Thursday 10 June 2021
[Mrs Maria Miller in the Chair]
Tobacco Control Plan
Virtual participation in proceedings commenced (Order, 25 February).
[NB: [V] denotes a Member participating virtually.]
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I beg to move,
That this House has considered recommendations for the forthcoming Tobacco Control Plan.
It is a pleasure to serve under your chairmanship, Mrs Miller. In December, the Minister confirmed to Parliament that the Government will publish a new tobacco control plan this year, setting out measures to deliver the smoke-free 2030 ambition in the 2019 prevention Green Paper. I welcome this announcement: as a former chair of the Gateshead tobacco control alliance, this issue is close to my heart. In my own area of County Durham, adult smoking prevalence is 17%, compared with 13.9% nationally, and rising to 27% among people in routine and manual occupations. Some 16.8% of mothers smoke during pregnancy, compared with 10.4% in England, and smoking in County Durham has an annual cost to society of approximately £122 million.
The Secretary of State himself stated that the “extremely challenging ambition” of a smoke-free 2030 will not be delivered by business as usual. The new report from the all-party parliamentary group on smoking and health sets out the evidence-based recommendations needed to achieve that ambition. Smoking is responsible for half the difference in life expectancy between rich and poor, and the impact is passed down through generations, with those who grow up in smoking households far more likely to become smokers. With 1,500 people dying from smoking-related diseases every week, and less than a decade to go to achieve a smoke-free 2030, there is no time to waste.
However, this will not happen without investment. That is why the key recommendation of the APPG’s report is for a smoke-free 2030 fund, requiring the tobacco industry to pay for tobacco control. This is the “polluters pay” approach that the Government committed to considering in the 2019 prevention Green Paper. As such, can the Minister assure me that the proposals put forward by the APPG on smoking and health will be considered as part of the forthcoming control plan? In particular, will the Government deliver on their commitment to consider a US-style “polluter pays” approach to fund the tobacco control measures needed to deliver a smoke-free 2030?
More investment is needed, because the huge gap in smoking prevalence between those in routine and manual occupations and those in other occupations is stubbornly persistent. Ending smoking would lift around 450,000 households out of poverty, including more than 250,000 million children and 140,000 pensioners, concentrated in the most disadvantaged parts of the country. That would not only benefit the health and wellbeing of individuals but inject money into local economies, which would show just how serious the Government are about the levelling-up agenda.
Smoking is linked to almost every indicator of disadvantage, and those indicators overlap different communities. Smokers in routine and manual occupations or who are unemployed are also more likely to live in social housing and to be diagnosed with mental health conditions. The Government have been unsuccessful so far in reducing the inequality gap in smoking and need to redouble their efforts to achieve a smoke-free 2030 for all. There is a clear need for a national strategy that targets investment and enhanced support at disadvantaged smokers.
Unfortunately, smokers from deprived communities with higher smoking rates tend to be more heavily addicted than those from more affluent areas. Analysis of Government data shows that in 2019 nearly half of England’s smokers were in routine and manual occupations or were long-term unemployed. They are just as motivated to quit as other smokers, but it is harder to succeed when smoking is more commonplace and cheap, illicit tobacco is widely available.
Regional tobacco control programmes have been effective in tackling these disparities, as shown by the example of Fresh in the north-east, which is the longest-running—indeed, the only surviving—regional office of tobacco control. When Fresh was founded in 2005, smoking prevalence in the north-east was over 20% higher than the national average for England, and the disparity was growing. Since then, the north-east has seen the greatest decline in smoking prevalence of any region: smoking prevalence in the north-east is now only 10% higher than the England average. However, the regional work done in the north-east and elsewhere has been limited by cuts to the public health grant for local authorities since 2015-16. This led to the closure of the regional offices in the north-west and the south-west, and funding in the north-east has been significantly reduced. New funding streams are needed.
Smokers can successfully quit only if they are motivated to make an attempt to quit. Sustained mass multimedia behaviour change campaigns are the most impactful and cost-effective way to provide that motivation. The US Government’s “Tips From Former Smokers” campaign was funded by tobacco manufacturers through the USA’s user-free scheme, which raises $711 million annually from the tobacco industry. The Food and Drug Administration campaign led to over half a million sustained quits in three years, and it was associated with healthcare cost savings of $11,400 per lifetime quit.
Such campaigns have an immediate impact and can be targeted with precision at disadvantaged smokers, yet investment in behaviour change campaigns has fallen year on year in England. This has coincided with a significant decline in the number of adult smokers who have tried to quit. In 2008, 40% of adult smokers in England had tried to quit within the previous year; by 2018, that had fallen to just 30%. Over the same period, funding for mass media campaigns fell by over £20 million.
Behaviour change campaigns need to be targeted at key groups and communities to reduce socioeconomic inequalities. The effectiveness of national campaigns can be significantly enhanced when they are supplemented by targeted regional campaigns. Regional funding for stop-smoking behaviour change campaigns in the north and midlands would support the levelling up of some of the more deprived regions of England. These are the regions with the highest rates of smoking, combined with the lowest gross disposable household income. Supporting smokers in these regions to quit will prevent people’s hard-earned incomes from going up in smoke, lifting thousands of households out of poverty and providing a boost to local economies.
Modelling by University College London for the all-party parliamentary group on smoking and health estimates that a sustained national behaviour change campaign aimed at deprived smokers, combined with regional campaigns in the north and midlands, would result in an additional 1 million quit attempts, 179,000 successful quit attempts and 45,000 more ex-smokers in C2/DE occupations in England by 2030. The investment required is estimated to be about £28 million a year, which the tobacco manufacturers could easily afford to pay from their £900 million profits in the UK—and more than three quarters of the public want the tobacco manufacturers to pay for those measures. Does the Minister agree that targeted investment to tackle high rates of smoking among our most deprived communities is vital to delivering the Government’s levelling-up agenda?
Sadly, illicit tobacco is more accessible to children, and as it is cheaper than legally sold tobacco it reduces the incentive for adult smokers to quit. In 2018-19, the total tax revenue lost because of illicit tobacco was estimated by Her Majesty’s Revenue and Customs to be £1.9 billion. The illicit trade is heavily concentrated in the more deprived communities, contributing to higher smoking rates. Addressing that disparity requires tackling both the supply and demand for illicit tobacco in communities where it is endemic.
In the north-east, there have been dedicated multi-stranded programmes of work in place since 2007 to reduce the supply and demand as part of a broader activity to reduce smoking prevalence and improve the population’s health. Such programmes drive a strategic approach to tackling illicit tobacco at local, regional and national level. One programme was described as follows:
“an exemplar of partnership working…and…deserves to be widely disseminated”—
a recommendation supported by the National Audit Office. Unfortunately, that has not yet been possible owing to lack of funding, and the funding in the regions where it does exist is under threat because of cuts to public health budgets. Fresh and the Greater Manchester health and social care partnership have estimated that it would cost approximately £5 million annually to roll it out across England.
As the Minister said at the launch of our report, we need to get HMRC to do more to tackle illicit tobacco. Just £5 million for a highly effective regional programme is peanuts and would return far more in lost revenue than it costs. Will the Minister commit to discussing with HMRC how funding can be found for the illicit tobacco partnership to extend cover to all the regions of England to reduce the use of illicit tobacco, which is endemic in poorer communities in every part of England?
We are delighted that the Minister was able to attend the launch of the report by the APPG. I know how passionate she is about the issue. I look forward to hearing her response to our report and recommendations. I am confident that if the Government can embrace our recommendations in the forthcoming tobacco control plan, we will be well on the way to a smoke-free England by 2030.
It is a pleasure to serve under your chairmanship, Mrs Miller. I am the co-sponsor of the motion, so I crave your indulgence slightly because I have a rather longer speech than five minutes will allow. It is a pleasure to follow my co-sponsor, the hon. Member for City of Durham (Mary Kelly Foy). I chair the all-party parliamentary group on smoking and health, which published the report on the tobacco control plan yesterday.
We were delighted when my hon. Friend the Minister set out the need for a new control plan last December, and we commissioned Action on Smoking and Health and SPECTRUM, a widely acknowledged scientific research consortium, to put together a report for us on what needed to be done and why. The importance of the ambition is very clear: the chief medical officer, Professor Chris Whitty, recently said that smoking is likely to have killed more people in Britain than the covid-19 pandemic, with more than 70,000 people dying from smoking last year in England alone—and for every person killed by smoking, another 30 live with the serious consequences of smoking-related illnesses. Ending smoking is essential if we are to reduce health inequalities between rich and poor, level up the nation and increase healthy life expectancy by five years, in line with the Government’s manifesto commitments.
The smoking rate in my Harrow East constituency is lower than average for England, but there is no room for complacency. More than one in 10 of my constituents smoke, and smoking kills 250 of my constituents every year. In 2018, there were 1,566 smoking-attributable hospital admissions in Harrow alone. Research shows that smokers are likely to need social care a decade earlier than non-smokers because of the impact of smoking-related diseases and disability.
Inequalities in smoking have grown, not shrunk, in recent years. To be smoke free by 2030, we need to reduce smoking by two thirds in only a decade, and by three quarters for smokers in routine and manual occupations. Cancer Research UK has said that, at current rates of decline, we will miss the target by seven years, and by double that for the poorest in society, because there are still 6 million smokers in England. We will achieve a smoke-free 2030 only by motivating more smokers to attempt to quit using the most effective quitting aids, while reducing the number of children and young adults who start smoking.
It is right that the Government brought forward the ambition of the prevention Green Paper, and we need to ensure that bold action is implemented, with appropriate investment. The Health Foundation estimates that a minimum of £1.2 billion is needed to restore public health funding to 2015 levels, and that a further £2.6 billion is needed to level up public health across the country.
The APPG’s view is that when it comes to ending smoking, the industry that makes excess profits from the sale of tobacco should pay, as it does in the US. The US’s user fee legislation raises $711 million annually from the tobacco industry; a similar approach could be introduced in the UK, with a statutory smoke-free 2030 fund imposing a targeted tobacco manufacturer profit cap and utility-style price controls in order to raise funds from the industry through a charge-based mechanism on sales volumes. It would not apply just to tobacco, because obviously this is about incentivising the industry to deliver on making smoking obsolete by 2030. It is quite clear that this is more than demonstrated by the market failure that has happened, and we need to get on with it. Will the Minister commit that the APPG recommendations for a “polluter pays” approach will be considered as a funding mechanism for the forthcoming tobacco control plan?
We also need to look at raising the age at which young people can buy cigarettes. Clearly, young people who start smoking continue to smoke into adulthood, so one of the areas that we have explored is raising the age of sale. It was raised from 16 to 18, which produced a 30% reduction in smokers aged 16 to 17 years old. It would be helpful if we could get to a position whereby 18 to 20-year-olds were prevented from smoking, so will the Minister commit to conducting a consultation on raising the age of sale from 18 to 21 and to coming to a decision about whether to go ahead by the end of 2021?
We have been a leader in the tobacco control plan, but obviously the position is that we have set the record. Now that we are free from the European Union, we can make decisions on our own. Will the Minister investigate extending Official Development Assistance funding for the FCTC 2030 project for a further five years?
Finally, the Minister is the lead for the World Health Organisation’s FCTC in the Department of Health and Social Care, so will she commit to provide the leadership in other Government Departments and public authorities that we need to fulfil their legal obligations to prevent tobacco policy from being influenced by the tobacco industry?
I have been able to touch on only four of the recommendations that we have made, and there are 12 in the report. I urge all Members to read the full report and the recommendations. The recommendations are supported not just by the APPG, but by leading health organisations too numerous for me to mention. There is good evidence that the recommendations will work in synergy to drive down smoking rates, and the forthcoming tobacco control plan offers the perfect opportunity to put them in place. I commend our recommendations to the House, and look forward to the reply of my hon. Friend the Minister.
It is an honour to serve under your chairmanship, Mrs Miller. I thank my hon. Friend the Member for City of Durham (Mary Kelly Foy) for having secured this important debate and speaking so eloquently, especially as the Department of Health and Social Care is looking to publish a new tobacco control plan later this year. The forthcoming plan is an enormous opportunity for the Government to cement the UK as a global leader in tobacco harm reduction. Having left the European Union, the Government must—alongside the post-implementation review of the tobacco and related products regulations—set a clear direction for reducing smoking prevalence and improving public health.
However, if the Government are to achieve their ambition for a smoke-free society by 2030, their forthcoming tobacco control plan must champion the less harmful alternatives to combustible tobacco. In particular, a significant and growing body of scientific evidence shows vaping to be the most effective alternative for adult smokers looking to quit smoking. In their blueprint for better regulation, the UK Vaping Industry Association made a series of recommendations to the Department of Health for consideration when reviewing the tobacco and related products regulations—a process that is already underway. These recommendations, many of which I support, can also be applied to the Government’s tobacco control plan.
The first recommendation involves effectively tackling the increasing levels of misinformation, as well as the increasing misperception of the relative harm of e-cigarettes versus combustible tobacco. Action on Smoking and Health data suggests that millions of smokers—more than half of the 6.9 million remaining in the UK—could now be dissuaded from exploring switching to e-cigarettes because of incorrect views or confusion about the harm of e-cigarettes. To combat increasing misinformation, the UKVIA recommends that the Department of Health launch an effective communication strategy. This should include the introduction of approved health claims and switching messages that can be displayed on vape device and e-liquid packaging alongside nicotine health warnings, a proposal similar to those explored by the Governments of Canada and New Zealand.
In addition, it is important that medical professionals at local stop smoking services are sufficiently supported, with clinicians signposted to the latest clinical guidance and evidence on e-cigarettes. An evidence-based approach to smoking cessation must be adopted consistently by local stop smoking services to support patients in their harm reduction journey. This is critical, considering the upcoming trials in NHS A&E departments. The forthcoming tobacco control plan should also make provisions for a review of the regulation of nicotine in e-cigarettes, to better understand the role nicotine plays in allowing e-cigarettes to be a satisfying alternative for adult smokers wishing to make the switch away from smoking. For them to compete with combustible cigarettes and provide a satisfactory alternative for those looking to switch, they must provide a comparably satisfying nicotine experience. It is the toxic by-products of combustion, not the nicotine, that are responsible for smoking-related death and disease.
Understanding the alternatives to combustible cigarettes and making a clear distinction between smoking and vaping is critical to our smoke-free ambitions and changing misconceptions. Our all-party parliamentary group for vaping made several recommendations in our report on vaping in workplaces and public places. These are endorsed by the UKVIA and, if implemented, would support adult smokers in their transition to less harmful alternatives and give those who have already made the switch the best chance of sticking at it. I can provide the Minister with a copy of that report, if she so wishes. My late husband Ray is an example of such a switcher: having smoked from the age of nine with a couple of interludes, he made the switch to vaping several years ago, and was never separated from what he called his “pipe”. I might add that he did not die of a smoking-related illness.
Finally, I turn to another opportunity to enact the meaningful regulatory change to support smoking cessation. The Government are currently considering the submissions made to the consultation on the review of the Tobacco and Related Products Regulations 2016. Like many others, I eagerly await the publication of the Department’s response, which has already been delayed from May 2021 until later this year. It is hoped that the Department of Health and Social Care will continue to take an evidence-based approach to the regulations and listen to the experts. The TRPR review can help shape the UK’s approach to tobacco harm reduction considerably and can significantly support the next tobacco control plan. I look forward to the Government’s response to the tobacco and related products regulations review and the publication of the tobacco control plan. I hope that they make the most of these unique opportunities to support adult smokers in their transition to a less harmful alternative.
It is good to serve under your chairmanship, Mrs Miller. I congratulate the hon. Member for City of Durham (Mary Kelly Foy) and the APPG on securing this debate. I declare an interest: I am an honorary life governor of Cancer Research UK.
Smoking is, of course, a significant cause of ill health and death in this country, and the Government should be congratulated on the progress they have made to reduce the incidence of smoking, but the rate of reduction is sadly still not enough. A recent Cancer Research UK report found that, at current quit rates, the UK will not reach its smoke-free target until 2037 at the earliest—seven years late. To meet the target, quit rates will need to increase by some 40% over the next 10 years. In other words, we are at risk of enduring several more years of heartbreak for families, strain on the NHS and avoidable deaths—a pattern that can, and of course should, be broken.
Three months ago, I was fortunate enough to be selected for a Westminster Hall debate on this issue. I made the point then that the tobacco control plan was our chance to break that pattern. Now is our opportunity, and if we are to seize it, the control plan must be ambitious. I would like briefly to propose three courses that I believe should form part of the plan’s recommendations.
First, the key issue with smoking is, of course, the smoke. An evidence-based policy that seeks to assist the 7 million cigarette smokers in the UK must put forward alternative products to combustible tobacco. Continuing to raise awareness of those products is key, so I suggest that the plan should facilitate the use of cigarette pack inserts and online communications as ways of reaching smokers directly. E-cigarettes and other alternatives to combustible tobacco save lives, and we should make sure that that message reaches every smoker in Britain.
My second point is about access to those alternative products. E-cigarettes have been hugely important in the fight against smoking, and I commend NHS England for promoting them to smokers. The strategy is based on evidence, and has a proven positive effect on the health of the nation. In 2017, more than 50,000 smokers who would otherwise have carried on smoking stopped with the aid of a vaping product.
The tobacco control plan should advise what else can and should be used to assist smokers to quit, in addition to e-cigarettes. That is crucial when we consider that, for all the impact vaping has had, 50% of people who have tried e-cigarettes go back to smoking. We should not limit our response to one weapon. Nicotine pouches, heated tobacco and other emerging products are there to be used, and their efficacy and utility should be the subject of urgent study. The tobacco control plan should embrace the new products and allow for more measures for companies to promote.
Thirdly—this relates to my previous point—the plan should contemplate legislation for a new robust regulatory framework that can cover all the products within the market. We should not allow our focus to be narrowed to e-cigarettes alone. New products are entering the market, and the UK must be open to the kinds of innovations that save lives.
I have two brief final points that I wish to make, to which I hope the Minister will respond. First, there is a slight lack of clarity about whether the new plan will take account of the conclusions of the post-implementation review of the Tobacco and Related Products Regulations 2016 and the Standardised Packaging of Tobacco Products Regulations 2015. On Monday, I received a written reply from the Minister, in answer to a written question, which said:
“Evidence gathered from this Review will be considered as part of the development of the new TCP.”
I hope the Minister will confirm that all the evidence from the review will be fully reflected in the plan.
Secondly, I return to a point I made in the previous Westminster Hall debate—that is, the opposition of the World Health Organisation, which has called for a ban on reduced risk alternatives to combustible tobacco. To listen to that call would run counter to the success in smoking reduction that has been achieved in the UK, and I strongly urged the Government to stand up to the WHO at COP9 and to advocate a change in policy from it.
It is an honour to serve under your chairmanship, Mrs Miller, and lovely to see you in the Chair. I refer Members to my registered interests. I am the chairman of the Gallaher charitable trust, which was formed after the closure of a tobacco company in Northern Ireland.
Let me turn to the subject of the debate. Facts are stubborn things. We all appreciate that, and we must ensure that any actions we take to address facts are based on evidence. I am a non-smoker. I do not encourage people to smoke. I do not want people to smoke, and I recognise the impact that smoking has on people’s lives, but like many substances, tobacco is a lawful product, and I will not tell other adults what they should do or not do with lawful products.
Tobacco is one of the most highly regulated products and the most highly taxed product in the UK—about 90% of the cost of an average packet of cigarettes is taxation. That tax disadvantages poorer households in my constituency and across this country than the most affluent. The UK tax regime is designed to control tobacco and the sale of tobacco, but it has had the opposite impact. It has driven up the price of the product and encouraged smuggling of illicit product. Many people have made the wrong choice to purchase that illegal product. Therefore, under the current mechanism, everyone is a loser. It is not working.
On 2 June—just nine days ago—the Northern Ireland Border Force, at the real border in Northern Ireland, which is the land border, seized 4.4 tonnes of illegal tobacco, which, if sold, would have stolen from you, Mrs Miller, and me and our taxpaying constituents £7.24 million in unpaid duty. Tobacco control measures ought not to be about trophy taxation or gimmicks, but should be primarily about reducing consumption by good education and good enforcement, and secondly about minimising crime by directing resources to the tackling of criminality associated with activities related to illegal tobacco.
None of the control measures addresses that issue seriously. Government policy has failed to do that, and I believe that today’s proposals fail to do it. Instead, they are about unnecessary tax and minor tinkering such as putting another written warning on the cigarette stick. When the cigarette is in a person’s mouth, it is too late to put such a warning to them.
HMRC already generates £11.8 billion in tax on tobacco, yet it loses almost £2 billion in revenue annually in illegal sales of tobacco product. That is because the control plan is one-dimensional and, frankly, stupid. It does not work. Since 2000, tobacco smuggling has stolen from you, Mrs Miller, and me and our taxpaying constituents a revenue loss of—wait for it—£47.2 billion. That has been stolen from us by tobacco smugglers. Surely we can have a plan that, instead of punitively taxing a lawful product more, lets consumers see that money being spent on tackling this international, multibillion-pound crime of racketeering. Imagine a control plan that, over the next 10 years, would deliver £40 billion in revenue to hon. Members’ constituencies. Imagine what we could do for hospitals, schools and the defence budget. Imagine what we could do with the overseas aid budget.
I want the Government to be creative and to stand up to people who say, “Just put on more tax,” because clearly that does not work. Frankly, the control plan will not save one life from the effects of smoking, will not stop one smoker from smoking, and will not stop one smuggler from bringing in illegal products. If the Government want, unintentionally, to fill the pockets of organised crime gangs, undermine legitimate businesses and ruin small shops throughout the country, they should stick with the plan, but they should not be smug about it, because the plan is not working.
It is a pleasure to serve under your strong and stable chairmanship, Mrs Miller. It is a great privilege to speak in the debate, and I thank the hon. Member for City of Durham (Mary Kelly Foy) for introducing it.
We are debating a vital issue, and the UK can be No. 1 in the world for its approach on reducing smoking and the harm it causes. I commend my hon. Friend the Member for Harrow East (Bob Blackman) for his input into the report and his earlier contribution, and my right hon. Friend the Member for Clwyd West (Mr Jones) for his apposite remarks, which I am sure the Minister took on board. I also commend the Minister herself, and the Government, for their approach. I would say that she is mistress of the brief, as we have had many conversations and interactions through correspondence, and there is no doubt that she gets all the issues to do with smoking cessation devices and the tobacco control plan.
The industry in the UK seems to be aligned with the Government’s objectives on reducing smoking, as Philip Morris, British American Tobacco and many of the other firms recognise that this is the end of the game—it is the end of smoking in the United Kingdom, even if that might not be the case in certain far eastern countries, in Africa or elsewhere. The companies accept their responsibilities, and it would be of no surprise to them—they would not be disappointed about this—that they needed to make contributions to a fund to help to secure the goal of a smoke-free Britain, which should certainly be firmly on the table.
I speak as chair of the Parliamentary Office of Science and Technology and a member of the all-party group on e-cigarettes, and it seems to me that we are in an era in which we must be driven by data and evidence. There can be no doubt that the data is completely one way on vaping devices, electronic nicotine delivery systems and all sorts of other technologies to help smoking cessation. Vaping, using an electronic device or even using snus is so much safer than smoking. Smoke is the killer; tobacco is the killer. I urge the Minister not to do what the European Union has done, or what the World Health Organisation seems to be doing, by mangling the two issues. Tobacco is one thing; smoking cessation devices, which in most cases contain nicotine, are a completely different thing, with a completely different scale of harm and risk.
I recognise that other hon. Members will talk about various recommendations from the all-party group on smoking and health, so let me briefly focus on three. Recommendation 5 says that smokers should be advised annually of their options for quitting. Reminding people that they can choose an alternative to smoking is an important step forward. If we ask any smoker—I was a smoker for a few years, some time ago—“Would you like your children to smoke?” they all say no. It is clear that no one really wants to smoke, no matter what their brain says about dopamine levels. In that scenario, I think it a good idea to remind people annually that there are alternatives. Nicotine patches are not the only alternatives. Those have some efficacy, but, to be frank, very little for the money that is paid for them. People should certainly consider vaping devices.
The second recommendation I draw to hon. Members’ attention to is No. 6, which is support for those with mental health challenges. It also says
“for those living in social housing”,
but I will broaden that slightly to those on lower incomes and in lower-paid jobs, among whom there is a far higher incidence of smoking than in the general population. There is work to be done to focus the efforts in those areas.
Recommendation 11 is also important, because there is still an ambiguity about whether vaping is a smoking cessation device or just another way of inhaling nicotine. It is clear from the evidence that it is a smoking cessation device that works, and it is twice as effective—if not more—at helping smokers to cease smoking as the other available treatments. Let us dig into the pockets of the tobacco companies—they are actually happy for their pockets to be dug into—and use that money to publish the relative health benefits of vaping, e-cigarettes and other alternatives to smoking.
Windsor is a lovely seat, and thankfully we have slightly lower smoking rates than the rest of the country, but we still have perhaps 200 or 300 people a year dying of smoking-related diseases, as well as all sorts of other challenges.
In conclusion, we are first in the world for genomics, for the vaccine roll-out, and for FinTech and financial services. Let us make this another one: let us be the first in the world to implement a tobacco control plan that completely takes on board the wonderful innovation of vaping devices, e-cigarettes and all the other technology, and let us not mangle it together in a tobacco directive.
It is a pleasure to serve with you in the Chair, Mrs Miller. I thank my hon. Friend the Member for City of Durham (Mary Kelly Foy) and the hon. Member for Harrow East (Bob Blackman) for securing this important debate to consider smoking cessation.
I will start with a few figures, just to show why this issue is important to me. It is very difficult to get constituency figures, as I am sure colleagues have found, so we are looking at local authority areas. The covid-19 pandemic recovery makes it particularly important to set out an ambitious national strategy to tackle smoking and to address, once and for all, the tragic health inequalities that smoking causes.
In Gateshead, 17.1% of the population smokes, compared with 15.3% across the north-east. That figure is well above the England average of 13.9%. It is estimated that smoking costs Gateshead around £48.3 million a year through smoking-related health and care needs, lost productivity and premature death. Between 2016 and 2018, there were 1,227 deaths attributable to smoking in Gateshead, which is significantly higher than the per population average for England. Between 2016 and 2018 in Gateshead, there were 515 deaths from lung cancer and 412 deaths from chronic obstructive pulmonary disease. More than 80% of those disease cases were caused by smoking. Between 2016 and 2018, there were, sadly, 29 stillbirths in Gateshead, which is above the per population average for England. Smoking during pregnancy has been shown to double the risk of stillbirth.
Although adult smoking rates have declined in recent years, inequalities in smoking rates between different groups have remained stubbornly high. The next tobacco control plan must go further in providing additional quick support for smokers in communities and groups with high rates of smoking. That is essential if we are to tackle the health inequalities in our society after covid-19, and indeed before that time comes.
I support wholeheartedly the recommendation of the APPG that tobacco manufacturers should pay the costs—on the “polluter pays” principle—of creating a smoke-free 2030 fund and helping to meet that target. Indeed, it is absolutely essential that we achieve that target.
Smoking during pregnancy is the leading modifiable risk factor for poor birth outcomes, including stillbirth, miscarriage and pre-term birth. The Government’s ambition is to reduce smoking in pregnancy to 6% by 2022, but with a rate of 10.4% in 2019-20, that target is unlikely to be met. National rates of smoking in pregnancy have only declined by 0.6 percentage points since 2015, although some regions—such as the north-east, I am glad to say—have seen much larger declines. Clearly, there is much to be done.
Ensuring that pregnancies are smoke-free and that there is greater consistency across the country must be a major focus of the next tobacco control plan, if we are to deliver a smoke-free start for every child by 2030 and give them the best start in life. The highest rates of smoking among pregnant women are in young pregnant women. Nearly a third of pregnant women in England under the age of 20 are smoking during early pregnancy and at delivery, compared to around one in 10 pregnant women overall. As well as being more likely to smoke in the first place, younger mothers are less likely to quit prior to conception, whereas older mothers are more likely to have quit when planning a pregnancy. As such, driving down rates of smoking in the younger population should have a rapid impact on rates of smoking in pregnancy.
A woman’s circumstances also greatly affect the likelihood that she will smoke in pregnancy, with smoking in pregnancy concentrated among those who live in an area of deprivation or high smoking prevalence, those who live with a smoker, those who smoked through a previous pregnancy, and younger women.
There is so much more we could say on this issue, but the key thing is that we need to consider ideas such as financial incentive schemes. Those that have been implemented in Greater Manchester and south Tyneside are highly effective at reducing rates of smoking in pregnancy among women from deprived backgrounds. They are also cost-effective, with an estimated return on investment of £4 for every £1 invested.
To finish, can the Minister assure me that the next tobacco control plan will include a national strategy for reducing rates of smoking in pregnancy, learning the lessons from the areas where the greatest declines in smoking in pregnancy have occurred? Will she commit to introducing a national financial incentive scheme to achieve the aim set out in the tobacco control plan? Will she also commit to consulting on raising the age for the sale of tobacco to 21, to reduce the number of young people who become addicted to smoking?
It is a pleasure to serve under your chairmanship, Mrs Miller, as others have said.
I also follow others in thanking the hon. Member for City of Durham (Mary Kelly Foy) for securing this debate. I also thank Action on Smoking and Health for providing a briefing for it. I am conscious that most of this debate and this documentation relates to England. There are some aspects that apply to Scotland; indeed, I hope they will be replicated in Scotland and I will do my best to encourage some action to be taken, because some actions are cross-border, if not universal. It is from that perspective that I come to this debate.
As others have said, or confessed to, I do not smoke; I never have smoked and I have discouraged my family from so doing. I come from a generation in which youngsters, such as myself, who were quite interested in sport were told by Jim Watt, the boxer, that he could be caught by a right but never with a fag in his hand. I think that Scotland would be a better place if we had had similar efforts on alcohol, but we only concentrated on smoking. That is where we are coming from. We have made progress from the time of my childhood in the ’60s and ’70s, but there is still a considerable distance to travel, especially when we find smoking rooted in the poorest areas, where there are already underlying health vulnerabilities, and indeed in other sections of our society. There is considerable work still to be done.
The question is this: what action is to be taken? It is not a question of what action per se, because action has to be taken; it is more about the extent and calibration of the action that is taken. I say that because I wish to ensure that the social progress that we need to make, and want to make, in tackling smoking and the social ill that it is does not come at a cost to other communities or, indeed, in the form of other aspects that cause harm in our community.
I come from the perspective of having served as Justice Secretary in Scotland for seven and a half years. I established a serious organised crime taskforce. As other speakers have mentioned, there is a link between illegal tobacco and serious organised crime. Not only is there a link between them; it also turns into other harms that plague our communities. In my interlude between Parliaments, I chaired the Scottish Anti-Illicit Trade Group, which sought to bring together all organisations involved in law enforcement and keeping communities safe, at whatever level and in whatever jurisdiction. Indeed, it also brought in business, because a problem shared is a problem halved.
I want simply to highlight that cost loading has limits. That is not to say that there should not be cost loading. It is quite correct that the “polluter pays” aspect should be considered. I certainly argued that as Justice Secretary in the case of alcohol, and that has been taken up. Equally, to what extent do we load it? I am no free market capitalist, but I recognise, as did Adam Smith, that there has to be some regulation and that we have to ensure that there is some control over the market, because we know that in other aspects of society, if we close down supply, we find it simply results in aspects coming around in other ways.
I am not here to make a special plea for big tobacco. I would not seek to do that. They can fight their own battles, but there is an effect on others. As was mentioned by the hon. Member for North Antrim (Ian Paisley), small grocers—people who pay their taxes—are affected. They employ staff, provide for their communities, work on limited margins and yet they lose out. The tragedy we face is that people view illicit tobacco as simply ripping off big tobacco or, even more likely, ripping off the taxman—they have no love for him either—but the reality is that they are harming their communities and those who pay their taxes and work hard. They are harming their families and, indeed, their neighbours who work in and depend on employment in local stores, whether they purchase from a pop-up Facebook page or from a white van man.
Action has to be taken, and I support calls for an improvement in what we do to tackle the illicit trade. Much more could be done at a governmental level on both sides of the border. In terms of today’s debate, I welcome progress and fully support what has been called for here today. I simply emphasise that we have to ensure that we get the calibration right. In seeking to tackle harm within our communities, we must keep it proportionate and at a level that will not be counterproductive, because we do not want to make further progress in tackling tobacco that at the same time results in fuelling organised crime and in other aspects being abused. It is therefore a matter of balance.
Thank you for calling me to speak in this important discussion, Mrs Miller. It is a pleasure to speak here under such a distinguished Chair. I congratulate my hon. Friend the Member for City of Durham (Mary Kelly Foy) and the hon. Member for Harrow East (Bob Blackman), who secured this important debate.
I should declare an interest as a member of the all-party parliamentary group on smoking and health. We have made fantastic strides in this country to reduce smoking, but black and minority ethnic communities are being left behind. Rates of smoking among Asians are declining more slowly than the national average, so I want to see more done to empower them to choose to go smoke-free. One size fits all does not work anywhere. When I chaired the health scrutiny taskforce on smoking cessation as a councillor in 2003, we knew that differential outcomes were inescapable while we did not offer a range of options. Now, nearly 20 years on, we have gone backwards. Government money for cessation services has dried up.
The report that our APPG launched yesterday says that polluters should pay. That is a principle we all recognise, and I agree with it. Some tobacco companies have been clear that they will fund smoking cessation services for local authorities at this time of massive pressure on local health budgets. I assume that that would be welcome. The real costs of losing smoking cessation services are the years of good health lost, and there is a range of lower-risk options out there right now. Any of them is better than smoking.
I come from a family of smokers, although I do not smoke and have never done so. Personally, I do not see the appeal, but clearly people are addicted, and addiction needs treatment, not moralising. Three million people now vape, and nearly all of them are former smokers. That is 3 million fewer people choosing a less harmful option. This is good news, but BAME communities, and people with manual jobs and without university degrees, are about two and a half times more likely to smoke than their white, office-working and university-educated colleagues. That has to be addressed, and it has to be part of our future plan to support everyone we can to be smoke-free.
Emerging opportunities, such as tobacco-free nicotine pouches and “heat not burn” products, still present a health risk, but it is less than that of cigarettes. I want my constituents, and anyone who wants to smoke less, to know about the opportunities to improve their health. A range of options make it easier to quit eventually, as we noted in the health scrutiny taskforce on smoking cessation. We need an ambitious tobacco control plan that recognises the opportunities and legislates for new products. “Heat not burn” products and tobacco-free nicotine pouches will play a role, just as vaping has persuaded more people to quit smoking or to move to less harmful alternatives.
In Asian communities, we need to offer alternatives to chewing tobacco and betel. There are terrible statistics about the rates of oral cancers, and anything that reduces those rates will save lives. Pretending that millions of people will give up smoking just because we hope they will do so will get us nowhere, but working to move people down a ladder of lower-risk products really would save lives.
Thank you, Mrs Miller, for giving me the opportunity to contribute my few thoughts.
It is a pleasure to serve under your chairmanship, Mrs Miller. I thank my hon. Friend the Member for City of Durham (Mary Kelly Foy) and the APPG for securing this important debate.
I must first announce my interest in the debate as a former smoker. I grew up in the ’80s, and most of my peer group smoked. I can recall purchasing cigarettes at the local sweet shop, which was happy to accommodate the limited budget of schoolchildren by allowing us to buy our cigarettes individually. I came from a household in which there were adult smokers, and for me to take up the habit seemed almost inevitable. I have fought a lifelong struggle against smoking to kick the habit, but it was not until I was pregnant with my first son that I felt able to give up. Although I have returned to it once or twice, I am pleased to say that I have now not smoked for more than a decade.
The tobacco industry’s excessive profits are built on establishing an addiction in people like me in their teens, who unfortunately will often not succeed in stopping before it kills them. My hon. Friend the Member for Blaydon (Liz Twist) spoke about the figures in Gateshead, which is one of my local authorities. Smoking is estimated to cost my other local authority, South Tyneside, about £37.9 million every year. That is through smoking-related health and care needs, lost productivity and premature deaths.
I support the recommendations made by the all-party parliamentary group on smoking and health for a comprehensive strategy. It calls for additional regulation and targeted investment, with the full engagement of health and care services and a shared mission to end smoking. The communities where smoking is still part of the daily fabric of life need investment to ensure that the support is there, particularly for those with high levels of addiction. Services need to be much closer to the people who need them—in social housing, mental health services, children’s centres and LGBT service settings. Wherever the need is greatest, we should make the support available. I agree with the APPG that it is not the taxpayer but highly profitable tobacco companies that should foot the bill for these important services. Funding is needed now—we cannot wait—so does the Minister agree that the Government should include provision for a smoke-free 2030 fund in the health and social care Bill and bring this measure into force in 2022?
Funding and investment in communities with the greatest need are important to help more smokers to quit, but we also need to prevent young people from starting. Reducing the availability of tobacco to young people can help to achieve that, and existing laws on age of sale need to be fully enforced. Although retailers need a licence to sell alcohol, no licence is required for the sale of tobacco products. Therefore enforcement action can be slower and more complex and, ultimately, have less impact on retailers that break the law than would be the case if a licensing scheme were in place. Data from both YouGov and ASH, which I thank for their help with my contribution, show that retailers and the public support the introduction of a licence for retailers selling tobacco products.
Introducing a licence need not be costly. The tracking and tracing system is already in place for tobacco retailers. As a result, there would be minimum extra burden for retailers and wholesalers in turning it into a public health licensing scheme; there would be little additional administrative cost. At the same time, it would equip local authorities with more effective powers to protect their local communities from those who sell tobacco products to children. Will the Minister commit to establishing a public health licensing scheme for tobacco retailers to make it easier to prevent underage and illicit sales of tobacco in order to further protect children from taking up smoking?
The NHS has committed to supporting more smokers through the NHS long-term plan, but as with all plans, the proof of the pudding is in the eating. With all the pressures in the system right now, there is a risk that the roll-out is uneven, with smokers who need support missing out. Integrated care systems are responsible for putting in place prevention plans for their populations, and those plans need to meet the needs of smokers and ensure that the commitments in the long-term plan are delivered on. Will the Minister ensure that all ICS prevention plans are published and include as an objective achieving a smoke-free 2030? Finally, I hope that the Minister will consider tasking NHS England with establishing an operational plan to support all smokers in primary care and community mental health settings.
It is a pleasure to serve under you in the Chair, Mrs Miller. I say a big thank you to my hon. Friend the Member for City of Durham (Mary Kelly Foy) and the hon. Member for Harrow East (Bob Blackman) for their doughty leadership on this issue, for their work in the APPG on smoking and health and for securing this debate, which has been a particularly good one. The points that my hon. Friend made about regional disadvantage and the way in which that links to every indicator of social deprivation and then to smoking were really good ones. It was very interesting and pleasing to hear about the work that has been done in the north-east about closing the gap. That, to me, served as an endorsement of regional approaches and, beyond that, sub-regional approaches, which I think we have lost in recent years and which I hope, through this plan, we can rebuild.
On the regional theme, my hon Friend was joined by a fine array of north-east MPs, who surround me here— I did feel rather out of place. My hon. Friend the Member for North Tyneside (Mary Glindon) made a really strong and compelling case for alternatives such as e-cigarettes and vaping. The thing I took away from that was how unequivocal it was. There is a real danger of being squeamish and equivocal about these new models, and I do not think that serves anyone. That is a theme that I will come to shortly.
That theme was shared by the right hon. Member for Clwyd West (Mr Jones). I agreed with the points he made about the new regulatory framework and the regulations. The review gives us a real chance to look at these things, so I hope we will hear some more from the Minister on that. Similarly, the hon. Member for Windsor (Adam Afriyie) talked about data and evidence. We have a common goal: we want fewer people to smoke and die. It behoves us, therefore, to follow the data and evidence about how to do that and not to be squeamish when they point one way.
My hon. Friend the Member for Blaydon (Liz Twist) made very poignant points about baby loss and smoking during pregnancy. She and other hon. Members will have heard some of the reasons why women smoke in pregnancy, which include perceptions about having a smaller baby and family traditions of doing so. The reasons are complicated and various, so we need ground-level, peer-led services to tackle that. Much of the content of the Leadsom review will help us in that space, so I hope to hear a commitment to that from the Minister.
My hon. Friend the Member for Jarrow (Kate Osborne) talked about regional inequalities and made a point about having services nearer to people. I will return to that shortly. My hon. Friend the Member for Ealing, Southall (Mr Sharma) also talked about inequalities—this time around ethnicity. We should not lose that in this debate. He also talked about localised approaches by service leaders who know their communities and have effective ways to reach different people. I think that is the whole battle here.
The hon. Member for Harrow East spoke with characteristic plainness, but we needed a bit of that. The 2030 target is a stretching one. At the current rate, we are seven years behind, but in the poorest communities it is 14. That means that we need big ideas. The document that he co-authored through the APPG has big ideas, and I will touch on a couple shortly.
I agree with the points that the hon. Member for North Antrim (Ian Paisley) made about organised crime. Again, that can form part of a tobacco control plan. I think there is complete political consensus about that. I do not agree that increasing the cost has not been an effective way of reducing smoking. Over two decades, it absolutely has. I also do not agree that tobacco control plans over the past couple of decades have not had an impact. Clearly, they have, and I will touch on that shortly.
For me, smoking is the ultimate equalities issue. It accounts for half the difference in premature death between the best and the worst off, so if levelling up is to be the theme of this Parliament, post covid, it seems that smoking is a very good place to start. I have similar statistics to those of my colleagues. In Nottingham, where I live, smoking rates are well above the national average: 20.9% of our community smokes, compared with an England average of 13.9%; and 16.5% of pregnant women are smokers when their baby is born, compared with 10% nationally. The cost to us is about £75 million every year through health and care needs, lost productivity and premature death, so tackling this is a really big prize for a community such as mine.
We should be confident that we are building on a platform of two decades of good progress on smoking cessation. Under Labour and Conservative Governments, we have implemented a comprehensive approach to tobacco control, including banning smoking in public places and cars, point-of-sale display bans and standardised packaging. All that has contributed to driving down smoking rates and discouraging young people from starting. We are here in a spirit of cross-party co-operation, and we are in lockstep in support of the goal of being smoke free by 2030.
I very much welcome the APPG’s report, which sets out the bold steps that we ought to take if we are to achieve this extremely challenging ambition. Among other things—this is always a very good place to start—it highlights the strong public support for that ambition: three quarters of the public are in favour, and that includes majority support for key recommendations from voters of all political parties. There is a clear mandate for action. I want to take the opportunity to thank Action on Smoking and Health, both for its work as the secretariat to the APPG and for the support it has given me in developing policy.
In this debate and the one we had a few months ago, colleagues have given the Minister plenty of content for the new control plan—in fact, probably a whole control plan and a bit more—but I want to offer a few points myself. First, the focus must now be on inequalities. Yes, this is a national goal and effort, but to make the most progress, we need locally led, community-sensitive smoking cessation services. The evidence for those is very strong indeed. It is a source of sadness that the Government have lopped away at the public health grant to the point that it has reduced by more than 40% since 2013, and those cuts have of course fallen disproportionately on poorer communities. If we are wondering why progress is stubborn in those areas, that is a significant reason, so I hope to hear a commitment from the Minister today to restore funds lost, with a particular focus on need. The report helpfully suggests an industry fund to cover the cost. Frankly, we should never have disinvested in the first place—cutting smoking cessation services is the falsest of false economies—but if the Government come up with an alternative along those lines, we will of course be supportive.
I want briefly to mention raising the age of sale to 21. We know that the best way to reduce smoking is never to start and we know that young people who start smoking generally tend to regret doing so. Seventy per cent. of adult smokers in England want to quit and an even bigger proportion—three quarters—regret ever having started, which makes an interesting point about raising the age of sale to 21. One of the things that surprised me in the report was the level of public support for that proposal—I did not think it would be as popular as it is—so the recommendation of at least a public consultation is a sound one. I would be interested to hear the Minister’s views on that, because it would be a very interesting public debate to have.
Turning to e-cigarettes, vaping and similar, this must be a feature of the tobacco control plan. I hope that the Minister and the Government more generally, via their role in the World Health Organisation, can push harder for stronger and clearer messages, based on the data and evidence, at the WHO level. I looked at the WHO website yesterday, and while I fancy myself as quite a smart guy—I might hide it well sometimes—I could not fathom what it was trying to tell me. It was incredible. That sort of equivocation makes it really hard for people thinking about alternatives to know whether they are supposed to go ahead or not.
I always rely on the Public Health England position in 2018 that these products represent a 95% reduction in harm, which seems a pretty good place to start. The APPG report says that in 2017 they helped 50,000 people to stop smoking and that concerns around children’s starting have not materialised. The 2017 tobacco control plan included a promise that:
“The Medicines and Healthcare products Regulatory Agency...will ensure that the route to medicinal regulation for e-cigarette products is fit for purpose so that a range of safe and effective products can potentially be made available for NHS prescription.”
This has not happened; it now must happen, and I hope it is a main feature of the new plan. The Government should also seek to regulate this market through the regulations review, to ensure that it promotes quality, safety and protection of young people.
Finally, the 2030 target is a vital and unifying goal, but we cannot wait until 31 December 2030 to look at the stats and see whether we have made it. We know it is a stretching target and we know we are currently not on course, hence the need for a new plan as soon as possible, but that plan has to have interim goals so that we know whether we are making enough progress. Again, the APPG report made some very good suggestions on that.
The report also makes strong recommendations on the data we do not currently have, which is a particular challenge in the case of people living with mental health conditions, who we know have disproportionately high rates of smoking. Data is collected in primary care on smoking status and mental health, but not routinely analysed. Smoking status data can also be collected through the mental health services dataset, but this is not done routinely. As a result, our data for folks with serious mental illness and others in secondary mental health services is not good. Reliable data is an important part of being sure that we are making the progress that we want to in this area, so I hope we will hear a commitment from the Minister on interim targets and better data.
To conclude, if we want a big public policy win—and goodness, this is about as big as they come—whether it is early intervention we are into or reducing inequalities, this is a major chance to make a step change. We need a plan, we need a good plan, and we very much look forward to playing our role in that process.
It is a pleasure to serve under your chairmanship, Mrs Miller. I congratulate the hon. Member for City of Durham (Mary Kelly Foy) and my hon. Friend the Member for Harrow East (Bob Blackman) on securing this important debate. I also thank everybody for the constructive tone in which we have discussed what is an incredibly important subject and for the acknowledgement that if we are to meet what is a very stretching target, we will all need to work together.
The hon. Member for City of Durham has highlighted the excellent work being done through the smoke-free programme in County Durham to drive rates in her area down, and I know that she fully supports that. As she alluded to, the aim is to reach 5% by 2025 through the regional tobacco control plan that Fresh drives forward, but since the launch of that in 2005, the north-east has seen a massive—47%—drop in smoking rates. I know that those rates are still above the national average, but I wanted to highlight how much I agree with that localised approach to delivery, making sure that we can focus services on those living in the local area.
I congratulate people on their successes so far, but as several right hon. and hon. Members have said, we cannot be complacent. Smoking rates at the time of delivery are among the lowest the country has ever seen, and my hon. Friend the Member for Harrow East has a relatively low rate in his area. I appreciate the passion shown through the cross-party work that has taken place to bring together these recommendations, because, as many have highlighted, one of the big challenges is the variation—across different groups in our society, but also across different regions of the country. If we are going to target those with higher incidence, we are going to have to accept that some areas will probably need more help than others.
We need to work together, and yesterday I was incredibly pleased to go to the launch of this report. I found the speech by the hon. Member for Blaydon (Liz Twist) incredibly poignant. I could not agree more: specialist cessation to help young mothers quit is so important, and the hon. Member for Jarrow (Kate Osborne) has said that it was that point in her life that was pivotal in helping her make that decision. Yesterday, we listened to a respiratory consultant who said that she ran out of her office and downstairs to speak to a young mother who was pregnant with twins, to try to get her to stop smoking. I do hope that mother was able to quit, and I assure hon. Members that this is a particular focus of mine. I have already spoken to the chief medical officer about the new Office for Health Promotion making smoking, and particularly smoking in pregnancy, a real focus. As I said yesterday, we get more bang for our buck here: not only do we help Mum but, in this case, we helped twins—that is three people—and as I have seen through some fantastic smoking cessation work in Bolton, we often get a partner, a mother, or someone who is supporting Mum to quit as well. That helps everybody to move forward.
The report and its recommendations are excellent, and I have listened with interest to the remarks made by right hon. and hon. Members today. Smoking prevalence is at an all-time low—just under 14%, and almost half the rate it was back in 2002—and it is right to celebrate where we have come to, but it is also right to say that we have a long way to go. The continued support through stop smoking services across England has been pivotal: since 1990, these services have stopped 4.7 million people smoking. That is more people quitting than the combined populations of Birmingham, Greater Manchester and Leeds, which is quite a remarkable achievement.
Smoking is linked to half a million hospital admissions each year, so the role that the NHS and charities play in helping smokers quit is also essential. The NHS long-term plan commits to supporting smokers admitted to hospital to quit, as well as pregnant smokers—pregnant mums—and their partners. It also commits to helping long-term users of specialist mental health and learning disability services, and we are ensuring that there is sufficient training, with challenge groups making sure that people get the right interventions and the right help when they intersect with these services. Funded early-implementer sites and services are also being stood up, because we cannot be complacent and we cannot wait for these timelines. I heard strongly that people want interim targets, and we will look at that in the strategy. It is important that we try to keep on track and ensure that we keep our focus on 5%.
Smoking is responsible for an estimated 75,000 deaths in England each year. That is unacceptable because it does not just affect the individual; families and everybody around them also suffer. As many hon. Members pointed out, it has a substantial financial impact on the country as well as a health and emotional impact. As my right hon. Friend the Member for Clwyd West (Mr Jones) said, we have to go at things hard if we are to see that success.
I assure everyone that we are considering alternative products in the plan in so far as they are alternatives. Ultimately, we want people to quit, but as the hon. Member for Nottingham North (Alex Norris) said just a few moments ago, the indication is that e-cigarettes, for example, are 95% better than smoking, so let us be sensible about how we take people on this journey. My hon. Friend the Member for Windsor (Adam Afriyie) will be interested to hear that, although snus is currently banned under the regulations, we are undertaking a review and will consider the evidence base.
The Government will publish the new tobacco control plan, which will set out how we achieve this, and I am pushing hard to ensure that the strategy is published as soon as possible; I am ambitious to try to publish ahead of the recess in July. However, as I am sure all right hon. and hon. Members are aware, new data on smoking prevalence will be released in July and I want to have time to ensure that the plan takes appropriate, targeted action on that data. Anecdotal evidence causes me some concern that we may have seen individuals taking up smoking. The new plan, which will expand on the success of the 2017 plan, builds momentum to support communities and groups where rates are not falling enough. As I say, I am exploring many of the issues we have covered to guarantee that the new plan will be bold enough for smoke-free 2030.
We know that reductions in smoking at a national level mask the significant health inequalities that many right hon. and hon. Members have spoken about. Smoking remains very high in certain areas of the country, particularly in deprived areas and among communities who can least afford the financial effects—as if anyone can afford the health effects. For example, prevalence in Blackpool is nearly 24%; in Richmond, it is down at 8%.
I am encouraged by the Minister’s words. Will she confirm that she sees this as part of the levelling-up agenda? Given that particular regions and social groups have more of a challenge than others, it seems to me that it collides well with the Prime Minister’s levelling-up agenda, certainly in terms of health inequality.
Indeed I do. Actually, the levelling-up agenda and our manifesto commitment to ensure five more healthy life years must be driven by achieving the targets we have set ourselves. Smoking has such a direct correlation with other illnesses. My right hon. Friend the Member for Clwyd West mentioned his interest with Cancer Research UK, and we know about the link to cancer, but there is also a link to chronic obstructive pulmonary disease as well as other respiratory challenges and so on. As I say, a disproportionate burden is borne by those disadvantaged families and communities.
I thank the hon. Member for Ealing, Southall (Mr Sharma) for making an interesting point. I assure him that we are focused on the need to make these interventions local. The local directors of public health and PHE drive plans in localities. I would like to think that we have taken, and can take, much learning from the successful local interventions of the past 18 months, such as with the vaccination programme. There are also clever uses of technology, where we have prompted people to take a vaccination. That might be interesting to look at in connection with recommendation 11, to which my hon. Friend the Member for Windsor (Adam Afriyie) alluded—I think it was him—requiring people to be prompted annually. They might look at that particular behaviour in order to modify it.
I could not agree more with the person who said that data saves lives—indeed, it does. The more we understand about the data held across the NHS, the more we can use it effectively to target interventions and to ensure that people get not only the right treatment but the right care, at the right point on their life’s journey.
In the new plan, we will ensure that we have a strong focus to drive down rates across the whole country, ensuring that they are level to where rates are the lowest, because everybody deserves to live in an area where we have targeted smoking rates and are achieving success. For too long, the harms from smoking have hit those areas that already face challenges. One in 10 babies is born to a mother who smokes. It is estimated that one in five new mothers smokes in Kingston upon Hull, compared with one in 50 in west London. It is those disparities that we need to tackle.
We must also close the gap seen among smokers with mental health conditions and smokers in routine and manual occupations. Could we be cleverer? Could we work in workplaces, for example? It is vital we continue to support interventions that make the most difference, helping people to cease smoking and encouraging them to move to less harmful products.
We have not had much time to talk about mental health in any detail. Will the Minister ensure that funding is found to deliver the original NHS long-term plan commitment to provide tobacco dependence treatment to all smokers accessing secondary mental health services?
If I have time, I will come on to that—I will try to speed up.
Many Members will be pleased to know that, within the plan, we will recommit to our evidenced approach to e-cigarettes. The products certainly have a role in supporting smokers to quit, and we will ensure that they remain accessible to smokers while protecting non-smokers and young people.
The fight against tobacco is not one we can win alone. It requires a joint effort through the health and care system and working across Government. There are good examples of that, because while NHS England is working to roll out the tobacco dependence treatment and the commitments in the long-term plan—we know there have been some delays—we are putting effort into driving the agenda forward, funding seven early implementer sites across England and establishing services as we speak.
Other Departments, such as HMRC, are tackling illicit tobacco. Her Majesty’s Treasury has taken action to raise tobacco taxation. We have also introduced a ring-fenced grant of £1 million to support an HMRC and trading standards intelligence cell called Operation CeCe. That was operational earlier this year. We are also working with the Department for Environment, Food and Rural Affairs on the suitability of options for littering.
I shall have to come to a close, but I will address the question of my right hon. Friend the Member for Clwyd West about how we are working with the WHO. We are a global leader in tobacco control and were instrumental in the framework convention on tobacco control. We will continue to take our treaty obligations seriously, including the commitment under article 5.3. I was particularly proud that we have been recognised in that work. The recognised commitment to our global prevention work with the WHO is important.
I hope the Chamber is aware that I am determined to protect the population from the harms of tobacco. As we build back better, we must make smoking a thing of the past, to improve the health of the nation and level up society, freeing up the billions of pounds spent on smoking by disadvantaged families and protecting the NHS. Clearly, with investment and with us all pushing in the same direction, we can truly make that target.
I thank you, Mrs Miller, the Minister and right hon. and hon. Members for their contributions to the debate. I am so pleased that there is cross-party support. I just want to reiterate that in order to go some way towards reducing inequalities, levelling up and increasing healthy life expectancy—especially in poorer communities—we must implement this plan.
Motion lapsed (Standing Order No. 10(6)).
Winterbourne View Hospital and the Transforming Care Programme
[Esther McVey in the Chair]
I remind hon. Members that there have been some changes to normal practice in order to support the new hybrid arrangements. Timings of debates have been amended to allow technical arrangements to be made for the next debate. There will also be suspensions between each debate.
I remind Members participating physically and virtually that they must arrive for the start of debates in Westminster Hall. Members are expected to remain for the entire debate. I must also remind Members participating virtually that they are visible at all times to each other and to us in the Boothroyd Room. If Members attending virtually have any technical problems, they should email the Westminster Hall Clerks’ email address, which is: firstname.lastname@example.org. Members attending physically should clean their spaces before they use them and before they leave the room and please take the cleaning materials they have used with them and put them in the bin.
I beg to move,
That this House has considered the 10th anniversary of the investigation into the Winterbourne View Hospital and the Transforming Care Programme.
It is a pleasure to speak in this debate with you in the Chair, Ms McVey. I thank the Backbench Business Committee for allocating time for this important debate.
The debate is being held to mark the 10th anniversary of the BBC “Panorama” programme that revealed the scandalous treatment of autistic people and people with learning disabilities in Winterbourne View Hospital. One of the experts on the programme said that Winterbourne View was
“run by a group of bullies for their own entertainment.”
It should shame everyone involved in the healthcare system that it took a team of journalists to uncover those abuses, when complaints from whistleblower Terry Bryan were ignored by the management of Castlebeck, which ran the hospital, and by the regulator, the Care Quality Commission.
I recently re-watched the programme—a decade on, the abuse shown is still shocking. At the time, it was rightly described as “torture”. One resident was showered while fully clothed, and had mouthwash poured in her eyes. On the same day, she had jugs of cold water poured over her head and was kept outside in March until she was shivering. Another resident was asked by a member of staff whether they wanted the staff member to
“get a cheese grater and grate their face off”’.
Residents were slapped and held down under chairs. They had their hair pulled and were pinned down while medication was forced into their mouths. One resident was so distressed by that treatment that she tried to throw herself out of a second-floor window and was then mocked by staff.
That behaviour was the end result of a system that did not see residents as people. Rather than the person-centred support that we would rightly expect in any hospital, a closed culture developed where abuse became normalised. Such abuse should not have been left to be uncovered by a journalist and secret filming. A whistleblower, Terry Bryan, had taken his concerns to the management of Castlebeck, then to the local safeguarding board, then to the Royal College of Nursing and then to the Care Quality Commission on three separate occasions. It was only when all that led to no action that he approached the BBC.
Ultimately, 11 members of staff at Winterbourne View pleaded guilty to neglect or abuse, and six of them ended up spending time in jail. However, Winterbourne View was not just a failure of one hospital or a few staff—although it certainly was that. The people in that hospital were let down by the entire system: from a provider that did not pay enough to attract or retain dedicated or qualified staff and did not supervise or manage them, to a regulator that failed to listen to the concerns of a whistleblower and to commissioners who were happy to put people in that hospital and then fail to monitor the placement or follow up with discharge plans.
Since 2011, residents in other in-patient units have been subject to similar abuse. As recently as 2019, another BBC “Panorama” programme uncovered similar treatment at Whorlton Hall in County Durham. Staff there were filmed verbally and physically abusing residents.
If the residents of Winterbourne View were let down by a system that simply did not place enough value on them to intervene, everyone who has faced abuse in those units since 2011 has been let down by a string of Governments, who have failed to take the action necessary to stop the abuse happening.
The only way we can ensure that there is no abusive treatment in those units is to move autistic people and people with learning disabilities into the community, where they can be given appropriate support to live independently. In 2011, following those shocking revelations, the Government seemed to recognise that, and David Cameron pledged to close all inappropriate in-patient units by 2014—but that was only the first in a long line of broken promises. By 2014, there were still thousands of people detained in those inappropriate institutions.
In 2015, NHS England pledged to reduce the number of people in assessment and treatment units by between 35% and 50% by 2019, but that target was missed, with the number falling only 5%. NHS England then pushed the target back a year, but that was also missed. By April 2020, the number of people in in-patient units had fallen only 15% in five years.
The NHS long-term plan then committed to reducing the number in units by 50% of the 2015 level by 2024, but on the current trajectory that will be yet another target the Government do not get close to meeting. A decade after the abuse at Winterbourne View was uncovered, more than 2,000 people are still detained in inappropriate institutions. As today’s learning disability mortality review shows, people with learning disabilities who end up in mental health units are nearly five times more likely to die young than their peers. The mistreatment people experience in those units stays with them for life, even after they are discharged. On average, people in such units have been detained in some form of hospital placement for more than five years.
What progress we have seen has been painfully slow. We still see hundreds of people admitted to in-patient units every year, and the number of children detained has risen by a third since 2015. We normally talk of admission to hospital being for care or for treatment, but neither of those words is appropriate here, and far too many people admitted to such a unit will have stories of poor treatment and abuse by staff.
Dan was left scarred by poor treatment in in-patient units, which led to him trying to overdose on pills when he was discharged, and then being detained in hospital for another 18 months. Kayleigh was moved from Winterbourne View to another hospital. Within weeks, she had been pushed and hit, and had made more serious accusations against the staff. Ryan was first detained when he was 17. Over the years, he has been isolated and held in long-term segregation. He has been heavily medicated with drugs so powerful that their side effects meant he had to have 18 teeth removed.
Hospital reports show that Ryan has experienced broken bones, and other injuries that sometimes were treated only after a week had passed. Ryan was supposed to be discharged three years ago. He has had an independent case review, which flagged urgent issues with his care. Over the past year, his family have seen their visits restricted and there have been covid-19 outbreaks on his ward. Despite media attention and legal support, Ryan’s discharge plan stalled repeatedly. While things are now looking up for him, hundreds of other people have not been so lucky, and it should not need TV crews and lawyers to get people basic dignity and proper care and support.
People end up in these totally inappropriate units because the funding is not available to support them in the community. One Winterbourne View resident, Dan, had previously been supported at home by a small specialist provider. When it asked for funding for two more hours a day of support so it could manage the triggers that set off Dan’s challenging behaviour, it was turned down. Dan’s family were then told they had no choice but to allow him to be moved to an assessment and treatment unit. That removed him from his home and from his support network. In the unit, Dan was forcibly restrained and ultimately ended up in Winterbourne View. That abusive care cost the Government £3,500 a week—far more than the extra couple of support hours he needed to remain at home.
Clearly, that was not inevitable. After the BBC’s “Panorama” programme, Dan’s family were supported to move him back home. A suitable property was found in his home village and the care staff who had worked with him before he was admitted to Winterbourne View were rehired. Nearly a decade later, he is still living independently in his own home. Unfortunately, such success stories are far too rare.
A similar story is that of a young autistic woman, Bethany, which I have raised many times in the House. She ended up in in-patient units because her local authority said it needed
“a break from paying for her support”.
By sending her to an assessment and treatment unit, it could shift the burden of funding to the NHS. That is the root cause of the Government’s failure to address this scandal over the last decade. If people are moved out of an in-patient unit, they need to be moved somewhere they will be supported. Under our current system, that kind of community support is funded by local authorities, which have had £9 billion taken out of their social care budgets over the past 10 years. Supporting a person with learning disabilities who might have complex needs is not cheap when compared with many other social care packages, so it is not surprising that cash-strapped local authorities have tried to pass the buck on funding to the NHS.
In the 1980s and 1990s, when the long-term psychiatric hospitals were closed, there was a system of dowries whereby the funding moved with the person as they were discharged to a local authority. That discouraged the kind of siloed thinking that sees a person’s human rights denied because a local authority cannot afford to fund the care they need. The Government could have reinstated those dowries. They could have given local authorities far more funding to ensure that they can support autistic people and people with learning disabilities properly in the community. They could have matched the ambition of their rhetoric with the resources that are needed.
Instead, we currently have a £62 million funding pot spread over three years to support people to be discharged. High-quality community support for people moved out of those units can cost as much as £100,000 a year, but even that is much less expensive than placements in private hospitals, which can cost six times as much. That means that the Government’s funding settlement is probably only enough to discharge 200 of the 2,000 people currently trapped in in-patient units. Because the funding only runs for three years, there is a real risk that when the funding runs out, those people will be readmitted to an in-patient unit.
We are not talking about huge sums of money when compared with the expenditure the Government have taken on over the last year. In 2019, the Labour party proposed spending £355 million a year on dedicated and targeted support, which would have been sufficient to move everyone currently in an in-patient unit into their community.
At the same time as discharging the 2,000 people currently detained, we also need to ensure that nobody else is admitted to those units, and we may need legislative measures to ensure that that happens. Underpinning any changes must be the reform of our adult social care system. We are still awaiting the details of that long-promised reform, but perhaps the Minister can tell us more today. Perhaps she can tell us whether the Government’s reform will increase funding so that local authorities can afford to support everyone who needs help to live independently in their community, including autistic people and people with learning disabilities. If it will not, one of the largest issues in our social care system will be left unaddressed.
It is a decade since BBC “Panorama” revealed the appalling treatment of the residents of Winterbourne View. As a society, we could and should have taken that as a cue to say, “Never again,” and to ensure that all autistic people and people with learning disabilities were given the support they needed to live independently in their own communities. Instead, we have had a decade of broken promises and broken targets. Rather than putting in place an ambitious programme of change, the Government have repeatedly promised reform while simultaneously cutting the funding for the very local services that would deliver that reform.
Autistic people and people with learning disabilities trapped in those inappropriate institutions cannot afford to wait any longer. Rather than more empty promises, they need legal changes to end the use of detention. Alongside that, we must see a radical programme of investment in community social care services to support them to live independently in bespoke accommodation, with care packages designed around their needs. We need a new commissioner, independent of Government, to oversee the process of moving people out of those institutions and hold the Government to account if they fail to make the progress that is needed.
After a decade of failure, I hope today the Minister can give autistic people and people with learning disabilities and their families the reassurance that they need and deserve, because it is long past time that we fixed this problem. However slow the progress, there is no excuse for not making sure all the people detained in institutions are safe. That needs to happen now—today. The two most important changes are the proper oversight of community provision, which is centred round choice and personalisation. We need bespoke packages of accommodation and care, not institutions. People can live happily and independently with an environment and support made for them.
Thank you, Ms McVey. First, let me put on the record a declaration of interest: I chair the all-party parliamentary group on learning disability, so that is the context in which I am speaking. Mencap, which provides the secretariat for the APPG, has provided a very helpful briefing for the debate, which it has made available to all Members.
It is a great pleasure to follow the hon. Member for Worsley and Eccles South (Barbara Keeley). I do not propose to repeat everything she said, although I agree with the large bulk of it and the thrust of her remarks. I want to focus on the specific commitments that the Government have made. I am afraid—I say this with no great pleasure as a Government Back Bencher—that the Government have missed commitments on a number of occasions. I want to put on the record some very specific questions for the Minister about what the Government are doing to ensure they hit the revised targets that they have set out. I also want to remind people listening that the Government have now made a clear commitment to introduce proposals to reform social care this year. I know the Minister is well aware, as is the shadow Minister and everyone present, that social care does not just include care for older people; it includes care for people with disabilities.
I say that is because, when the public conversation happens, after about five seconds it immediately turns into a discussion only about older people—usually older people in a residential setting. We tend not to talk about older people who receive domiciliary care that enables them to stay in their homes, and the media do not focus on the fact that, actually—I think it is still the case—the majority of public spending on social care in England is not on older people; it is on people of working age. If we are to introduce social care reforms, they will not be worth having unless they properly encompass people of working age, including people with learning disabilities or autism. They will need to be very different reforms from those that deal with older people, because although many older people, though not all, have assets that enable them to make a contribution—obviously we will have a debate about the appropriate level of contribution—people of working age do not have such assets, particularly if they have been disabled from birth. If we were to have a means test of any description, we would simply build in a new barrier to people of working age with learning disabilities or autism getting into the workplace and working, which is what most of them want to do. Most of them are able to do so if we provide the tools.
I want to focus specifically on some questions for the Minister. I am mindful about what you said about ensuring we can get everyone in, Ms McVey, so I will try not to make my remarks too lengthy. The hon. Member for Worsley and Eccles South set out the various targets that have been missed. As I said, I take no great pleasure in that as a Government Back Bencher, so I will not repeat all the misses. I want to focus on the latest target in NHS England’s long-term plan, which is to deliver a 50% reduction in in-patient beds by March 2024.
First, I want to ask the Minister whether the Government have done any thinking about whether the 50% reduction is ambitious enough. It would be ideal if we did not have anybody in such settings and we were able to support almost everybody in the community. Perhaps the Minister could comment on whether the target remains ambitious enough. Given that the original target was to deliver a 35% to 50% reduction by March 2019, and that another five years has been added on and we are only in 2021, is March 2024 an ambitious enough target to hit the 50% reduction? Given that the previous targets have been missed, I accept that it might seem ridiculously ambitious to talk about introducing the latest target. However, given that we have let it slip by another five years, I want to test whether it is actually the right target.
The second thing is to focus on how we will reach the target. The hon. Member for Worsley and Eccles South rightly said that the only way we can really stop people being in those institutions is to provide proper support in the community. The Government have set out how they will do that with their transforming care plan and objectives about building the right support. I understand that the intention is that a cross-government action plan will be produced, so it will be helpful if the Minister will tell us how that is going and when it will be published. To what extent will the proposals to reform social care that are being worked on improve or transform care in the community for people with learning disabilities and autism? Will the decisions to be taken this year—alongside the comprehensive spending review, I presume—provide an opportunity for a step change in getting this ambitious target delivered on time?
The Minister will be familiar with the fact that the cross-party Joint Committee on Human Rights said in its report that it had no confidence that the Government would hit the target in the NHS long-term plan. It proposed a No. 10 unit with Cabinet-level leadership to ensure reform. I listened carefully to what the hon. Member for Worsley and Eccles South said about a commissioner, but I am slightly traditional and old-fashioned, and I think that accountability in government is held by Ministers. They are elected and accountable to both Houses of Parliament, and political responsibility for delivering on the proposals sits with the Secretary of State and the Minister. I am not keen on having a commissioner as another person who feels that it is their job to chivvy Ministers along, because that is our job, collectively, in Parliament.
I do want to know, however, what mechanisms are in place whereby the Secretary of State for Health and the Minister for Care can monitor what NHS England is doing. At present—this will not be the case under the proposed legislation—NHS England is an arm’s length body with a chief executive, so what are the Secretary of State and the Minister doing, on a regular basis, to hold NHS England to account to ensure that it delivers on this ambitious timetable, and perhaps achieves a more ambitious one?
My experience in government is that if something challenging has not happened in the past, there is only one way to get it done: Ministers making it clear, and saying, that they care about it; and, most importantly, showing that they care about it by focusing on it regularly, asking for information about delivery across the country—Mencap’s report shows that delivery is inconsistent throughout the country—and getting regular updates on progress, putting a bit of stick about when things are not on track. To do that, they need a plan with regular milestones so that progress towards a target can be measured. It would be helpful—there is no reason why it could not be done—if progress towards such milestones were not just shared with the House, but published, so that the families of people who have been badly treated, including those at Winterbourne View, can see that we are making progress.
Before I conclude, I wish to focus on the use of restraint, seclusion and segregation. I understand that a trigger for the Joint Committee on Human Rights inquiry and a CQC investigation was a BBC Radio 4 “File on 4” programme revealing the shocking use of restrictive practices in in-patient units. The CQC report, which was ordered by the Secretary of State, revealed widespread and frequent use of restrictive practices, including physical and chemical restraint, long-term seclusion and segregation. I understand that we are still waiting for the Government’s response to the report, so it would be helpful if the Minister would set out when it will be published so that we can find out what the Government will do as a result.
I hope that the Minister will set out a plan to make sure that we deliver against the new target so that we will not sit here in a few years saying, “The target that was set has been missed and rolled forward again,” with the families who have been subjected to unacceptable care feeling that no one is listening to them, and we are back on the hamster wheel with nothing having been done. If the Minister can focus on that, we will have taken a big step forward.
It is a pleasure to see you in the Chair today, Ms McVey. I am grateful to my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) for having secured today’s debate, and for the depth of her commitment to the rights of disabled and autistic people over many years.
The 10th anniversary of the screening of the “Panorama” documentary that showed the horrific abuse of vulnerable residents at Winterbourne View near Bristol is a time for sober reflection. We remember the victims and their families, and the horrific trauma they suffered. What happened at Winterbourne View was sickening, and it was chilling that despite safeguarding concerns having been raised several times previously, it took an undercover documentary to prompt urgent action. The Winterbourne View scandal should have led to a genuine transformation of care and support for people with learning disabilities and autistic people. The scandal revealed a system that was not fit for purpose; a level of institutionalisation that resulted in a dehumanising culture; and huge problems with transparency and accountability. The Government acknowledged that hospitals were not the right place for people with learning disabilities and autistic people to be living, and promised to end that practice.
However, in a terrible failure, not only are around 2,000 autistic people and people with learning disabilities still trapped in inappropriate hospitals, there have been further appalling scandals. At Mendip House, eight years after Winterbourne View, we saw the taunting, bulling and abuse of autistic people. At Whorlton Hall, nine years after Winterbourne View, we saw a disturbingly similar revelation of horrific abuse in a private hospital behind closed doors. There have been many, many individual stories of families whose loved ones end up in assessment and treatment units under the Mental Health Act 1983, who battle—sometimes for years—to get them out, and live in fear for their health and safety every single day as they do so.
The failures are all the more distressing because we know what good care and support in the community looks like, from examples such as Alderwood LLA in Northamptonshire. It runs small homes for autistic people, and all of its services are rated by the Care Quality Commission as good or outstanding. I have spoken many times in this place about my constituent Matthew Garnett, who as a 15-year-old was sectioned and taken to an ATU. I supported Matthew’s parents as they battled for months to get him out of hospitals. With his parents, I visited him in hospital—at St Andrew’s in Northampton—where I was shocked both by how ill Matthew had become, particularly how much weight he had lost, and by the attitude of some of the staff who were responsible for his care. St Andrew’s has been found by the CQC to have multiple failings in several different inspections. Later, I visited Matthew in his new home, provided by Alderwood, where he was almost unrecognisable—a healthy, happy young man, enjoying football and trips to the seaside, volunteering in his local community, requiring a tiny fraction of the medication he had been prescribed in hospital, and living life to the full.
One of the keys to Alderwood’s success was undoubtedly the training and skill of their staff, who are highly specialised in communicating with, and supporting, autistic people. They were able to see such huge improvements in Matthew’s health in part because they were able to communicate with him in ways that reduced, rather than exacerbated, his anxiety. I pay tribute to the campaigning work of Matthew’s mother, Isabelle Garnett, who in recent years has used her family’s terrible experience to campaign under the banner of Homes Not Hospitals. Matthew should never have been in St Andrew’s, yet the Government continue to funnel millions of pounds into inappropriate hospital-based accommodation —places where health and wellbeing deteriorates, where people are physically and chemically restrained or put into seclusion, where contact with friends and family is limited, and where patient advocacy is in short supply.
The Government’s failure to deliver transforming care has been due to a lack of political will. It is not enough to just close hospital beds if the funding is not available to deliver homes in communities. It is not enough to expect that people will not be admitted to hospital if there is such limited support available for people with learning disabilities and autistic people in communities that many families find that they are unable to cope, and face crises of mental health or increasingly challenging behaviour.
The failure to deliver transforming care is also fundamentally linked to the failure to deliver social care reform more widely, and to the paucity of the Government’s vision. We need a sustainably funded social care system that enables everyone with support needs—whether they are working-age adults or older people—to live as independently as possible with dignity and love, but the Government have dragged their feet, ignoring social care for more than a decade.
We have heard far too many statements of outrage and warm words from the Government; we need action. I call on the Minister to put in place the funding needed to deliver homes not hospitals for people with learning disabilities and autistic people, and to stop funnelling NHS money into inappropriate private hospital placements, which so often do more harm than good.
It is a pleasure to serve under your chairmanship, Ms McVey. I congratulate the hon. Member for Worsley and Eccles South (Barbara Keeley) on securing this important debate.
Winterbourne View Hospital was in my constituency. The horrifying evidence of the systematic abuse of some of the most vulnerable people in my society, which happened in a place where they were meant to be safe and looked after, came to light just a year after I was first elected to serve as the Member of Parliament for Filton and Bradley Stoke. Immediately after the “Panorama” documentary was broadcast, I summoned to Westminster the chief executive of Castlebeck, which ran the hospital, and told him that the hospital had to close and that patients must be properly looked after in a sympathetic and caring manner.
Nobody who watched the documentary could be anything other than horrified by what they saw: a total and complete failure of humanity, a lack of any sort of care on the part of the staff responsible for those vulnerable adults, and the catastrophic failure of agencies and organisations to act sooner, which could have stopped the abuse before so many people fell victim to it.
In 2010, Terry Bryan, a former senior nurse at the hospital, brought forward concerns to the review. As the council states in its report on the hospital, his concerns
“made no difference in an unnoticing environment.”
The Care Quality Commission also acknowledged that it did not respond to Mr Bryan’s concerns. According to the report, it did not follow up because it thought Castlebeck and the council were doing so.
As I said in the House in September 2012, 40 safe- guarding alerts were sent to the council but not acted upon, because the council assumed that the hospital was being honest. Many of those terrible incidents could have been avoided had those alerts been dealt with. Twenty-nine contacts between the hospital and Avon and Somerset police were reported between January 2008 and May 2011. The police acknowledge that for staff-on-patients incidents, they relied far too heavily on the hospital’s information instead of listening to what patients were telling them or properly investigating concerns. Only one member of staff was ever prosecuted before the documentary was aired. Winterbourne View was a catastrophic failure of corporate responsibility and care for the most vulnerable.
In October 2012, I asked at Prime Minister’s questions whether care providers should be prosecuted for wilful corporate negligence if patients in their care had been abused. In 2013, I co-sponsored a private Members’ Bill to hold corporations criminally accountable for abuse and neglect in care settings. I am glad that since that dreadful incident, the Government have put in place some measures to improve the care of residents, and I welcome the steps that the Government have taken through national agencies such as the NHS, and local authorities, to ensure that care providers and givers are adequately resourced, and that patients are adequately protected and that their families can have confidence in the care system.
In December 2012, the Government published the “Transforming Care” report. It was of course vital to look at what lessons had to be learned and at what actions the Government must take to stop that abuse ever happening again. Some changes were made. The Government introduced a more rigorous registration, assessment and inspection process for learning disability services, and the Care Act 2014 set out a new basis for adult social care, which included the concept of wellbeing for individuals, including people being in control of their day-to-day lives, and residents having suitable accommodation and being able to contribute to society. The Act also reiterates the importance of good-quality, independent advocacy, and supports people, their families and carers, to help them raise concerns. It also requires local authorities to consider people’s views, wishes and beliefs, and focus on the end results that the people themselves want to achieve.
In January this year, the Government closed the consultation on reforming the Mental Health Act 1983. The changes that the Government are proposing are based on four patient-centred principles. Those principles are choice, autonomy—using the Act’s powers in the least restrictive way—ensuring that patients are supported to get better and, crucially, ensuring that patients are viewed and treated as individuals. The changes will allow people to make choices about their own care when they are well, and choose who might represent them should they become unwell. The Government have focused, as has been said earlier, on reducing levels of in-patient care for people with a learning disability and/or autism. Hospitals are not where people should live, and the Government have committed to move more people into community-based support. However, as we all know, that ambition has been postponed. The most recent target, as set out in the NHS long-term plan, is for a reduction in in-patient provision of 50%, compared with 2015 levels, by 2023-24.
As the commission recommended, the priority for the Government now must be to improve access to community-based mental health support, including crisis care, to prevent avoidable detentions under the Mental Health Act. I am pleased that this is already under way, backed by a ring-fenced fund of £2.3 billion a year as part of the NHS long-term plan.
We must continue to learn the lessons from the terrible events at Winterbourne View. Those who are entrusted to the care system, and their families, must be confident that their wellbeing is the highest priority for those responsible for their care, and of course we must all continue to ensure that such horrific abuse can never be repeated. It cannot be in any way justifiable that alerts are ignored by local authorities and the police, as they were with those terrible incidents, which could have been prevented and should never have happened.
It is a pleasure to serve under your chairmanship, Ms McVey. I thank the hon. Member for Worsley and Eccles South (Barbara Keeley) for securing this debate. I am pleased to be here to speak on such a crucial topic. First, I want to reflect on the past 10 years since the Winterbourne View scandal, and secondly, look forward and ensure that such horrific events cannot happen again.
What the BBC “Panorama” programme exposed was absolutely shocking, disgusting and heartbreaking. It revealed patients with a learning disability and/or autism being repeatedly pinned down, slapped and taunted by staff. That community was let down. Following that, the Government promised to transform care for people with a learning disability and/or autism by 2014 by supporting those in assessment and treatment units to move out of those settings and get the right support in the community. The Government still have a long way to go before they achieve what was promised. It is vital that we continue to learn from Winterbourne View. The Government have shown that they are willing to make the necessary changes by publishing the White Paper on reforming the Mental Health Act. I commend the reforms that it has set out.
I want to send my personal thanks to the Department of Health and Social Care as well as the Lord Chancellor for driving forward reform of the Mental Health Act. The Act has long been outdated, and I hope that implementing many of the recommended changes will fire the starting gun on changing the way our country views and treats mental health conditions.
There is a clear desire, set out in the White Paper, to change the culture surrounding mental health by enacting a person-centred approach to care. That is a new approach to the way in which our mental health service is run, and will begin to achieve the desired goal of bringing the Mental Health Act in line with 21st-century principles in medical care.
Having spoken to stakeholders, including Mind, the National Autistic Society, Rethink Mental Illness and the Mental Health Foundation, I want to share the conclusions that I have drawn and the lessons that must be learnt following the atrocities of Winterbourne View. Broadly speaking, they are, first, ensuring that the shift from in-patient care to care in the community is backed by a Government commitment to provide community support services. Secondly, all in-patient facilities must take into consideration the requirements of all their residents, and ensure that when individuals are ready to be released, the right care in the community is in place for them. Thirdly, to prevent situations from reaching a stage where individuals have to be placed in an in-patient facility, we must emphasise early intervention.
I applaud the long overdue decision in the White Paper to remove autism and learning disabilities from the definition of mental disorder in the Mental Health Act. For too long, autism and learning disabilities have been grounds for detention under the Act. I also welcome the commitment to build new mental health hospitals, with two schemes already approved and more to come. And we will tackle the maintenance work needed in the mental health facilities where patients are treated.
Before new projects commence, however, it is essential that we ensure that all new facilities that are built take into account the needs of those with autism and learning difficulties. Removing autism and learning disabilities from the terminology of the Mental Health Act will not mean that individuals with autism and learning disorders will not suffer from poor mental health, so they will require access to those facilities in time. Therefore, we cannot continue establishing new mental health facilities that are not constructed with all those who will access them in mind. The needs of those with autism and learning difficulties may be different from those of others who access in-patient services, and those needs must be catered for. I would welcome a new approach to the creation of in-patient facilities that means that the needs of those with autism and learning disabilities are given greater consideration.
The White Paper states that care and treatment reviews will have statutory force to help to address inappropriately long stays in in-patient units. This is a welcome development that will ensure that people with autism and learning disabilities do not become trapped in in-patient care. In total, 2,040 people who have a learning disability and autism remain detained in in-patient settings and 59% of those people who have been detained in hospital have had a length of stay of over two years. That is simply not good enough. However, there are other barriers in place, ensuring that individuals are not being released from in-patient care at the appropriate time. There is a lack of programmes and facilities for people to be released into.
Without the appropriate resources in place, individuals are becoming trapped in facilities that may no longer have the correct environment. I spoke about this today with one of my constituents in Broxtowe, Justin Donne, who is chairman of the board of trustees at Autistic Nottingham. He had this to share:
“What has become clear in our communities is that the suffering of autistic people being locked up is needless, as our advocacy, social and personal assistance services have successfully kept most of our service users out of that condition. Moreover, we get occasional requests from outside our geographical remit”—
that is Nottinghamshire—
“regretting that they do not have the appropriate facilities in their location. This proves that we obviously need to significantly invest more funding in organisations such as ours”—
that is Autistic Nottingham—
“who provide real, tangible help that benefits both the individual and the community, and saves money and hospital resources by investing in essential preventative services.”
The National Autistic Society’s vital community work is a testament to just how successful community support can be in helping individuals outside an in-patient facility. More must be done to address these issues and I look forward to hearing the Government’s comments on this area in particular. I would welcome a commitment to evaluate and improve the services that are currently in place across the UK to support individuals with autism and learning disabilities when leaving in-patient facilities.
The Government have committed £31 million of mental health recovery funding for a range of projects, including admission avoidance and quality of in-patient care. I would welcome a breakdown from the Minister of what specific projects will be funded.
The focus of the White Paper is on a new person-centred approach to care. Putting the individual at the centre of their own treatment enables them to make their own decisions surrounding care and results in a more tailored approach. To those with autism or learning disabilities, it is even more vital that the care is centred on their specific needs. The introduction of a statutory advanced choice document will go a long way to ensuring that that is acted upon and to enable people to express their view on the care and treatment that works best for them as in-patients, and that is before the need arises for them to go to hospital. As the White Paper states, putting these plans on a statutory footing for the first time will require them to be developed in good time in partnership with patients.
My concern about shifting the emphasis of care away from in-patient facilities to community support relates to whether properly established and funded support is in place in the community. The NHS long-term plan established a commitment for increased community support for early mental health intervention, which is echoed in the White Paper. I would welcome a detailed outline of what this expansion of community support will look like at all levels, how and when it can be expected and how it will be implemented across the UK to ensure that all areas of the UK have the same levels of support. As I have stated, we need to focus on prevention. If that is not possible due to the complex needs of the individual, how can we ensure that individuals with learning disabilities and autism in hospitals are safe and respected, that their dignity is maintained and that their human rights are not violated?
I spoke recently with another constituent of mine, Ashley Swinscoe, who does vital work in my local community supporting those with autism and/or learning disabilities within our local community. He discussed early intervention and proposed that schools needed to offer support to individuals until they were 21 years old. He said that through this stage, consistent support should be offered from childhood to adulthood. This consistency would help the individuals manage the stress caused by the changes in life. That would also reduce the risk of behavioural and mental health declines.
If individuals are not ready for supported living and require residential care, providers must also offer supported living in the future. Residential care is not long term, and providers should promise to progress individuals to become more independent, with fewer restrictions, and to move to supported living. That is a suggestion from Ashley Swinscoe from my constituency.
It is a pleasure to serve under your chairmanship, Ms McVey. I am incredibly grateful to speak in this debate on such an important topic, which many of my constituents have written to me about. I am very grateful to the hon. Member for Worsley and Eccles South (Barbara Keeley) for bringing this matter to the House.
It was my constituency predecessor, the Care Minister at the time, Sir Norman Lamb, who publish the in-depth review commissioned by Paul Burstow into what happened at Winterbourne View. As we know, the abuse and neglect inflicted on patients there was utterly horrific. Inspections by the CQC of 150 hospitals and care homes for people with learning disabilities found inadequate practice in in-patient services, including poor person-centred care, limited appropriate activities and a lack of monitoring and learning from incidents of restraint. The inspections were clear: we can and, as it was pledged, must do better.
In my constituency it is a real pleasure to support Frances Dawney and all the staff and residents at Abbottswood Lodge. It is an exemplary care home for residents with complex needs and, sadly, with the pandemic I have been unable to visit as much as I would like to. It is a real model of what care and love with dignity should be for adults with learning disabilities.
Ten years on, we must recognise the NHS long-term plan and the much-needed changes that it will bring to in-patient units for those with disabilities and autism. Crucially, the plan states that by March 2023 or 2024 in-patient levels will have reduced to less than half of those in 2015, and that for every 1 million adults there will be no more than 30 people with a learning disability or autism in an in-patient unit. That is something that we absolutely must achieve, because we probably all recognise that progress has not been fast enough. It is also important to recognise, as I am sure we all do, that hospitals are not where people should live. As such, I absolutely support the long-terms plans and that commitment, as we move people towards community-based support and, ultimately, closer to home.
Drawing on the new care models in mental health services, local providers will be able to take control of budgets to reduce avoidable admissions, enable shorter lengths of stay and end out-of-area placements. Where possible, more people with a learning disability, autism or both will be able to have a personal health budget, which will give them a real opportunity to live in their own homes or with their families, rather than in an institution. In North Norfolk, I have worked tirelessly on mental health—my predecessor was such a champion of it. It is so important across the country that we get mental health hubs implemented in areas, and see mental health practitioners in primary care GP networks. That is something that is beginning to be rolled out in my constituency.
Since 2015, the number of people in in-patient care has decreased by almost a fifth, and about 635 people who have been in hospital for more than five years have been supported to move back into the community. Although that is encouraging, it is also a sign of how much we still need to do to ensure that every single person with a learning disability can lead a fulfilled life with the dignity and respect that they deserve.
Social care reform cannot come soon enough. It is rather nice that I have the Minister sitting so close to me. I regularly talk about this matter, and I want to go back to what was said earlier: older people dominate this agenda, but about 50% of all people requiring social care are adults with disabilities, and we must not forget them. The golden question for the Minister to answer is: will we see the social care reforms later this year? We must address social care reforms, not just for older people but for people with disabilities, right the way through to young carers. That is an apt point, as this week is Carers Week.
It is a pleasure to serve under your chairmanship, Ms McVey. I direct Members to my entry in the Register of Members’ Financial Interests. I congratulate the hon. Member for Worsley and Eccles South (Barbara Keeley) on securing this important debate.
The circumstances of the Winterbourne View scandal have already been described, so I do not want to repeat that history, but I share others’ shock and outrage at the way in which some of the most vulnerable patients in our healthcare system have been treated in assessment and treatment units. Those attitudes and that kind of abuse should be historical; the shameful thing is that they are still with us a decade later. Ten years after the NHS should have changed for good, new scandals keep emerging.
Across the system, the levels of physical and chemical restraint remain disturbingly high. The CQC report is the latest to recommend change, and the Government’s response is needed urgently. Although there has been a welcome emphasis on moving patients into other settings, we know that there are more than 2,000 people with a learning disability or autism in assessment and treatment units right now, and about 200 of them are children.
Progress has been slow. Admissions are not falling, and those patients are still staying in ATUs for an average of five and a half years. We have yet to build enough support in the community. The building the right support programme is a catalogue of missed targets, and I hope the Minister can tell us why. We should have done more, and we should have more confidence in the targets set by NHS England’s long-term plan.
The record to date is not encouraging. Until the cross-governmental action plan is published, as promised, scepticism will prevail. We have heard why families are worried. There are two aspects of current care that particularly trouble me. The first is the widespread use of anti-psychotic medication. Drugged-up patients are no doubt easier to manage, but it can take years to wean them off those drugs, and even then the consequences continue.
The second aspect, which can be read about in The Daily Telegraph today, is “do not resuscitate” notices. I put that matter to the Secretary of State for Health and Social Care at the Select Committee meeting today. What we are really talking about here is a culture—a culture in which the needs of those with learning difficulties or autistic people are sometimes treated as not important. As many hon. Members have said, these people are able to live fulfilled lives. They are human beings, with plenty to live for. It is hard to accept the idea that a “do not resuscitate” notice could be placed on the record of Sonia Deleon, who very sadly died. When they looked at why she would not be resuscitated, it simply said the words “learning disabilities”. That is unacceptable.
Our pride in the NHS should not blind us to its failings. It has systematically failed people with learning difficulties and autistic people. Their trauma is real. The damage is lasting. I have confidence that we now have a Government who are going to take their commitments on social care seriously and, as many Members have said, that includes those in the working-age population and not just those who are old. This action must finally happen.
It is a pleasure to speak under your chairmanship, Ms McVey. I join other hon. Members in this Westminster Hall debate by thanking the hon. Member for Worsley and Eccles South (Barbara Keeley) for leading it. The note that I passed to you, Ms McVey, was to apologise and to hope that you had received notification beforehand that I was running from the main Chamber to speak here. I very much hope that that was the case, but I apologise both to you and to the hon. Lady.
I begin by paying tribute to our former friend and colleague, the late Dame Cheryl Gillan, who chaired the all-party parliamentary group on autism and was a long-standing advocate for the 700,000 autistic adults and children and their 3 million family members and carers. I now chair that all-party parliamentary group, but I very much wish that I was sitting here, as I would tend to be in these debates, watching Dame Cheryl and listening to her advocate so finely for all of that community. She will be remembered for her passion, drive and kindness.
For more than a decade, Dame Cheryl worked tirelessly to ensure that Government and Parliament took more account of autistic people and the need to improve the support for them. She began her campaign for an autism Act in England in 2008 to tackle the lack of support for autistic people and to improve the understanding of autism. That landmark law—I think it is quite remarkable that she got it delivered—remains the only legislation aimed at supporting one particular group of disabled people. I am deeply saddened that Dame Cheryl passed away before getting to see the new autism strategy, which is set to be published shortly—I hope imminently. I hope that she would have been very proud of what gets delivered.
Following the passing of the Autism Act 2009, Dame Cheryl campaigned hard on so many of the crucial issues. Even during her illness, she fought hard to take on these issues, ranging from diagnosis to waiting times, teacher training, employment and, importantly, the subject that we are talking about today—health, mental health, and those who feel imprisoned by the system. It is a topic on which so much more needs to be done and, in Dame Cheryl’s memory, I very much hope that it will be.
As other hon. Members have said, it is 10 years since the appalling abuse and neglect of some of the residents of the Winterbourne View home were exposed. There were shocking levels of violence, degrading treatment and taunting. It was a scandal that led to widespread acknowledgement that a significant number of people with autism and with learning disabilities, or with both, were stuck inappropriately in in-patient settings. However, the latest monthly data show that 2,040 autistic people and people with learning disabilities are still in in-patient mental health hospitals, of whom 1,150 are autistic.
That means that since 2015, the number and proportion of identified autistic people in in-patient facilities has actually increased, from 38% to 56%. A lack of appropriate community support and issues with legislation have meant that a growing number of autistic people are ending up in mental health hospitals against their will and that of their families. Once a person has been admitted to an in-patient unit, they will stay there for an average of 5.6 years, and they will be on average over 60 miles from their home.
The National Autistic Society, which provides the secretariat for the all-party parliamentary group on autism, has continued to hear of alarming cases of over-medication, seclusion and unnecessary restraint. That is completely unacceptable in 2021. Autism is not a mental health condition, and hospital is not the right place for the vast majority of autistic people. Hospital wards can be noisy, bright and unpredictable. Without reasonable adjustments to the environment, and without the support of professionals who understand autism and how to adapt these people’s care, wards can be completely overwhelming for them.
For autistic people who are particularly sensitive to sound, light or touch, the experience of being in an in-patient setting can dramatically increase their level of distress and lead to further restrictions, making it even harder to be moved into the community. It becomes a perpetual cycle, unless something breaks that cycle. Even then, there is a challenge in finding the right type of mental health and social care services in the community for autistic people to move into. It is not right that thousands of autistic people are developing avoidable mental health conditions because they cannot access the support they need early on. To end the travesty, there must be commitment and significant investment in better social care and mental health services that work for autistic people.
I am the last Back-Bench speaker, so I will add my list, too, for the Minister for Care. I have worked with her over the years and know that she is absolutely dedicated to this cause. Without wishing to keep her at the ministerial level at which she is, we need consistency in ministerial position to follow this through. I understand that she is setting up a report group to ensure that all those responsible for delivering outcomes do act. I absolutely support the call from my right hon. Friend the Member for Forest of Dean (Mr Harper) that milestones need to be set. I had written that down before he said it, but I had not written down that they should be published. He is right. They should be published not just for us as Members of Parliament to hold the Government to account, but for the Government to hold to account those in the report group who have to deliver, so that there is no hiding place when it comes to what should be done by when. If there is a failure to meet individual timescales, more pressure and perhaps more resource can be added. The Minister will have all our support in holding their feet to the fire.
When will mental health legislation be amended? It will need to be amended. Indeed, it is not just an issue of moving the community from inappropriate settings into appropriate settings. Do we actually have those appropriate settings? Do those milestones include not just the transition but the provision that must be there? I will end there, because we want to hear from the shadow Minister and the Minister, but I very much support all the calls made by Dame Cheryl’s former colleagues that more must be done.
I thank the hon. Member for Bexhill and Battle (Huw Merriman) for acknowledging Dame Cheryl Gillan and all the work she did in the world of autism. I know we all share that view.
I will now call the Front-Bench speakers, mindful that we do want to hear from Barbara Keeley at the end to close the debate.
It is a pleasure to serve under your chairmanship, Ms McVey. I thank my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) for securing this extremely important debate, marking the 10th anniversary of the Winterbourne View scandal. I want to say at the start that the repeated and abject failure to move people with learning disabilities and autism out of long-stay institutions and into the community, following what we saw at Winterbourne View, is the worst political and institutional failure I have seen in my 25-year experience of working in health and social care as a Member of Parliament and before I became an MP. It is essential that we understand the underlying reasons for this failure and what we will do differently so that we can put it right in future. That is what I really want to focus on.
Many hon. Members have spoken about the horrors that the BBC’s “Panorama” programme exposed at Winterbourne View in May 2011, with patients repeatedly abused, pinned down, slapped, soaked with water, trapped under chairs, threatened and taunted by staff. The incidents included a member of staff slapping a resident across the cheek and—forgive me, Ms McVey—saying:
“Do you want a scrap? Do you want a fight? Go on and I will bite your bloody face off.”
A member of staff claimed a resident “loved pain”, and then said to the resident:
“Simone, come here and I’ll punch your face.”
Staff gave a patient cold showers as a punishment, leaving her outside in near-zero temperature, pouring mouthwash in her eyes. Patients were shown screaming and shaking, one trying to jump out of a second-floor window to escape the torment but just being mocked by members of staff.
Straight after the programme was aired, the then Minister commissioned an in-depth review into what happened, the results of which were published on 10 December 2012—a day I remember extremely clearly, as the Government statement to Parliament was the very first time I had spoken at the Dispatch Box as a Member of Parliament and a new shadow Minister. The new Minister of State promised that all patients, 3,400 in total, would have their placements reviewed by June 2013, and that everyone who was there inappropriately would be moved into the community no later than June 2014. This was followed by the Government’s transforming care programme, which aimed to close up to half of in-patient beds by June 2014.
June 2014 arrived; the Government had failed to deliver. There were still 2,615 people in in-patient units, including 148 children. Sir Stephen Bubb was commissioned to do another review, which was published in November 2014. As a result, NHS England announced a three-year closure programme called building the right support. This had a slightly reduced target of reducing the number of in-patient beds by between 35% and 50% by March 2019. March 2019 arrived; the target was once again missed. The Government had missed even the more modest target of a 35% reduction. Instead of trying to really get to grips with the cause of the failure, the target was downgraded again, from between 35% and 50% to just 35%. Surprise, surprise: a year later and even the downgraded target was missed.
The grim reality is that there are still 2,040 people with learning disabilities and autism in in-patient units, including 215 children. The average length of stay is over five and a half years, and 355 people have been in these units for at least 10 years. Unbelievably, after everything that has happened, there has been little if any change in the number of people being admitted into in-patient units each month, when, as many hon. Members have said, one of the key priorities must be preventing people from going into hospital in the first place.
Far from closing large-scale units, the Government are opening new ones. Last year, a new 123-bed medium-secure unit, including 45 beds for people with learning disabilities and autism, was opened by Mersey Care NHS Foundation Trust. Mersey Care also got planning permission to build an additional 40-bed unit, going against the Government’s own recommendations. Report after report has shown continuing unacceptable treatment in these long-stay institutions. In one month this year—just one month—3,390 restrictive interventions were used, by which we mean physically restricting people or restricting them with chemicals—drugging or isolating them. In reality, that is a massive underestimate because, scandalously, we have data for only 31 of 56 NHS providers, and for one of 16 private providers. I have one question that I hope the Minister will answer: why is providing that data every month not a requirement for every provider in this country and will she consider making it available a requirement of Care Quality Commission registration?
The latest target set out in the NHS long-term plan is to deliver a 50% reduction in in-patient beds by March 2024, but unless we are clear about why the Government have failed to achieve anywhere near that over the past decade and what we are going to do differently, we cannot have confidence that things will change.
It is my view that the first reason for that failure is simply that this has not been a political priority. I am singling out not the current Minister but Ministers over a decade who have failed to grip the issue, failed to make it one of the repeated, unmissable priorities for the Department of Health and the NHS, and failed to secure the funding that the NHS and local authorities need to shift the focus of services fundamentally towards prevention and co-ordinate support not just between the NHS and local authorities but with housing and other community services. Will the Government consider the recommendation of the Joint Committee on Human Rights to set up
“a Number 10 unit, with cabinet level leadership… to ensure reform is driven forward”?
If we do not change that, we will not have that leadership in place.
Secondly, there are institutional failings. It is just too easy for services to keep doing the same thing—commissioning large-hospital services—rather than the difficult work of individual, personalised support in the community or at home. We do not have the financial incentives in place, or the accountability mechanisms, to do things differently. Mencap says that in my own region, the east midlands provider collaborative, which commissions these services, includes some of the very private providers that have been shown to have poor records of care. How is that allowed and who is responsible?
Thirdly, and I really believe this is the key to change, we have failed to put families at the heart of the process and not just to listen to their views but put them in the driving seat of change. There are many ways to do that, but I know, and I have seen, that one of the most powerful ways to get that change is personal care budgets given to families and developed in partnership with the services. The average cost of a weekly stay in an in-patient unit run by the NHS is £3,000. If we gave families greater control over that money, I bet they could find a better way to spend it on care for the people they love.
Last but by no means least, one reason why people with learning disabilities and autism and their families believe change never happens is that they feel they just do not matter, are not important enough, and are out of sight and out of mind. As Members here know, what has happened in those in-patient units is part of a much wider pattern of unacceptable inequalities in access to services and in health outcomes for people with learning disabilities and autism. For example, women die 18 years earlier than the average and there are much worse health outcomes in a range of areas.
I am afraid that with covid-19, and despite initial claims they were at no greater risk, people with learning disabilities and autism have death rates six times higher than those for the rest of the general population. Changing that requires concerted action across the board. We need to change how we train health and care professionals, and ensure absolute clarity at every level about who is responsible for change and how they will be held to account. The trouble is that this is everybody’s and nobody’s problem. That is why we cannot get change.
I say all that to be constructive. The Minister knows that I want to solve problems, not just criticise. I would be happy to meet with her and the families and providers, as well as her officials, to see whether we can put in place a more effective plan of action. I ask her one thing: can she tell me what the Government and NHS England now propose that is different from the proposals of 10 years ago, five years ago or one year ago? From what I have read, there is no difference. The trouble with that is that we will get the same result. That is not good enough for people with learning disabilities and autism and their families.
It is a pleasure to serve under your chairmanship, Ms McVey. I thank the hon. Member for Worsley and Eccles South (Barbara Keeley) for securing this important debate, for opening the debate and for her committed campaigning for people with learning disabilities and for autistic people. I also thank all Members who have spoken powerfully today, both in the Chamber and virtually, and shown the strength of feeling on the issue among parliamentarians. I particularly thank my hon. Friend the Member for Bexhill and Battle (Huw Merriman), as he has taken on the role of chair of the all-party parliamentary group on autism following, as he said, the very sad death of our right hon. Friend Dame Cheryl Gillan. She is missed so much by all of us, both as a colleague and for her work for autistic people, which has made such a huge difference over the years, although there is clearly much further to go.
The appalling abuse uncovered at Winterbourne View has no place in our society, and I share the shock and anger that hon. Members have expressed today. It was rightly described as heartbreaking and disgusting by my hon. Friend the Member for Broxtowe (Darren Henry), and it should never have happened, as my hon. Friend the Member for Filton and Bradley Stoke (Jack Lopresti) said. None of us accepts this kind of cruel and abusive treatment of people with learning disabilities and autistic people, and none of us wants people to be in-patients unnecessarily when they could be better off living in the community. I will use my time to talk about the work of Government, the NHS, the CQC, local authorities, and others we are working with to stop poor and—worse still—abusive care, and to improve care. As part of that, I will talk about what we are doing to reduce the number of people with learning disabilities and autistic people in in-patient units, which we know are rarely the best place for those people to be. As I do so, I will seek to respond to questions raised by right hon. and hon. Members.
First, I will talk about the approach we are taking to stopping abusive care. We are working with the NHS as care commissioners, local authorities, and of course the CQC, which plays a critical part. I fully support the much tougher approach that the CQC is rightly taking through its more robust inspection regime and updated methodology, which includes speaking more to patients and families and really digging into the culture of providers. It is in some of these closed cultures where there has been such concerning treatment of patients, and the CQC is taking a robust enforcement approach, including wasting no time in closing down services when it uncovers unsafe care. The sad truth is that this tougher approach by the CQC has exposed more cases of poor care, and I fully support the CQC in taking very robust action in those cases.
A significant number of people with learning disabilities and autistic people in in-patient units, about 59%, are autistic. As my hon. Friend the Member for Bexhill and Battle said, an in-patient unit is rarely a good environment for someone who is autistic, and can often be a really inappropriate one. I am clear that no one should be in an in-patient unit if it is not to their benefit—if they are not receiving some form of therapeutic treatment that helps them. Even then, their time in an in-patient unit should be as short as possible, and that unit should be as close to home as possible. Our target is to achieve a 50% net reduction in in-patients by 2025, from a base starting in 2015. Back in 2015, there were 2,895 people with learning disabilities and autistic people in in-patient units; that figure has come down to 2,035, which is a 30% reduction. England is divided into 44 transforming care partnership areas, 17 of which are on track to achieve the target, but that means that 27 are not on track. I take that failure very seriously.
My right hon. Friend the Member for Forest of Dean (Mr Harper) asked whether our target of a 50% reduction is ambitious enough, and whether we should be aiming for zero in-patients. That is a question that I have asked myself, and I have also asked it of the NHS and of clinicians. It has been made clear to me that there are times when people with learning disabilities and autism may need to be in an in-patient unit, when they have a mental health condition that could benefit from in-patient treatment. As such, I do not think it would be right to say that it is never appropriate, but it should be rarely considered appropriate, and alternatives should be tried wherever possible. I must also mention to my right hon. Friend that just under 30% of the numbers I am talking about are individuals who are under Ministry of Justice restrictions, so that is another challenge to discharging them. Those are net figures, however, and in the period that we are talking about, there have been more than 10,000 discharges, so it is not a static population. Of course, given that reduction of 30% and more than 10,000 discharges, there have also been a large number of admissions.
When I became the Minister for Care, with this in my portfolio, I straightaway asked the question, right back at the beginning of the pandemic, why are we behind the target? Why have we not made the progress that we should be making? Why is it taking so long? What needs to be done to fix that and to get back on track? We need to have a plan that we can all be confident in—all of us in the Chamber and the families of in-patients.
Before the Minister moves on, may I test her? She said that she asked whether the 50% target was right. After all those conversations and yes, accepting that there might be some need for in-patient units, is the Government’s position that the 50% reduction is the right end state, or is there a different number? If it is 50%, will she publish the analysis that sets out why that is the right number?
I can tell him that achieving the 50% will be hard. I am all for being ambitious, but in fact, from everything I have seen, achieving it will be hard, partly because some are more easily discharged—I pause as I say that, because it has been difficult to discharge many because we have complex situations here. We have seen some people continuing to be in-patients with long lengths of stay, and it has become almost harder and harder to find a way to find the right support for them in the community. Achieving the 50% will not be easy. I will get to the other part of my right hon. Friend’s question.
When I saw the position we were in and that we were not on target, I asked why and how come. Clearly, however, this is a complex system—it involves the NHS and local authorities doing things, and there are questions about housing supply, community schools and in-patient services. I therefore set up the building the right support delivery board, to which my hon. Friend the Member for Bexhill and Battle referred—I thank him for his supportive words. That board’s aim is to bring those involved together, because, much though we all like a clear line of accountability, to point a finger at somebody to say, “Solve this!”, the reality is that solving this involves bringing different organisations and different parts of our system together.
The delivery board has identified six priorities that we need to focus on to overcome the barriers to achieving lower numbers of in-patients: first, identifying the best practice models of care in the community. What does good look like? That may sound obvious, but getting the right answers is not the easiest thing to do. What is the right care for people in the community? First we have to find out what we want to see in all our constituencies that is available for that group of people.
Secondly, we have to focus on improving the transition into adulthood, in particular for autistic young people, because that is a particular problem resulting in in-patient admission. Thirdly, we have to reduce the number of people in in-patient care with judicial restrictions who, as I mentioned, are a significant proportion. Fourthly, we have to address some of the issues with funding flows and potential financial disincentives in the system, which hon. Members have mentioned, including the hon. Member for Worsley and Eccles South. Fifthly, we have to address the lack of available suitable supported housing. Housing is often cited as the most frequent barrier to discharge. Finally, we have to ensure that we have the right workforce.
Those are the priorities. Yes, we are working on a delivery plan, which will include milestones, such as my right hon. Friend the Member for Forest of Dean rightly called for—we all need to be able to see those. Specifically on the NHS role, since the pandemic, I have asked each of the 44 areas in the NHS to review where they are on delivering against our target and to come to me with what their trajectory is. Where will they get to over the coming months and years and, to the extent that they may be below the ambition, what actions will they take to close that gap?
I hope that that addresses my right hon. Friend’s question about my similar commitment to ensuring that we have clear milestones and targets, can see who is doing what, and have a grip on getting this delivered.
Yes, we plan to publish the delivery plan. We want to have time for the delivery board to feed into it, because we set that up earlier this year. It is complex and cross-government, so it takes a bit of time to bring that together, but broadly yes.
I want to touch on funding, because it was mentioned a number of times as one of the barriers. As part of the NHS England long-term plan, we are investing £40 million this year in improving community support and preventing avoidable admissions. There is an initial £31 million of funding for this issue as part of the NHS mental health covid recovery package. There is £11.35 million specifically to accelerate discharges from mental health hospitals, which includes funding to strengthen advocacy for people with a learning disability and autistic people, and £19.65 million to help prevent crises from occurring and to avoid admissions into in-patient care. There is also the £62 million community discharge grant, which is a fund over three years. The first tranche was issued last year, with a further £21 million to be distributed this year and next. That is particularly to cover some of the double running costs involved when a discharge happens. Someone may need care as an in-patient, but it also has to be set up in the community.
My right hon. Friend the Member for Forest of Dean also asked about the response to the CQC’s “Out of sight” review, which was requested by the Secretary of State for Health and Social Care and which reported back in October last year. It was a review of the use of restraint, seclusion and segregation. My right hon. Friend the Member for Forest of Dean asked when we would respond to it, and I can say that we will do so imminently. I hope he finds that reassuring, even if I cannot give a specific date.
I am mindful of the time, so I will wrap up. I thank all right hon. and hon. Members who have contributed to the debate. I know we are all deeply committed to ensuring that everybody with learning disabilities and autistic people get the care and support that they need. None of this is easy. Some of the individuals we are worried about have really complex needs, but I do not accept that as an excuse for poor or, worse still, abusive care. I will continue to work with the CQC, the NHS, local authorities and other Government Departments, and with the families and user representatives, who play a really important part and are part of the delivery board. I will work together with them to bring an end to this and make sure that autistic people and those with learning disabilities get the care and support that they need, and the support that their families need, to live their lives to the full.
I thank the organisations and campaigners who supported the debate, including Mencap, Rightful Lives—particularly Julie Newcombe—Care England, Dimensions and the Equality and Human Rights Commission for their support and briefings, to which other Members have rightly referred.
There is not a lot of time left, but I have heard across the different contributions—I thank colleagues for them—a real desire for change. We do not agree on every last detail of that—not everybody agrees with my recommendation to have a commissioner—but there is a real hunger and desire for change. Across the contributions, a great deal was said about personalisation, changing cultures, having pride in the NHS and not binding us to its failings, to which the hon. Member for Peterborough (Paul Bristow) referred. My hon. Friend the Member for Leicester West (Liz Kendall) rightly talked about putting families in the driving seat of change.
A decade after Winterbourne View, it simply is not acceptable that people are still detained, when they could and should be supported in the community. There is real agreement about that. I hope the Minister will listen to what has been said and ensure that the necessary resources and political leadership are delivered, so that we can ensure that the horrors of Winterbourne View are finally a thing of the past.
Question put and agreed to.
That this House has considered the 10th anniversary of the investigation into the Winterbourne View Hospital and the Transforming Care Programme.