hon. Member for Lincoln (Gillian Merron). I welcome too the Minister of State, the right hon. and learned Member for North Warwickshire (Mr. O’Brien). As well as surnames, we have shared debates before, and I look forward to his generous acceptance of many of our amendments in Committee.
The NHS constitution was published in January this year. It is typical of the Prime Minister, who wants to return power to Parliament, that he held a closed signing ceremony in Downing street for this booklet, the contents of which have never been debated in Parliament—and still had not been at the time of the launch. It is right that our NHS should have a constitution. Like a number of proposals in this Bill, it is resonant of Conservative pledges of some years ago. But for such a constitution to be more than just print on paper, it must be put on a statutory footing. It is questionable whether this would make it a lawyers’ charter: as the Government have said, many of the principles of the constitution are already underpinned by legislation.
We have called for the 10 core principles of the Government’s NHS plan to be put in the legislation. It is worrying that a Labour Government, even such a tired one, have cut that number down to seven. The Government’s own Back Benchers, along with everyone on this side of the House, should worry that the Government have discarded principle 7, which is:
“Public funds for healthcare will be devoted solely to NHS patients”.
Indeed, it was the new Secretary of State, when he was a Minister, who made the decision. Where too is the principle that states the need to value NHS staff? In Committee, we will look to enshrine those and other principles in the legislation.
I note that we heard a speech from the hon. Member for Dartford (Dr. Stoate) who calls himself a practising GP and was concerned about the absence of GP-led commissioning as a principle. The doctor from Dartford made the biggest case yet to all his colleagues who wish to stop Members having a second job.
As for quality accounts, there is no doubt that, as we move the NHS towards greater patient choice, patients should have good data with which to make their choices. As yet, the Government have given insufficient assurance that quality accounts will be substantive pieces of work rather than silver-tongued advertising. The example that the Government have published—that of Sunnyview hospital—hardly inspires confidence.
We heard, too, from the other doctor in the House, the hon. Member for Wyre Forest (Dr. Taylor), who made an impassioned speech about what quality of care really means and what a vocation to nurse really means. He had hoped that the constitution could help to ensure that that becomes much more of a reality.
We also heard a very important contribution from my hon. Friend the Member for Basingstoke (Mrs. Miller), who made a number of points that ranged right across the Bill. In addition to her comments on the effect of the cap on some of the services at her local hospital, she made a most interesting point, which I had not yet understood, about the concern that children’s trusts will not be required to have regard to the NHS constitution. That is of particular concern if children’s trusts effectively end up as commissioners for children’s services, with a legal footing equivalent to that of primary care trusts. My hon. Friend made an important contribution that will no doubt feature in our discussions in Committee.
On direct payments, it will be good to see those on the Government Benches going through the Division Lobby this evening in favour of this opportunity for greater patient choice. We are, of course, a little surprised to see that provision encapsulated in legislation, despite the fact that we have been calling for direct payments since 2004. The Government rejected them in 2006, in a debate on the White Paper “Our health, our care, our say”. The then Health Secretary—there have been a number of Health Secretaries—the right hon. Member for Leicester, West (Ms Hewitt), called them a
“revival of the patient’s passport”.—[Official Report, 30 January 2006; Vol. 442, c. 29.]
For the sake of the 15 million patients with long-term conditions and for the sake of our NHS, I am glad that the Government have changed their mind.
The hon. Member for Romsey (Sandra Gidley) made some important points about direct payments. She asked about direct payments for maternity care, and that is an issue we shall need to explore in Committee. It struck me as a little odd, as mothers are supposed to have choice already. As Liberal Democrat spokesperson, she showed important support for pilots. However, what matters is that the Government should for once move away from their addiction to pilots and use them to produce an assessment and a proper review before rolling them out, so that the benefits can be enjoyed by all rather than simply by some selected places.
Most interestingly, we heard a powerful speech from my right hon. Friend the Member for North-West Hampshire (Sir George Young), who has long experience in this area. He made the very important point that we needed clarity about where direct payments will have an impact in relation to the top-ups that have caused some inconsistency in approach. Again, I hope the Government will take that on directly in Committee and that they will ensure it is explored.
We heard a powerful and impassioned speech by the right hon. Member for Makerfield (Mr. McCartney). He talked, among other things, about preventive health care—I think I heard him say that he did not believe that was a partisan point. He and I are London neighbours—just as he is a neighbour of the Secretary of State up in the north-west—and, as he said, he and I have in the past shared some of the great benefits of the NHS as well as some of the challenges that face its future.
Let me move on to innovation prizes. Like so much of the Bill, they arise from Lord Darzi’s next stage review of the NHS. An unspun reading of that document is “Things the Government have failed to do since 1997”. Supporting innovation in the NHS is one of those things. Lately, we have had the Health Innovation Council, created in October 2007, which has met only twice—the last time was in April 2008. The Government created the nine NHS innovation hubs in 2004, whose irrelevance might be linked with their coterminosity with regional development agencies. The NHS Institute for Innovation and Improvement and the National Innovation Centre were established in 2005.
It is common ground that well-motivated staff need no prizes for innovation. Those of us who have had experience outside this place—in my case, in manufacturing industry—know that company employees see it as part of their job. In the NHS, we have one of the most engaged, professional and hard-working work forces in the world. However, under this Government their morale has been perennially crushed and it is that demotivation, more than anything else, that stifles the sense of energy and optimism that is needed to fuel innovation, enthusiasm and an acceptance of new ideas and change. I was pleased to note that the Chairman of the Health Committee, the right hon. Member for Rother Valley (Mr. Barron), had some important points to make about trying to disentangle the idea of imposing a process from getting at what changes behaviour and motivates people not just to innovate but to have their innovations championed, accepted and implemented.
Although they may not look like it, the Government’s plans for trust special administrators are among the most worrying aspects of the Bill because they would change the nature of foundation trusts. Instead of final responsibility lying with foundation trust governors, and ultimately the independent regulator—Monitor—it will lie with the Secretary of State. That may sound like a good thing superficially, but what good is it for governance in any business and how is incentivisation to be accountable if people know that their bad decisions on risk will ultimately be bailed out by the Government?
There are also concerns about the power of the Secretary of State over trust special administrators, given that he can direct the meetings they hold. As my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) emphasised in a powerful opening speech, a transparent failure regime is required, so we shall need to look long and hard at those proposals in Committee.
The move to pharmaceutical needs assessments is welcome. It is clear that such questions should be determined locally rather than nationally. We shall, however, seek assurance from the Government in Committee that their proposals will not impede access to services from patients who currently benefit from dispensing GPs. Patient choice must be the priority in pharmaceutical needs assessments.
One of the arguments the Minister will no doubt use in favour of trust special administrators relates to the recent tragedies at Mid Staffordshire NHS Foundation Trust, but that is to shut the door after the horse has bolted. The real question that the new Secretary of State must answer is how the hospitals were ever given foundation trust status in the first place—ultimately solely the decision of the Secretary of State. Events at Mid Staffs and at Maidstone and Tunbridge Wells also inform the suspension clauses in the Bill. The Minister will have to answer questions about why those proposals were originally left out of the Government’s legislation. We shall seek assurances that the powers will not be abused—for example, by suspending people who ought to be fired. The speech of my hon. Friend the Member for Ilford, North (Mr. Scott), which drew a parallel with the provisions relating to doctors, was extremely well made.
Members on both sides of the House will have their own opinion about the tobacco clauses. Some will see them as too draconian and others will consider them too liberal. Each speaker in the debate touched on that part of the Bill. The right hon. Member for Makerfield made a particularly impassioned speech in that regard, but all Members made important contributions and the debate is to be joined.
It is clear that any action taken to reduce smoking must be based on solid evidence, and the Committee will provide a good opportunity to discuss the evidence base for the Government’s proposals. I hope the Government will consider how to enable evidence to be put to the Committee. Will they pursue the ideas for determining such matters handed down to us by the other place, such as restricting access to public area vending machines, or a bar or ban on their use, to prevent children from getting hold of cigarettes? We heard contributions on that point from the hon. Member for North-West Leicestershire (David Taylor), from the Chairman of the Health Committee and from my hon. Friends. If the evidence is weak, the emphasis must be more on the thoughts and feelings of Members, so we have given our side a free vote on that matter. I hope the Minister will confirm that his colleagues will be allowed a free vote, too.
Dispensing doctors have expressed concern about the move to pharmaceutical needs assessments. We must consider those concerns in Committee.
We have talked about the important aspect of adult social care in relation to clause 33. I hope we shall be able to cover it in Committee, too, but it is now 8 June and the Government promised the Green Paper on the subject in the spring. We thought that as carers week starts today, the Green Paper might be published today, but it is still not available. I hope the Minister responsible will be able to give us an indication about that.
A welcome amendment was made in the other place to enable the Secretary of State to support better NHS-funded care for patients in foundation trusts. However, Lord Warner told the other place that he repented of the sin of including the provision, which was, he said, only
“sops to parts of the Labour Party”.—[Official Report, House of Lords, 6 May 2009; Vol. 710, c. 656.]
He pointed out that the cap is arbitrarily applied across the NHS. Important speeches showed that a change from what has been handed to this place for consideration would deny people certain services.
In a parallel contribution, my hon. Friend the Member for Ludlow (Mr. Dunne) made a powerful point about where the funding was for the resurrection of community hospitals and refurbishment in his and other areas. I hope that that issue will be considered.
Clause 35 relates to the difficulties with disclosure of information. The Secretary of State is aware that, since 2005, the Government’s actions in that area have been illegal. It was interesting to hear him say—but not in these words—that he would put matters on a better legal footing. That is one way of not having to admit what had gone before.
In supporting Second Reading, I hope we will make sure that we have the parliamentary time needed to scrutinise the Bill. I hope we will have the chance to debate some of its provisions not just in Committee but, if the Government have the necessary courage, on the stump in a general election.
We have had a wide-ranging debate, with contributions from all parts of the House that touched on almost every aspect of the Bill. I do not think that I will be able to cover all those issues in my closing remarks, but I am glad that the main thrust of the Bill is broadly welcomed by all parties. It was almost a year ago that my noble Friend Lord Darzi produced the landmark next stage review of our national health service. That review was our opportunity to examine what we want for the NHS in the years and decades to come. I point out that that review emphasised the strong foundations that Labour’s record investment and reform in the NHS has achieved over the past 12 years. The NHS has gone from having a budget of some £35 billion in 1997 to one of almost £103 billion in 2009—a real-terms increase of more than 100 per cent. That is in stark contrast to the decades before.
We have gone from waiting times for operations of 18 months in the 1990s to the shortest waiting times ever recorded in the NHS. Some 2 million more operations are performed a year than in 1997. There have been dramatic reductions in the number of people dying from cancer, and virtually nobody now waits more than three months for a heart operation. The hon. Member for Wyre Forest (Dr. Taylor) acknowledged those massive improvements, and he reminded us that we also abolished prescription charges for cancer patients; he wanted us to go further. We are determined to go further. We want to build on that unique success of a Labour Government.
For the future of the national health service, we asked patients, the public and staff what they wanted from their health service in years to come. The result of that extensive, bottom-up consultation will be a health service that builds on that success and puts quality at the heart of its future. It will be a national health service where patients’ choice and patient experience is key to driving up the quality of services, and where power to shape and improve services is devolved to the lowest possible level. The Bill will provide the legal framework to achieve the ambition of the next stage review.
We have debated the NHS constitution. The first ever national health service constitution provides an opportunity to safeguard the future of the NHS, reaffirming its core values and refreshing them for the 21st century. I can tell my hon. Friend the Member for Dartford (Dr. Stoate) that the Bill will ensure that the constitution is reviewed at least every 10 years. The Secretary of State will have the ability to revise it in the meantime, although we anticipate that those revisions will be relatively minor amendments to keep the constitution up to date.
I say to the hon. Member for Romsey (Sandra Gidley) that the Bill proposes a new legal duty for all NHS bodies, primary care services, and third-sector and independent providers of NHS services to have regard to the constitution in all their decisions and actions. To my right hon. Friend the Member for Rother Valley (Mr. Barron) I say: yes, the constitution does talk about patients and the public, and their responsibility for their own health and how they behave towards the NHS; that is in clause 2. For the benefit of the hon. Member for South Cambridgeshire (Mr. Lansley), I point out that the constitution includes staff, too. Clause 3 spells out the rights and responsibilities of NHS staff, and commits the NHS to ensuring that staff have clear roles and responsibilities, have personal development and training and line management support, and are engaged in decision making.
For the record, the hon. Member for South Cambridgeshire said that there were no new rights in the constitution; he could not be more wrong. There are three new legal rights in that constitution—the right to make choices about NHS care, the right to vaccines, as recommended by the Joint Committee on Vaccination and Immunisation, and the right to rational decisions about the funding of drugs and treatments. The handbook accompanying the constitutions sets out rights relating to whistleblowing—a point made by the hon. Member for Wyre Forest in his contribution.
The hon. Member for Romsey and other Liberal Democrat Members spoke about integrating health and social care. The hon. Lady is right. She will be pleased to know that we will shortly publish a care and support Green Paper. The issue has been debated in the other place, and a central part of the Green Paper will deal with integrating better health and social care.
The hon. Member for Romsey raised the question of people with visual impairments accessing information from and about the NHS. Yes, the NHS constitution sets out the right not to be discriminated against in the provision of NHS services on the grounds of disability—and yes, disability, which will include visual impairment, is one of the seven equality strands in the Equality Bill. Different parts of Government working together closely on both topics are making sure that the Equality Bill and the NHS constitution go hand in glove.
We spoke a great deal about quality accounts. Health care organisations are at the cutting edge of quality, and we recognise that public reporting can be a spur to the improvement of quality in the NHS. The Bill will place a duty on all providers of NHS services to produce a quality account, setting out information for patients, the public and staff on the quality of the services that they provide. That information will be easy for the patient and the public to understand. I want to assure the hon. Member for Ilford, North (Mr. Scott) that we are working closely with clinicians and others to develop the new measures so that robust quality data feed into those quality accounts.
Our aspiration is not just to achieve minimum standards in the NHS, but to strive for excellence and the highest quality of care for all. Quality accounts will make services more accountable to patients, carers, managers and clinicians, and will allow clinical teams to benchmark their performance, and commissioners and providers to agree on priorities for improvement. I say to the hon. Member for South Cambridgeshire that this is one of the issues that will come up for debate in Committee.
There is an extensive and inclusive process under way to design the content of quality accounts. All foundation trusts nationally and a variety of other organisations, including the East of England strategic health authority region, are involved. A full consultation will follow. It is right, as I hope the hon. Gentleman would agree, that quality accounts should include a core of nationally consistent information that reflects national priorities. Our ambition is that they go further and reflect local priorities to improve accountability to local people.
We debated direct payments this afternoon. During the consultation for the next stage review, people said clearly and consistently that they wanted greater control of and influence over their health and health care. The Bill will enable primary care trusts to pilot the use of direct payments for health care as part of our wider programme for personal health budgets. If successful, those direct payments may be rolled out nationally through secondary legislation, subject to the approval of Parliament. My right hon. Friends the Members for Rother Valley and for Makerfield (Mr. McCartney) stressed the importance of that. We must get it right, which is why we are piloting personal health budgets, with 70 pilots now approved across every strategic health authority area, covering a range of services and conditions, including long-term conditions, mental health—a point raised by the hon. Member for Romsey—end-of-life care, and services for those with learning disabilities.
The right hon. Member for North-West Hampshire (Sir George Young) made a thoughtful contribution about how personal health budgets and direct payments will work in practice and the longer-term impact on the national health service. They will include advocacy and support, as he suggested. The pilots were intended to tease out and explore all those issues before we move to secondary legislation. We will, of course, put in place independent evaluation and we will publish the findings. The evaluation will take place alongside the pilots, and we will roll out direct payments for health care only after a review of information gathered from the pilots.
The hon. Member for Eddisbury (Mr. O'Brien) mentioned innovation. We want to actively challenge people to develop new solutions to some challenging health problems, particularly in areas where innovation appears to be lacking, and we want to reward the best innovation when we find it.
My hon. Friend the Member for Dartford (Dr. Stoate) helpfully identified the value of innovation, particularly in information and communication technology. The new innovation prizes are for innovations that directly benefit patients and the public, and the Bill will provide greater flexibility to reward those who are innovative and help to foster a culture of enterprise and innovation. I agree with my right hon. Friend the Member for Rother Valley that the prizes need to go further than grants for research, so we will engage staff from all parts of the NHS in that process. We propose to make available a prize fund of £5 million a year for three years, and it will be available to individuals and organisations, because both have valid contributions to make and flexibility is vital.
The hon. Member for Eddisbury mentioned trust special administrators. The majority of hospitals and trusts are performing well and providing high-quality services, but, in the rare cases where a challenged trust fails to turn itself around, it is important to set out clear processes to resolve that failure. The post of trust special administrator, which the Bill creates, will ensure that the organisation continues to provide safe and effective services for patients throughout the regime, and the administrator will then produce a report and consult on proposals for the future of services.
The Government are committed to the fundamental principle that all NHS providers must focus primarily on the provision of care to NHS patients. That is the governing principle behind the private patient income cap, which limits the income that foundation trusts can lawfully earn from private health care. The principle is non-negotiable, but the Government do not want to stand in the way of establishing a fairer system for foundation trusts. There were various contributions on that issue and, in the other place, we gave a commitment about our intention to begin a review, following the outcome of the ongoing judicial review of the existing legislation.
The question is: how do we create the right balance between protecting NHS services to NHS patients and allowing foundation trusts the flexibility that they need to operate effectively and in the best interests of patients? It is vital to ensure that any new legislation is workable and has broad support from the NHS and all key stakeholder organisations. We can see that the issue is complex, because we had that debate this afternoon. We should not rush through a quick fix; we need to get it right.
I am pleased to say that all parts of the House broadly welcomed the pharmacy provisions in the Bill and the measures, which the hon. Member for Ludlow (Mr. Dunne) mentioned, meaning that an individual service-user and anybody acting on their behalf will be able to raise—[Interruption.]
I guess that that tells us a little about the Opposition’s interest in these issues, as compared with that of Government Members. As I was about to say, social care users who arrange their own care will be able to raise a complaint with a local government ombudsman.
Last but not least, smoking is one of the most serious public health challenges and a major cause of health inequality. The aim of Government policy is to reduce the incidence of illness and death caused by tobacco. We have a particular responsibility to protect children and young people from taking up smoking, and that will ensure that young people from all backgrounds have a fair chance to enjoy a healthy life. We had some impassioned, knowledgeable and eloquent contributions. My right hon. Friend the Member for Rother Valley, my hon. Friend the Member for North-West Leicestershire (David Taylor), the right hon. Member for North-West Hampshire and my right hon. Friend the Member for Makerfield made clear the need for more action. Tobacco marketing through point-of-sale display is no longer acceptable, because we know that it promotes positive attitudes towards smoking, encourages people to start smoking, prompts impulse buying and undermines efforts to quit.
The Opposition’s denial on that issue is utterly bizarre, because the evidence exists for the taking of action to remove the display of tobacco products in shops in order to help protect children and young people from the marketing of them and the harm that smoking causes. The Opposition’s proposals on proxy purchasing and plain packaging are, if I may say so, a bit of a smokescreen for their failure to address the issues.
There are many aspects of the Bill. Its overall purpose is to help the NHS achieve the high ambitions of the next stage review. We will review the effects of the new requirements on restricting the sale of cigarettes from vending machines; if the requirements are not successful, we will move to ban cigarette vending machines altogether. I commend the Bill to the House.
Question put and agreed to.
Bill accordingly read a Second time.