House of Lords
Friday, 20 April 2007.
The House met at eleven o’clock: the LORD SPEAKER on the Woolsack.
Prayers—Read by the Lord Bishop of Worcester.
Victims of Overseas Terrorism Bill [HL]
My Lords, I beg to move that this Bill be now read a second time.
The spirit of our nation includes a sense of wanting to help those in need and wanting to right an injustice. In both those characteristics of our national spirit, we are failing the victims of terrorism abroad. For them, there is no system of assistance, compensation or, in simple terms, justice. Wherever the grieving spouse of a victim or an injured person might be, they are in a country abroad, suffering mentally and physically, culturally adrift and often without the means, either financial or organisational, to remedy their predicament.
In the second war, when London was subject to savage attack during the Blitz, the Prime Minister, Sir Winston Churchill, said that it was,
“unfair for British society to place the entire burden of the destruction on those unlucky enough to be hit”.
It is equally unfair not to compensate and assist those who are killed or injured by terrorism abroad when we give that assistance and compensation if it occurs here.
Let me explain the facts. We have, over the past seven or eight years, enacted with great force and parliamentary vigour many statutes against terrorism, on the fundamental premise that it is our duty as a Parliament, as a Government and as a nation to protect our citizens against terrorism. We provide protection for those citizens here, after the July bombings in 2005, under the criminal injuries compensation scheme. If they happen to be injured in a European country, each country is now obliged to provide compensation to any citizen of the European Union injured or killed by terrorism in their own territory. There is no such system beyond the United Kingdom and Europe.
Some 10 million or more British holidaymakers travel to countries outside Europe and the United States each year. Some of those were in Bali in October 2002, when 200 people were killed, 27 of them British. Some of those were in Turkey in 2005, when one was killed and half a dozen injured, Again in 2005, at Sharm el-Sheikh, 11 were killed and many more were injured. Those people were targeted because they were innocent, because they were tourists, because they were in a club, hotel or public space with no protection whatever; and they were so targeted to intimidate and create terror. Many countries have refused to accept that kind of threat. The United States, Australia, France, Italy, Sweden, Finland and Israel compensate their citizens for the effects of injury or death from terrorism wherever it occurs, each such country considering it its national duty so to act. Present today to listen to this debate are members of the families afflicted in those incidents that I have just described. They come to listen, in the expectation of parliamentary solutions to an injustice.
Those people—our people—injured abroad live here in their ordinary lives, pay their taxes here and act as citizens here, and we should not abandon them when they are injured by coincidence other than being here. At what cost? Doing the best that one can in an unpredictable state of affairs, having regard to what has happened and what might happen, it is thought that £3 million a year would present an adequate fund to meet the needs of such people. It almost embarrasses me to have to justify the expenditure of such a sum in such a noble cause. This state of affairs is a need that we must meet. The Foreign and Commonwealth Office seeks to do it through consular assistance and advice, but not beyond that. We have just agreed to pay £1 million in conjunction with the British Red Cross as an emergency fund, and by that very agreement we have thereby acknowledged the need, which is long term and not just short term.
Also, in insurance we do not meet the need. The House of Commons Treasury Committee, in its fourth report of this Session in February, on page 20, paragraph 2, said:
“We are especially concerned that there is insufficient awareness of exclusions in areas such as terrorist acts … and in particular by evidence that around ten million United Kingdom holidaymakers in 2006 would not have been covered for medical expenses in the event of terrorist incidents”.
When people in this country pay for their holiday insurance, they mostly have no idea at all that there is an exclusion for terrorism. When the bomb explodes and their lives are split asunder, there is no insurance.
The British Insurance Brokers’ Association has recently published a survey showing, from the results that it has been able to find involving 75 per cent of the market, that 78 per cent of policies have a terrorism exclusion clause, some of which will have a write-back provision for medical expenses—but that is an enormous proportion of the market. Some 15 per cent have no exclusion for terrorism and the existence of that 15 per cent illustrates that the risk can be insured, economically and on the open market. That state of affairs identified by the Treasury Committee and the British Insurance Brokers’ Association means that the insurance market should be the basic source for this kind of advice and assistance. The Bill seeks to use insurance to achieve that objective.
Clause 2 puts on a statutory footing that which is now a convention—namely, that our consular officials everywhere in the world should have a statutory duty to advise and assist our citizens in cases of terrorist attack and that the Secretary of State should consult and publish the arrangements reached after such consultation.
Secondly, regarding insurance, many of your Lordships will remember the IRA attacks in the City of London in the early 1990s. That led to the creation of an insurance system backed by the state, because the risk was thought to be enormous. The result of that arrangement between the Government and the insurance industry was enacted in the Reinsurance (Acts of Terrorism) Act 1993, whereby the Government became the reinsurer. That system, called Pool Re, now holds reserves of £1.664 billion; and through a retrocession agreement, the Government have been paid from that fund, since it was established, over £200 million. I await with interest anyone who suggests that £3 million is a figure that requires some special attention in the light of numbers such as that.
This Bill seeks to create a mirror of that which we thought was necessary to protect property as being the minimum we need to protect people. Clause 3 repeats, almost word for word, the property protection provisions of the 1993 Act and allows the Government to assimilate this scheme into that. It is neat, tidy, economical, practical and there is no reason why it cannot be done.
The fallback position under the Bill is a scheme similar to that for criminal injuries in this country. It is a fallback scheme; it should not be necessary—but the Bill makes provision for it, in case it becomes so, if arrangements with insurers do not bear fruit.
The scope of the Bill is directed at British people who are ordinarily resident in this country, but I realise that there is a problem, as many noble Lords have indicated to me—a person engaged in charitable work overseas can be just as much at risk as a transient visitor. The Bill allows the Secretary of State to introduce a wider range of protection than is presently envisaged in Clause 1.
What is the conclusion? I have been sent correspondence by Members of your Lordships' House from across the political parties and the Cross Benches, and from every political party in the Commons. Nobody—I stress, nobody—has suggested that there is anything wrong with this idea. No doubt, that is why in October 2005 the Prime Minister said that the Government would consider a scheme of this kind. This was pursued by Tessa Jowell in her ministerial role. She has been very helpful and co-operative with those who have been involved in seeking to implement these changes. She says that the £1 million that the Government have given is not a compensation scheme—it is temporary relief. In a recent letter, she stated:
“I recognise that this is not a compensation scheme and that there is a disparity between the state UK compensation scheme offered to those killed or injured at home, and the financial assistance offered to those affected abroad”.
She promised that the Government would consider the issue and, I hope, might act.
I emphasise that this Bill does not make any primary call on public funds. It says to the Government, “Do for your people that which you did for your property owners”. It does, however, create substantive provisions that allow negotiation and consultation to take place, followed, we hope, by the implementation of a different insurance market covering this risk.
One of our parliamentarians, Toby Ellwood, the Conservative Member for Bournemouth East, lost his brother in the Bali incident. He is quoted as saying that terrorism has no borders and neither should our support for the victims of terrorism. It is unbecoming of our country that this state of affairs exists. We should act before it shames us. I commend the Bill to the House.
Moved, That the Bill be now read a second time.—(Lord Brennan.)
My Lords, I declare an interest as the chairman and chief executive of an insurance broking and financial services organisation.
The Government currently provide compensation for British nationals who become victims of terror within the United Kingdom. They also provide compensation to non-British citizens of terror in this country; for example, all victims of the 7/7 bombings have been compensated. Compensation is paid by the Criminal Injuries Compensation Authority and total payments amount to about £200 million annually.
Unfortunately, British citizens who are victims of terrorism overseas are not compensated unless they are in a country where compensation arrangements already exist. Over the past decade, British citizens have been killed or injured in a number of overseas territories. There is considerable hardship in these cases and there is therefore a need to set up a scheme whereby payments are made.
Although I am very sympathetic to the intention behind the Bill, I should like to raise a number of points relating to the proposals in it.
Insurers who provide travel cover are committed to paying claims as quickly as possible, but it must be pointed out that travel insurance is not primarily designed to cover personal injury or death claims. A travel insurance policy is a package-type of insurance providing cover under various sections, including personal accident, medical expenses, baggage, cancellation and curtailment benefits, loss of personal money and personal liability. Cover in regard to death, injury and long-term care are more appropriately provided under personal accident, life insurance and income protection policies.
Travel insurance is very competitively priced, but the more you add on, the more it will cost. We believe that one-third of travellers who go abroad from the United Kingdom do not effect travel insurance and they therefore expose themselves to considerable risks if things go wrong. Insurers would like to provide as much cover as possible at a competitive price to encourage people to effect cover. Unfortunately, however, only about 66 per cent of people take out policies, which is not satisfactory.
Practice among insurers regarding terrorism varies and can be summarised as follows: first, no cover at all; secondly, only medical expenses and repatriation cover following a terrorist attack; thirdly, medical, repatriation and personal accident cover for terrorism except in cases of nuclear, chemical or biological attacks; fourthly, personal accident medical expenses sections which apply unless people travel to a country or specific area where the Foreign and Commonwealth Office has advised them not to go.
Those standard covers are available to all policyholders, but insurance is available for both travel and personal accident to people who wish to travel to countries where there is a danger of terrorism or hostilities. Insurers underwrite that separately and the premiums are high. There is therefore special insurance to cover terrorism abroad, which provides appropriate benefits.
I feel that proposals to provide insurance generally to everyone would be difficult to implement. There are several factors in this regard, which can be summarised as follows: first, there is a question of cost and how the premiums are to be assessed; and, secondly, for a scheme to be meaningful, it needs to be made compulsory. The only compulsory insurances in the United Kingdom are employer's liability and motor insurance for third-party risks; in other words, cover is mandatory where there is a possibility of death or injury to other people. A number of drivers do not effect motor insurance, despite road traffic legislation, and payments for their liabilities are paid by the Motor Insurance Bureau, an organisation set up by insurance companies and funded by levies on the insurers.
I have already pointed out that at present one-third of people who go abroad do not take out travel insurance, and compulsory insurance requirements would therefore be difficult to implement and difficult to police. Arrangements for insuring property damage and business interruption caused by terrorism in the UK came into force in 1993. Prior to that, insurers were unwilling to provide full cover for terrorism and cover was granted with limited indemnity liability.
The Reinsurance (Acts of Terrorism) Act 1993 was enacted to address the provision of full cover, and Pool Re was set up as a response to the Act. HM Treasury is the reinsurer of last resort for Pool Re, protecting it in the event that it exhausts all its financial resources following payments.
Since 1993, Pool Re has made payments of £612 million and has reserves of £1.664 billion. Insurance cover for policyholders provided under the Pool Re arrangement is optional, and policies are taken out by property owners who can afford the premiums. Therefore, the insurance is not compulsory. However, there would be a problem of affordability with regard to overseas travel cover for the general public, and, as I said earlier, to be meaningful, it would need to be mandatory.
I have heard people say that reserves built up by Pool Re could perhaps be released to pay for injuries to people who travel abroad. As I have said, Pool Re has reserves of more than £1.6 billion, but I believe that the release of these funds would be unwise as the reserves are necessary to pay large claims following a major incident or incidents occurring in future. I may add that the damage at Canary Wharf, Baltic Exchange and the Arndale centre was in excess of £1 billion each. Furthermore, it could be argued that the premiums have been paid by policyholders who have insured their properties, and to use them for any other purpose would not be appropriate.
There is another option regarding funding, which is to apply a levy of some sort, which could be considered. If such a levy were applied, it would be considered as a tax on holidays and travel. A levy would therefore cause difficulties and not be very popular. I therefore feel that compensation for injuries for terrorism overseas can be considered as an extension of the Criminal Injuries Compensation Authority arrangements. The existing scheme is successful; matters are investigated fully and fraudulent claims are resisted. At present, payments under the compensation scheme are made under the Home Office budget, which may have been frozen by the Chancellor.
In October 2005 the Prime Minster announced that the Government were looking at setting up a separate compensation scheme to cover British victims of terrorism overseas, and perhaps this matter can be pursued further. I understand that there are compensation schemes operating in other countries, which are funded by their governments. It remains to be seen if there is the political will to arrange state-run schemes in the United Kingdom and whether funds can be made available to implement the scheme. The mechanism is, however, here to process the claims.
The cost of the scheme will, of course, depend on the scale of benefits, who will be the beneficiaries and the number of incidents involved. I understand that a figure of £3 million has been suggested, and I am not sure if this will be sufficient. I add a note of warning that, if consideration is given to extending the Criminal Injuries Compensation Authority scheme to pay for terrorism overseas, there could be a demand that the scheme should be extended further to pay for victims of all violent crimes overseas.
My Lords, I strongly support this Bill and hope that it will find its way on to the statute book very soon. I congratulate the noble Lord, Lord Brennan, on bringing it forward. The arguments advanced to justify it are compelling; the benefits are immeasurable and the political and financial cost to the Government appears to be virtually nil.
However, I should like to outline a case for widening some of the definitions in the Bill. I have discussed this briefly with the noble Lord, Lord Brennan, and he took note of that in his opening speech. I understand why the definitions in the Bill prevail, but nevertheless, I should like my concerns to be on the record.
The definition of a victim is to my mind unnecessarily narrow; the Bill refers to UK citizens as,
“ordinarily resident in the United Kingdom”,
which would preclude those UK victims temporarily working in the Wall Street district of New York City on 9/11, who may well have become non-resident for a matter of a few months. I therefore suggest that the legislation should apply to British citizens generally, and not only to those resident in the UK. Again, I acknowledge that the noble Lord, Lord Brennan, addressed that.
Secondly, the definition of the victim is construed so as to include only those who suffer injury as a direct consequence of a terrorist act such as the Bali bombing or that in Sharm el-Sheikh in 2005. However, we all know that immediately following such an outrage, local authorities round up potential suspects, who eventually may, and indeed do, turn out to have been completely innocent bystanders. They are detained and all too often tortured with the aim of getting a confession. They, too, are victims and could perhaps be included in the definition as individuals who have sustained injury as a direct result of an act of terrorism or unlawful counter-terrorism measures constituting crimes under international law.
If those amendments were accepted, it would be logical to replace the heading in Clause 2, “Advice and Assistance”, with “Advice, Assistance and Protection”. That implies that at times there would be an obligation to afford diplomatic protection that goes beyond mere advice or assistance.
In addition to extending the scope of the definitions in the Bill, the question of the compensation of victims suffering injury overseas invokes some consideration of the role of the UK Government through their diplomatic representatives in not only assisting victims but preventing any possibility of abuse such as torture. Now, it may well be concluded that adding this dimension would stretch the Bill beyond acceptability—it probably will—nevertheless, I wish to take the opportunity to at least outline the kind of difficulties that victims face when caught up in arbitrary and terrifying actions on the part of foreign Governments, and in so doing I acknowledge the great contribution to this area of law by the Redress Trust.
Let me give a short and hypothetical example—hypothetical but culled from real-life experiences. A young British citizen of north African origin is arrested following a terrorist incident in Egypt. He is detained at the local police station. As a British citizen, and under international law, he has a right to humane treatment, to be free of torture and to have access to a lawyer. Under the UK rules applying to international claims governing diplomatic actions, he should be visited by a representative and his safety guaranteed while investigation takes place and before any charges are brought. The likelihood of the detainee being tortured in countries such as Egypt is extremely high; and the international standards on human rights should be the benchmark for consular or other diplomatic staff actions.
However, and here again I emphasise that this example reflects the reality of several cases, under UK domestic rules there is no obligation to protect the individual or pay reparation if to do so would be contrary to broader foreign policy needs. In other words, the interests of the state always come first. Since the UK has not incorporated the doctrine of diplomatic protection into its domestic legislation, the rules are in fact a statement of general policy and have no effect in law.
Apart from this gap, torture survivors also report a depressing litany of failures on the part of officials, including, for example, insufficient warnings to travellers about human rights violations in certain countries. In this context, I should mention that often contradictory advice is given by the Home Office or the Foreign and Commonwealth Office. There is often a failure of consular officials to make timely visits. In one case, despite having been informed, a British official visited the prison where the UK national was being held four weeks after he had been detained and, in another case, after two months. Very unfortunate things can happen in such a period.
The fundamental point is that a torture victim is in the most vulnerable position imaginable and even a day’s delay is too long. Another victim was given the name of a lawyer 11 months after his arrest. When complaints are made by UK officials they are often made to the perpetrators of torture and ill treatment, rather than to a higher level, thereby rendering the victim liable to further ill treatment.
The Bill is about proper reparation to victims of terrorist attack. Of course, I realise that I have strayed far beyond its remit. However, I believe that victims and their relatives are not the only injured; the illegally detained and the abused are also injured. In these cases the role of UK officials abroad is crucial. The more timely and resolute the action, the greater the chance that those UK citizens in countries where abuse and torture are endemic will be better protected.
My Lords, I had not intended to speak on this subject, but it is one of the rare occasions when I feel emotional about the issue and part of the reason for the debate. I know the young people in Bali very well. They are quite different from the sort of people who normally attract terrorism on this sophisticated level.
Bali does not have masses of military around, so they are not a target. It does not have many big, rich hotels. It contains one thing in large quantities: young people, water skiing and drinking. They normally do so in Gang Poppies, a lane based around a small pub set up 20-odd years ago by two Australians. They go there to enjoy themselves, and they were prime targets for terrorists of this type. It will not happen once, twice or three times; it will be done over and over again. They are not big names. Nobody knows who they are. But it brings a new edge to the evilness of those who are happy with what they have achieved through this. The upset caused will happen many times. It will not just be the children who are upset and killed in a ghastly manner.
At a little hall that I also know very well, attackers set fire to the inside and, as they came out, they blew up cars across the entrance for the sheer fun of it. The Government of that area are not particularly popular in many respects, but they tracked those people down. Within 78 hours, a large number of them were already under arrest—that was additional to insurance. Governments themselves might begin to take a rougher view of terrorism on this scale.
My Lords, the Bill addresses a real problem which the Government have addressed in other aspects of our lives: the idea that people caught up in terrorism should be compensated. It deals with a gap which we had not seen before. As the noble Lord, Lord Marsh, has said, I am afraid that the Government are once again being reactive; they have to be. We had not thought that terrorism would strike in this way or format.
The noble Lord, Lord Brennan, has therefore come up with a solution. Whether it is the best solution conceivably available might be open to question, but it is the one now before us. The noble Lord deserves credit for bringing it forward now, in the face of absolutely nothing happening elsewhere—or, if not nothing, then at least not enough.
Is it affordable? When he gave us a briefing on this, I asked the noble Lord whether he thought it was. He came up with the figure of £3 million, repeated today. If that is the case, it should be made available. Is the insurance industry as it stands capable of doing this? Probably not. If you have an exclusion against something which you think will probably not happen but could be very expensive—it is safe to say that insurers are there to make money—something else must happen to fill the gap. Normal policies will probably not provide for that.
This scheme gives us a potential way of dealing with a problem. It is less a matter of asking the Government than of asking the Treasury Bench whether they think there is another way of doing it or whether the Government have any information about another way forward. If there is an objection to the scheme or a way of extending treaties overseas, or if it is reasonable to expect potentially poor countries to provide this degree of compensation, I would be interested to hear about it. I doubt there will be an objection, but it is just the kind of question I want to hear answered. If the Government cannot give us a compelling answer why the Bill is not needed, we should accept it or something like it. It gives us a last resort.
What else could we do? We could adopt something totally unlinked to insurance, leaving it up to the Government. That is a possible answer. Unless we address this problem through some government scheme, however, we should look very hard at the Bill in front of us, or something very like it, and we should do so soon.
My Lords, the noble Lord, Lord Brennan, has made a powerful case for the victims of overseas terrorism. I do not think that anyone can fail to be moved by the plight of the victims of incidents such as those at Sharm el-Sheikh or Bali.
The Bill allows us to debate the nature of the relationship between citizens and the state in today’s world and, more specifically, what citizens can expect from their state. It is clear that citizens can expect the state to protect them from physical harm within its own boundaries, whether from hostile incursion or, in today’s world, from terrorist attacks from within. However, I do not believe it has been established as a general principle in our country that there is an absolute right for citizens to be protected from economic harm caused by those who attack our nation. In practice, the Government have provided compensation to victims of violent crime, including terrorist acts committed in our country, through the Criminal Injuries Compensation Authority.
The Bill forces us to confront the question of how far the state—or, more accurately, taxpayers—must seek to protect its citizens from economic harm if they choose to travel beyond our boundaries. Overseas travel is now affordable by many in our society; indeed, it is available on a scale which would have been unthinkable less than a generation ago. The question we have to ask is whether it is reasonable that those who travel overseas should impose a financial burden on those who do not wish to travel or perhaps do not have the resources to travel. We do not find this easy, and I do not think that there has yet been a proper debate on this whole issue. The Bill gives us an opportunity today to start that debate, and we are grateful for that, but it also raises complex issues.
There should also be a debate on whether there should be an obligation on those who travel abroad to carry proper insurance. My noble friend Lord Sheikh, who has much insurance expertise, thought that that would be difficult to achieve, and I am sure that that is the case. The British Insurance Brokers’ Association, to which other noble Lords have referred today, noted that 15 per cent of policies have no terrorism exclusion and a further 29 per cent cover medical expenses and some other costs. So, it is clear that insurance is available. Of course, part of the problem is that large numbers of our citizens go abroad without any insurance cover at all, and others go with inadequate cover. Is it then reasonable for the state to assume the role of de facto insurer for those who choose, either knowingly or through ignorance, to travel uninsured or inadequately insured?
I am not sure that Clause 3 is necessary, since cover is currently available. Does the noble Lord, Lord Brennan, know whether the insurance industry wants to enter into arrangements such as Pool Re, with the Treasury acting as reinsurer of last resort? The noble Lord said that the Treasury acted as reinsurer in those cases. In fact, Pool Re is the reinsurer, and it is a mutual arrangement for the insurance industry. The Treasury merely acts as the reinsurer of last resort. That enabled the insurance market to provide much needed and desired, though not obligatory, business cover in the wake of the attacks referred to. Is there a similar demand for terrorism cover within travel policies, which will of course have a cost, and which needs to be facilitated in this way? After all, if the arrangements for compensation in Clause 4 are brought into effect, why should anyone pay for insurance? They will see the state standing behind, ultimately, as the insurer.
We are concerned about the scope of the Bill in Clause 1. The definition of “overseas terrorism” is wide. On my reading of the Bill, it would cover businessmen or contractors who were working in, say, Iraq and were caught up in the attacks that happen there all too frequently. It seems that, as Clause 1 is drafted, they would be within the Bill’s scope, but should they be? Those who choose to go to Iraq know the risks that they run, and, as we heard earlier, specialist insurance is available for that. The Bill will also give favoured treatment to those who can show that terrorism, as defined, is the cause of what has happened to them. But is there a logical distinction between someone injured as the result of a terrorist attack and someone who is injured, for example, as a consequence of a hit-and-run accident or of some other kind of violent crime while on holiday abroad?
We understand and sympathise with the starting date of 1 January 2002 although, as a general principle, we do not like retrospection. The plain fact is that terrorism did not start on that date. Since the insurance arrangements by definition cannot have retrospective effect, the Bill in effect creates a special class of victim qualifying for compensation on a retrospective basis. We are not sure if that is a proper legislative principle.
The core of the Bill lies not in the advice and assistance in Clause 2, which may not need to be provided in statute at all. It is certainly not in Clause 3, because insurance will not in any event be compulsory under the Bill. The heart of the Bill is in the compensation arrangements, which are called an “awards” scheme but are plainly a compensation scheme. Here, the crucial issue is cost. The noble Lord, Lord Brennan, has referred to the cost of £3 million per annum, which seems modest. The criminal injuries compensation scheme currently costs around £200 million a year. While terrorist incidents to date may not be so numerous, the average cost of those incidents must be high. I find it difficult to see £3 million as the likely cost of such a scheme if it were introduced. We cannot go forward with the scheme unless there is a clear understanding of the costs that are to be imposed on the taxpayer.
Last year the Government announced a donation of £1 million to a fund to be administered by the Red Cross to assist victims of overseas terrorism. Clearly that would not match the kind of payouts envisaged by the noble Lord, Lord Brennan, but it was something positive. I hope that the Minister will say something about that fund today.
There remains the possibility of seeking compensation in the relevant overseas courts for loss or damage or under local compensation schemes. Perhaps the Minister will say something about the opportunities that exist for victims to seek compensation abroad, and whether the Government intend to support victims in that endeavour.
We have tremendous sympathy with and compassion for the victims of terrorism, wherever it takes place. But we have to temper our sympathy and compassion with realism. In today’s global world, should we look to the state—and therefore its taxpayers—to keep its citizens free from economic harm without geographic or other limit? That is a question I cannot answer today, but I welcome the debate that the noble Lord’s Bill has allowed us to have.
My Lords, I join all noble Lords who have thanked my noble friend Lord Brennan for introducing such an important Bill today. It has led to productive debate upon an issue about which we are all concerned. He was right when he indicated that the support for the principle behind his Bill would extend across all parts of this House, and indeed in all parts of the other place too. If one had doubted that for one moment, the noble Lord, Lord Marsh, testified to that effect with an unscripted and unheralded speech in which he indicated that these issues are of great concern to us all. My noble friend made his case with his usual eloquence and skill, and those whose cause he is seeking to advance should be suitably grateful to him for his concern about this area. They could not have a better advocate in this complex and important matter.
I also thank the families of the victims and the survivors of previous overseas terrorist incidents, who have done a great deal to bring this issue to public attention and to ensure that the Government address it. I shall respond to the Bill and indicate where it will need improvements, but also indicate just what the Government’s thinking is and how we hope to be productive in this area.
In recent years UK citizens have been affected by terrorism overseas, and we have to respond to that. It raises new issues for us. After the 7 July bombings, it became obvious that to enable a seamless and co-ordinated response from Government to the short-term and longer-term needs of those affected, we would have to address this issue in much clearer terms than we had done in the past. That is why we established a new Humanitarian Assistance Unit within the Department for Culture, Media and Sport to address these needs, and to ensure that the work is grounded in the direct experience of those who have suffered in previous tragedies. A great deal of that work is inevitably with other government departments, particularly the Foreign and Commonwealth Office, ensuring that the Government continue to offer assistance to victims of overseas disasters once they return to the UK, and improvements are continually being made to the provision of clear information and practical support to all those who are involved.
In addition, the charitable fund creates a base for some financial assistance to victims of overseas terrorist attacks. We recognise that there is a very clear disparity between the financial support available to overseas victims and that available to those who suffer from terrorist attacks within this country. We announced last year that we would contribute £1 million to the charitable fund for overseas victims, an issue that the noble Baroness, Lady Noakes, raised. The fund will be run by the Red Cross, and it will be ready to launch formally very soon.
In the mean time, the Red Cross has already made payments to all those bereaved or seriously injured by overseas terrorism since the fund was announced in March this year. So far 21 payments have been made from the fund: one bereavement payment and 20 payments relating to injuries from attacks in Egypt, Turkey, Jordan and Thailand. Those payments were not intended to meet the longer-term needs of those involved but the immediate financial needs that we recognise arise, such as the immediate need to meet mortgage or rent payments and telephone calls and travel to the affected areas. We recognise that the charitable fund is not a compensation scheme; it will never purport to be that, and it does not meet the issue of the disparity between what is available in this country to victims of terrorist attack and what is available to those overseas, which is the burden of the Bill. I recognise the importance of our response to that.
We have therefore been looking at the financial options available for victims of overseas terrorism. We understand the argument put forward for a new compensation scheme, but there are important issues to consider. First, should we look for compensation for UK citizens from the country where the attack occurred? Many countries offer their compensation schemes and my noble friend Lord Brennan indicated the extent of that in European Union countries. The problem is that they are only some of the countries which are visited by British tourists and that recent attacks have been outside Europe.
The principle at stake is whether the Government should fill the gaps or whether we should look to other Governments to do so. I respect the point made by the noble Lord, Lord Addington, that some countries and Governments may be ill placed to make such provision. However, others are directly comparable with the states of the European Union and it would be reasonable for them to adopt the same strategies.
Secondly, should we treat victims of terrorism differently from victims of other violent crime? I am afraid that there are victims of horrific, life-changing crime committed overseas and the significance of its impact on them and their families is as bad as terrorist incidents. The Criminal Injuries Compensation Authority does not treat victims of terrorism differently from victims of other violent crime committed within the UK, nor does the separate Northern Ireland scheme. They are treated equally. Therefore, to do so overseas would mean taking a different approach and we are not confident that that would be the right decision.
Neither of those issues would prevent us establishing a compensation scheme if we decided to do so, but it is clear that we need to examine them in close detail before reaching a conclusion. We are committed to solving these problems and we do not pretend that they are anything other than difficult to tackle. We must define who would be eligible for compensation; we must define “British”, “injury” and “terrorism”; and we must define how a scheme would work alongside the existing domestic Criminal Injuries Compensation Scheme and the reciprocal schemes in Europe.
We are therefore not in a position to be as categorical as the Bill requires us to be. Although I am offering my noble friend the Government’s commitment to tackling this issue, we are not in a position to say that the Bill provides the solution that we need. It certainly goes some way towards it and it advances the cause, as shown by the contributions to today’s debate. Furthermore, there is the issue of travel insurance, commented on by the noble Lord, Lord Sheikh, and dealt with in considerable detail by the noble Baroness, Lady Noakes. It is essential that when people choose travel insurance they understand exactly what they are covered for. Travel insurance is designed to provide immediate assistance to individuals when travelling abroad. It is not designed to compensate them for loss or suffering, although some policies pay out for some personal injuries.
As the noble Lord, Lord Sheikh, indicated, there is a range of policies on the market at different prices offering consumers different levels of cover. We do not think that it is the Government’s role to compel insurers to offer cover. The noble Lord, Lord Sheikh, deployed arguments against compulsion which raised philosophical and political decisions about the nature of compulsion on our society. Decisions on price and coverage are ultimately commercial ones for the insurer. However, cover is available for terrorist attacks and it is important that our people are aware of it and take advantage of that. We do not believe that there is a market failure which warrants government intervention to compel insurers to provide cover or to set up the Government as an insurer of last resort. That is not the position that confronts us.
However, we believe it is necessary that my department and the Treasury continue to work closely with the insurance industry to ensure that terrorism cover is readily available and that where exclusions exist consumers are all too well aware of them. A recent Treasury Select Committee report recommended that the Government and the FSA should work together to develop insurance policies that are clear, in plain English and effectively promoted to ensure that holidaymakers know exactly what is included. We are about to respond to its recommendations.
Clause 5 of the Bill requires that sums paid by the compensation scheme following injury or loss resulting from an act of terrorism overseas take into account an insurance payment made to the injured person in respect of that injury or loss. However, as I have noted, travel insurance is designed to provide immediate assistance, not to provide compensation for long-term suffering and loss. Such a clause might well act as a disincentive to individuals to take out terrorism insurance cover and there would be the danger that insurance cover, if stretched too far, might be unattractive because of the inevitable rise in premiums. It is important that consumers purchasing travel insurance are able to make informed choices about what they are, or are not, covered for. Insurance covering individuals for terrorism in certain cases is available on the market and we see it as the task of government to raise people’s awareness of what they are purchasing in travel policies.
There are aspects of the Bill which, my noble friend Lord Brennan will recognise from today’s contributions, raise difficulties. A brief reference was made to the retrospective aspect of the provision, which is an important issue. Government schemes do not operate retrospectively because we are concerned that that can cause unfairness as regards existing schemes. My noble friend will recognise that that is a significant argument that he will need to confront when piloting the Bill further in this House and during its passage in another place.
We recognise that the Bill reflects the considerable work undertaken by a large number of people in tackling this issue. Where we are able to give support, we intend to do so and we are giving our support to the Red Cross scheme. However, there is another aspect of the Bill which raises interesting issues. My noble friend Lord Brennan mentioned consular assistance being placed on a statutory basis and that has significant implications for government. The noble Baroness, Lady D’Souza, indicated where she wants to see an extension of such activity and that certainly fits within the desired aims. However, it will be recognised that putting consular assistance on a statutory basis is a profound legal proposition. It may be a modest aspect of the Bill, but it raises substantial issues for the Government. Once it was in statute, it would mean that all the consular service’s actions in respect of incidents abroad would potentially become subject to litigation. We are all too well aware that consulates do their best and work constructively under enormous difficulties and in a vast range of circumstances. The House will recognise how significant it would be if such actions were potentially subject to litigation in this country about their effectiveness.
I recognise the enormous amount of work that has gone into the Bill, which addresses an issue that needs urgent action. I assure the House that it is part of the process to which the Government are responding. We intend to respond in the very near future about how we tackle these issues because there is a clear obligation on us. However, as my noble friend will recognise, these are not straightforward or easy issues. Even within the framework of the Bill, there are issues that raise fundamental difficulties. The Government regard the Bill as a contribution to the debate and a pressure upon us to effect solutions, but we are not convinced that it provides the solution that the whole nation is looking forward to the Government providing.
My Lords, the Minister’s closing words were that we are dealing with an issue that needs urgent action, and I welcome them. I agree. It would be most unwise of the Government, the leaders of other political parties and civil servants to assume that the people can be ignored on this issue because it is too complicated. We do not expect that kind of longer term debate about something that needs an urgent solution.
I shall make four short points. First, I talked about compensation, but it would be infelicitous to treat that as synonymous with economic harm. I am talking about people who are killed, who have their arms shredded or who lose their eyes. They have to pay for their medical expenses, their rent and their families. That is what I mean by compensation, not something that so many in the country deride, but the simple means of keeping a family on its feet.
Secondly, I am gratified that the issues that have been raised as creating difficulties were entirely predictable and, in my view, entirely soluble. The question is the intent, not the capacity to overcome detail.
Thirdly, there is the question of cost. I, and those working with me, sought to produce a cost. Those who oppose my cost can produce their own, and we can examine it. Nobody has yet done so.
I shall make two points about the insurance industry. If there are 10 million holidays to countries that do not have systems of compensation that we can call upon and we say that the average premium is £15 or £20, that is touching £100 million for the two-thirds of the 10 million who might take out a policy. Out of that £100 million, our Government takes 17.5 per cent insurance premium tax, which is £17.5 million. They are acutely aware of the value of the travel insurance market. There are six national insurance firms providing cover, and they must be doing so on the basis that it is economic, it covers the risk and there is a reasonable premium to be charged. So this is a case not of insoluble complexities but of a meeting—I am happy to propose one—between the insurers, the Government, the British Insurance Brokers Association and all interested parties in order to come up with a solution.
My last point is that if an American, an Australian, a Frenchman, an Italian, a Finn, a Swede or an Israeli was sitting in the Public Gallery, he would say to himself, “My Government provide me with this, either through insurance or through government schemes. Why doesn’t it happen in the United Kingdom?”. Are our complexities different from theirs? I think not. It is time for action. The Bill will pursue it, and I invite your Lordships to give it a Second Reading.
On Question, Bill read a second time, and committed to a Committee of the Whole House.
Alcohol Labelling Bill [HL]
My Lords, I beg to move that this Bill be now read a second time. It has a very simple objective: it seeks to compel manufacturers, distributors and retailers of alcoholic products to display a warning label on all bottles or cans that contain alcohol. The label will state the following:
“GOVERNMENT WARNING: drinking alcoholic beverages during pregnancy, even in small quantities, can have serious consequences for the health of the baby”.
In drafting the Bill, several points have been uppermost in my mind. The first is that the Bill should be tightly focused. We could have widened it much further, but we judged that for a privately introduced Bill of this nature, the wider it is, the less likely will be our chances of success.
We also thought long and hard about the inevitable objections that will be raised. The words “nanny state” have already been raised in some quarters, so we have ensured that the Bill is only about giving a warning and is not about forcing any member of the public to do anything that he or she does not want to do.
Finally, we have thought about the cost of labelling. It is predictable that the alcohol industry will raise this matter, but its argument looks a little thin when it already meets identical costs in other countries where labelling is compulsory.
In a nutshell, the Bill is being introduced because drinking alcohol while pregnant is dangerous. Many women are unaware of the danger. We seek to make them, their partners and the world in general aware of the risks to the unborn baby.
It does not need me to stand here today to tell your Lordships about the alcohol pandemic that plagues our country; we see it in the media, and we see it in all its harsh and revolting reality on our streets. However, we are walking a tightrope; we do not want to come across as puritans preaching against fun. Drinking is a highly pleasurable experience, and most of us enjoy it. We are not against young people drinking, even occasionally to excess—after all, which of us never did that? However, what we do want to do is to increase the awareness of the dangers of drinking while pregnant.
Since time immemorial, drunken young people have engaged in sexual encounters that when sober they might have avoided, and there is nothing much we can do about that. However, put sex and alcohol together and there is indeed a cocktail, but of a very different kind. The physiology is simple. The developing foetus in its early stages in the womb has no liver. Its formative body is unable to deal with the same toxins as the fully fledged human being. Therefore, all the poisons its mother ingests will pass through the placenta into the baby’s bloodstream.
Alcohol is a lethal poison. It has the potential to cause great harm to a foetus. It can kill brain cells that can never be replaced; it can damage the nervous system and connections within the brain itself; and it can retard the growth of vital organs, particularly the heart and lungs.
Like tobacco and lung cancer, the correlation is not perfect. People who do not smoke still get lung cancer, just as people who smoke do not get lung cancer. Nevertheless, the relationship of one to the other is now beyond dispute. So it is with drinking when pregnant. Harm is not certain, but it is more likely. It is the risk of this harm that we are trying to address.
Through no fault of their own, future children are being sentenced to lifelong brain damage. Tragically, many of their mothers have not been educated or informed about the risks of alcohol in pregnancy. That is the objective of the Bill—to inform them of the harm that their unborn babies could be exposed to. That harm is called foetal alcohol spectrum disorder. As a spectrum it has many forms. In its most benign form it can cause many types of behavioural problems. It is claimed that, for example, some forms of attention deficit disorder are caused by FASD. It is also felt that many forms of juvenile unsocial behaviour can be similarly traced back to FASD.
The cost to our society resulting from such conduct is vast. Any action taken to ameliorate this condition would be of benefit to society as a whole. It is believed that one live birth in 100 produces a baby with some form of foetal alcohol spectrum disorder. Put another way, this equals 7,500 babies per year.
At the other end of the spectrum is foetal alcohol syndrome. This takes the problem into a different and more acute dimension. It is judged that in this country between one and three children in 1,000 are born with the condition. That represents somewhere between 750 and 2,250 per year. That is more than the combined number of babies born with muscular dystrophy, spina bifida, HIV and Down’s syndrome. Foetal alcohol syndrome manifests itself in many ways. In some cases the child appears physically normal; in others the child has a series of facial deformities. Widely spaced eyes, a small head due to a smaller brain, thin lips and a flattened philtrum between the base of the nose and the upper lip are all indicators of the presence of the syndrome.
However, it is the hidden brain damage that causes maximum problems. Children with FAS are emotionally and mentally delayed. Typically, they have difficulty in telling time, they get lost, they cannot remember instructions and they are largely innumerate. Eighty per cent are not able to live independently and will always need to rely on the state or other carers.
Sadly, many children in this world are born with all sorts of physical or mental handicaps and sometimes with both. But the harsh reality of foetal alcohol syndrome is that these births are not inevitable. They are not a quirk of nature; they are the result of someone else's actions, and that someone is the child's mother. The fact is that foetal alcohol syndrome and the complete spectrum is preventable: it does not have to happen.
For many years I and others have been lobbying the Department of Health, the alcohol industry and anyone else we can get our hands on, to make them aware of this problem. In the beginning we received polite but cool brush-offs. They asked: where is the evidence? And when confronted with experiences elsewhere, particularly in the United States, we heard, “Just because other countries make it mandatory for alcoholic containers to have labels attached to them, doesn't mean that we have to follow suit”. That is an odd and somewhat parochial conclusion when you think about how rampant binge drinking and alcohol abuse is in this country.
Refusing to take no for an answer is now paying dividends. We hear that the Department of Health is close to reaching an agreement with the alcohol industry. It has been reported that the industry is willing to adopt a code that will encourage labelling. I gather that the label will warn the public in general to restrict alcohol consumption to a number of units per week. I have always had a problem with units as a measure; it is too imprecise and too easily fudged. What is a unit? Is it a glass of wine? How big is that glass of wine, and how strong is that wine? Is it 14 units per week spaced over the week, or is it 14 units consumed in one boozy evening? And, “If they say 14 units, they probably mean 20; and if they mean 20 then probably we can get away with 25”. Such is human nature.
Standing around a bar with a bunch of friends is no place to consult the alcohol unit calculator. Nevertheless it is a start. What would be even better is if the label had a warning specifically directed at the dangers of drinking while pregnant. That would be the bold decision.
When it comes to pregnancy we are dealing with an imprecise measure. We do not know how much alcohol is safe. Neither do we know when it is safe. It is a game of Russian roulette—drink at one moment and the chances are you will be safe, but pick the wrong time, without realising it is the wrong time, and the consequences can be lethal.
I therefore ask the Department of Health to reconsider its current position, which is that for pregnant women a few units per week are acceptable. The only reliable message that they should be giving is that no alcohol is safe during pregnancy, and it is to be totally avoided.
Then the question is whether a code imposed by self-regulation is sufficient. I do not think it is, and that is why I believe that this Bill, making it mandatory to include a warning label, is a better solution. I simply do not believe that all suppliers of alcoholic beverages will abide by the code all of the time. The bottle of Bacardi Breezer may have the label attached, but will the bottle of Château Lafite 1982? Perhaps the Minister will let us know the department's thinking on that point.
Other countries have taken the lead on this issue. In the United States compulsory labelling has been in place since 1989. In France a law was passed last year. Others are following; for example, Finland, Chile and Poland. Of course this causes the alcohol industry a great dilemma. How can it possibly object to compulsory labelling in our country when it is forced to include it elsewhere? Where is the logic that requires one consignment of Scotch whisky going to New York to have an American label stuck on at the distillery, whereas a similar consignment bound for London from the same distillery will not? Is it really saying that British women are not entitled to have the same health message as American women? I sincerely hope not.
I should like to take a few moments to make a further comparison with the tobacco and cancer issue, because it is relevant and a pointer as to how matters could develop if not addressed now. The tobacco companies were well aware of the links between smoking and cancer from the early 1950s, yet they sat on the evidence and denied it in public. Labelling was eventually introduced on tobacco products, despite intensive lobbying by the very well resourced tobacco industry. Finally, the anti-smoking lobby won through. Warning labels are now printed on every pack of cigarettes, and with great success. Today, smoking in public places has become socially unacceptable. In many countries it has been banned outright, including our own with effect from 1 July of this year.
At least that is true in the developed western world. Elsewhere the tobacco companies ply their wares with ever increasing resolve. All of this is a pretty strong indicator that multinational companies, whether tobacco or alcohol, will respond to imperatives only if legally compelled to do so. The alcohol companies would do well to study what happened to the tobacco industry and the potential for legal actions against them.
In a recent article in the Lancet, Dr Raja Mukherjee of St George's Hospital in London and Mr Nigel Eastman address some of the legal and ethical issues. Dr Mukherjee has been to the forefront in matters to do with foetal alcohol syndrome, and we should all thank him for his persistence and scholarship. He cites a case in the American state of Wisconsin where a mother was charged with attempted murder and reckless endangerment because she drank heavily during her pregnancy. It was held that she should be held accountable to her unborn child by her actions.
The Wisconsin appeals court concluded that because a foetus is not a human being the mother could not be held criminally liable. In our country, if a mother were to feed her newly born baby with neat alcohol, she could be prosecuted for doing so, but if she feeds her unborn child alcohol through her bloodstream, she has no responsibility. I find this somewhat bizarre.
Dr Mukherjee also shows in the same article that many healthcare professionals have shown difficulties in diagnosing FAS. In Canada, in a survey, 98 per cent of paediatricians and GPs had heard of FAS but fewer than half felt able to diagnose it. Dr Mukherjee states that diagnosis is key because after the birth of a single child with FAS, the risk of another child, similarly affected, being born to the same mother increases by 800 times. The ethical issues are enormous.
In getting to this point, I have been helped by many people whom I must thank. In particular, I have been ably assisted by Susan Fleisher, who heads NOFAS-UK, and Mr Ross Cranston, a former MP who helped me to draft this Bill. I owe both of them a huge debt. There are also many people who confront the consequences of foetal alcohol spectrum disorder every day of the year; that is, doctors, social workers and other carers, but most of all parents, particularly mothers. Imagine, if you can, the guilt and grief that thousands of mothers endure, realising only too well what the momentary pleasure of drinking went on to cause. It does not bear thinking about. Finally, the children themselves only want normality. There is somehow a haunting plea from all of them—“Mummy, why can’t I be normal?”.
In market research that we commissioned, 61 per cent of women admit to drinking when they are pregnant and 75 per cent are aware that it might have some effect on their unborn child. Sadly, it is still the young and less-educated women who are unaware of the dangers and it is particularly them we seek to inform. Ask a mother-to-be what she wants for her baby and, whoever she is and whatever her background, the answer will be the same: “I want my baby to be healthy”. It is not given to us to make all babies healthy. That is beyond our power. But this Bill, by making the dangers of alcohol more widely known, will undoubtedly result in some babies being born healthy who otherwise would not be. If we can do that, we will spread joy where otherwise there would be sadness. That is why I have introduced this Bill and why I hope your Lordships will support me in taking it further.
Moved, That the Bill be now read a second time.—(Lord Mitchell.)
My Lords, I support the Bill introduced by the noble Lord, Lord Mitchell. Drinking alcohol to excess in pregnancy is known to harm the unborn child. As the noble Lord has said, we do not know whether there is a safe level of alcohol intake during pregnancy. Although there is overwhelming evidence of harm, there is no evidence of harm from abstinence. The Government’s policy, which is based on a precautionary principle, is eminently sensible but it could go further. Therefore, the Bill misses a potential opportunity, but I understand why it does not target the many others who are at risk from alcohol abuse. Let me be clear that it is not alcohol but excessive binge drinking which leads to some of the problems that we see in society today. It seems that in pregnancy the drip-drip of alcohol is also harmful. Therefore, the problem of foetal alcohol spectrum disorder is being addressed in this Bill.
The Bill also raises a question, and an opportunity, as to whether other health benefits could come from labelling. In the sub-committee on allergy, which I have the privilege to chair, we have heard about the allergenic potential of the sulphites found in wines and the benefit that a statement of the sulphite content would have for those allergy sufferers who can tolerate low but not high levels of sulphites. In this Bill, labelling is confined to pregnancy, although there would be benefits in extending the warnings about the dangers of excessive drinking to everyone, not just to pregnant mothers. My support is built on the evidence that we need a commitment to a broad-reaching approach. I fear that this Bill, by itself, may not prevent mothers drinking while pregnant, but it is a very important move towards prevention.
We have seen from warning labels on tobacco products about harmful effects that labels are not enough to bring about culture change. Warning labels on alcohol may act as a deterrent where alcohol is sold in sealed containers to people who are sober, but they will not deter those buying excessive alcohol in licensed premises, such as pubs and clubs, where it is dispensed in glasses, which cannot, of course, be labelled. I would like to see an amendment to require such premises to display a warning similar to that proposed for labels.
Drinking in moderation produces health benefits in those who are not pregnant and is an enjoyable social interaction, but excessive drinking harms individuals and society. The social role of drinking together is deeply embedded in our society and has been for thousands of years. We now have beautifully designed labels on some wine bottles, some of which are glass works of art in themselves. I am sure that some objections will come from those who find the proposed labels aesthetically unpleasant. But I do not think our intention to protect the unborn child should be inhibited by such objections and I am confident that we have such good graphic designers that the challenge posed could be easily surmounted.
The excellent report by the Academy of Medical Sciences, Calling Time: The Nation’s Drinking as a Major Health Issue, suggests that price and availability make a difference to alcohol consumption and, therefore, to alcohol-related health damage. In order to decrease excessive drinking, we need to consider measures affecting both those factors. Such measures will often be unpopular.
Alcohol has never been cheaper in real terms in living memory. The price is determined in large part by the duty on alcohol, but that is no longer linked to the strength of the drink. White cider, at up to 7.5 per cent alcohol by volume, is taxed at only half the excise duty on weaker beers. Sadly, there is a cohort of poor, stressed single mothers who find escape in alcohol. I am informed by Professor Gilmore, president of the Royal College of Physicians, that some mums with liver damage are drinking up to two litres of white cider a day because of the combination of high strength and low price, which allows them to escape from their problems. We also know that when these mums are under the influence of alcohol they are at a higher risk of unplanned pregnancy. Therefore, the unborn child is at high risk again and there is a cycle which perpetuates itself. The low price of alcohol also makes it more available to young people and puts it within the financial, if not always legal, reach of teenagers. Most pregnancies occur in young women, so it is important to ensure that they heed the warnings in order that the next generation is not damaged.
Increasing tax is never popular. In October last year, the Health Secretary asked the Chancellor to raise the tax on alcopops and other drinks favoured by teenagers, recognising the clear link between the price and availability of alcohol and its consumption. This is not just a problem for government; retailers have their part to play in supplying alcohol in a responsible way. We have to remember that many groups of young girls go to the supermarket to buy cheap alcohol, often spirits, to get tanked up before going out clubbing. When girls are sober they are more likely to read the label or get pressure from their peers. If a young girl knows that her friend is pregnant, there is a chance she might warn her not to drink that night.
In most EU countries wines and spirits are sold in separate areas in supermarkets, but in the UK they are presented as end-of-aisle offers. Let me be clear: as someone who buys wine in a local supermarket, I do not suggest that retailers should try to sell less alcohol in a way that would damage profits. However, many retailers sell alcohol as loss leaders, particularly at Christmas, with end-of aisle promotions most visible. An end to that practice would not only demonstrate corporate responsibility, it would certainly not harm retailers’ profits and it might allow reductions on food, vegetables, toys and other products.
I hope that a broad-ranging approach would also include guidelines on the advertising of alcohol. Adverts for alcohol play a large part in fostering our culture of excessive drinking, as adverts increase positive beliefs about alcohol and reduce perceptions of risk. Advertising bans are controversial, but it is interesting to note that there is no watershed for alcohol adverts, and many of them are focused strongly towards young people. We take a remarkably liberal approach in this country. France, which is not famed for a puritanical approach to alcohol, allows no broadcast advertising for alcohol.
One further area I would like to see covered is that of drink driving. Lowering the UK maximum blood-alcohol level from 80 milligrams of alcohol in 100 millilitres of blood to 50 milligrams, as is more generally the case across the EU, would be a significant move. In Australia, lowering the drink-driving limit from 80 to 50 milligrams resulted in a lower accident rate and a fall in health-related harm.
The Bill takes an important step towards tackling the increasing problem of the effect of alcohol on the foetus, and I hope that it might have a secondary effect on drink driving and other areas of life. It is when babies’ brains are developing that they are damaged by booze abuse. Let us not forget the cost to society and the cost to the child, and I hope the Minister will remember the cost to health and social services in the care these children require, as well as the cost to education departments in meeting their specific learning needs. Such a Bill could well prove to be remarkably cost-effective in terms of its impact on our health services. I hope that the success of this Bill will come to represent the first in a series of measures to bring about a healthier, safer and happier drinking culture. I wish it well and I end by saying, “Cheers, my Lords”.
My Lords, I apologise for not putting my name down on the speakers’ list, but I had a long-standing hospital appointment this morning which I feared might overrun. Luckily, I have been able to make it just in time. Courtesy dictates that this Bill should receive an unopposed Second Reading, but I hope it will not go much further, certainly not in its present form. As my noble friend Lord Walton of Detchant said only a couple of days ago when speaking in a health debate:
“My Lords, we are in serious danger of living in a grossly over-regulated society”.—[Official Report, 18/4/07; col. 289.]
There is no empirical evidence that for the great majority, taking alcohol in moderation—one must stress the word—during pregnancy harms the unborn child. If it did, neither I nor my siblings would be here today to tell the tale, and nor would most of my contemporaries. The same goes, I think, for my sons’ generation. The noble Lord, Lord Mitchell, said that a survey had revealed that 61 per cent of pregnant women admitted to drinking. I would have thought that 40, 50, 60 or 70 years ago it was probably more like 90 per cent, the difference being that pregnant women would restrict their drinking to a glass of sherry or half a pint of mild at one end of the social scale up to a dry martini or a glass of scotch at the other. Binge drinking simply did not happen, except perhaps at university after finals or something like that. It is a modern phenomenon which was then unknown, and I agree that it is a serious one. I shall come back to that issue in a moment.
Not so long ago, doctors and district nurses would urge nursing mothers to drink a pint of Guinness a day for the sake of their health and that of their baby. Medical fashions change from year to year, and indeed from month to month. We were told not long ago that butter was a deadly poison and we must all switch to margarine. The position has totally reversed and now margarine with its hydrogenated fats is the villain of the piece while butter in moderation is perfectly all right. A decade before that, antibiotics were prescribed for everything under the sun—for anything from a scratched finger to a boil on the bum. That has resulted in people becoming desensitised to antibiotics so they no longer work. A decade earlier, anyone feeling slightly down in the dumps was prescribed tranquillisers, and hundreds of thousands were prescribed to ill effect. A couple of decades before then, asbestos was considered God’s gift to mankind. You were doing a public service by lining your house or place of business with as much asbestos as possible. Now we know better. Medical and health fashions do change.
In two or three years’ time it may well be decided that on balance it is beneficial once again for pregnant women to have a single glass of red wine a day, but that would be a bit too late if this Bill goes through. Moreover, the Bill would target the wrong people. Young, university-educated women are having babies later and later, mainly for economic reasons, and are finding it harder to conceive. Once pregnant they are more prone than younger women to complications. So they will usually religiously avoid drink, and often tea and coffee as well. The Bill is not necessary for them. Women from a more feckless background—the binge drinkers to whom the noble Lord, Lord Mitchell, referred—are likely to do most of their drinking in pubs and clubs. When they buy bottles, they are unlikely to peruse the labels carefully.
That brings me, lastly, to an aesthetic objection. The noble Lord, Lord Mitchell, talked about Château Lafite 1982. Imagine how terrible it would have been if those marvellous Château Mouton Rothschilds—I have only tasted it once—with their magnificent labels designed by Dufy, Matisse, Picasso and so on, had been ruined by ugly warnings plastered all over them, especially when such warnings are not really necessary, and certainly not on the front of the bottle.
My Lords, first I pay tribute to the noble Lord, Lord Mitchell, for his persistence in highlighting foetal alcohol spectrum disorder and for keeping his campaign going over the years, and for introducing his excellent Bill. Let me say now that had it been possible to add a second name to a Private Member’s Bill, I would have done that, so convinced am I that this is the right way forward. I am sure that the Minister will tell us more about the voluntary labelling of alcohol that is already taking place. Scottish & Newcastle is the leader, and all credit should go to the company for doing it.
However, a voluntary labelling system, however admirable, is not enough. The Minister for Public Health in another place is on record as saying that warning labels for alcohol will be voluntary initially, but if the drinks industry ignores them, the Government will consider legislating. That is absurd. We are asking for labelling that is not punitive but informative. The industry should not be allowed to resist precisely because so many women are ignorant of the possible effects of alcohol on the unborn child, and the duty to inform on the bottle or the can should be comparable with what is done on cigarette and tobacco packets.
This is even more important because the level of ignorance in the general population is quite high. My children are what might be described as quite aged now, at 27 and 25. When I was pregnant—which sometimes I think was not all that long ago—no one thought that drinking moderate amounts of alcohol was dangerous for the foetus or the very young baby. Indeed, in my day experienced maternity nurses and health visitors advised drinking a glass of wine before the last feed at night to help the new baby sleep. I do not think they would be saying that now, and that was not so very long ago. Our knowledge of foetal alcohol spectrum disorder has increased hugely, but public awareness has not kept pace. Most young women, especially the less well educated and the very young, do not know about the risks at all. They have not heard forensic psychiatrists talking about the prevalence of foetal alcohol spectrum disorders among young people in prison, and those with the condition are not by any means all identified because of a continuing lack of clinical awareness of these conditions in many cases.
Only last night I was with Professor Sue Bailey, the registrar of the Royal College of Psychiatrists, who is a child and adolescent forensic psychiatrist at the University of Central Lancashire. She said that signs of foetal alcohol spectrum disorder are frequently missed within prisons, even by those who know about it. Young women who do not know about it have not heard prison governors talk about how prisons are becoming the last closed institutions in this country, and it is suspected that in among the sheer misery of the huge incidence of mental illness among prisoners, there is also a fair prevalence of undiagnosed learning disability within which foetal alcohol syndrome may well figure to a considerable extent. Unlike the case with cigarettes, the public do not know about the risks of alcohol in pregnancy.
I am not of the view that we should forbid drinking alcohol in pregnancy or that we should regard the pregnant woman who drinks alcohol as a criminal because I do not want even more of a nanny state than we already have. However, I would like women to know about the risks so that they can decide whether to accept them. Few pregnant women are really willing to add consciously to the risk of having a child with a problem such as foetal alcohol spectrum disorder. All women fear the possibility of having a child with some kind of disability, much as those disabled children are usually dearly loved after their birth. But we all want the best for our children and if not drinking during pregnancy means lowering the risk of some kinds of birth and developmental defects, that is something most women would accept if they knew. So information is critical, and making it widely available—which is why I think it has to be compulsory—is also critical.
However, let us not be puritanical about this, as the noble Lord, Lord Mitchell, said. I am certainly no puritan about this: I come, on my mother’s side, from a family of small-time wine growers and wine merchants in southern Germany. My grandfather’s drinking companions—and he could certainly drink—in the prisoner-of-war camp in France during the First World War were also the people who went into my grandparents’ apartment three days before the Second World War broke out, just after my grandparents had left for this country, and packed up all their possessions which they then sent them after them.
Drinking can provide strong social bonds. This House has its bars, and most of us drink socially. The difference is this: if we knew that by drinking we were risking the development of our unborn children, most of us would stop, just as many of our own young are so much better in many cases about not drinking at all if they are going to drive. We are talking not about abstinence but about abstinence for nine months. Similarly, no one asks for total abstinence from those who are drivers, only that they do not drink when they are going to drive. Some women are fortunate enough to have their tastes change so much during pregnancy that they cannot face even a single glass of wine. But the evidence shows that just under 50 per cent of mothers visiting the teenage antenatal clinic at St George’s Hospital drank more than four units in one go, and 27 per cent occasionally got seriously drunk when pregnant.
With an increasing culture of binge drinking among young women, to which the noble Baroness, Lady Finlay, drew our attention, we should be all too aware that this will rise. The noble Baroness is right to suggest that warning notices about alcohol when pregnant should also be displayed in bars and pubs.
We do not really know the extent of harm. The estimate is that one in 100 of live births is affected with foetal alcohol spectrum disorder, making it the most common cause of learning disabilities worldwide. The acute form of foetal alcohol syndrome occurs in between one and three live births per 1,000. So Dr Raja Mukherjee, one of the UK’s foremost experts, along with Professor Nigel Eastman and Professor Sheila Hollins, the president of the Royal College of Psychiatrists, summarised the position when she said:
“The uncertain level of individual risk to the developing fetus, together with the possibility of misinterpreting a health promotion message, mean the only safe message in pregnancy is abstinence”.
Unlike the noble Lord, Lord Monson, I think the case is irresistible. I hope that the Minister will agree that this is not about voluntary labelling. We need it made compulsory, because the level of knowledge is low, and, from what we can now see, the incidence of binge drinking and drinking in pregnancy is high and the conditions are preventable. We on these Benches strongly support the Bill.
My Lords, I join other noble Lords in congratulating the noble Lord, Lord Mitchell, on bringing forward this Bill. It is two and a half years since he introduced his memorable debate on foetal alcohol syndrome. None of us who researched the subject at that time was left in any doubt that we were dealing with something of major importance. I felt then, and I feel now, that doing nothing is simply not an option. The noble Lord reminded us today about the devastating and lifelong consequences which can ensue for children born to mothers who have indulged in binge drinking during pregnancy or who, in some cases, have consumed a relatively modest amount of alcohol at the wrong time.
The wider issues to do with FAS present challenges in relation to prevention, as well as to the issues further down the track such as the diagnosis, education and appropriate care of children and adults afflicted with the syndrome. The Bill deals with the preventive aspect, so I shall not talk about the other ones today.
I think that the noble Lord has successfully made the case for putting warning labels on alcohol containers. Awareness of this issue is generally low—61 per cent of British women drink while pregnant. In the background, as noble Lords have emphasised, we need to be mindful of the increasing culture of heavy drinking among the young in all socio-economic groups.
It is true that the Government have spent not inconsiderable sums on public information initiatives over the past few months, such as the Know Your Limits campaign, and these are to be welcomed. But campaigns of this sort are inevitably transitory and we cannot know that the message has reached everyone who needs to hear it. As a means of raising awareness, appropriate labelling has much to recommend it.
The questions we need to settle are twofold: first, do we need a piece of legislation to do this, as opposed to a voluntary agreement with the drinks industry; and secondly, what exactly should the label say? When we debated FAS in 2004, the Minister replying, the noble Baroness, Lady Andrews, told us that the Government were taking the problem very seriously and were working with the drinks industry on developing a voluntary labelling scheme. I was more than prepared to accept those assurances at face value, but here we are, two and a half years later, and there has been no visible result from those discussions. I would much prefer a voluntary scheme as long as it could be made to work, but after this interval of time one has to wonder whether there is actually any mileage in the idea; and I frankly am not surprised that the noble Lord has lost patience. It may be that the Minister will deliver some words of genuine comfort on the matter today, but if we carry on without agreeing on a voluntary scheme, then yes, I think the Government need to take at least back-up powers to introduce a scheme of statutory regulation.
The noble Lord has made a very good fist indeed of drawing up his Bill. One could criticise it for being too detailed: quite a lot is perhaps more suited to secondary than to primary legislation. But notwithstanding that, full marks to the noble Lord for showing us exactly what he intends Parliament to consider.
It is not only America that is pointing the way on this. If we look at what is happening in France, Finland, Canada, Australia and New Zealand, we see that public health messages on bottles and cans about not drinking alcohol during pregnancy are gaining widespread acceptance. Indeed, in 2004, a YouGov poll of more than 2,000 people found that 67 per cent of those asked would welcome labels warning of the dangers to the unborn child. I do not think we need be too fearful that warning labels may be seen as an unnecessary piece of nannying. It is, after all, only a label.
I am afraid I cannot, my Lords. Perhaps the noble Lord, Lord Mitchell, can enlighten us when he winds up.
The problem, in my view, is how to achieve a message that reflects the current state of scientific knowledge and does not run the risk of alarming women without due cause. The fact is that many women when pregnant can have a couple of units of alcohol once or twice a week without any apparent detriment to the health of their baby. Indeed, the current official advice from the Royal College of Obstetricians and Gynaecologists says that drinking alcohol at that level has not been shown to be harmful, even though it makes it clear that the safest approach for a pregnant woman is to choose not to drink at all. The guidelines also warn that episodic binge drinking around conception and early pregnancy is especially harmful to a woman and her baby, and this line is echoed by the Royal College of Midwives.
I do not think that anybody disputes the advice about binge drinking. The real question is whether we can justify a message as drastic and uncompromising as the one contained in Clause 1. We must be guided, surely, by the science. There is no consensus at the moment about the threshold below which consumption of alcohol causes negligible damage in the expectant mother. Nor is there consensus about the causal mechanisms which lead to foetal alcohol syndrome. We know that some populations are more prone to alcohol-related disorders; for example, those in lower socio-economic groups and ethnic minorities. The prevalence of these disorders also seems to be a function of maternal age, poor nutrition, drug use and use of tobacco, so the picture on causation is not wholly cut and dried. There is scope for further research into these issues to enable us to explain why some babies are more affected than others.
The research that we do have suggests increasingly that if we err at all it should be on the side of caution. In the 1990s, Ann Streissguth, at the University of Washington, established that children of mothers who had drunk seven to 14 standard drinks per week in pregnancy tended to have specific problems with arithmetic and attention, as well as behavioural difficulties when older. These results have been confirmed by the work of Sandra and Joseph Jacobson at Wayne State University, Detroit. At the same time, what is important is not just the number of drinks you consume: it is when you are drinking them, whether you have eaten beforehand and how fast your body metabolises alcohol. Drinking all seven units at one session during a week would amount to a binge which potentially puts the baby at risk.
What do we know about very low levels of alcohol consumption? The Jacobsons found that children of mothers who drank fewer than seven drinks a week had no detectable mental deficits. But a study by Hepper at Queen's University, Belfast, indicated that fewer than seven drinks a week can have a measurable effect on the developing nervous system of an unborn baby. John Olney, a neuroscientist at Washington State University, has performed studies on rats. These show that cell death in the brain can occur when developing rats are exposed to only mildly raised blood alcohol levels equivalent in humans to 50 milligrams per 100 millilitres of blood for a period of only 45 minutes. This level would be sufficient to delete 20 million neurons in the brain of a foetus—not enough to translate into a detectable effect on a child's cognitive abilities, but nevertheless a measure of damage.
What does all that say to us? It says, rather messily, that we cannot as yet convert our current scientific knowledge into categoric blanket advice for all women about how many drinks they can have when pregnant. But we appear to know that the less alcohol she consumes, the better it is likely to be. Meanwhile, the noble Lord's approach in this Bill is to adopt the precautionary principle. In the circumstances, it is hard to disagree with that approach. It is right that we should think carefully about the precise wording of the warning message and whether it could be improved on, but I would not wish to suggest to the noble Lord that the general tenor of the message he has proposed is misplaced.
If I have a worry at all, it is on an associated issue—the vagueness of alcoholic measures, to which the noble Lord, Lord Mitchell, referred. If we are to talk in terms of units of alcohol, people need to be aware of the true number of units they are consuming. A 125 millilitre glass of wine contains roughly one unit. But a glass of wine that you pour at home is likely to be larger. It may also have a stronger alcohol content, so a glass of wine at home may be far more than one unit. The lack of awareness of these basic things needs to be addressed every bit as much as the matters covered by the Bill.
Naturally, I hope that the Minister will look at the Bill in a positive light. I wish the noble Lord, Lord Mitchell, well with its future progress.
My Lords, I congratulate my noble friend Lord Mitchell on introducing and securing the Second Reading of his Bill. I also congratulate him on the fine quality of his speech, as I do other noble Lords who have spoken. It has been a short but highly informed and high quality debate.
This issue, I know, is close to my noble friend’s heart, reflecting his close involvement with the National Organisation on Fetal Alcohol Syndrome, to which I pay warm tribute today. The organisation is at the forefront of efforts to alert women to the potential dangers of alcohol consumption during pregnancy, and its work is well known to the Government, particularly through its regular contact with my ministerial colleagues in the Department of Health. I commend the organisation and wish it well in the future.
There is no doubt whatever that foetal alcohol syndrome is a devastating condition and the effects of foetal alcohol spectrum disorder on a child’s future life can be grave. The Prime Minister’s Strategy Unit interim analytical report on alcohol estimated that there are between 240 and 1,190 cases of foetal alcohol syndrome per year in England and Wales. Moreover, NOFAS estimates that in the UK as a whole, more than 6,000 children are born each year with the more prevalent condition of foetal alcohol spectrum disorder.
When my noble friend last spoke to the House about this subject, he painted a worrying picture of the health symptoms of the syndrome and the spectrum disorder. He did so again today and was very persuasive on that point. His remarks and those of the noble Baroness, Lady Neuberger, about the problems of misdiagnosis and non-diagnosis were also persuasive. It is clear that much more needs to be done to educate health professionals in this area.
Understandably, our debate took in a number of issues around alcohol consumption. There is no question that, particularly among young women, there has been an increase in alcohol consumption. The evidence that I have is that the proportion of 16 to 24 year-old women who had drunk more than six units on at least one day in the previous week increased from 24 per cent to 28 per cent between 1998 and 2002 but had fallen to 22 per cent in 2005.
Thirty-nine per cent of women aged 16 to 24 reported drinking more than three units on at least one day compared with 5 per cent of those aged 65 and over. Average weekly alcohol consumption in the past 12 months in England for women increased from 5.5 units in 1992 to 7.6 units in 2002. Among women, the proportion drinking more than the recommended weekly benchmark of 14 units increased from 12 per cent in 1992 to 17 per cent in 2002. Nine per cent of women are drinking more than twice the recommended daily amount and 15 per cent of women drink at hazardous or harmful alcohol levels.
The latest figures that I have are that in the UK in 2000, 30 per cent of mothers who drank before pregnancy reported giving up drinking during pregnancy. Those mothers who continued to drink during pregnancy reported drinking very little, and 71 per cent of those who continued to drink consumed less than one unit of alcohol a week on average. Only 3 per cent drank on average more than seven units a week.
In 2000, 87 per cent of mothers who had recently given birth reported drinking alcohol before their pregnancy and 61 per cent continued to drink while they were pregnant—a fall from 66 per cent in 1995. I understand that older mothers are more likely to drink during pregnancy—71 per cent of mothers aged 35 or over did so compared with 53 per cent of those under 20. Thirty per cent of mothers who drank before pregnancy reported giving up drinking during pregnancy, which compares to 24 per cent in 1995. In addition to the 30 per cent of mothers who gave up drinking during their pregnancy, 65 per cent said that they reduced their alcohol intake.
Clearly, there are a lot of statistics there. They suggest that there is a general issue about an increase in alcohol consumption, but they also suggest that pregnant women have taken to heart some of the messages that have come through.
Noble Lords made a number of interesting remarks on the question of units of alcohol. Noble Lords will know that the Chief Medical Officer recommends that men should not regularly drink more than three to four units a day and that women should not regularly drink more than two to three units a day. The definition that I have of a unit is 8 grams of alcohol—typically, one small glass of wine, one half pint of beer, though not a strong variety of beer, and one measure of spirits. However, I fully accept the arguments made by noble Lords that the size of glasses can vary considerably and the use of very large glasses has become more frequent, both in pubs and restaurants but also at home. Equally, more generally, I take to heart the point that the noble Earl, Lord Howe, and my noble friend raised about the lack of awareness in that regard.
The noble Baroness, Lady Finlay, made some very telling points about the more general issues in relation to alcohol, and gave some recommendations for the Government to take on board. I listened very carefully to that. We launched the alcohol harm reduction strategy for England in 2004, with the specific aim of minimising the harm caused by alcohol through better education, prevention efforts and the improved identification and treatment of alcohol problems. We are committed this year to reviewing that strategy and to identifying what further actions we wish to take. Of course, today’s debate will be very helpful in informing officials as they advise the Government on taking the new strategy forward. We have launched the Know Your Limits campaign—the first national campaign on alcohol, focusing on young people who binge drink, to which a number of noble Lords have referred. We are taking action to tackle underage drinking, which has led to targeted enforcement including the wider use of issuing fixed penalty notices.
Drinkaware Trust has been established as a new organisation, independent of government and the alcohol industry, and it is developing work to change behaviour and the UK national drinking culture. We have developed Models of Care for Alcohol Misuse Services, published in June 2006, and we have launched alcohol misuse interventions, which is guidance on developing local programmes of improvement. We are not complacent; we understand very clearly the importance of action in this area. As I have said, the review of this strategy in 2007 will be a very good way in which to take on board the comments that noble Lords have made today.
The noble Lord, Lord Monson, and the noble Earl, Lord Howe, referred to the evidence specifically in relation to alcohol drinking by pregnant women. In 2005, my department commissioned the National Perinatal Epidemiology Unit to undertake a review of existing evidence. The main aims were to update what we knew from existing evidence about the effects of prenatal alcohol exposure. The principal findings were that there is no consistent evidence that low to moderate consumption of alcohol during pregnancy has any adverse effects, although there is some evidence that binge drinking can affect neuro-development of the foetus. The department has commissioned a recent review from the National Perinatal Epidemiology Unit on the effects of low to moderate alcohol consumption in pregnancy. The review has broadly concluded in support of the scientific conclusions of the 1995 Sensible Drinking working group.
I have to say that this evidence base is not strong. While the current advice remains scientifically correct, there is a perception that it might be construed as too permissive. It is interpreted by some as meaning that it is safe to drink a little when pregnant, when a little can differ from person to person. Most women, as we know, stop drinking or drink very little in pregnancy, so a slightly stronger message could be aimed at those who do not reduce their consumption to appropriate levels. I echo the words of the noble Earl, Lord Howe, that action must be based on scientific evidence. His speech was a tour de force of some of the available evidence that we now have. It is clear that we do not have enough evidence—but clearly we need to do more to obtain it.
It is clearly important that labelling is used as a strong component in a preventive approach. We are committed to action on labelling, as was laid out in the Government’s alcohol harm reduction strategy, which was published in 2004. We know that the public support labelling. I refer noble Lords to the recently published Eurobarometer survey on attitudes to alcohol, which showed that almost eight out of 10 people agree with putting warning labels on alcohol products and in adverts, in particular, to warn pregnant women of the dangers of misusing alcohol. In the UK, 75 per cent of people supported labelling.
Labelling is not a panacea and is no substitute for other actions, such as education and wider information. The evidence for the effectiveness of health warnings alone is not particularly strong, but it can be an essential component of a broader strategy to help consumers to estimate their own unit consumption and to help people to become more conscious of drinking in relation to their health.
I agree with the noble Earl, Lord Howe, and my noble friend that doing nothing is not an option. We are working in close partnership with the alcohol industry and wider stakeholders to implement the many initiatives that were set out in the 2004 alcohol harm reduction strategy. Industry has shown its willingness to help us to achieve that aim and we know that more than 75 per cent of spirit labels and 85 per cent of beer for sale in the UK market already carries information on unit content. It is much less for wine and it is clear that more needs to be done. It is also pleasing to remark that many supermarkets’ own brand beers, wines and spirits include that information on their labels—but we need to move beyond this.
Providing only unit information, important though it is, is not sufficient. We have asked the industry to go further to ensure that there is more consistency and visibility in the information that is provided and to add a short health message on drinking for adults and on pregnancy to ensure a link to the Government’s wider campaigns, and that there is an agreed timetable for intervention. We want government intervention to regulate the industry to be proportionate. We do not want to impact unfairly on responsible consumers, manufacturers and retailers, and we need to work with industry on this, but we are not opposed in principle to legislating in this area should a voluntary approach fail or prove ineffective. I can say to the noble Baroness, Lady Neuberger, that I think that that is an entirely sensible approach. If in a very short time we can pull off an agreement with industry that produces the kind of advice that we want, that is a very desirable way forward.
My Lords, what does the Minister make of the observation of the noble Earl, Lord Howe, that we started having this debate in this Chamber in 2004 and nothing has happened? I regard it as absurd that nothing has happened since 2004—and that is why maybe the voluntary method is not enough.
My Lords, my understanding is that we hope that we can report progress on our discussions with the industry very soon. I entirely accept that if talks became protracted and it looked as if there would not be a successful outcome, noble Lords would be absolutely right to come back and say to the Government, “The time for talking is over; let’s see some action”. But I have discussed this with officials and we are confident that we shall be able to report progress very soon. However, I reiterate that we shall not shrink from tougher measures if we do not reach a satisfactory agreement with the industry. I say to my noble friend that there is no question that there is a need for women to be alerted to the potential dangers of alcohol for the unborn child and his or her future well-being. The points made by noble Lords today were entirely persuasive. We have a responsibility to future generations to ensure that parents, and mothers in particular, are fully aware of the dangers for unborn children of drinking. This is a very serious matter.
We consider that there is great hope of partnership with the industry. It is worth spending a little more time ensuring that we reach agreement. I thank my noble friend for raising this matter so effectively and powerfully. I again reassure the House that if a voluntary approach does not work, the legislative option remains.
My Lords, it was almost predictable that we would have a good Second Reading debate today given the list of speakers. I thank all noble Lords for their contributions.
I say to the noble Baroness, Lady Finlay, that I thought very seriously about notices in pubs and off-licences. She made a very strong point. As I said in my opening remarks, I wanted to keep my speech very focused. I take the point that she made about the cost to society and the nation of children who are affected by this syndrome.
I say to the noble Lord, Lord Monson, that we are not saying that all pregnant women who binge drink will have foetuses with some form of foetal alcohol syndrome. Nor are we saying that the foetuses of all pregnant woman who drink will have foetal alcohol syndrome. We are talking about the minority who drink a lot or perhaps even a little, whose foetuses may be affected if the alcohol is consumed at the wrong time. We are not preventing them from drinking, we are just issuing a warning.
On the subject of labels, to the best of my knowledge the relevant labels that I have seen are on the back of bottles of wine. That is certainly the case with bottles that I have seen in the United States. In Australia, I believe that they are on the side. I have no desire for such labels to be inspired by the designs of Matisse or any other great artist.
I should have loved the noble Baroness, Lady Neuberger, to be a co-sponsor. I agreed with everything that she said. I thank the noble Earl, Lord Howe, for the support that he gave on the previous occasion the Bill was introduced and again today.
I thank the Minister for his remarks. It was good that he said there was government understanding of the issue and no complacency about the fact that something needed to be done. He gave a very strong hint about a voluntary code. If such a code were 100 per cent effective, it would be a good thing. However, he hinted strongly that if there were any wavering on this issue, the Government would support legislative action. That is as much as we can hope for. I ask the House to give the Bill a Second Reading.
On Question, Bill read a second time, and committed to a Committee of the Whole House.
Sexual Health: Contraceptive Services
rose to ask Her Majesty’s Government what steps they are taking to increase provision of contraceptive services, prevent the closure of specialist community clinics and increase the availability of training in contraceptive services and sexual health.
The noble Baroness said: My Lords, it gives me great pleasure to bring this matter to the attention of the House. I know that noble Lords—members of the all-party pro-choice and sexual health group—who cannot be here due to short notice, will read with great interest what the Minister says in response to the debate.
For 30 years of my medical career I was closely involved with family planning services and services for women in general, from the early years when services were run by charities such as the Family Planning Association, Marie Stopes and Brook, through to the heady years when services were at last taken over by the National Health Service and were free to all women who needed them—family planning and abortion counselling in particular. Those were very heady days for those of us who had campaigned so hard and long.
Special clinics were set aside for young people in every area. Screening services for cervical and breast cancer were introduced and latterly the clinics played a significant part in helping to meet the genito-urinary medicine 48-hour access targets. As noble Lords know, those clinics are very hard pressed and the community family planning clinics have helped a lot in that area. In most areas, initially area health authorities and then primary care trusts had a senior doctor and senior nurse to run the service. I was one such for many years, being head of women’s services for Ealing Health Authority. These community specialists managed the service, supported primary care and managed complex contraceptive problems in liaison with GPs if the latter did not feel competent to deal with them.
A faculty of family planning and reproductive health was formed at the Royal College of Obstetricians and Gynaecologists—a great leap forward—to set standards and organise training for doctors and nurses who wished to pass the faculty’s diploma or membership examinations. It was a very thorough and rigorous training with heavy emphasis on practical skills and took place under the guidance of a training doctor such as myself in the community clinics. Until recently, 80 per cent of the training of doctors in family planning took place in the community clinics.
In the early days women and young people loved us because the service was mainly walk-in and easy access, often to a woman doctor. We forget that 20 years ago or more there were not so many women doctors but patients liked to see one if they could, to avoid the embarrassment of seeing the family doctor, who they probably knew well, for very personal matters. The services were particularly valuable in areas with large ethnic minorities. I have worked among ethnic minority communities in Birmingham, north London and Southall, trying to make the services more accessible and to understand their problems in the context of their cultures. We even set up a cervical screening service in a local mosque for women who were either reluctant or prevented by their families from coming to a clinic. We provided the service in the mosque instead. The home visiting service was also useful for difficult cases.
When I entered Parliament in 1997 I received huge support and enthusiasm from the then Ministers, in particular Frank Dobson and Yvette Cooper, and civil servants at the Department of Health, particularly for my campaign to allow emergency contraception, the morning after pill, to be available over the counter in local pharmacies. That was another great leap forward for womankind. The Government are still hugely enthusiastic and supportive whenever we talk to them.
Both White Papers, The Health of the Nation and Choosing Health, have focused on public health and preventive health services, and the latest paper also promised an audit of contraceptive services. Three years later, however, we have still not seen the results. I am a little worried, because there may be nothing left to audit if it is not done pretty quickly. The audit is important because, despite £300 million being earmarked for sexual health services, there have been reports of closures of community family planning and sexual health clinics all over the country. We suspect that primary care trusts have used the money to offset their deficits and to address target services, such as the genito-urinary medicine clinic targets. Because there are no targets for the family planning service, it is a soft option for closure by PCTs, who expect the work to be done by the general practitioner.
Community specialist posts in reproductive healthcare, such as the one that I occupied many years ago, are not being advertised, and retiring doctors and nurses are not being replaced. Dr Penny Oakeley, whom I know and who is a hugely experienced and valuable doctor who ran superb services in Wandsworth, retired in September 2006, but the trust is not replacing her or the senior nurse, who retires this May. There is no intention of continuing the service. Doctors wishing to obtain the family planning diploma or membership now have great difficulty accessing practical training. They do not know where to go. That practical training is required under the NICE guidelines if they are to offer the full range of family planning methods, particularly the long-acting ones such as implants and IUCDs. We are telling patients that these methods should be available, but the doctors cannot access the training. The service is disappearing, and with it patient choice.
The Faculty of Family Planning and Reproductive Health Care conducted a survey of just under 3,000 clinicians in 2004, which is sadly a bit of a time ago. It was useful, however, and included GPs, family planning doctors, senior doctors in the health service, and consultant obstetricians and gynaecologists. Eighty-four per cent of GPs in that service were worried about the standstill or actual reduction in resources for family planning in their area. Ninety per cent wanted the services to continue to ensure that patients had choice and that there was the expertise for them to refer their patients to. Forty-five per cent were very concerned about restricted access to training in long-acting methods of family planning. Seventy-six per cent were concerned about the postcode lottery for abortion services, which I know the Minister will tell us has improved considerably, and it has. There has been a great improvement in abortion services, but I do hope that this improvement will be maintained, especially in the light of the news this week of the shortage of doctors willing to perform the operation. I suspect that there is another problem of a slightly different kind looming there. Eighty per cent of doctors surveyed emphasised the value of those community clinics for the distribution of condoms. Condoms are still seen as the first defence against sexually transmitted disease. Indeed, the fact that young people in particular can get them free in those clinics means that there is a way of contacting that young person and perhaps giving them more advice or letting them find out a little more about themselves and relationships and what they should do with their lives. Clinics are a very good point of access for young people in particular to get those free condoms.
To sum up, the faculty survey showed clear evidence of the lack of investment in family planning services. We are losing clinics all over the country, clients are being turned away from those that remain, and patients’ choice of method of treatment is being restricted. In the past three generations, there is no doubt that women’s lives have been transformed by the availability of contraception. The ability to limit the size of our families is a huge advance for mankind economically and socially, as well as environmentally, both in the developing world and here at home. Women are as vital now to the economy as they are to their families. This depends on them being able to limit the size of their families. I am not accusing the Government for one moment of neglecting this issue. In fact, I think they have spent a lot of time thinking about it, discussing it, agonising over it and surveying it. However, I very much want them to know this morning what is really happening out there. As a manager in the health service, I learnt quite often that you set your great plans and think that this is the way forward, but something quite different is happening on the ground, and you must be aware of the consequences of the action that you take. I therefore urge the Government to take my remarks seriously and to act. If they do not, women could lose so much.
My Lords, of all the many aspects of the Government’s truly woeful record on public health during their time in office, there is surely no failure more stark or more far-reaching than their failure on sexual health services. Noble Lords of all parties respect and admire the noble Baroness, Lady Royall, but it is rather telling that the Minister of State in the Department of Health, who has only just answered a debate in this Chamber, should have left the noble Baroness to reply to this one. I am, frankly, surprised at him.
These are major issues. My noble friend Lord Fowler, who has done so much to champion the promotion of sexual health services both as a Minister and ever since, has said that he regrets not being able to be here to take part in this debate. We are looking at a dreadful picture. England and Wales have the highest teenage birth rate in western Europe. In 2006, the Health Protection Agency recorded another rise in the incidence of most sexually transmitted diseases, notably chlamydia, where the graph has been moving upwards for the last 10 years. A few days ago, the Aids Funders’ Forum published stinging criticism of the services available for people with HIV/AIDS. Glenys Kinnock and the noble Lord, Lord Smith of Finsbury, who are both staunch friends of the Government, have added their voices to that criticism—Lady Kinnock stating that HIV is,
“one of the lowest priorities in the already neglected area of sexual health”,
and the noble Lord, Lord Smith, observing that,
“there are too many people living with HIV who are simply not getting access to the services they need”.
The number of people who are HIV positive is growing. Indeed, the figure is up by 300 per cent in the past 12 years. The report by the AIDS Funders’ Forum says that the health needs of gay men and those over 50 are not being properly considered by NHS commissioners, who often have little knowledge about managing HIV effectively. A recent report by four bodies—the British HIV Association, the Royal College of Physicians, the British Association for Sexual Health and HIV, and the British Infection Society—says that HIV diagnoses are too often late, missed or simply wrong, and that inappropriate treatment is commonplace. The Terrence Higgins Trust published its annual survey in February. It found that almost half the number of PCTs had not assessed local sexual health needs for at least three years; prescribing restrictions were becoming more common; and sexual health issues such as contraception, HIV and abortion had assumed a lower profile in local health plans. There has been a loss of expertise in local sexual health planning, with the responsibility for commissioning shifting to non-specialist junior staff.
As if all that were not enough, research published in February by the Faculty of Family Planning and Reproductive Health Care reported that 40 per cent of sexual health clinics are having to reduce services, whether by accepting only a fixed number of patients or only seeing people with urgent problems. The vice-president of the faculty said:
“Patient care is suffering in community based sexual and reproductive health services ... Disinvestment and woefully inadequate IT systems are restricting client convenience and choice”.
Community contraceptive services contribute significantly to the training of professionals, which is one of the issues mentioned in the Question; but the faculty found that service cuts, understaffed clinics and high demand were not infrequently resulting in pressure on training activity.
Why is all this happening? The Government consistently tell us that sexual health is a priority. Indeed, in late 2004, John Reid announced £300 million of funding for sexual health services. As the noble Baroness, Lady Tonge, rightly said, much of that money has failed to reach the front line. The Department of Health’s own independent advisory group on sexual health and HIV reported last year that 45 per cent of PCTs had either withheld some or most of the new funding or absorbed the entire allocation into their general budget. The Chief Medical Officer, in his previous annual report, told us that public health budgets were being raided to pay off deficits elsewhere in the NHS. The Terrence Higgins Trust has recently amplified that; two-thirds of PCTs that responded to its survey said that Choosing Health money intended for sexual health services had been diverted elsewhere.
The Minister will no doubt tell us that it is up to PCTs to decide local priorities. If she does so, I would invite her to tell that to the patients up and down the country whose serious health needs are not being met by the NHS. Ministers should not shift the blame on to PCTs. In December, the chief executive of the NHS, David Nicholson, announced that not only was the NHS expected to balance its books in the next year, he also expected there to be a financial surplus in the health service by 2008. That pressure on the NHS to balance its books, alongside the abiding imperative to meet waiting time targets in acute care, has been a very significant driver behind the decisions by PCTs to divert funds away from public health services.
Even the central budgets for sexual health have been cut. Of the £300 million extra money announced in 2004, £50 million was to be spent on an awareness- raising campaign on sexual health. Last November, Caroline Flint announced a campaign worth only £4 million. When, in this Chamber, I asked the then Minister, the noble Lord, Lord Warner, what had happened to the other £46 million, he replied that it was,
“stored carefully in the coffers of the NHS”.—[Official Report, 21/11/06; col. 236.]
That makes one wonder what reliance one can place on any government announcement on future spending.
There are several specific issues that the Government could address now. The first is about the targeting of sexual health services. All the research tells us that there is a strong association between deprivation and teenage conceptions. The teenage conception rate in the most deprived wards in England and Wales is over four times that in the least deprived wards. Professor David Paton, at the University of Nottingham Business School, has said that the underlying social deprivation of an area, family breakdown rates and religion have a greater effect on teenage pregnancy rates than other more obvious policies. That tells us that access to family planning services cannot be the whole answer for this group of individuals. The Government’s steadfast refusal to reflect the value of marriage and the family in their wider policies could well be viewed as a contributory factor.
The National Institute for Health and Clinical Excellence has issued guidance that focuses on one-to-one interventions that aim to address the personal factors that influence an individual’s sexual behaviour and thus bring down the transmission of STIs and under-18 conceptions. The emphasis is on health professionals identifying those at high risk from disadvantaged communities and targeting interventions accordingly. That is sensible guidance from NICE; but one has to ask how on earth it can be implemented against the background of funding cuts that I have referred to. There really is only one answer here, unpalatable as it may be to the Minister, and that is to introduce some form of ring-fencing for this and other areas of public health expenditure.
I also respectfully draw the Minister’s attention to local safeguarding children boards and the protocols that they employ for working with sexually active young people. Last November, Brook and Action on Rights for Children sent out a survey to find out how LSCBs had implemented the Working Together guidance published by the Department for Education and Skills nearly a year ago. The survey found that a significant number of areas were introducing protocols requiring automatic referral to police and social services of all cases of sexually active under-13 year-olds. That policy produces the very opposite of what is needed: it deters young people from seeking the help that they need, sometimes desperately, because they know that they will immediately be reported to the authorities. The protocols that require mandatory reporting are inconsistent with the Working Together guidance, but they are nevertheless out there. Of the 70 LSCBs responding to the survey, 28 did not comply with the guidance. I ask the Minister: how has that situation been allowed to arise?
It is a great pity that this debate should have been consigned to a Friday afternoon. However, the Minister can be certain that for some of us in this House, the spotlight on these issues will remain fully on.
My Lords, I am grateful to the noble Baroness, Lady Tonge, for tabling such an important Question today, and she is clearly extremely well equipped to do so. I am also grateful to the noble Earl, Lord Howe, for being present. I must say that I do not recognise the bleak picture that he has presented, but I shall attempt to explain why. I understand that many noble Lords including my noble friend Lady Gould would wish to have been present, but the Question was tabled rather rapidly, hence their absence. That is why my noble friend Lord Hunt, the Minister, could not be here—he has a long-standing engagement that he could not break, and he sends his apologies.
The provision of contraception is a vital healthcare service which contributes to better maternal and child health. The cost benefit of contraception is well established and has been estimated at £11 for every £1 spent. It is also estimated that the prevention of unplanned pregnancy by NHS contraceptive services already saves the NHS over £2.5 billion a year.
This Government have made improving sexual health a key priority, including considerable new investment through primary care trusts. Reducing unintended pregnancies, improving access to contraceptive services and the full range of methods of contraception are crucial aspects of our overall sexual health strategy. Before I set out some of the actions we are taking nationally to support these goals, I wish to address the key concern that has been expressed today—that some clinics delivering contraceptive services in the community have been closed.
I have heard loud and clear the points that have been made and I well understand and share that concern. I understand that once a clinic has been closed, it is very difficult for it to be reopened. However, PCTs have been allocated resources to give them the freedom and flexibility to deliver on key targets, as well as financial balance. My own PCT in West Gloucestershire has increased expenditure by 9.9 per cent this year. It is not that the Government are trying to evade their national responsibilities; we are devolving power to PCTs. Ultimately, it is for those PCTs to determine the level of contraceptive service that they provide and from whom they commission those services to meet the needs of their local populations. Under the National Health Service Act 1977, a duty is delegated to PCTs,
“to meet all reasonable requirements … for the giving of advice on contraception, the medical examination of persons seeking advice on contraception, the treatment of such persons and the supply of contraceptive substances and appliances”.
I point out also that we have included sexual health and health inequalities in our six key priorities. This gives a clear direction to PCTs that, whatever else happens, they have to make progress on those key priorities and will be held to account for delivery on them. While the NHS budget will have almost tripled by 2008, I recognise that there have been real challenges for PCTs over the past year as the NHS has achieved financial balance. Contraceptive clinics have suffered and they should not be considered a soft option.
About three-quarters of the 4 million women using contraceptive services are seen each year by a GP. That leaves around 1.2 million women who attend community contraceptive clinics; that figure has remained constant over the past 10 years. Young women, in particular, prefer to use the clinics, and 16 to 19 years old is the peak age for attendance. The clinics play a crucial role in protecting against unintended pregnancies and sexually transmitted infections, as was highlighted in the White Paper Choosing Health: Making Healthy Choices Easier.
The availability of a well publicised, young people-centred contraceptive and sexual health advice service is a vital element of the strategy to reduce teenage pregnancies, which have such a profound effect on the lives of girls, especially, as the noble Earl pointed out, the most disadvantaged. There is a clear link between deprivation and teenage pregnancies. However, I refute his comment that the Government do not support marriage. We very much value the stability of marriage, but we also value other stable relationships.
The Government gave a commitment in the White Paper to undertake a baseline review of contraceptive services in England to identify gaps in local services and ensure that the full range of contraceptive services is available, that good practice is spread and that services are modernised. In January 2006, all PCT sexual health leads were asked to complete the baseline review of contraception services, thus providing a snapshot of service provision. The review incorporated a PCT questionnaire for use locally to identify gaps and areas for action, and nationally to provide a strategic overview of contraceptive services in England. Eighty-two per cent of PCTs completed the questionnaire.
Nationally, we have included centrally held information on prescribing data, rates of teenage pregnancies and abortion to provide a national picture of sexual health indicators pertinent to the provision of community contraception services. Contraception service commissioners and providers were advised to use the findings of the PCT questionnaire to address gaps in service provision locally in advance of the Department of Health publishing the findings, which we shall be doing very shortly.
My Lords, I understand that it is ready for publication but, because of the purdah imposed by local government elections, it cannot be published until after those elections.
The results will also feed into best-practice guidance on reproductive health care, which is being drafted. This will be comprehensive guidance covering abortion and contraception provision, service delivery, professional roles and leadership, training and counselling for abortion. I understand that it will be published in the next few months, before the summer.
Last November, we launched a major media campaign on sexual health called “Condom: Essential Wear”. This is aimed at young men and women aged 18 to 24 and its purpose is to ensure that they understand the real risk of unprotected sex and to persuade them of the benefits of using condoms to avoid the risks of STIs and unplanned pregnancies. We have spent £6 million on the campaign in the past year. I know that that is not £50 million but it is a start. This is just one of three government campaigns working to improve sexual health and reduce teenage pregnancy. It complements the DfES's teenage pregnancy campaigns, “R U Thinking”, which is aimed at 13 to 16 year-olds, and “Want Respect? Use a Condom”, aimed at 16 to 18 year-olds. This integrated communications approach enables us effectively to target young people across the age groups. From some evaluation tracking, I understand that the messages really are getting through, the key messages being, “Don’t be pressured into having sex” and “Use a condom”.
One of our key aims is to improve access to the full range of methods of contraception. Expert opinion is that long-acting reversible methods of contraception—LARC—have a wider role to play in contraception and that their increased uptake could help to reduce the number of unintended pregnancies. The effectiveness of condoms and the contraceptive pill depends on their correct and consistent use. By contrast, the effectiveness of LARC methods does not depend on daily concordance. However, the uptake of LARC has been very low compared with usage of the contraceptive pill and other less reliable methods of preventing pregnancy.
The National Institute for Clinical Excellence published guidance on the use of LARC in 2005. This highlighted that these methods are more effective than the pill, and we strongly support that guidance. The use of LARC has been slowly increasing and it is encouraging that in 2005-06 it accounted for a fifth of all methods chosen. The noble Baroness is absolutely right that we need more training for LARC, and I understand that we are working with commercial partners to promote LARC methods in general practice, including training for the health professions.
Having children at a young age can damage young women’s health and well-being and severely limit their education and career prospects. The UK has a poor record on teenage conception, which is why we developed a 10-year, multi-faceted strategy on teenage pregnancy, which was launched by the Prime Minister in 1999. We also have a PSA target to halve the under-18 conception rate by 2010. The strategy is based on international research evidence on what works to reduce teenage pregnancy and improve health education outcomes for teenage parents and their children.
Teenage conception rates for under-18s have fallen by 11.8 per cent, and for under-16s by 12.1 per cent since 1998. While there has been steady progress nationally, there is huge variation in performance between areas. The best local authority has seen a reduction of over 40 per cent, whereas in some areas rates have increased. We know what works and have issued detailed guidance to local authorities and PCTs, setting out the key ingredients of successful local strategies. Recently, my right honourable and honourable friends—Beverley Hughes and Caroline Flint—had a meeting with the 22 areas in which there are the greatest number of teenage pregnancies, to try to encourage them to adopt all the best practice that is out there and cited in the guidance.
I shall move on briefly to the wider sexual health initiatives. Improving sexual health and access to genito-urinary medicine clinics is one of the top priorities for the NHS. Our key target is to ensure that, by 2008, everyone who needs an appointment at a clinic is offered one within 48 hours. Data recently published by the HPA shows that 70 per cent of patients were seen within 48 hours and a further 11 per cent were offered an appointment but chose not to attend. In May 2004, only 38 per cent of attendees were seen within 48 hours. Community contraception services can play a role in supporting delivery of this target as increasingly they are taking on more routine testing and treatment for STIs. The target is an opportunity to use levers, such as practice-based commissioning, to further develop the role of contraception services in this area.
Community contraception clinics already play an important role as a setting for screening young people between the ages of 16 to 24 in the National Chlamydia Screening Programme. More than 104,000 screens were undertaken in year three of the programme, and community contraceptive services remain the most common screening location for both men and women. The noble Earl is right to draw our attention to the fact that we have problems with chlamydia, and we must do everything that we can to ensure that more and more young people are properly screened.
The noble Earl raised the question of HIV, and I draw his attention to the fact that we have increased our investment this year and next year by £1 million in our targeted HIV health promotion for gay men and African communities, who are most at risk of HIV in the UK. We believe that targeting these groups is the most sensible way forward.
The noble Baroness mentioned the vital role of training. We are, of course, aware of the major role that specialist contraception services play in providing training and, in particular, the role they play in supporting general practice, so any reduction in these services may have an impact on the number of providers being trained. We also recognise that there is an urgent need to increase the numbers of sexual and reproductive health consultants, and the department is working closely with the Royal College of Obstetricians and Gynaecologists to address workforce issues.
We are committed to supporting training and competency development for contraception. For example, the Department of Health is funding the associate nurses working group of the faculty of family planning and reproductive healthcare to develop national recommended training standards in contraception, sexual and reproductive health for non-medical healthcare professionals. The standards and core package will be disseminated to all higher education institutions, commissioners and providers for use in ensuring provision of post-basic training in contraception and sexual health.
The noble Earl raised the question of IT. There are plans for the future inclusion of sexual health services in Connecting for Health. We are confident that this will be done. Clearly, however, there are difficulties of confidentiality which we are currently addressing.
Community contraceptive services undertake high quality and absolutely essential work. They do an excellent job, and I pay tribute to them, especially as they grapple with the challenges of a reformed and modernised health service. We will develop new commissioning guidance this year which will include commissioning of contraception provision. This and all the other actions I have highlighted today underline the Government’s commitment to ensuring continued access to high quality contraception provision, whether in general practice, community or voluntary sector settings. Contraceptive services are absolutely vital to the future economic and social well-being of our country, especially for those who live in the most deprived areas.
House adjourned at 2.01 pm.