Thursday, 11 December 2014.
Female Genital Mutilation
Question for Short Debate
My Lords, in the past 30 years there have been two Acts of Parliament concerning the law on female genital mutilation. The second one, in 2003, superseded and expanded the first, making the maximum punishment for carrying out genital mutilation 14 years’ imprisonment. In the past year, at last, and for the first time, FGM has been very much to the fore. Those of us who have always believed that schools have a major part to play in detecting which children are at risk of FGM have seen teachers alerted to identifying those in danger. Nurses and midwives—many of whom knew nothing about the risk, and who had among their patients those who were likely to have been mutilated and those who would be liable to be—have now been taught what to look out for. Young girls subjected to FGM as small children or recently in their teens have come forward, told their stories to newspapers and magazines and been featured in the many campaigns intended to put an end to what has long been known as a cruel and revolting practice.
This week, as part of the Government’s reducing and preventing crime strategy, mandatory reporting of FGM begins. The Home Office particularly wants to hear from health professionals, the judiciary, social workers, criminal justice practitioners, service providers and local authorities. Sanctions are to be applied if professionals fail to report FGM. This is an important step forward, but those of us who have worked against FGM have long been convinced that the best way of stopping it would be to prosecute the perpetrators. One single successful prosecution would do much. With a law in place allowing no mercy on perpetrators of FGM, making no excuses for them and uncompromisingly calling their action a crime and child abuse, a newcomer to the UK who had never previously heard of FGM, on learning what it was and what the law was, would refuse to believe that there had been no prosecutions.
In many countries where the law is similar prosecutions happen and are successful. There have been more than 100 successful prosecutions in France, in Italy and in Sweden, and there have been successful prosecutions in countries in east Africa as well. In Kuria East, in central Africa, the parents of a 13 year-old girl were prosecuted for employing a so-called circumciser to cut her and were sent to prison for three years. In France, girls are routinely examined by their doctors to check if they have had FGM or are in danger of having it. However, there have been no prosecutions here. The reasons given are that a girl will not go into court and give evidence against her parents about abuse carried out on her. In parts of Europe where girls have given evidence against their parents, they have never returned to their parents’ home after the case was over. The communities from which they, their parents or even their grandparents have come are known for the closeness of their families. Appearing in court and stating openly under oath what a mother or even a father did to them would be a betrayal many could not face carrying out. But to put an end to FGM such evidence almost certainly must be given. Perhaps we have to find a way to expand the law, to change the law, if we are to make successful prosecutions happen in future.
I have talked to surgeons from France who have carried out reversals of mutilation. Such reversals now include restoring parts of the genitalia, which used to be considered impossible. The time will come, it is hoped, when complete restoration can be achieved. One fine surgeon well known to me in London carries out reversals but has yet to restore sensation to the clitoris. But are we really to look forward to the repair of a hideous, brutally perpetrated wound—a repair carried out with great difficulty and enormous skill—as the only certain solution to the problem of FGM? What kind of a society uses circumcisers who are ignorant of medicine and surgery to deliberately maim young women and girls, who can only be restored to health and a normal life by the operations of a highly skilled surgeon?
The number of cases of FGM cutting in this country, in Europe and in Africa vary. Indeed, I may say that they vary wildly. At present we hear of 66,000 cases in the UK with a further 24,000 at risk, while a few months ago I heard the figures of 133,000 and then of 137,000. In Africa the figure is 3 million, but is liable to change according to who arrives at it.
The Home Office, the Department of Health and the Department for International Development now recognise that tackling violence against women and girls, which includes FGM, requires a sustained, robust and dynamic cross-government approach, and that every department needs to play its part in addressing FGM. We hear less these days about the supposed cultural value of FGM or about not interfering with ancient traditions. Foot binding in China had to be banned, as did such practices as neck lengthening which result in disablement. We now hear less, if anything, about the value to society of the tradition of FGM and the need to retain it.
The Department of Health is working to improve the information collected by the NHS on FGM. Health staff may now have to include a type of so-called female circumcision in their attentions. This, which appears to be Islamic in origin, is now being practised in the UK, according to information reaching the FGM National Clinical Group. It claims to be close to male circumcision and involves cutting the area around the clitoris. It appears to have its origin in the Caribbean. Claims are made that it brings enhanced pleasure to men and women but, whether or not that bears any relation to the truth, the fact is that it too is illegal here. It is just another variation on a damaging cutting procedure, which every victim would be better off without.
The Department for International Development has established a £35 million programme to address FGM in Africa and beyond, which aims to end FGM in one generation. The Home Office’s action plan, the Call to End Violence against Women and Girls, has renewed its focus on protecting potential victims. The Home Office aims to use this plan to work closely with partners across government to help secure an FGM conviction. The Home Office has launched a statement which sends out a strong message to anyone involved in the practice of FGM. This statement is set out on leaflets, of which 37,000 have gone out.
The Home Office continues to work closely with the Crown Prosecution Service to ensure that the Government are doing everything they can to secure a prosecution. The Director of Public Prosecutions’ assessment is that it is now only a matter of time before a perpetrator is brought to justice. A doctor is due to appear at the Central Criminal Court in January, and if this case goes ahead it will be the first instance of a prosecution under the Female Genital Mutilation Act 2003. One successful prosecution might arguably do more than cautionary leaflets. This case is long awaited and I hope it may take place, whatever the outcome, because 133,000 or 137,000 young women and girl children’s future lives depend on it. The publicity which it gives rise to alone will spread the news of what FGM is as nothing else can.
My Lords, it is an honour to follow the noble Baroness, Lady Rendell of Babergh, who has espoused the cause of halting FGM for at least as many years as I have months. When I entered your Lordships’ House, I very much felt that I did so to represent music, culture and the arts, but what I discovered from listening to debates about FGM so appalled me that I became quite passionate in my own espousal of this cause. It is an appalling practice, and what really staggered me was that it is happening in Great Britain; I simply could not believe it. It is bad enough that it is happening in the way that it is in many countries—and I know that there are charities tackling that—but that this is going on in this country is completely staggering. I gather that some children are brought to this country to be subjected to FGM. Does the Minister have any figures not just on the people who live here who are being cut but on the ones who are possibly being brought here for that purpose? It would suggest that there is not a sufficient fear of the law.
When this issue was recently debated in your Lordships’ House, the noble Earl, Lord Howe, was asked about the discrepancy between this country and France, which the noble Baroness has just referred to. He said, with considerable justification, that France is a very different country from this one and that the idea of mandatory examination here would offend civil liberties and the mothers of young girls would be very upset. It is a fair point. I therefore undertook to ask several friends with young children how they would feel about it. Their initial response was exactly as the noble Earl predicted. However, when I said to them, “If the fact that you allowed your young child to be sensitively examined—however much you may baulk at it—saved five, 10, 20, 100 or who knows how many other children from being mutilated, would you feel differently?”. At which point they said, “If you put it like that, yes; I could not possibly refuse something that might save other children from this horrendous practice”.
I know that the Minister and everyone in his department and the Department of Health are very concerned about this—none of us doubt that. None of us wants to see this practice continue. We all think that it is barbaric. However, although progress is being made, we have not yet, as we have heard, obtained a conviction. I ask the Minister to consider—I use that word very carefully—mandatory targeted examination. If one is considering it one is not necessarily saying that it is going to happen, but the fact that the Government say that they may need to consider it would send a message to families who might be considering cutting their children. They might suddenly realise that they could be held to account. As far as I can see, this is a win-win situation for the Government. Even if it stopped a handful of children being cut, it would have achieved something.
I shall keep my speech very short because I have previously gone on and on about the barbarity of the practice. We do not need to hear those arguments again because we all share the same feelings about the practice. I simply ask whether the Minister will consider the possible mandatory targeted examination of children.
I, too, thank the noble Baroness, Lady Rendell, for highlighting this important area and giving us yet another opportunity to air some of these complex but vitally important matters. I pay tribute to her determination in trying to keep this issue in the public domain. I also thank Her Majesty’s Government for the splendid, recently published action plan. It is encouraging that many people want to make an impact on this problem, across all the parties. That is the secret. We need to get cross-party support and expand it much more widely.
Yesterday marked the end of a 16-day campaign, the origins of which lie with the Women’s Global Leadership Institute. The 16 Days of Activism Against Gender Violence campaign began on 25 November—the International Day for the Elimination of Violence against Women—and ended yesterday, 10 December, which was Human Rights Day. A specific part of this campaign is to target the ending of FGM.
Within my own sphere of operation within the Anglican Communion, the Mothers’ Union, which has more than 4 million members worldwide, has participated in this campaign. Indeed, in my own diocese of St Albans we have recently had a debate on gender-based violence, including the horror of FGM. In response to that, we have committed ourselves as a diocese to campaign on this issue and to try to raise it across all sorts of different bodies and groups. As a direct result of that and other initiatives, in the last few days I have tabled a number of Questions to Her Majesty’s Government on the subject of FGM.
This debate is specifically about encouraging prosecutions under the 2003 Act—something which, as we have already heard, has not so far been accomplished, although I understand that that may change shortly. I also note that under the Serious Crime Bill, which is now having its Second Reading in the other place, we have been beefing up the legislation in several areas relating to this. For example, the scope for prosecuting someone for assisting an offence of FGM overseas is being extended to all residents of the UK, not just permanent residents. There will be a guarantee of lifelong anonymity for anyone who is alleged to have been the victim of FGM, which is more likely to make victims feel willing to come forward. There will be a new offence of failing to protect a girl from risk of FGM on the part of someone with parental responsibility for her, and female genital mutilation protection orders will be introduced. Those are all things which I warmly welcome. It is intended that they will help to prevent vacation cutting, while allowing the child to stay with her family and not be taken into care.
I know that a number of your Lordships will share my regret that one amendment was lost earlier in the passage of that legislation. It sought to add to FGM protection orders the words:
“For the purpose of determining whether an operation is necessary for the mental health of a girl or woman, it is immaterial whether she or any other person believes that the operation is required as a matter of custom or ritual”.
I did not take part in the debate at that stage but I understand that the amendment was rejected because some people believe that it is already covered in the 2003 Act. However, in my mind it highlights that, while we are busy trying to pass more legislation, somehow we are not getting convictions under the existing legislation. We have already heard that there have been a number of prosecutions in France, and I think that just last month there was a successful prosecution in Uganda. I found myself wondering whether what we need is not more legislation but to work out where the blocks are. In particular, for example, do we need to get people from the CPS to go to France to discover what the problems have been in working through this? Are there other blockages? If Uganda is achieving prosecution, surely it cannot be beyond our wit to do the same. If this is going on, it is clearly established, because the evidence is there in some cases. I hope that we can take a close look at why we do not seem to make more progress.
However, I want to underline that, as well as hoping to get prosecutions, we need to work really hard on changing culture. Law is a blunt instrument. We have loads of laws on drugs and substance abuse and we try to enforce them, but, in that and other areas, we need to keep trying to get behind the issue which is causing the problem in the first place. We need to look at how we can help those very often traditional societies. I hear the point being made by my noble friends about sending out signals, but in some of these communities very few people are able to speak English, some of them do not listen to any radio stations that we listen to, and some of them are not able to read what we would call a usual English newspaper. The question is whether some of these signals are being heard. I spent some years working in Walsall in the West Midlands in an area with a large number of people of other cultures. In many ways, they were quite separate from what we accepted as the norm. As well as making a push on convictions, which will send out a strong signal, I hope that we can find ways of engaging much more with the leaders of these communities.
It is very often, I am told—I have no direct experience of this—the older women in the communities who push for this as the norm; it is not just men who see this as an issue. In particular, we need community leaders who are willing to say publicly that they not only do not agree with it, but that they would be willing to marry someone who has not had FGM. There have been one or two such statements and these will dig right into the culture and help us move forward. So, as well as making a push on the legal opportunities, the prosecutions, I hope that we will not lose sight of some very useful material in the national action plan about dealing with cultural issues at the same time.
My Lords, I, too, congratulate the noble Baroness on raising this issue. On Tuesday the House debated judicial review and its importance in ensuring that Ministers act according to law. In a country without a Bill of Rights, this is an essential cog to uphold the rule of law, as the House decided overwhelmingly. In my short speech I talked about how a government department that I was responsible for reacted to an adverse decision of the courts, and the non-statutory inquiry I set up, as Attorney-General, following criticism of the Director of Public Prosecutions and the Crown Prosecution Service.
I am confident that the current Director of Public Prosecutions, whom I know, with her long experience of prosecuting, can be relied upon to fulfil the proper tests for prosecution: the public interest one and the evidential one. But you cannot make bricks without straw. I think that the public interest test is clear. However, there seems, from the paucity of prosecutions, to be substantial difficulties in the presentation of evidence. Do the difficulties lie with the families, with the victims, with the medical profession? If it is with the medical profession, where is the Hippocratic oath? If there is fault, where are the disciplinary procedures of the medical profession?
According to the Times, yesterday the Home Secretary said:
“Doctors who perform cosmetic vagina surgery could be committing a criminal offence”.
She added that that would be a matter for the courts to decide. However, if there are hardly any cases for the courts to decide, how is the rule of law being complied with? The Home Secretary also said that,
“prosecutions were already possible under 2003 legislation which strengthened the ban on FGM”.
Well, it is good to know the obvious. In my view, it is high time that there was a high-powered inquiry, with the co-operation of the medical profession, as to where and what the problem is.
In my time as Attorney-General I had regular meetings with the Director of Public Prosecutions, week in, week out, when we discussed significant and important cases. However, the decision to prosecute or not was for the DPP alone. Given the concern that so few cases are coming before the courts, and that there are prima facie cases that the rule of law is being flouted, how many times has the issue been raised in the regular meetings of the Attorney-General and the director? I have no doubt, given the significance of concern over this issue, that had I been in that chair, I would have raised it with my DPP, and I am sure that my DPPs would have raised it with me.
My Lords, I, too, would like to congratulate the noble Baroness, Lady Rendell, not just for raising this issue but for raising it again and again. We appreciate that because it reminds us all that we still have not done very much about this problem. I can remember in the early 1990s my very first clinical experience of this, so it is as recent as that. A patient had come to me for advice because she was planning to get married. She was a very intelligent girl, at university, from Somalia as it happens, and we know now that that is where the practice goes on. She came and I examined her and I honestly did not know what I was looking at. I did not know whether she had a congenital abnormality or what, and she told me about FGM. The patient herself explained it to me. In all the years of obstetric, gynaecological and general medical training and all the practice I had had up to that time I had never seen a case or heard about it. I think that really shows how recent the problem is, even for the medical profession.
In 2000, when I was in the other place, the All-Party Parliamentary Group on Population, Development and Reproductive Health produced a report. We did a survey of attitudes to try to find out what was going on in this country. Out of the 240 doctors, nurses, clinics, schools and a range of facilities that we asked, we had only a 22% response. People just did not know about it. That was 14 years ago. Here I must pay another tribute to the NGO Forward which is headed by Naana Otoo-Oyortey because she, like the noble Baroness, has never left this subject alone. She comes back to us time and again. That survey showed there was very little knowledge and training, despite the fact that in 2002 and 2003 Ann Clwyd, whose Private Members’ Bill I supported, extended the prohibition to the practice of girls being taken abroad to have this done. Despite all of this and despite the efforts of the noble Baroness and others, by 2012 there were still no prosecutions in the UK.
A meeting was arranged with Keir Starmer in 2012, the then Director of Public Prosecutions, who was extremely enthusiastic and got a big group of people together to investigate why there were no prosecutions, and this action plan has been carried through by his successor. So things have been done at all levels. At the Girl Summit the Prime Minister said he was committed to prosecutions. Again this year the Serious Crime Bill, as we have heard, is planning to extend prosecutions to people who are habitually resident here and not normally resident. I expect the lawyers to explain the distinction to me. So things are happening all the time on this. Also this year we have been assured that information has been sent and training given to schools, doctors, nurses and midwives. Midwives are especially important because girls who had this mutilation at a very young age are now having babies and coming to our maternity hospitals and obstetric departments to have their babies, so that is a point when we can identify that they had it done. They are not necessarily very old.
Despite all this, and the passage of the summer holidays when we know girls have been taken abroad to have this torture done—there is no other way of describing it—we have no prosecutions. What has happened to mandatory reporting? Was it not going to be a duty of doctors, teachers, nurses and other groups to report it if they discovered a girl who had this done? How is the training of professionals progressing? What plans are there for prosecuting community leaders and even family members? As the Bishop mentioned, grannies like me in other cultures and societies will be the people who will be promoting traditional practices. What plans are there for prosecuting those people?
I have written here, because I was angry when I was writing it this morning, “Stop pussyfooting around”. I apologise for the language, but we really have got to stop it. All the child protection legislation that we have had over the years surely covers this. It is the most grotesque form of child abuse. It is horrible and violent. It causes untold physical damage to a woman and, we should remember, a huge charge on the National Health Service. We must remember all these things. Surely the legislation is already there, as it is child abuse. If a family member sexually abuses a young girl, he goes to prison. Why does he not in this case? It should be the same for FGM.
We do not need to have the child as a witness standing in court. It is the parents’ responsibility and if this has happened to the child, my view is that those parents should be prosecuted. I know that it will cause terrible hardship, fear and damage to a few families but maybe we have to have a few families go through this to make the point that it is illegal. It is grotesque child abuse. It must not happen and we must see a stop to it.
My Lords, I associate myself with the tributes paid to the noble Baroness, Lady Rendell, first, for giving us the opportunity to have what has been a very thoughtful debate on this issue and, secondly, for her tireless campaigning on an issue that—let us be honest—is so awful that most of us do not even want to think about it. However, we have to think about it and take action on it so her campaigning, and the way that she has drawn the wider public’s attention to this issue, is something that she should be very proud of and we are very grateful for.
I also welcome the Minister who is responding to this debate. As we have heard, there have been some debates that were responded to by the Department of Health. During the many debates on the changes that we were making to legislation on the Serious Crime Bill, it was the Home Office responding. It is appropriate that we also have a response from the Ministry of Justice, as there are specific issues related to that department. That just shows how important it is for those three departments, and others, to work together and be co-ordinated on this.
The scale of this problem is hard to comprehend. We have had some figures from the noble Baroness, Lady Rendell, but there are thousands of young women and girls in this country who have been mutilated. For those who think that it happens somewhere else over there, it does not; it is happening here. There could be a young girl somewhere in the UK today who is being mutilated. It is that serious. The euphemism that we sometimes use of girls being “cut” belies the horror of what is really involved, which I think is the point made by the noble Lord, Lord Berkeley of Knighton. It was right that the noble Baronesses, Lady Tonge and Lady Rendell, were also clear about the horrors of what is involved. When we spoke about this in debate on the Serious Crime Bill, I think that I was the first person to appear on “Yesterday in Parliament” in a programme that was given a certificate and a warning before it went out. I thought that it was important to say exactly what is involved, and in somewhat embarrassing graphic detail.
We are talking about thousands of young girls and women. The noble Baroness, Lady Tonge, made the point about these girls having children. It is estimated that up to 60,000 girls have been born in England and Wales to mothers who had FGM, which means that they have been sealed up after they have been cut and that the process of birth, where they have to be operated on beforehand, is extremely difficult. Whatever the numbers, we are talking about thousands. The process known as infibulation sounds quite a normal word for something that will continue to cause pain and trauma throughout the life of that woman. It is a mutilation that leaves permanent scars, on the mind as well as on the body.
The lack of prosecutions should concern us all. It would be fine if we thought that there was a lack of prosecutions because the law had been so successful that it was preventing this happening. However, we know that that is not the case and that thousands of young girls every year undergo FGM here in the UK.
I would like to raise two issues because it seems to me that the purpose of legislation here is twofold. We have such legislation in place, first, to try to prevent such mutilation occurring and, secondly, to take action against those who break the law. We had discussions in debate on the Serious Crime Bill on female genital mutilation orders, which the Government introduced in response to our proposals for such orders. They seek to protect young women from this vile practice before it happens, so they are similar to the forced marriage orders in their aim being prevention. By recognising all the problems in getting evidence for a criminal prosecution, they take the route that this is a civil measure to protect a young girl rather than a criminal measure.
The Minister was not in the debate because it was not his Bill, but I am sure that he will be aware of the discussions that we had. We have concerns about the process that the Government have chosen. Rather than placing such orders clearly and firmly in family law in a civil process, they are placed in a civil process within criminal law. I will not go into the detail now but all the advice that we have received from lawyers with expertise in this field tells us that this will make the gain of such an order more difficult, for some of the reasons that we have explained before. That is part of why we have had a lack of prosecutions for those who have committed FGM.
The Minister’s experience will tell him that lawyers dealing with family court cases and issues are not the same as those who deal with criminal law. We welcome the orders that prevent this happening and we welcome the Government’s support, but we just want them to be as effective as they possibly can be, because a child’s future depends on us getting this right. We want to ensure that there are no barriers for someone to seek an order to protect a young girl from being mutilated. We want to make it as easy and straightforward as possible, without any loopholes or problems. So before the Serious Crime Bill finishes its passage through Parliament, could the Minister bring his legal expertise to look again at this issue to ensure that we have got it right, because we have serious doubts that the orders as currently proposed will get as many prosecutions as they could if they were wholly within family law courts and not within a criminal prosecution, although it is a civil measure?
I am not talking about prosecutions—I am talking about the FGM orders that are currently civil orders that the Government have placed within criminal law to keep all FGM legislation the same. It is a very different process from prosecuting afterwards.
My second point is that we wanted these FGM orders to be based on the same principles as forced marriage orders, which have been significantly successful. One aspect on which I sought clarity from the Minister at Third Reading—I have also spoken privately to the Minister and have not yet got an answer—is whether legal aid would be made available for those seeking an FGM order as it currently is with forced marriage orders? The Minister was unclear on that in the House and although I have spoken to him since it seems that there is still a lack of clarity in the Government over whether these orders would attract legal aid. It seems impossible to me that they could proceed in any way without legal aid.
During the passage of the LASPO Bill, because of the changes made to legal aid by the Government, there was a specific provision was made for forced marriage orders, in paragraph 16 to Schedule 1. No such provision has yet been made for FGM orders. I find it strange that the Government would consider bringing in such orders without providing these young girls or those acting on their behalf to prevent them being mutilated with the ability to bring something before the courts and have legal aid. Are the Government intending to make legal aid available? If not, or if the position remains unclear, how does the Minister expect the orders to be obtained and how many does he think that there will be?
We do not think that the Government are wrong on the orders. On prosecutions, we believe that they share our objectives to stamp out this practice and hold those responsible to account. We believe that that is a genuine commitment from the Government. However, the laws that we have at the moment are not working as well as they should, or were intended to do. We have an opportunity in the Serious Crime Bill to make changes and get it right, but as the right reverend Prelate said, we need to have a cultural change as well. If it was made clear that successful prosecutions could be made under the existing law, that would help to drive a cultural change. If the expectation was that this was something that could be prosecuted, that would have an impact in those communities.
We all want to see those responsible for mutilating the genitals of young girls being prosecuted, and we want to see this twin-track approach whereby we prevent it happening in the first place and make a difference to the lives of these girls.
My Lords, I join other noble Lords in thanking the noble Baroness, Lady Rendell, for securing this important debate and for introducing it so effectively and economically. The fact that she has returned to this subject so many times is a tribute to her tenacity on what is such an important issue for all of us. This issue is very much in the news now; coverage of it has exploded. However, that was a long time coming and is due to many people, including those such as the noble Baroness, Lady Rendell, who have kept the matter high on the agenda, and I pay tribute to her and to other speakers who have an equal interest in this important subject.
There is, I think, complete agreement that this is an abhorrent crime that affects some of the most vulnerable girls and women in our society. The Government are committed to preventing and ending the harmful and unacceptable practice. I agree that successful prosecutions are a key part of stamping out FGM and would send out a strong message on the rule of law, something to which the noble and learned Lord, Lord Morris, referred. There is a prosecution due in January. It is probably not appropriate to comment on what one hopes the outcome of the case would be, but, whatever happens, the publicity that will attend that prosecution should, I hope, send a strong message in itself.
The DPP announced the first prosecutions of FGM in March of this year. The first defendant is charged with carrying out FGM. The second defendant is charged with intentionally encouraging an offence of FGM and aiding and abetting, counselling or procuring an offence. I am sure that it is a source of frustration to all noble Lords that while FGM has been a specific criminal offence for 29 years—the original Act—no prosecutions were brought. Indeed, the noble Baroness, Lady Rendell, played a significant part in the Prohibition of Female Circumcision Act 1985. The Female Genital Mutilation Act, which she steered through this House, extended significantly the protection that the law affords to victims of this unacceptable practice. The Act created extraterritorial offences to deter people from taking girls abroad, and, to reflect the serious harm caused, it increased the maximum penalty for any of the female genital mutilation offences from five to 14 years.
However, there has been increasing public concern at the failure to achieve a successful prosecution. Records indicate that no cases were referred to the CPS for a decision on whether to bring proceedings until 2010. In the last couple of years, a small number of cases have been reported to the police, which they have duly investigated. Some of those cases have since been referred by the police to the CPS for advice. However, the prevalence of FGM here—a study, part-funded by the Government and published in July 2014, revealed that approximately 60,000 girls are at risk of FGM in the UK—clearly should give rise to far more investigations and prosecutions than are taking place.
The CPS can, of course, only consider prosecuting cases of FGM which have been referred to it by the police following an investigation. However, the real problem has always been persuading victims to come forward at all. There are a number of challenges faced by the police in investigating cases of FGM. Many victims may be too young or vulnerable, or too afraid to report offences or to give evidence in court. As referred to by the noble Baroness, Lady Rendell, the consequence of giving evidence and coming forward can be complete ostracisation from family or community: they may seem to pay a very high price. There may be evidential problems and other difficulties if cases are reported many years after the event. And of course FGM may take place out of the jurisdiction, leading to challenges in obtaining reliable and admissible evidence.
The CPS has been working closely with the Government, police, medical professionals and the third sector to address some of these challenges, and is now in a much stronger position to bring successful prosecutions against those who perpetrate this practice. The DPP wrote to the Ministry of Justice and to Home Office Ministers in February 2014 proposing changes to strengthen the legislation. The proposals were informed by a review of cases referred to the CPS by the police in which prosecutors had been unable to charge and prosecute. A number of areas were identified in which legislation could be strengthened.
As has already been mentioned, in July 2014, the Prime Minister hosted the UK’s first Girl Summit. At the summit, a package of measures was announced, including commitments to strengthen the law and improve the enforcement response. There has been reference to legislative changes included in the Serious Crime Bill. While I readily concede that legislation is not of itself the answer, it is nevertheless important that there is the appropriate legislative framework. Some of the cases referred to the CPS highlighted, in the context to which I referred earlier, that a prosecution for FGM committed abroad could not be brought if those involved were not, at the material time, permanent UK residents as defined in the Female Genital Mutilation Act 2003. Clause 67, which was included on its introduction, extended the reach to habitual as well as permanent UK residents. Many textbooks have been written about the different between “habitually” and “permanent”. I will not deal with the issue now, but it certainly covers those who seek to say that they were not permanently resident here. This means that it will in future be possible to prosecute a non-UK national for an offence under Sections 1 to 3 of the 2003 Act where that person is only habitually resident in this country.
More amendments were added on Report. It was thought that victims were reluctant to come forward because they did not want to be identified in the media, so lifelong anonymity is granted by Clause 68. We hope that will help to encourage people. I pay tribute to those who are courageous enough not only to come forward but to identify themselves—there are one or two. We hope that that will be followed.
Clause 69 creates a new offence of failing to protect a girl from the risk of FGM and would make someone who has parental responsibility for a girl who has been mutilated aged under 16, and is in frequent contact with her, or who has assumed responsibility for such a girl, potentially liable if they knew, or ought to have known, that there was a significant risk of FGM.
Of course, we are very keen to see the criminal law being used, but ideally one would want to prevent FGM happening at all. So, following a consultation launched at the Girl Summit, Clause 70 introduces the civil order referred to by the noble Baroness, Lady Smith, to protect those at risk of FGM. She said that she is concerned that in the particular court in which such an order can be obtained the relevant experience may not be there for those who might seek an order and it would be better obtained elsewhere. We will consider that matter and I will pass on the concern that she has expressed. However, what is important is that wherever it is appropriate to seek such an order there is the relevant experience. We will work with the legal profession and others to ensure that the provisions are widely publicised and understood so that they can be proceeded with.
The noble Baroness asked about legal aid. I inquired specifically on this. The position is that we are considering the question of legal aid. I hear what she says about that. It is a matter which will be considered, I hope, in short order.
Safeguarding professionals are key to reporting FGM. The Government have committed to consult on how best to introduce a new mandatory reporting duty to ensure professionals report cases of FGM to the police. Alerting the police to actual cases will allow them to investigate the facts of each case and increase the number of perpetrators apprehended.
The CPS has appointed lead FGM prosecutors for each CPS area in England and Wales and local police/CPS FGM investigation protocols have been agreed with the 42 police force areas. That deals to some extent with the point made by the right reverend Prelate about the need to skill up prosecutors and the police to make sure that there is not just legislation but some practical understanding of the problems that are to be confronted here.
The Government have published multiagency practice guidelines on FGM, highlighting the risk factors that teachers, nurses, GPs, police officers and social workers should be looking out for during their work—matters on which the noble Baroness, Lady Tonge, was keen to establish we were making progress. We are supporting and funding community engagement work to raise awareness of the issue. We are ensuring that NHS acute hospitals routinely record information relating to FGM and use it to support social services and police, as well as sharing it to provide appropriate healthcare for girls and women.
The Home Office has launched an e-learning tool so that all practitioners are able to undertake an introduction to FGM. There are reforms to social work, education and practice to protect children from FGM and other forms of abuse. There is also work to tackle FGM internationally, and DfID has announced a £35 million programme. The right reverend Prelate referred to our response to the Select Committee’s report and the action plan. I think that all noble Lords will agree that we have done all we can to grapple with this issue, although progress is frustratingly slow.
The noble Lord, Lord Berkeley, asked whether this country was in some way particularly attractive to those who might wish to perpetrate this crime on young girls. Of course, one of the problems is that this is a largely hidden crime. However, the Government are committed to trying to stamp it out. They do not keep data on this matter but we are convinced that what we are doing will not do anything other than discourage it because of all the publicity and the various steps that we are taking.
As to the question of compulsory examinations, which the noble Lord raised on a previous occasion, I understand why he thinks that that is important. At the moment, the Government are not convinced that introducing medical examinations to identify FGM should be compulsory. I say “at the moment”; there are no current plans but the Government’s mind is not closed to these things. However, I do not want to mislead Parliament or the noble Lord by saying that they are actively considering that course.
There is very active engagement with foreign jurisdictions. We are learning from other countries, including France and common law jurisdictions in Australia.
The noble and learned Lord, Lord Morris, mentioned discussions between the DPP and law officers. As he will well know, they have regular meetings on a range of matters, including violence against women and girls. There was reference to Keir Starmer and his interest. Although I do not have personal knowledge of this, I am sure that such conversations continue under the current Government, and we know that there is a trial coming up in January.
I know that there was a debate about whether there should be a new criminal offence of inciting or encouraging FGM generally, as opposed to specifically. At the moment—indeed, it is the subject of one of the prosecutions—the Government think that prosecutions should relate to a particular offence rather than more generally, but I entirely take the point that it is important that community leaders outlaw this. Following the Girl Summit, 350 community and faith leaders from all major religions have condemned this practice, and we hope that that will continue.
The noble Baroness, Lady Smith, quite rightly pointed to the fact that this issue goes across government. Of course, the Department of Health, DfID, the Department for Communities and Local Government, the MoJ, the Solicitor-General and the Department for Education are all concerned with this. There are regular meetings, an FGM unit has been established at the Home Office, and the Government’s cross-government strategy is contained—
I see that the Minister is drawing to a conclusion but I am bursting to ask him a question. Does he agree that female genital mutilation is grotesque child abuse? Therefore, why do we have to have all this extra wrapping around it? Why can it not just be dealt with like child abuse? I have had children brought to me in my clinics where teachers have suspected that sexual abuse has been going on. Why cannot the same thing happen with FGM? Why is it all so peculiar?
I do not think there is anything peculiar about it. There is no doubt that it is a criminal offence. In fact, France does not have a specific offence of genital mutilation; it simply has offences of assault and the like. Whether it is sexual abuse, assault or FGM, it is a criminal offence. So there is no special precaution about this. One of the points correctly made by the noble Baroness, Lady Rendell, is that we have left the exaggerated respect for cultural norms and traditions and we hear no more about that, I am glad to say.
Across departments, the Government are committed to doing everything we can to stamp this out. We hope its prosecution is a success, that more people come forward and that a complete consensus can be established to stamp out this abhorrent practice. This has been a passionate and well informed debate. The Government fully understand the concerns expressed here and outside and are resolutely committed to fighting FGM.
Question for Short Debate
My Lords, I have waited a long time to have the opportunity to bring this issue to at least some of your Lordships’ notice. I am extremely concerned about what is happening to British Muslim women. It is not about religious freedom or what we are trying to change, but what is happening in the everyday lives of British Muslim women. If we cannot protect British women, whether they are Muslim or not, then we are not providing the right kind of help.
In 2010, when we were discussing the Equality Bill, I tried to table an amendment to try to stop Sharia law impacting on women’s lives. I was told then that it was too late and if I brought this new topic into the Bill it would be likely that the Bill would fall. I had a letter from the noble Baroness, Lady Royall, and several telephone conversations with her. I still have the letter. She said, “We will look at this seriously. Do not table the amendment. We will take it up later and look at it”. I had constant telephone calls from the noble Lord, Lord Lester of Herne Hill. He was then an adviser to Gordon Brown. He said, “Don’t worry, we will at look at this. We will look into what is happening to the women”. I am still waiting. They did nothing. I tried very hard to remind them that they had given me this undertaking—well, they would not call it an undertaking; it was about stopping my amendment. Since then I have spoken to Ken Clarke and he said, “Well, you know, it is their choice if they choose to go to Sharia councils”. Yes, it is their choice, and they do go—and my noble friend Lady Cox will talk more about choice. But a choice can be made only if you know what the choices are. A choice cannot be made if you are told, “This is your choice”. It was very short-sighted of Ken Clarke not to look into it.
I also had discussions with the Ministry of Justice, particularly about the Sharia councils. As your Lordships probably know, there are now more than 80 Sharia councils. As far as I know, they are not trained lawyers. I think they are imams who have some training. The decisions—please correct me anybody who knows more—are ad hoc on that particular case. There is no record kept. Nobody knows what previous decisions have been. Nobody knows what the next decision will be. So women cannot get a divorce—the councils put them off and put them off. This was also shown in a programme on television where a woman went every year to try to get a divorce but she could not. Some women, of course, have a registered marriage, which means that they are subject to British law and can get a British divorce, and they do. The problem there is if they go to an Islamic country their husband can come and claim the children. This, of course, is unacceptable to the mothers. In any case with Sharia, a seven year-old boy is given to the wife; girls are given at puberty. If the woman marries somebody else, it could be worse.
The retired Bishop of Rochester, who has studied Sharia, has said clearly that Sharia is discriminatory against women, not only in relation to marriage and children, but in most aspects. A woman’s status does not come up to more than half that of a man. Two women have to give evidence to equal a man’s evidence. When a Sharia will is made, a woman gets half of what a man gets. This is happening in our country today, here and now, and we are letting it happen. It is not fair: these women have come here to be with their husbands; they have been allowed to live here legally. We women spent the whole of last century trying to change women’s lives. We wanted equality—we are still fighting for it, but at least we do not have all these things happening to us.
I wrote to the noble Baroness, Lady Warsi, who said that we need to work with the Sharia councils. I suppose she means that it is work in progress, but I have not heard anything about what work has been done with the Sharia councils. The most important thing, if we cannot do without them, is that records should be kept. If they keep records, then we can look at the records and see whether there is a similarity between cases, or whether different things are happening in different ways. These women have no support from the community or the family, and only a third of women have their marriages registered, because the men work hard not to get the marriages registered.
It helps men in these ways. Polygamy allows them to have two or three wives. Many women have said that they were absolutely taken aback to find that the man had two or three wives already. They have control over custody of the children. They do not need to provide any financial support, and there is plenty of evidence that no support has been provided for the women. They cannot be charged with bigamy, because the other women are also not registered—they are just women in the household. I think that this is absolute abuse of the British system and it has to be looked at very carefully.
If a man brings a woman into this country as his wife, it should be legally essential for him to register that woman as his wife. Then, when the next wife comes, at least we will know how many wives he has. Your Lordships may remember that I said some time ago that we should not give benefits for an unlimited number of children, since those people who are in work cannot afford more than one or two children. At that time I did a radio interview and a man said, “I have three wives”. The interviewer asked him, “How do you manage three wives?” He said, “It is on a rota basis”. There are wives living separately from the household. One woman—my noble friend Lady Cox will talk about this further—says that she lives in the household, but she gets benefits which are used to pay the mortgage for the house. There is so much going on under the surface.
The noble Baroness, Lady Warsi, feels that this is a religious matter. No, it is not a religious matter. It is not about praying to God. Did God really make us half as good as a man? We do not believe that any more. Maybe at one time people did believe that, but we are not half of a man. We are also people; we are also persons. I think that if Muslims come to this country, and if they bring a wife—or a husband—the marriage must be registered. Even just doing that will change many things in the system. Once the marriages are registered, the men will be subject to a charge of bigamy and subject to having to pay maintenance to the wife if they divorce her.
Another thing, of course, is that a man can divorce a woman by saying, “I divorce you”. I cannot understand how we can accept that today. Maybe 600 or 700 years ago it was fine, but it is not fine in this country today. Communities are moving backwards. Things are happening in schools which are unacceptable. They are trying to segregate girls and boys. In Birmingham there was a takeover of schools and Leicester University decided that girls and boys would sit separately when somebody came to speak to them. What is so amazing is that the university council said this was all right. Well, it is not all right; none of this is all right. We need to protect all British women, whether or not they are Muslim.
My Lords, I start by apologising for the fact that I may not sound completely coherent today. I am suffering from a migraine and not able to see my notes properly, so I am going to have to guess at what I was going to say. I thank the noble Baroness, Lady Flather, for calling this debate as it is an important subject to be discussed but I urge her to read back the speech that she just made in Hansard. I say that because it is important for us to work out what it is that we are debating here today. If we are debating a series of headlines which regularly appear in the Daily Mail about what may have happened around the country, then that is a completely different debate. Invariably, as we have found out, those newspapers are incredibly good at headlines but carry very little factually. I urge the noble Baroness to look at a fantastic programme made by Peter Oborne—
The noble Baroness says I am relying on headlines and newspaper reports. I am not. There is so much evidence which has been collected by various researchers and taken from women. These are their own stories and views; this is not about headlines. I am sorry, I cannot accept that. It is an easy-peasy way to put it down.
I urge the noble Baroness to listen to an incredibly interesting programme by Peter Oborne, “It Shouldn’t Happen to a Muslim”, where he unpicks some of these stories about takeovers in Birmingham, girls and boys at Leicester University, et cetera.
Let me take this back to what I think it is about: a distinction between Sharia and Sharia law. Sharia exists in the United Kingdom in our multicultural society. Noble Lords will be aware that only this year Britain announced to a loud fanfare that we had become the first western country in the world to issue sukuks—Islamic, Sharia-compliant bonds with which we raise funds to finance government, among other things. We announced that we would put in place Sharia-compliant student loans, start-up loans and home loans to ensure that the Muslim community could take full advantage of the opportunities this country has to offer. We have Sharia in the form of dietary requirements, with clear responsibilities in relation to halal and to shechita under Jewish law. We have very clear Sharia responsibilities in relation to births and deaths—for example, the way in which circumcisions are conducted in hospitals around this country in accordance with people’s religious rights. Sharia, like other religious practices, is therefore an everyday part of British life and has been for many years.
However, what I think we are debating today is whether we have Sharia law. As I am sure the Minister will answer, we do not. We have one system of law in England and Wales; it is English law, and that is paramount. Even within Sharia law as those discussions go—predominantly those discussions in the Daily Mail—there are two distinctions. There is a civil aspect and a criminal aspect. A criminal penal code has never been part of a discussion in the United Kingdom but civil practices have been, predominantly in domestic situations when marriages break down, and so-called Sharia councils have been set up as an alternative arbitration system for people to resolve their disputes.
The most important point that the noble Baroness makes is that all women in this country deserve the same protection, irrespective of their religion. The noble Baroness says that this is an abuse of the system. My argument would be that it is a failure of the system that Muslim women find themselves having to go before Sharia councils, because the mainstream system in the form of the civil courts does not allow them the support and protections that they deserve.
Dealing with it on that basis, we must look at what the mischief is. It is that Muslim women are not protected in the same way as other women when their marriages break down. There is a simple answer to that: recognise their marriage. That would deal with the mischief and meet all the concerns that the noble Baroness raises today. If I conduct a Muslim marriage with a Muslim man which is recognised under English law, I am afforded exactly the same protections as any other woman who conducts a marriage in this country. This means that when my marriage breaks down, I do not have to go to a Sharia council but to the civil courts. That option has been presented to both this Government and previous Governments. It is a simple amendment which can be made to allow for the recognition of such marriages. It would mean, effectively, that if any further religious marriage were conducted, the man would be charged with bigamy. Both would be legally recognised and we would therefore have the evidential basis on which to put a case of bigamy. That is what it boils down to.
If the Government can formally recognise a nikah in the way in which many government papers have submitted that it is possible to do, we will deal with this issue. If, despite having that civil protection, system and recognition, there is still a thirst out there for alternative dispute resolution, let us make sure that the alternative dispute resolution has a code of conduct, that there is a sense of training and education for people who take part in it and that it is properly monitored. Let us also make it clear that the alternative dispute resolution option is subject to English law. That is the way in which we can deal with this issue, without any reference to the plethora of other issues which are not part of this debate.
My Lords, I congratulate my noble friend Lady Flather on initiating this debate on a very important subject. I appreciate the way in which she opened it. She did not rely on headlines but on some very substantive issues. I take the distinction made by the noble Baroness, Lady Warsi, between Sharia and Sharia law. Sharia is much wider. It contains many aspects of ways of life, including times of prayer and so on, and no one can take issue with those. However, what we are looking at today are those aspects of Sharia law which adversely affect women in this country.
I take this opportunity to raise some of the concerns that are reflected in my Private Member’s Bill, which is currently in your Lordships’ House, with particular reference to aspects of religiously-sanctioned gender discrimination and threats to the fundamental principle of liberal democracy and of one law for all. However, first I emphasise my primary and fundamental commitment to the essential freedom: freedom of religion and belief, as enshrined in Article 18 of the Universal Declaration of Human Rights. I do so as a vice-chair of the All-Party Parliamentary Group on International Freedom of Religion or Belief.
There may be various institutions and aspects of different faith traditions which embody gender discrimination, both in policies and practices. If women are aware of the implications of these discriminations, make an informed choice and are happy to accept these provisions then they have every right to do so. However, where women and girls involuntarily suffer as a result of such policies and practices, this should be a matter of concern in a country committed to the eradication of unacceptable gender discrimination and the promotion of gender equality.
The concerns that I will highlight in this debate are associated with the fundamental tenets inherent in many interpretations of Sharia law, which are inherently discriminatory with regard to provisions for men and women. The establishment of Sharia courts or councils in this country has promoted the application of such gender-discriminatory provisions in ways which are currently causing considerable distress for many women. I am not relying on headlines but on talking to Muslim women and their organisations.
These provisions include unequal access to divorce. As has already been said, in many situations a husband can obtain a divorce merely by saying “I divorce you” three times. Women, on the other hand, have to obtain permission from a religious authority, often a Sharia council or court, and they may have to pay and fulfil other conditions. Sometimes their husbands will not give them money, so they are trapped in the marriage. One Muslim lady described to me how, in theory, she knew she could obtain a divorce. However, she had to pay for it and, as she could not obtain the money—her husband would not give it to her—she felt as though she was in a room with an open door to freedom, but tied to a chair so that she could not walk out of that door to enjoy that freedom. Conversely, the husband usually does not have to pay anything to obtain his divorce.
Another lady, a devout Muslim, described how her husband had divorced her. When she asked her imam for a divorce, he told her that she must bring her marriage certificate, but this was in her husband’s possession. When she asked for it, he told her that it was with his family, back in their country of origin. When her family there went to his family to ask for the certificate, they beat her younger brother because she was bringing shame on the family by asking for a divorce. She is a devout Muslim, so she will not remarry without a religiously-sanctioned divorce. She is trapped and, several years later, still very lonely in this country. When I asked an imam from a major mosque why a man does not have to pay, and indicated that it takes two people to divorce, I never received a reply.
Another problem for many Muslim women is their lack of knowledge regarding the implications of having only a religious marriage, without an accompanying legally registered civil marriage. This leaves them and their children without any rights in law if they are divorced. Many say that they are not told that their religious marriage does not simultaneously provide for a legal marriage, while others say that their husbands-to-be and/or the families discourage them from obtaining a legal marriage. Of course, this leaves the husband free to practise polygamy without breaking the law against bigamy. Another aspect of gender discrimination which often applies in the practice of Sharia law relates to polygamy. A husband is entitled to take up to four wives, provided he takes responsibility for making appropriate provision for them all.
No, I am sorry; this is a timed debate. If I have time at the end, I will answer.
In many Muslim communities in this country polygamy is commonplace, although in this nation bigamy is legally forbidden. A report written by a courageous Muslim woman named Habiba Jaan, Equal and Free? 50 Muslim Women’s Experiences of Marriage in Britain Today, has just been published. In this report, Habiba describes the marital situation of 50 Muslim women in the West Midlands. Two-thirds of those who are married are in polygamous marriages. Some say that they did not know that they were a second or third wife when they were married. Of these, almost all said that their husbands fail to provide them with financial support, in contravention of Islamic teaching. Many of these women are desperately unhappy.
A related aspect of these practices of polygamy and unequal access to divorce is the number of children which one man may have. Several Muslim women have told me that men in their communities may each have up to 20 children. This clearly paves the way for children to grow up in dysfunctional families. Those children may become very vulnerable to disaffection, marginalisation and potential radicalisation.
My Private Member’s Bill, the Arbitration and Mediation Services (Equality) Bill, seeks to address some of these problems by trying to ensure that women know their rights under law in this country, as well as by providing more protection for victims of domestic violence and outlawing the operation of quasi-legal courts. In another initiative last year, I moved an amendment to what was then the Anti-social Behaviour, Crime and Policing Bill. This would have made it a requirement for the celebrant of any religious marriage which does not also provide for a legally registered marriage to ensure that both parties to the marriage are aware of the implications of that. The importance of a legal marriage was also alluded to by the noble Baroness, Lady Warsi. For some reason which I fail to understand, the Government did not accept that amendment.
The heart-wrenching, award-winning documentary film “Banaz: A Love Story” depicts the true story of a young girl who was murdered by men in her family for bringing what they saw as shame on the family. A disturbing aspect of that film was the failure of the police to provide protection for Banaz, despite her having made several visits to the police station to seek help. The Government do not support my Private Member’s Bill or my amendment, on the grounds that they are unnecessary because every citizen in this country ostensibly has access to the law of our land. However, this implies that every citizen knows their rights, and this is clearly not the case. It also ignores the reality that many closed communities can put a great deal of pressure on families and individuals not to bring what they deem to be shame on the community.
The chasm between the Government’s de jure position and the de facto reality for so many women and girls in this country today is resulting in widespread suffering, intimidation and such gender discrimination as would make the suffragettes turn in their graves. I hope that in the Palace of Westminster, where there are memorials to those suffragettes for their achievements in obtaining votes for women at a very high price, our modern-day Parliament will not betray their sacrifices or their achievements. While respecting freedom of religion and cultural diversity, I do not believe that we should allow that freedom to override the law of our land or to deny women the knowledge of their rights and their freedom—genuine freedom—to access those rights. At present, we are looking the other way while many women are suffering in our country. That is documented by Muslim women, not by headlines I have read. We have responsibility in our country to protect and promote fundamental freedoms and gender equality. At the moment, we are seriously failing to do so.
I thank the noble Baroness because that is just the point that I was making. It is more than the point I was making, because I have been told that that has not been deemed acceptable at the moment. We have raised it in many discussions and I would strongly support the noble Baroness, Lady Warsi, if that could be accepted. The related point that I raised in my speech is that if any religious marriage—I am not talking only about Islamic marriages—does not bring in at the same time a legally registered marriage, the woman ought at least to know the implications of not having a legally registered marriage. At the moment, they do not even know. They are often told by their families that it is a legally registered marriage or think that if it is carried out in the UK, it will bring a legally registered marriage. At the moment, they are in a state of ignorance. The amendment that I moved would go one step towards remedying that situation so that they would at least know. They would not necessarily have freedom of choice because of the pressures put on them by families and local communities, but it would be one step. If the suggestion of the noble Baroness, Lady Warsi, were to become an amendment I would support it wholeheartedly.
My Lords, I wish to touch on three areas during this debate: first, the areas where there are clearly no conflicts between the use of Sharia courts and the law of this land; secondly, the areas where there clearly are conflicts between the use of Sharia courts and the law of the land; and, thirdly—and I realise that this will be disappointing to some people in the debate—is the unfortunate conflation which I often hear between Sharia law, religious extremism and persistent forms of Islamophobia.
I start by saying that I admire virtually all the world’s great religions because, by and large, their original prophets exhorted their followers to be peaceful, empathetic and active citizens who treat others with humanity and humility. That is the theory. Nowhere is this clearer than in the teachings of the Prophet Muhammad and those around him at the birth of Islam. Personally, I wish that we listened more to what they had said, rather than less. I am Jewish—I should say that I am a Jewish atheist—but I studied Islam at university. I was very surprised to find that, as it turns out, by the standards of his time, the Prophet Muhammad was basically a raving feminist when looking at the situation surrounding him in the 7th century. The Prophet would never sanction what has been done in his name in recent times, whether to women in this or any other country, or what is happening at the moment to the enemies of Islamic State.
The disciple closest to Muhammad was his cousin, Ali ibn Abi Talib, who Muhammad himself brought up and who was the first person to convert to Islam. I mention him because he is considered one of the foremost experts in Islamic jurisprudence, which is what we are debating today. It is amazing to look at the letter that he wrote to the emissary he was sending to govern Egypt in 658 AD, because it is a lesson to us all today. It holds lessons for us when considering the conflicting views in this debate. On the selection of a chief justice to deliver judgments in legal disputes, he gave the following instruction. He said that he should choose,
“one who cannot be intimidated … one who is not self-centred or avaricious, one who will not decide before knowing the full facts, one who will weigh with care every attendant doubt … who will examine with patience every new disclosure of fact and who will be strictly impartial in his decision, one who flattery cannot mislead”.
With regard to having patience at the disclosure of every fact, I was interested to hear the proposal of the noble Baroness, Lady Warsi, regarding marriage. That is a very important thing to consider.
On bloodshed, he said—again, one can only wish that the leaders of Islamic State would follow Ali ibn Abi Talib’s commands:
“Beware! Abstain from shedding blood without a valid cause. There is nothing more harmful than this which brings about one’s ruin. The blood that is wilfully shed shortens the life of a state. On the Day of Judgment it is this crime for which one will have to answer first. So, beware! Do not wish to build the strength of your state on blood ... Before me and my God no excuse for wilful killing can be entertained”.
Given that the founders of Islam were so keen that Muslims were fair and just, and that they built their legal system on fair and just principles, why is there such uproar about Sharia in Britain today? Why does it so often seem that so much of our debate is governed by the Daily Mail? We have to weigh that Islamophobic hysteria against the problems and discrimination that have been shown to exist towards women within some rulings of some Sharia councils.
The obvious point is that, although Sharia gave women in the seventh and eighth centuries more entitlements than they previously had, today in some areas of Sharia, such as inheritance and divorce, it gives them less entitlement. As we all agree, everyone in Britain must be equal before the law. Thus, wherever Sharia does not conflict with this requirement, Muslims should have exactly the same rights as other religious groups in Britain, such as Christians and Jews, to seek guidance from institutions within their respective faith. At the same time, equally obviously, they must always have the right to take any dispute to a British court. I do not think that any of us disagree on that.
It is important to flag up that Sharia is different things to different people. Different Islamic sects interpret Sharia rulings differently. Even within sects, opinions and rulings vary among scholars. Therefore, it is difficult to use the broad-brush term “Sharia law”. One problem is the unregulated nature of the Sharia councils, to which attention has been drawn. This is where they differ slightly from, for example, the similar religious Jewish councils. Nobody really knows the number of Sharia courts or councils in the UK but I wonder whether the Minister can give us the latest estimate. The latest study in 2009 by Civitas suggested that there was evidence of at least 85 Sharia councils across Britain, but the number could be far higher.
It is also very important to distinguish between the actions of arbitrators or tribunals working on a formal level and those operating informally, and the difference between applying actual judgments and giving advice. It is crucial to make it 100% clear, as the noble Baroness, Lady Warsi, did and as I think everyone here accepts, that Sharia law is not part of the British legal system, and there are absolutely no plans to make it a part of our legal system.
The Sharia councils that have been in existence here since the 1980s have to operate as tribunals under the Arbitration Act 1996. The Act allows for consenting adults to resolve disputes and conflicts, be they civil or commercial, as long as they do not conflict with UK law. The same applies to the Jewish Beth Din courts. Jewish families have that right. My mother was brought up in an orthodox Jewish family, although it was not that orthodox because her mother had converted. There was a question over whether her parents’ marriage was kosher, so to speak, and it was the Beth Din court that my family went to. I do not think that in a tolerant society it is up to others to say, “No, you can’t go and seek counsel from your religious institutions and organisations”. It is not the choice that I would make—as I said, I am an atheist and I take a secular approach on all matters—but I absolutely believe that it is the right of those who are guided by their faith to have that choice, and we have to ensure that that choice does not conflict with the absolute need for women in Britain not to be discriminated against because they choose to use a Sharia council.
In closing, I ask the Minister where we are up to in increasing the regulation around Sharia bodies, and whether he is convinced that their activities currently fall within the Arbitration Act 1996. Is he also convinced that they uphold fundamental human rights for all citizens, and what further action does he believe is required to ensure that they are properly monitored, so that neither women nor individuals from other groups face any discrimination, intentional or otherwise, for choosing to receive guidance and rulings from their religious faith bodies?
My Lords, I join other noble Lords in thanking the noble Baroness for initiating an important debate. It is important to reflect on where we are now. I am glad to see that both the diversity and the gender balance in this House are alive and kicking. We have had contributions in a ratio of four to one: four women and one man. We have also had a healthy sprinkling of different religious identities: contributions from—if I may sum the noble Baroness up thus—a Hindu humanist; from a Muslim; from a committed—and, I know, strong—Christian, and from a Jewish atheist. I suppose that with a debate such as one on Sharia it is entirely appropriate that there is a slight bias towards a Muslim man responding to bring it all into proportion.
I stress from the outset, in order to make it abundantly clear—the noble Baroness, Lady King, made the same point—that Sharia law has no jurisdiction in the court systems of England and Wales: we do not recognise it. There is no parallel court system in this country. Again reiterating what the noble Baroness said, we have no intention of changing this position in relation to any part of England and Wales. I make that statement from the outset because it is important to get it on record—that that is the law of the land and the law of the land will prevail irrespective of what religious practice or community you may belong to.
A question posed very ably—I would expect nothing less—by my predecessor in this role of faith Minister is: what does Sharia and the distinction between Sharia and Sharia law mean? As we have heard—the noble Baroness, Lady Cox, also alluded to this—Sharia can mean many things. Essentially, the first code of Sharia is: do not lie. That is perhaps a teaching and a learning for us all. It is also about halal food, and we see plenty of that. It is abstention from alcohol—I am teetotal, I can commit to that. It is also about service to charity and humanity. It is about welfare for all. If you look at the diversity of our great country today, specifically the Muslim community, the charitable nature of what they do is guided by Sharia law, which we are debating today. As law-abiding citizens of our great country they reflect that code of conduct in their charitable giving—their alms giving—to the poor, the needy, across the country. We are at the forefront of that. That is something that, across the country, irrespective of faith or religion, we should be proud of.
The noble Baroness, Lady King, asked specifically about Sharia councils. She talked about the figure of 85 in 2009. The Government have not made a specific assessment of Sharia in this country and are not involved in the administration—which she also asked about—of Sharia councils in any way. However, I emphasise again that the law of the land is supreme: regardless of our beliefs we are all equal under the law of the country.
I move on to some of the pertinent issues that have been raised. The noble Baroness, Lady Cox, gave some quite specific examples. I totally relate to them and they are true not just of one particular community but of many. Women have suffered terrible abuse and had terrible dilemmas. Because of limits on time, all I would say at this juncture is that she will know as well as I do—and as I am sure all noble Lords will agree—that the faith in its actual learning and theory protects women. It is unfortunate that we see practice failing with individual abuses or abuses in certain communities. These have to be eradicated and the full force of the law must apply.
Again, I need to make it absolutely clear that Sharia councils, Sharia courts—whatever name may be attributed to them—have no part in the court system in this country and no means of enforcing their decisions. If any of the decisions or recommendations made by Sharia councils or committees are illegal or contrary to national law, national law will prevail every time and where it does not criminal sanctions should apply. Any member of any community should know that they have a right to refer to an English court at any point, particularly if they feel pressured or coerced.
The noble Baronesses, Lady Cox and Lady Flather, highlighted the fact that where women are vulnerable they are not perhaps informed or educated. Therefore, it is also important that we work with communities in identifying these women. As Minister for Communities I am encouraged by the programmes and am laying greater emphasis on learning English, empowering women in particular through language. There are some excellent programmes targeting these very vulnerable groups. I recently saw QED, a practical project in Bradford. Muslim women who came from abroad, as spouses of husbands, actually had the education and knowledge but did not have the confidence to extend themselves into the fabric of the country. It is projects such as that one about empowering women where a lot of our focus should be, and rightly.
I also pay tribute to my predecessor in this role, the noble Baroness, Lady Warsi, for setting up the integration roadshows. I am pleased to say that I will be nimble-footed from this debate because I am travelling up to Manchester immediately afterwards to conduct one of the integration roadshows. There we take some of the challenges facing different communities—in particular Muslim communities—that come out of practice that is founded not on the religion but unfortunately on interpretations that are removed from the faith. I totally take what the noble Baroness said. We need to tackle these head on.
No, I am not saying that, and the noble Baroness is correct to point that out. The same common law principles would apply in that case. I would like to clarify one thing. The point was made on a couple of occasions about access within Sharia for a woman to take a divorce. Again, this is the difference between theory and practice. The avenue does exist. There is the concept of Khula which allows a woman to take a divorce without citing a reason. The problem arises in certain communities because although some practise this very well, others unfortunately do not make it available. That is where the focus should be. I want to be absolutely clear that, in the context of concerns about Muslim marriages and Sharia councils, the Government believe that the key issue is raising the primacy of English law and the importance of a clear understanding of how English law works.
My noble friend raised the issue of recognising the nikah in terms of the law of the land. She will know from her experience as a Minister, and she also speaks very ably as a lawyer, that there are certain complexities that we need to address. This is far more than just a simple issue, a simple adjustment to make. It would need careful consideration before the Government could give any commitment. I am sure she appreciates that there are things that need to be discussed fully to balance out what the implications of that would be. I have already alluded to the importance of communities coming together to effect real change. We can amplify the message of those communities where women are not empowered to speak up and help them to get their messages out, but we believe that building integration is ultimately the responsibility of everyone in society.
This is a useful and timely debate. Let me assure the noble Baronesses, Lady Flather and Lady Cox, and, indeed, all noble Lords, that, as they know, I am personally committed to ensuring the eradication of some of the challenges we have seen, such as the evils of forced marriage. The Government have been very serious about this. Indeed, as noble Lords will know, we took steps by criminalising this heinous activity. As we have seen with FGM as well as with forced marriages, the important thing is first of all to ensure that this is communicated effectively, and that people understand what the law of the land means. It is important to make that accessible to all people and to educate people in that respect as well.
I wish to conclude my remarks today by thanking all noble Lords who participated in what has been a very useful debate. I again underline the fact that what defines our great country of Britain is that it allows people to practise, profess, propagate and preach their faith with great freedom and liberty across all boundaries. It does not matter who or where you are.
Before the Minister draws his remarks to a conclusion, could he give any further clarification on what if any legislative changes would be required to bring the activities of Sharia councils under further regulation at the present time? Or is it just a question of implementing guidance?
There are no plans to legislate on Sharia councils in that sense. We believe that the rule of law should prevail, and I have re-emphasised that point. We see plenty of good practice within the Muslim community. For example, many Muslim communities employ a simple resolution to this question. Before any imam is sanctioned to perform a nikah ceremony, the couple are asked to produce a certificate of registration. That is a good practice, and it means that the civil marriage is registered prior to the Islamic marriage, ensuring protection for both men and women. It is right that we do not seek to interject in people’s religions from a government perspective, but where we see that there is good practice it should be shared across the country. That is certainly the approach that the Government are taking.
I note that I have a minute to go, so I will make full use of it by once again reiterating the Government’s commitment to ensuring that wherever we see abuse, whoever the perpetrator and whoever the victim, the Government will stand up strongly to provide protection. We have a strong record over the past four years of doing just that. Protecting religious identity is an important part of what defines our great nation, but not to the detriment of the rule of law. Ultimately, whatever religious practice one may follow and whatever religious community one may belong to, one thing prevails above all else, and that is the rule of law.
Food Hygiene Rating Scheme
Question for Short Debate
My Lords, the food hygiene rating scheme with its distinctive black, green and white certificates was launched in 2010. Indeed, I recall that on 10 December 2010, at the launch in the Bluewater shopping centre, six inches of snow fell while we were inside.
This scheme, which is a partnership between the Food Standards Agency and the local authority, has, on a voluntary basis, been adopted by all local authorities in England, Scotland, Wales and Northern Ireland, except for one, which I will come to later. This is a remarkable example of a good, well thought-out, cheap idea which benefits both consumers with information and businesses with an incentive to raise standards in an easy way.
There are three things to bear in mind. First, it is not gold-plating; a top 5 score is only “very good”, not “excellent”, and the requirement is fully to comply with legal regulation. Secondly, it is a virtually no-cost scheme. The score is worked out during the normal environmental health officers’ inspection of the food premises, so it is not an add-on. Thirdly, it is about food hygiene rather than the factors used by the Good Food Guide.
With more than 50% of meals taken outside the home, food hygiene in the kitchen is important. There are more than 1 million food-borne illnesses, 20,000 hospitalisations and, sadly, more than 400 deaths. The scheme covers more than retail catering establishments, such as cafes, sandwich bars and restaurants. It includes, for example, school kitchens and the kitchens of care homes. Military kitchens are included, as are the kitchens in the Palace of Westminster. It is an open and transparent scheme because all the information about the hygiene scores is on the FSA and local authority websites, classified by location, so you do not need to be in ignorance. Parents can check the school kitchen score and families can check the hygiene score in granny’s nursing home.
A crucial factor, in addition to the cleanliness and how food is stored, is the record-keeping. I once heard someone say they that had a 3, which is “generally satisfactory”. They said that the hygiene was fine; it was only the paperwork preventing them getting a higher score, as though it did not matter. The paperwork and record-keeping are crucial so there is traceability of materials if there is an illness outbreak.
So the scheme is pro-consumer and improves business performance at almost no cost, but it is not gold-plating or the nanny state. It is a great example for the Cabinet Office of nudge policy. The public can eat where they want, but can choose to discriminate based on reliable, national, standard information. This national, locally operated scheme replaces lots of local schemes which were operating across the nation. A score of 0 to 5 means the same across England, Wales and Northern Ireland.
Notwithstanding the information on the websites, it is better if potential customers can see the score level before they use an establishment. Noble Lords will have seen many window stickers with a 5, which is very good. They will have seen rather fewer with 3, 2, 1 or 0. I should add that anything less than a 0 means the place is shut down. The low scores mean that urgent action is needed, which is carried out and regularly monitored. The rule of thumb that I have adopted is: if there is no certificate on the window an establishment has less than a 5. I know establishments at home in Ludlow—the food capital of the Midlands—selling fast food, bacon butties, hot dogs, et cetera, scoring a 5 which is proudly on the window display. Next door is a posher restaurant with nothing on the door. The website says that it is a lot less than a 5. That is why it is not displayed. Whenever I have checked, the ones without a sticker are generally less than a 5 score, but not always. Earlier this week—in fact, at 7 am yesterday morning—I did a walkabout in the Victoria Street area. In 20 eating places, I found eight with a 5 score and one with a 4 proudly displayed. That left 11 without any information on the door, so I checked them all on the website. Amazingly, five of them had a 5 score. Three had a 4; one each had a 3, a 2 and a 1 score. One of them without a score, in the new development in Victoria Street, was literally sandwiched between two restaurants which both had a 5. You have guessed it, it had a lot less than a 5 and hence it was not displayed.
Food is a devolved area and the food hygiene rating scheme is an excellent example of partnership in devolution. At present, Wales has to be the safest country in which to eat, because a year ago the Welsh Government introduced legislation for mandatory display. It is early days, but I am informed that compliance on scores has improved: low scorers wanted to improve because they had to display. The Northern Ireland Government have introduced legislation for mandatory display and legislation is going through in Scotland which allows for mandatory display. I want to press the case for England to follow.
I am not alone. One of the strongest supporters of the food hygiene rating scheme is the noble Lord, Lord Young of Graffham. He saw the benefit to consumers and businesses straightaway and said so in his seminal report to the Prime Minister, Common Sense Common Safety. I shall give two quotations from his report. Page 34 says:
“It is clear that the FSA’s Food Hygiene Rating Scheme will do much to improve existing standards without adding bureaucracy or burdens on business”.
Page 35 recommends:
“Encourage the voluntary display of ratings, but review this after 12 months and, if necessary make display compulsory—particularly for those businesses that fail to achieve a ‘generally satisfactory’ rating”.
The “generally satisfactory” rating is a 3. Indeed, the noble Lord wanted to get local authorities joined up more quickly by legislating. The Food Standards Agency board took the view that if we could get a really good uptake in two to three years, we could achieve the aim more speedily via a voluntary route than by legislation, and that is what has happened.
Anyone can get a 4, which is “good”, or a 5, which is “very good”, as I have seen from dozens of visits when I had the privilege to chair the Food Standards Agency for four years between 2009 and 2013. It is not based on size, poshness, or prices. The score is converted from the regular environmental health officer inspection, as was brilliantly explained by an officer from the Suffolk Coastal local authority when I was there at the launch of the scheme. It is clearly not fair on the good performers that the poor performers can seek to hide the fact. Not everyone checks the website; not everyone is on the web. We need also to ensure that takeaways have to give the score to telephone orders.
MPs and Peers can eat here in the Palace, in one of a dozen restaurants, safe in the knowledge that the kitchens scored 5 in both Houses, although this is not always displayed. They might want to think about constituents having the same right to know. Legislation was drafted a while ago to bring this about. I think Ministers should add it to existing legislation: I do not see why it should not be done on Report on the Deregulation Bill after Christmas—everything else has been put there. However, it will need to be tweaked, if that is the case, to bring on board the only UK local authority which refuses to join.
I remind noble Lords that all 400-plus local authorities in the UK have joined this UK-wide scheme, except Rutland County Council. This leaves Wales as the safest place to eat for consumer information and Rutland as the least safe place to eat, for lack of customer information. Parents in Rutland cannot access the scores of the school kitchens, families cannot access the kitchen scores in residential homes, et cetera. Rutland County Council leaders have been asked about this more than once. I went to visit personally to explain the benefits of the scheme for consumers. They are doing the inspections; this is the point. The inspections are taking place, but not being a member of the scheme, they are not sharing the results with consumers or businesses. Most outlets in most places are good scorers, so why deprive businesses in Rutland of the commercial advantage of showing the scores to potential customers? In fact, insurance companies might want to take a look at the premiums for low scorers, but let us let the public decide.
The cost of mandatory display to the business, as one FSA official put it, is the time it takes to open the envelope received by all food businesses after the environmental health officer’s inspection, walk to the window and put the sticker on display. Why should England wait any longer? We should have English information for English consumers.
My Lords, there are points when you prepare something and then somebody stands up and says it all and slightly better than you were going to say it, so it is an easy task to agree with the noble Lord, Lord Rooker—something I have managed to do throughout the time we have been in the House together. Sometimes I did not admit to it but, on this occasion, I am quite prepared to do so.
This is basically about making knowledge public. You have done a test, you have found out what is going on and you let the public see. That is what we are talking about here, as far as I can see. It is possible that I have missed something, but that seems to be the essence of it—making sure that at a glance you can tell what is going on. There is also the issue of letting the public know what the scheme means. I think a bit of effort needs to go into this. If you get a rating of 1, you may not know that is a bad score so possibly a bit of information is required. You need to know that it is 5 you are aiming for, not one, but that is a small quibble that can easily be corrected. You need to make sure that people know at a glance what it means.
The advantage of certificates being on display, as the noble Lord pointed out, is that it shows you have kept your kitchens clean, done your job and shown basic competence and you deserve a pat on the back and a small commercial advantage for that. Consumers have a right to know that, although they may prefer the chilli at the kebab shop down the road, they are playing fast and loose with their digestive systems—so let us let them know. This is not the nanny state; it is merely giving information about work that has been done. There is a very simple and good case for doing that.
Let us look at the wonderful example of Rutland. It is not a big county. I have this image of people wanting a sandwich and taking a short walk or driving for two minutes across the border because they have come to Rutland to enjoy the views but it is not recommended that they buy a sandwich there. It is ridiculous that somebody does not simply let the general public know when the work has been done. If there is another way of doing this easily and cheaply, I look forward to hearing about it. This is about taking information we have and presenting it. We have a scheme that seems to be working well. It is not offending anybody terribly. The overwhelming majority of the country is using it in a form which is easy to interpret. “Devolution can work” seems to be part of the subtext to what the noble Lord was saying. If we can get this going, we will make our lives a little easier and better and reward those who have done things properly. This is not a terribly difficult thing to do or something that will rock the world. It will make this a slightly easier and safer place to go and buy a sandwich at lunchtime. Surely, if we can walk away with that, it is a pretty good day here.
My Lords, I begin by declaring myself as president of the Royal Society for Public Health, which is relevant to this debate. I welcome the debate. I congratulate my noble friend on it and on the excellence of his leadership of the FSA between 2009 and 2013. With the noble Baroness, Lady Hayman, I had the privilege of taking a Bill through your Lordships’ House which created the FSA as a non-ministerial department, answering to the Department of Health. Noble Lords will recall that the reason this was done was because the BSE outbreak and the way it was handled had led to a loss of confidence in a Minister-led government department being able to give objective advice on food safety. The FSA has done a great job since it was established. It has restored public confidence in official pronouncements in relation to food safety and it must be congratulated on the success of the scheme to which my noble friend referred.
This is an important issue: food hygiene is not a marginal nicety. We know that as a result of food poisoning and so on, many people have a poor time of it. We also know that this is an area which puts unmeasured pressure on our National Health Service, in both primary and secondary care. It is therefore important that we do everything we can to make sure that in these outlets hygiene is of the highest quality.
It is remarkable that, on a voluntary basis, this scheme has been adopted by virtually every local authority in the country except Rutland. I have no doubt the noble Baroness will be able to inform the Committee of what is going on in Rutland, or is her advice that it definitely is not safe to eat there? We should be told. I assume that my noble friend ate in each of the 20 restaurants. He looks pretty good on it.
As the noble Baroness knows, we are debating the Deregulation Bill, which is proving to be of great interest. Mandation in this case would be warranted—as my noble friend said, it would cost virtually nothing—and would be of real advantage to the consumer. It is a pity that, given this wonderful scheme, not all food outlets put out information for the public to see.
Does the noble Baroness agree that the voluntary scheme—and, it is to be hoped, the mandation of it and of public display—is but one aspect of the strategy to improve food hygiene? For example, the Royal Society for Public Health does invaluable work issuing certificates in food hygiene. These are aimed at first-line workers in the food industry. This year, in 11 months, 37,000 qualifications have been issued in food hygiene and food safety in retail and in the catering sector more generally, of which 30,000 were at level 2, essentially to front-line staff.
I hope the noble Baroness accepts that, alongside my noble friend’s helpful suggestion, the work of the Royal Society for Public Health and other organisations in seeking to improve hygiene is an element in the required overall strategy. It will be good to hear from the noble Baroness about the Government’s overall approach to food hygiene alongside her response to my noble friend.
My Lords, I am pleased to answer this Question for Short Debate but I fear there is a serious danger of an outbreak of consensus. At the outset I emphasise that public health protection remains high on the Government’s agenda. Food poisoning continues to be a serious problem despite the excellent work of the Food Standards Agency, which works together with local authorities and the food industry for consumers and food businesses. The benefits of prevention are absolutely clear. Reducing food poisoning requires an all-encompassing approach and those involved at every point in the food chain must play their part. The Government must play their part, too, in helping all these players to take more responsibility to do everything they can to ensure that our food is safe to eat.
The food hygiene rating scheme—sometimes referred to as “scores on the doors”—plays a key part in this and I strongly support this flagship initiative. Telling people about hygiene standards in food outlets in a way that is clear and easy to understand allows them to make better choices and gives them the power to vote with their feet. The transparency that the scheme provides puts those businesses not meeting the grade in the spotlight. For those with the highest standards, it gives them the opportunity to show their consumers that they take food hygiene seriously.
To pick up on one point made by the noble Lord, Lord Rooker, about insurance companies and premiums for good scores, they are already starting to offer better premiums for ratings of 3 or more. Perhaps Rutland should be listening to this. The FSA is linking with those scores. With regard to his other point on the critical importance of paperwork, it is not about just paperwork or red tape but ensuring that a food safety management system is in place. As the noble Lord said, if there should be some sort of outbreak you would have an audit trail.
The FSA operates this scheme in partnership with local authorities and I am pleased to report that it is now running in all authorities in Wales and Northern Ireland, and all but one in England. The latest to join, the Royal Borough of Greenwich, launched it this year just in time for the tall ships festival in September. I know that the noble Lord, Lord Rooker, had a major hand in securing local authority support when he was at the helm of the FSA’s board. I commend him for this and congratulate him on his success. He asked what sort of work is being undertaken to encourage Rutland County Council to join. I know that he worked really hard on Rutland—he has given us chapter and verse on that. However, the county council there remains concerned that local businesses could be disadvantaged by the scheme and wanted to see what impact it had elsewhere. This evidence as to what has happened elsewhere is available across England and Wales. The FSA now has results from independently conducted research and evaluation work that highlight the benefits that businesses are finding when displaying hygiene ratings, and show significantly improved standards in areas where the scheme is introduced. The FSA will be sending details of these findings to the council.
The noble Lord, Lord Hunt, asked whether it is safe to eat in Rutland. The irony is that it is, but nobody knows because they do not put the scores on the doors. I should also reassure the noble Lord that the FSA is continuing to encourage Rutland County Council to join, so that local businesses and residents can benefit.
Four years on from the Bluewater launch at which the noble Lord spoke, I can report that there is information on the FSA website on more than 436,000 businesses—a humungous achievement and a great feat in itself. More importantly, the scheme’s aims and objectives are being realised. It is working. It is driving up hygiene standards. Local authorities are reporting this but there is also hard evidence from independently conducted research. This shows that the scheme has resulted in a significant increase in the proportion of businesses with ratings in the top half of the FHRS scale and in those getting the top score. Importantly, it has also resulted in a significant reduction in those getting a 0 or 1. Businesses are all shifting the right way. This is really good news in terms of reducing consumer risk.
Continued success will increasingly depend on consumer awareness, and the Government recognise the importance of ensuring that ratings information is available at the right time and in the right place. Ratings are all published on the FSA’s website. I can reassure your Lordships, for example, that the eateries in both Houses have all achieved the top rating. Most people make spontaneous choices, however, so having the ratings at the point of choice is particularly important. A restaurant that looks promising from 100 yards away may not look quite so hot when you get to it and look at the scores. Voluntary display at food outlets is still relatively low but the FSA and local authorities are working hard with businesses—from the smallest independents to the largest chains—to highlight the benefits and encourage more of them to put stickers in their windows.
I am confident that this work will help to increase the visibility of the scheme and provide added incentives to businesses to improve, and, more importantly, that people will start to question and draw their own conclusions if they do not see a sticker on display. However, the noble Lord made an important point about making the display compulsory. It is certainly reasonable to conclude that doing so will increase the scheme’s potential to drive up standards and increase public health protection. The FSA has a clear position in favour of doing so. It has worked closely with the Welsh Government to introduce the legislation necessary for this in Wales, and is working on a Bill that is being considered by the Northern Ireland Assembly. The agency is now gathering evidence to demonstrate the case for similar legislation in England. It is monitoring the impact of the change in Wales and the early signs are promising. FSA monitoring data for the year since mandatory display was introduced show that businesses with compliance levels equivalent to ratings of 3 and above have significantly increased.
Any extra burdens on businesses that may result must also be considered. The scheme is certainly designed so that there is a level playing field and so that businesses are treated fairly, but ensuring that we do not add red tape by putting the scheme on a statutory footing is important. The FSA is exploring this. It will also look carefully at the impact on local authorities and monitor the impact of the new requirement for care homes to display the ratings given to them by the Care Quality Commission. I understand that there is a care home somewhere that proudly displays its sticker with one star, and noble Lords might wonder why. The Government will consider this evidence once it is available. I am really pleased that the scheme is making a real difference. It is equipping consumers with knowledge about hygiene standards in food outlets, and encouraging businesses to raise their game and strive to achieve the highest ratings. This is just the sort of initiative that the Government want.
I was pushed by the noble Lord, Lord Hunt, on the Deregulation Bill. My team has told me that it is perfectly okay for me to say that I am going to go away and talk to colleagues in the Department of Health. Deregulation is in the Cabinet Office, but I am sure that the Department of Health can talk to the Cabinet Office. Ultimately, in all this, improved public health protection is the winner.
My Lords, it is time for a cup of tea and a sandwich. The Grand Committee stands adjourned until 4 pm.
Question for Short Debate
My Lords, I seek a response from the Minister to my Question, but I must first congratulate the Government, and in particular the former Home Office Minister Norman Baker, on the production of the report Drugs: International Comparators. The report benefits greatly from fact-finding visits and discussions with 11 countries. It is a great pity that the executive summary omits the key findings of the report, most particularly that there is no clear correlation between the “toughness” of an approach and the levels of drug use. This is probably the most significant finding, with very clear implications for drugs policy, and yet the executive summary makes no mention of it. The report also omits all the recommendations that I understand had been prepared by officials.
The report makes clear that the UK has experienced a recent fall in the use of traditional drugs. There are at least two explanations for this. One is a rapid rise in the use of so-called new psychoactive substances, many of which are of course extremely dangerous, and are in fact more dangerous than the original, traditional drugs. More particularly, the second reason is that, although the possession of illicit drugs remains a criminal offence, the police now focus fewer of their resources on arresting drug users. Therefore, fewer young people are criminalised and, as a result, many will quickly recover from their drug problem and return to school or to work. It is interesting that our police have to compensate for the failure of our politicians, is it not?
Nevertheless, the UK remains the overall highest user in Europe of the four most used drugs. This is an incredibly important point. We are the hub for the distribution of new psychoactive substances across Europe. We have no reason to be satisfied with our performance. What are the Government therefore doing to promote an open debate on effective policies, which we clearly do not have here? Which options are being actively considered?
Will the Minister also inform the House what the Government’s response is to the recent change in US drugs policy? The US policy shift was defined in the recent statement by William Brownfield, the US Assistant Secretary of State for the Bureau of International Narcotics and Law Enforcement Affairs. The US of course drove the “war on drugs” for 50 years. Now the US is driving policy in the other direction, and is at last in line with the fundamental objectives of the UN conventions: the health and welfare of individuals. We have never had that before. Brownfield envisages changes in policy through shifting enforcement priorities, such as decisions not to arrest drug users and greater flexibility in interpreting the conventions.
The Brownfield doctrine, as it has come to be called, is based upon four simple points: defending the integrity of the core of the conventions; allowing flexible interpretation of the treaties; allowing different national and regional strategies; and tackling organised crime, which is fair enough. This is all incredibly new. Do the UK Government agree with these four points?
In support of the doctrine of flexibility, we can point to one of the key architects of the 1961 convention on narcotic drugs, Herbert May. We should not forget him. He argued in 1955—he was a man of foresight—that a central goal of the convention was to provide “greater flexibility” to the international system due to the likelihood of changes in circumstances—surprise, surprise—as well as medical and scientific innovations and research. Yes, Herbert May, this is precisely the argument behind the new Brownfield doctrine. The modern world cannot turn its back on the evidence of effective drug policies, nor can we turn our backs on the need for further experiments and evaluation of them.
What does this mean in practice? For the UK, much of the evidence is summed up in the Government’s excellent report, Drugs: International Comparators. On the basis of the evidence, the UK should be rolling out heroin-assisted treatment clinics and decriminalising the possession and use of all drugs. Heroin-assisted treatment clinics have been trialled and evaluated extensively in Switzerland, and introduced in the Netherlands, Spain, Canada, Germany, Belgium and Denmark, with pilots in the UK. The European Monitoring Centre for Drugs and Drug Addiction reviewed recent studies of this approach and concluded that there is strong evidence for the efficacy of HAT, when compared with methadone treatment, for long-term heroin-dependent individuals who do not respond to other forms of treatment. HAT achieves, in its words, marked reductions in the continued use of illicit street heroin and, to a lesser extent, in the use of other drugs such as cocaine and alcohol. It also achieves improvements in physical and mental health, as well as reductions in criminal activity, compared with levels prior to entering treatment. Would it not be wonderful if we could achieve that here? Will the Minister explain to the Committee why the Government have only three pilots rather than rolling out this well tried and evaluated policy across the country?
The Portuguese model of decriminalisation of drug possession, which involves dissuasion commissions and an increase in spending on treatment rather than on prisons, has been extensively evaluated and found to be beneficial. The essence of the policy is that, instead of arresting and charging a person caught in possession of a small quantity of any illegal drug, that person will have their drug confiscated and will then be referred to the local commission for the dissuasion of drug addiction, composed of a lawyer, a doctor and a social worker. The main aim of the commission is to explore the need for treatment and to promote healthy recovery.
In the UK, a person found in possession of even a small quantity of an illicit drug is still far too often, despite attempts by the police to go in the right direction, arrested and will have a criminal record, with all the disadvantages throughout life that such a record brings. Can the Minister explain to the Committee what the Government see as the advantages of the UK system over the Portuguese model? The evidence suggests that there is no advantage whatever.
There are two other policies which merit an open debate, as proposed by the UN Secretary-General. The first is a transfer of the primary responsibility for drug policy from the Home Office to the Department of Health. Most of our European neighbours did this some years ago, and it would make an awful lot of sense if we followed suit. Of course, close liaison with the Home Office would be necessary to deal with certain aspects.
Secondly, also very important is the rescheduling of cannabis from Schedule 1 to Schedule 2 to recognise the fact—not an illusion—that cannabis has medicinal properties. That is all that this would mean. It makes no sense to have Sativex, a cannabis-based medication, available on the NHS while having cannabis in Schedule 1, implying that it has no medicinal properties. We know that patients with multiple sclerosis and those suffering the side-effects of chemotherapy—very sick people—go to enormous lengths, travelling to Europe to pick up less than three month’s worth of cannabis. They say that it is the only thing that helps their symptoms. If they could obtain the drug just through a simple prescription on the basis of their diagnosis, would that not be a reasonable policy? Again, will the Minister agree to consider this proposal and ask the Home Office to undertake a serious study of the feasibility of such a change?
Finally, I want to put on record that the APPG for Drug Policy Reform, which I chair, is working with Latin American and European Governments to provide guidance across the world—it sounds a bit ambitious—on interpreting the UN drug conventions for the 21st century. The focus will be on the need to promote the central purpose of the UN conventions for the health and well-being of individuals and communities, and it will take account of the Brownfield doctrine. Can the Minister give the Committee an assurance that the Government will support an open debate on that guidance when it is fully prepared? The US, Latin America and Europe are all moving forward. Will the UK continue to be left behind?
My Lords, as the first speaker after the noble Baroness, I can do no better than say that I agree with practically everything that she said. I thank her not only for bringing this subject to your Lordships’ attention today but for the tireless work that she has done in looking at the international aspects of drug policy and in bringing together players who are not happy with the present policies. As she said, the 1971 Act, based on the 1961 UN convention, aims to reduce or eradicate drug use through legislation which treats drug users as offenders rather than as patients needing treatment and care. Many people, now joined by the Secretary-General of the United Nations, question the effectiveness of the war on drugs as currently waged, with most funds going into enforcement rather than the treatment of users. It has remarkably little effect.
At the risk of repeating several speeches I have made over the years in your Lordships’ House, I first became involved in the drug scene as a GP in a north London practice in an area where drug use was pretty rife. I practised in association with the UCH drug clinic, which had a methadone substitution programme. We found that drug abusers were very problematic patients and, despite the methadone substitution, we had several deaths from heroin overdoses due to the drugs having an unexpectedly high heroin content. Users were not satisfied with the methadone dose they were prescribed.
It is worth noting that, although heroin use has fallen among younger people in this country recently, death from heroin overdose continues at a high level. This occurs because the supply is totally unregulated, of completely unknown strength and in the hands of a criminal system. It became clear to me when I was in practice that most of the harm caused by drugs occurred because of the unknown purity and strength of the drugs. The need to regulate drug supply seems very clear since the current punitive approach is not reducing the levels of demand or of drug abuse. Regulating the supply of drugs needs to be in responsible hands, but this is not easy when the substances are prohibited.
I will leave that for the time being and go on to mention what we can perhaps do in the mean time to ameliorate or reduce the number of deaths. One thing is the use of needle exchange clinics, which greatly reduce the transmission of HIV. Luckily we have needle exchange clinics in this country. Not all countries do. I am glad to say that they continue to exist, as I am afraid they are still necessary. Another thing that can be done to reduce heroin deaths is to increase the use of naloxone, the opiate antagonist. Several drug clinics are now working with schemes to supply naloxone, with accompanying educational programmes. The noble Lord, Lord Ramsbotham, will perhaps amplify this when he speaks.
As the noble Baroness described, there is now some light on the horizon. The recent Home Office report on international comparators, which she described, has shown that less punitive policies can be more effective in controlling the effects of drug abuse. Like the noble Baroness, I hope that the Government can learn from the study of this document and start to move with the times.
My Lords, I, too, thank the noble Baroness, Lady Meacher, for tabling this debate and for her unflagging work to bring about a less damaging global drug control regime. In many parts of the world, she is seen as a leading engine of the movement to bring about change, and her energy, commitment and strategic wisdom bring great credit to the United Kingdom and your Lordships’ House. This is a small debate, but it is a contribution to the very big debates that the United Nations Secretary-General has called for.
The noble Baroness, Lady Meacher, has given us some very good news about the changed approach of the United States Government, at last. I shall begin with more good news. It was reported last week that Iran is debating ending the use of the death penalty for drug offences. I declare an interest as chair of the All-Party Parliamentary Group for the Abolition of the Death Penalty. Apparently 80% of Iran’s executions are for offences connected with drug trafficking, and the numbers are estimated to be large. We have the figure of 331 executions for drug offences in Iran in 2013. I was in Iran some years ago discussing criminal justice reform. I attended a meeting with a group of reform-minded young people. One man said, “We execute many drug traffickers in this country. We have a very draconian approach, yet every year the number of drug addicts increases and the volume of drugs entering the country grows. There must be a better way”. Indeed, there must be a better way than a system that leads to the execution of drug traffickers. I want to acknowledge the excellent work done by the Foreign Office to try to ensure that the UK does not support drug interdiction efforts that could lead to the imposition of the death penalty.
Of course, the execution of drug traffickers is just one—a most egregious one—of a range of harms that result from the current drug regime, which prioritises interdiction and punishment over treatment and other social measures. The effect on the prisons of the world has been disastrous. Prisons are full of an increasing number of small-time drug users and low-level dealers, all crammed into overcrowded, violent prisons. The health consequences are serious. For example, Hepatitis C, which is spread by injecting drugs, is rife in prisons. Research suggests that in some parts of the world the infection rate in prisons is at least 10 times higher than in the community generally. This is a harm that affects a segment of a country’s population.
The harm caused by the criminality and violence of the drug trade is incalculable. In Mexico alone, 50,000 people have been killed in the past five years due to drug and organised crime-related violence. Sick people suffer because the drug control system puts barriers in the way of providing opiates for pain control and palliative care. The damage caused by the current arrangements is also made clear in the report from the West African Commission on Drugs, chaired by Kofi Annan and the former Nigerian President Obasanjo. It notes the progress that west Africa has made. It states:
“Civil wars have receded, democracy has gained ground and our economies are growing. But a destructive new threat is jeopardizing this progress: with local collusion, international drug cartels are undermining our countries and communities, and devastating lives”.
Do the Government intend to participate fully in the upcoming debate about global drug policy? The Minister will know that DfID is regarded around the world as the premier development body. It is widely admired and seen as a model. The Foreign and Commonwealth Office is similarly highly regarded for its excellent human rights policy.
Drug policy reform is essential both for ensuring further development in low and middle-income countries and for protecting human rights. Will the United Kingdom be in the forefront of the international process that is now under way? Will it support what DfID and the Foreign Office have done so successfully for many years? Will it be advocating an approach that aims to reduce harm and protect vulnerable people from violence and destabilisation?
My Lords, I, too, pay tribute to the amazing and valuable work of my noble friend Lady Meacher on making drugs policy more effective and relevant in today’s national and global situation. She has been indefatigable, and I admire her persistence.
I had been interested in drugs policy for many years before I met the noble Baroness, but I find myself very much in tune with her views. In 2001, I was asked to chair a Liberal Democrat policy working party on drugs policy. It was then that I first met my noble friend Lord Paddick, who at that time was a senior Metropolitan Police officer and was taking the lead in doing exactly what the noble Baroness has recommended—having his officers focus on the dealers rather than the users—and getting a lot of stick for it.
The thrust of our report was that the use of illegal drugs should be treated as a health matter rather than as a criminal matter. Even at that time we had evidence that the UK’s punitive regime was not working. Our objectives then, as now, were to reduce harm, address the crimes of those who destroy people’s lives by peddling drugs to them, and get the big drug money out of organised crime. We were aware then, as we are now, that whole families are destroyed by drug use and that addiction can be a major tragedy for families, especially when there are children in the household. So to say that the Liberal Democrats are soft on drugs is, and always has been, untrue: we have simply identified that the war on drugs has failed many of our citizens and we need to find a more effective strategy.
We were aware even then that a major barrier to a more imaginative approach was the usual narrow interpretation of the UN convention. Our report committed us to work with other countries to arrive at a consensus about how to move forward within the convention. So the UN Secretary-General’s statement of 26 June last year was particularly welcome to me, and it should be regarded as an open invitation to all countries to consider all options. That is why I am so pleased that the noble Baroness, Lady Meacher, has worked with the leaders of many other countries who have courageously spoken out and said that we need new approaches. We should not be frightened that the international community will condemn us if we do things differently.
The recent publication by my right honourable friend Norman Baker MP of a research paper called Drugs: International Comparators was particularly welcome. As he has said, we must look at the evidence without prejudice and consider carefully whether some of these new ideas might work for us in this country. Of course, different cultures and circumstances apply in different countries, and you can rarely transplant ideas lock, stock and barrel. However, there is often a germ of an idea that can be useful. It was clear from the report that there is no correlation at all between reduction in drug use and a punitive criminal justice approach. Indeed, pragmatism and a health-based approach are showing great results all over the world, and that is how we should approach it here.
I was surprised to read that there is little evidence that the special drug courts are reducing reoffending. I had the opportunity to question Norman Baker about that at a meeting yesterday. It seems that here is a good idea which has not produced the results for which it had the potential, merely because of the lack of treatment and diversion services that are needed to sit alongside a drug court system. It is a great shame that the resources were not made available, since many of the judiciary were very enthusiastic about this approach. I believe it could have worked, given the availability of the appropriate services. It has the potential, in particular, for helping addicted women to address their drug habit and keep their children.
I was also interested in the pragmatic idea of providing clean needles in prisons, which is done in some other countries. Apparently the law prevents this here. However, the law is currently failing abysmally to keep drugs out of prison. Indeed, the saddest thing is that some offenders go into prison clean and come out as drug users. Of all the things that would encourage them to go back to offending, that is it. I believe that we should find a way to provide clean needles under the auspices of providing medical services.
My main objective is to discourage young people from taking up the use of drugs at all through information and education. So-called legal highs, which are no such thing, have become very widespread, and this is worrying. I support a blanket ban, but at the same time I believe that a health and diversionary approach to users—not dealers—is the right approach, for these as well as the more traditional illegal drugs. I also support the pilot schemes for last-resort use of opiates for hard-core heroin users for whom other methods have failed. I hope that the Government will seriously consider a rollout of the pilots that have been successful.
Under this Government we have continued to try many innovative ways to discourage drug use and address its harms. However, the mood music is still punitive and the responsibility is still within the Home Office. I, like the noble Baroness, Lady Meacher, would like to see a change in the tone of government rhetoric on drugs and a wholesale shift of responsibility for users to the Department of Health, so that the criminal justice system can be freed up to deal with the real villains, the dealers. I also hope that this and future Governments will become more open-minded about talking to other countries about new approaches within the convention and new interpretations of our international obligation, so that we can really start to fight drugs more effectively in the international community. This is what the Secretary-General wanted to see resulting from his statement.
My Lords, I declare an interest as chairman of the cross-party group on criminal justice, drugs and alcohol. I agree with every word that my noble friend Lady Meacher said. I thank her for obtaining this debate, and I salute her for her determined attention to all aspects of national and international drugs policy. I want to comment on two things in particular and then give one example of where I think the policy really needs to pull indecision together. I hope that the debate called for, when it happens, will have as its objective the production of a clear, consistent and continuous national policy which can be followed by all those who have any responsibility for dealing with users and abusers of drugs.
It first became clear to me that there was no national policy when I was in the Army and we had to guard two prisons because of strikes by prison officers. One of my military police sergeant-majors complained to me that he had seen two prisoners exchanging cannabis, had taken them in front of the governor and had been told to dismiss it because cannabis was common in prison. He said to me, “This is ridiculous—we kick out any soldier who is using drugs, yet this is going on in our prisons”.
I then found, of course, that there was absolutely no policy when I started inspecting prisons. Drug responsibility was in the hands of the director of nursing, which may have been a predicator of what America has adopted, but it was absolutely pointless because no governor took any notice of what the director of nursing said. No prison had any common policy on who was assessed when they came in. There was no common policy on treatment, no common treatment for withdrawal and no interest in people who might pick up stronger drugs on release and subsequently die. In fact, there was nothing, and there is still nobody in prisons who is responsible for making certain that there is a common policy in every type of prison.
Going further, I ask whoever conducts the debate called for to add two words to the words “wide-ranging and open”, and those words are “cross-party”. I feel that one of the problems that we have suffered from is the ping-pong between parties, which has led to nothing more than inertia. The real tragedy of the inertia is that it leads to ruined and lost lives because delay in doing anything will inevitably lead to that. Rather than risk one party saying this and one that, could we please have a cross-party consensus so that everyone will be able to follow the common national policy that comes out of it?
I raise the issue of the use of naloxone, which the noble Lord, Lord Rea, mentioned, because we were given a good briefing the other day in our cross-party group. The Advisory Council on the Misuse of Drugs gave advice to the Government on whether naloxone should be made more widely available in order to prevent future drug-related deaths and to help engage and educate those most vulnerable to suffering an opioid overdose in May 2012. Its advice was that, first, naloxone is a safe, effective, evidence-based, World Health Organization-recommended drug with no dependency-forming potential. Its only action is to save lives by reversing the effects of opioid overdoses, and it is already used by emergency services personnel.
The prevention of drug-related deaths, of which there were 1,957 in 2013, is one of the eight key outcomes for delivery in a recovery-orientated drug treatment system, which is what we claim to have. Currently, naloxone is available on prescription to people at risk of opioid overdose, but it will have its maximum effect on deaths if it is made available to people with the greatest opportunity to use it and those who can best engage with heroin users, such as their families and carers. They will, of course, have to be educated in its use, but that is not impossible. Following the 2012 report, Scotland and Wales conducted successful pilots and have since introduced national strategies for its use. England, which ran a programme, has had no similar rollout and none is planned until October 2015, three years after the report.
However, it is not going to be a national strategy but will be left to local authorities. One of the organisations in our cross-party group made a freedom of information request to find out how much knowledge there was of naloxone in the local authorities. It found that, of the ones that replied, 60 local authorities had no plans and had given no priority or money to naloxone; 10 were thinking about it; and 60 have local strategies, some of which are good and some of which are poor. I merely rest on that because the lesson of naloxone should be borne in mind when we are looking for a common national strategy.
My Lords, I join others in expressing my extreme admiration for my noble friend Lady Meacher for bringing this debate. As has been said already, it is a tiny taster of the enormous debate we will have later. She has worked at an international level and has interested herself in the problem we are facing today in the United Kingdom and in a coherent government strategy which will lead to a revolutionary change of view.
I wish to say a little about the entrenched view that drugs are a matter of criminality. People of my age and of up to 15 years younger than me need to go back and think about the 1960s, which was when drugs hit the general consciousness. It was a time of student revolt and the introduction of the pill. At the time, I was the headmistress of a girls’ school, and we were completely ignorant of the drugs scene and absolutely terrified. We had the most terrible problems in Oxford with undergraduates occupying the Examination Schools and smoking cannabis just for fun. We knew where the cannabis came from. There was a kind of route that started in Birmingham and came down to Oxford and then London, and round and round it went. What I remember most about that time was the fear—the absolute terror that we felt and all parents felt.
If I had any success as a headmistress it was entirely because I had teenage children myself and therefore nothing shocked me. I had one son who still does me a great deal of good, but he did me great good then by being expelled from his public school for cannabis use. The school did not admit that but I knew it. This meant that parents realised that I was not going to be surprised or overreact or anything.
At that time, I must say, I was thankful that the use and possession of drugs was a criminal offence. The reason I was thankful was that I could threaten my pupils that if they were caught with possessing drugs or sharing drugs, if any drugs were found on school premises, I would hand them over to the police because they would have committed a criminal offence. This did restrain them. I felt at the time that the only way of preventing what started as recreational use but could so easily have become addiction—we did not know—was threatening criminal action. So I started off from that point in the 1960s, and I was very slow to change my mind. I did not think about it very much; it just seemed self-evident that it was the using of the drugs which had to be picked on and not the trafficking of them. We hardly thought about trafficking and where the drugs came from and the criminality that goes with drug trafficking. It vaguely passed our minds but it was not what we concentrated on; it was the use. I think that what we now need, and what my noble friend has done so much to get us to think about, is a complete change of attitude towards the use of drugs compared with the trafficking of drugs. This, of course, has the wide international consequences with which she has been and is so greatly involved.
The first thing that made me change my mind was that I had a very good former pupil who later became a victim of MS; she wrote to me, saying that she spent hours of her life trying to negotiate with all her friends to get hold of cannabis because cannabis-related drugs were the only thing that gave her any relief. That seemed to me such an appalling, inhumane attitude towards cannabis that from that moment on I started to think that drugs with a medicinal use, at least, must be treated in a different way.
The other thing is that I have family connections with Portugal, so I know quite a lot about what happens in Portugal, and how it works. I am simply defeated in trying to answer the question of why the Government do not give more attention to following what is in fact a strikingly successful model.
The final thing is, of course, you only have to look at the prison population to see that the so-called war on drugs just does not work and, therefore, it is inevitable that we must change our minds. So I beseech the Government to take a strong and revolutionary look at where we are and make some policy which is coherent, consistent and well understood.
My Lords, I hope you can spare me two minutes in the gap. I, too, risk—as the noble Lord, Lord Rea did—boring noble Lords by repeating what I have said in your Lordships’ House many times before. Drugs are primarily a health problem, with significant social consequences, as we all know. It was for the historic reasons that the noble Baroness, Lady Warnock, just told us about so very graphically that the establishment of the day, and the political establishment, decided to address what we now know is a health problem by using the criminal justice system to restrict drugs, a pillar of this policy being the Misuse of Drugs Act 1971. Indeed, the international comparators report says:
“Our legislative response to drugs is based in the 1971 Misuse of Drugs Act, which continues to provide a flexible yet consistent legislative framework to control emerging harmful drugs and target illegal suppliers”.
The problem is it does not actually work and that is why we are having this debate today.
We have been given evidence that drug use in the United Kingdom has levelled out and is, perhaps, even falling. Most of the evidence comes from the national crime survey. I have to tell the Government that no reasonable, intelligent, well informed person outside either the House of Commons or the Home Office actually believes this to be true. Public opinion—well informed opinion—has moved on significantly. We know that drug use is not falling. Virtually every other piece of evidence tells us this. I ask your Lordships to push your minds back a bit; one of the reasons we were given for sending soldiers into Afghanistan was to eradicate the poppy crop, but the United Nations tells us that in the 10 years since we have been there the poppy crop has increased fourfold, and 80% of the Afghan poppy crop is aimed at the United Kingdom. Are we really pretending that a fourfold increase in production is aimed at a falling market? That simply is not realistic. At the other end of the equation, the numbers accessing treatment continue to rise, and there is some evidence that the waiting lists are continuing to rise too.
None of this would matter if the second plank of the Government’s drug strategy was working. In the introduction to the 2010 drugs strategy the Home Secretary said:
“This strategy sets out a fundamentally different approach to tackling drugs and an entirely new ambition to reduce drug use and dependence. It will consider dependence on all drugs, including prescription and over-the-counter medicines”.
I noticed that only last night when I was writing this as I was watching the television programme about the appalling rise in prescription drug use in this country. That clearly has not worked either.
Why is this so important? It is very simple. Millions of people in the United Kingdom take drugs. We can debate whether the number is going up or down or, probably, staying vaguely the same, but the number is in the millions. The vast majority of the people who take drugs in this country have minimal, if any, health or social consequences. They do not get arrested, they do not commit repeated acquisitive crimes and they do not visit A&E. The 350,000 chronic and chaotic drug users are the ones who cost us money and it is those people we should be spending our £15.5 billion on, not the remaining people in the population who do not cause us any problems.
My Lords, I add my thanks to the noble Baroness, Lady Meacher, for the opportunity to have this debate today. She is a doughty campaigner for drugs reform. She and I have had a number of discussions on different issues in your Lordships’ House and although we may not always agree on policy, I think that we have a very similar goal as regards the drugs issue. I, too, welcome debate and believe that evidence-based policy is extremely important. A wide-ranging and open debate that considers all the options can only be the way forward. If we do not consider all the options we will be doing a disservice to those who are affected by drugs and to their families.
I was also struck by the noble Baroness’s comments on the new psychoactive drugs. We have recently had two areas of debate, in two different Bills, regarding drugs. One of the Bills was on drug driving, and the other was the anti-social behaviour Bill, which deals with the so-called and completely misnamed “legal highs”. One of the things that struck me was the communications that I received from families who had lost somebody. These family members had either died or been seriously ill from using these psychoactive drugs. The situation is horrendous. If you talk to young people now and ask them whether they know where to get these drugs, most will say that they know where to find them.
Unusually for me, I made a few notes before I came into the debate. I wanted first to listen to the debate—which has been very thoughtful—and then make a few observations. I have heard the noble Baroness, Lady Meacher, speak before about Portugal, and when she first mentioned it I did not know about the Portuguese examples. I have since read quite a bit about it. There is certainly a great deal of merit in such an approach, and it seems to have successes. This should be fed into any debate that the Government undertake about the kind of approach that could be taken to get people away from drugs, and reduce the associated criminality.
Although the debate is concentrated on the end-user and the value of treatment rather than a punitive approach, we also have to recognise the serious criminality that goes alongside drug dealing. Huge benefits and profits are made by unscrupulous dealers and criminal gangs, who use this money to fund their other activities. It is a trade in absolute misery for others. It has to be a criminal offence; we can never deny that it is such and it should be treated as such. The availability of drugs has to be taken into account, and the point has also been made about prisons. Obviously, there have been some massive police successes and some amazing seizures. In my own county, where we have ports and airports and various ways of entering, there have been a number of seizures of drugs, and yet this does not seem to have a serious impact on the drugs that are available on the ground. This is partly because of the new compounds, the new psychoactive substances that can be manufactured.
Perhaps I was naive as a teenager, but I would not have known where to get drugs. I saw a noble Baroness smile; I do not think I was particularly naive. Talking to youngsters in schools now, I am surprised by the number of them who know far more than I do about this. They have far more knowledge of what is available. They even tell me the prices, which seem to me to be extraordinarily low. This can only be a matter of supply and demand.
The noble Lord, Lord Ramsbotham, referred to the ping-pong of politics. That is a great shame in a number of ways. Being a party-political hack, I consider that, although sometimes it is impossible to reach agreements between parties, there are areas where there could be far more of that kind of cross-party discussion, which would be very helpful.
I am conscious of time, but I wanted to raise one further point. I felt very sympathetic to the comments that were made in much of the debate, but I would have to put an alternative point of view about removing drugs policy from the Home Office and into the area of health. On face value, I would have considerable sympathy with that, partly because we recognise that treatment works. If you look at the figures, we have a much better record on treatment in this country than in many European countries. The number of opiate users receiving treatment in the UK is 60%, compared to only 12% in the Netherlands and 25% in Sweden. I recognise the enormous value of having health-based policies.
I do not know whether other noble Lords saw a recent article in the Guardian on 25 November. It was written by Paul Hayes, who is a former chief executive of the National Treatment Agency for Substance Misuse, which works between the Home Office and the Department of Health. His view is that the only reason why Governments put money into treatment programmes is the criminality which goes alongside so much drug use. In the article, he writes that:
“The government estimates that drug misuse causes £15bn worth of harm to society—£13bn of this being the cost of drug-related crime—dwarfing the £5bn of health harm from smoking”.
His point is that that is one of the drivers which puts money into treatment. There is that driver of the Home Office recognising that this involves aspects of community safety, for example. In contrast, the Department of Health sees ongoing treatments, which are essential for many drug addicts, as being perhaps not the best use of their money. He writes:
“Put simply, the Home Office sees drug treatment as value for money, while the DH sees it as a wasted opportunity”.
“So what may appear at first sight as ‘common sense’, or a more liberal-minded approach to drugs misuse—by treating it as a health issue rather than a criminal activity—would most likely result in drug policy becoming the responsibility of a department”—
he means the Department of Health—
“that isn’t very interested, has a wealth of competing priorities, and a track record of seeking to disinvest from the very intervention that the proposal is designed to promote”.
I am not offering that as my particular view, but I think that it has to be included in the mix if we are looking at evidence-based policy.
My Lords, along with other noble Lords, I thank the noble Baroness, Lady Meacher, for tabling this Question. She has championed the importance of having a balanced and evidence-based approach to drugs policy, which I strongly support, and I am grateful to have the opportunity today to set out the Government’s action on this policy. We have debated drug policy privately and publicly, and, as many noble Lords have said, we seek the same outcome—the restriction of the supply of and demand for drugs to keep our nation healthy.
Our 2010 drug strategy aims to tackle the harm caused by drugs by balancing activity across three strands: reducing the demand, restricting the supply, and building the recovery of those who have taken to drug use or are dependent on drugs. We are reducing the demand for drugs by preventing their use in the first place through various strategies and methods. We are restricting the supply by tackling drug dealing on our streets, strengthening our response at the border and combating the international flow of drugs to the UK by disrupting drug trafficking upstream. There has been great progress in this area.
Many noble Lords, in different ways, referred to a proportionate approach to people caught in possession of an illegal drug. Our law enforcement officers take a proportionate approach and the vast majority of people caught in possession of an illegal drug are not imprisoned, with only 3% of offenders found guilty of drug possession last year being sentenced to immediate custody.
It is vital that the police and the criminal justice system have a range of measures available to them, including community-based interventions and referral to appropriate treatment, as well as tools to deal robustly with serious and repeat offenders, who cause the most harm in our communities.
Building recovery is important and we are doing it by supporting individuals to recover from dependence through timely and effective treatment, as well as through local services which encompass housing, employment and appropriate support to maintain a stable family life and a life free from crime. For example, we have maximised public health benefits for users through the legal provision of foil, which came into force in September 2014, and we have agreed the wider provision of Naloxone, to which a number of noble Lords referred, from October 2015. As the noble Lord, Lord Ramsbotham, pointed out, Naloxone can reverse the effects of opiate overdose. We will work with local authorities, prisons and others to ensure that it is available to those who need it and those who can administer it.
There are positive signs that the balanced approach is working. Despite the cynicism of the noble Lord, Lord Mancroft, on this point, there has been a long-term downward trend in drug use over the last decade. More people are recovering from their dependencies now than in 2009-10 and the number of heroin and crack cocaine users in England has fallen to 294,000.
A number of noble Lords referred to the international comparator study. The Government need to continue to consider further options by looking to others to see where our learning and understanding can be enhanced. The challenges that drugs present in the UK and other countries are always changing and we need to stay abreast of developments around the world. That is why we recently published the findings of the international comparator study, which looked at responses to the misuse of drugs in other countries and makes clear that this is a complex problem. Each country’s social, cultural and legal context has shaped its responses, and what works in one country can be inappropriate in another.
The noble Baroness, Lady Meacher, has referred to Portugal in the past and she referred to it again today. The report on the decriminalisation work in Portugal is clear that the decrease cannot be attributed to decriminalisation alone. Drug use has gone down and outcomes have gone up, but there has of course been a significant investment in treatment in Portugal.
The study has made an important contribution to the ongoing development of and debate on drugs policy, and it provides us with a strong body of evidence on which to consider further responses to the evolving challenges of drug misuse. It has also reinforced our commitment to a balanced approach based on evidence, and we will continue to advocate for this approach to be pursued internationally.
The noble Baroness, Lady Smith, has spoken about the inaptly named legal highs. She responded to the amendment to the Misuse of Drugs Act that I proposed the other day. We have added a number of new legal highs, so they will now become illegal highs once the measure is implemented. We have led the international response to this challenge, putting in place a forensic early warning system, using innovative legislation to ban more than 350 substances and galvanising international action with partners at the UN and G7.
In December last year, we established an expert panel to look at this matter. The panel considered all available options for how the UK’s response to new psychoactive substances can be enhanced beyond the existing measures. I understand that the noble Baroness also contributed to this review, for which we are grateful. The panel made a large number of recommendations, which we are already taking forward, including developing proposals for a general ban, which we also talked about, similar to that introduced in other countries, such as Ireland.
We do not have much time left to deal with individual points that noble Lords made. The noble Baroness, Lady Meacher, said that the ICS showed that there is no link between tough penalties and drug use. However, it does not say that there is no link or impact. It makes clear that approaches to drugs legislation and drugs possession are only one element in a complex set of factors that affect drug use, including prevention, treatment and wider social and cultural factors. It would be inappropriate to compare the success of drugs policies in different countries based solely on trends which are subject to differences in data collection.
The noble Baroness also talked about medicinal cannabis which is not used to treat multiple sclerosis. Other noble Lords made this point. Some years ago, I worked as a nutritionist with sufferers of multiple sclerosis, and I remember the campaigning that went on then to try to make Sativex available. I am very pleased that it is now available. We have no plans to legalise cannabis or to change our approach to its use as a medicine. I was not sure what medicinal cannabis the noble Baroness was referring to in treatment for things other than multiple sclerosis.
The noble Baroness, Lady Stern, made a very important point about the death penalty. I personally and the Government are absolutely against the death penalty for all sorts of reasons. I think the noble Baroness will understand that.
The noble Lord, Lord Ramsbotham, asked what the Government are doing to get prisoners off drugs. The Ministry of Justice is taking various approaches, including piloting drug recovery wings, increasing the number of drug-free environments and developing and testing liaison and diversion services in police custody suites and courts.
I am rapidly running out of time. It is important to mention the United Nations General Assembly Special Session on Drugs in 2016. In addition to leading the global response on new psychoactive substances, we continue to advocate for a balanced, evidence-based approach to drugs internationally. We agree with the UN Secretary-General that the UN General Assembly Special Session on Drugs will be a key forum for engaging in open dialogue on these issues. This event represents a unique opportunity to engage with all UN member states, international organisations and civil society on how we can improve the global approach to drugs.
On that note, I thank all noble Lords. I will reply in writing if there are any points I have not addressed. It would be great if we could have a cross-party approach on this.
Question for Short Debate
My Lords, I am very grateful to have the opportunity this afternoon to raise the extremely important subject of tuberculosis in the United Kingdom, and I am very grateful to colleagues for agreeing to take part in this debate.
Like all 13 and 14 year-olds of my generation in the UK, I had my BCG vaccination while I was at high school. I remember that we all compared our scars for months afterwards. We believed at that time that TB, like smallpox, could be eradicated from our society. TB, or consumption, was supposed to be an illness of poverty of times gone by. In Victorian Britain it was known as the “silent killer” and as many as one in four deaths were attributable to it. So high was the death rate, in fact, that TB has been estimated to have killed more people than any other infectious disease in human history.
Shortly after I was appointed to this House, I became involved with the APPG on TB. Much to my surprise, I quickly had many of my preconceptions shattered, as I learnt that TB has not, in fact, disappeared and remains a very real problem. While great progress has been made against the disease in the West, globally TB is as deadly as ever. The latest estimates from the World Health Organization are that the disease kills 1.5 million people every year. The Lancet estimates that TB kills more people than any other single infectious agent worldwide. To put it in context, TB kills nearly as many people every single day as have died from Ebola since March.
TB today is not the same disease it was 100 years ago. Our failure to develop new drugs or to properly apply the ones we have has given TB bacteria the chance to evolve new, drug-resistant strains. The issue of drug-resistant TB is particularly pertinent today, following the first report from Jim O’Neill’s AMR commission. The report estimates that antimicrobial resistance could cost the world economy $100 trillion over the next 35 years, and it cites TB as a major driver of that cost. In this context, it is no overstatement to say that MDR TB is a threat to social and economic well-being across the world.
A growing percentage of global cases are resistant to our best drugs. Patients diagnosed with multidrug-resistant or MDR TB face two years of treatment, taking 14,000 pills, which are often associated with permanent and debilitating side-effects and which have only a 50% chance of cure.
In June this year, I took part in a delegation to Romania looking into the Romanian experience of the treatment and prevention of TB. Romania has the highest incidence of TB in the EU. At one clinic, I spoke to a young mother of two children who had been diagnosed with MDR TB. She had already had half of one lung removed and was expecting an operation imminently to remove a section of her other lung. She was struggling with the harsh regimen of drugs for her disease and constantly felt unwell and nauseous. She was also deeply worried for her two young children, who were in the process of being tested to see whether they, too, had MDR TB.
Of course, this debate today is not about global TB; it is about TB in the UK. London is regarded as the TB capital of western Europe. Some parts of the capital have rates equal to those in sub-Saharan Africa. The BCG vaccination with which we are all so familiar provides far less protection than many think and offers no protection at all to adults.
I would like to focus briefly on three key areas: education and awareness; testing and diagnosis; and tackling the problem at source—namely, developing new and better medication and a vaccine that works. TB is infectious and airborne. When patients start treatment, they become less infectious. If there is a delay in diagnosis, they remain infectious for longer, allowing the disease to progress, and develop more severe symptoms, thus exposing others to the risk of transmission, so the first thing we must tackle is delayed diagnosis.
I am pleased that Public Health England and NHS England have, together with a number of other stakeholders, drawn up a collaborative TB strategy for England. I also note that this strategy acknowledges:
“An additional factor that frequently delays diagnosis is the lack of TB awareness among health professionals and appropriate training among social care staff”.
In short, it is a problem that high-risk populations as well as many healthcare professionals are currently insufficiently well informed about TB. Earlier this year when I visited Romania with RESULTS UK, we went to a prison outside Bucharest which had an impressive TB education programme that far surpasses anything I have encountered in this country. Will the Minister outline our existing TB awareness programmes, particularly in prisons? We are not going to reduce delays in diagnosis unless we make people aware that TB is a genuine threat to public health across the UK.
Of course, there are other ways to reduce delays between the onset of symptoms and the diagnosis of the disease. Find & Treat screens up to 10,000 people a year in the UK. It works with some of the hardest-to-reach people and yet has a treatment success rate higher than the national average. In fact, the service is of such sufficiently high quality that the clinical lead, Dr Alistair Story, who I met a few months ago, has been asked by the World Health Organization to participate in a working group exploring how to eliminate TB in low-burden countries. Yet the Find & Treat service is on an uncertain financial footing and, although seeking to expand, is unable to do so. Will the Minister commit to seeing the work of Find & Treat first-hand and support it in its efforts to scale up?
Find & Treat is also behind a project that I visited in North London known as Olallo. Olallo offers accommodation and social support for homeless patients receiving drug-resistant TB treatments. Patients receive free lodging, food, education and skills training to support them in finding permanent employment. The project is an exemplary demonstration of how we can support those with chaotic lifestyles. As a model it could also save us money. The average cost of treating a TB patient in a hospital is £500 a day, and even more in a negative-pressure isolation room, whereas hostel accommodation with all the additional social support can cost between £60 and £80 a night. Will the Minister detail what the Government are doing to support and expand projects like Olallo?
Finally, I would like to speak briefly about TB treatment. Every time I have spoken to a TB patient or a healthcare professional, the conversation has turned to the terrible treatment burden and the awful side effects. Patients have told me of the risk of hearing loss, blindness, liver damage and suicidal urges. Healthcare experts have explained the very real dilemma of having to put an MDR TB patient on treatment, knowing the misery that the drugs can bring. In the 21st century it is simply unacceptable that a patient should face the choice between a disease that could kill them and a treatment that could leave them permanently disabled.
I am proud that the UK Government are the second biggest public funder in global health research and development in the world. Investments and product development partnerships, such as Aeras and TB Alliance, are life-saving. The concordat between DfID and the Medical Research Council is practically unique in the developed world and yet there is much more that can and should be done. At the root of our global failure to develop TB drugs and vaccines is a simple truth: people who suffer from TB are usually poor and do not offer a market of sufficient scale to incentivise pharmaceutical companies to invest in research and development. To put it more crudely, the commercial market has failed TB patients. In the face of this market failure, Governments must act. The UK Government could do even more than they currently do. We need to reclaim that thought-leadership and work with leading donors around the world to drive a new global consensus on overcoming the market failure in R&D for global health.
The response to the global HIV epidemic has been one of the greatest examples of the world responding to a global health threat, and HIV has lots of advocates and celebrity supporters. Ebola, too, has gripped the attention of the world’s media, and rightly so.
I mentioned at the beginning of my remarks that TB was once known as the silent killer. If politicians, the media and Governments continue to be largely silent as the disease kills millions every year we will never be rid of the disease, not in the UK and certainly not around the world. I very much hope that the Government will lead the way to reverse this situation.
My Lords, I thank the noble Baroness, Lady Suttie, for this important debate.
Many people think TB is a thing of the past. However, here in London, Newham has been named the capital of tuberculosis in Europe. With modern travel, the world is very small. I will mention a few points on the international scene before concentrating on the UK.
I was very impressed and moved recently by a film on drug-resistant TB, shot in Africa. The 2014 WHO report also states that the problem of drug-resistant TB is worsening, with an estimated 480,000 new cases of MDR-TB in 2013. This, too, may be an underestimate, since estimates of the true burden of drug-resistant TB across sub-Saharan Africa, Asia and eastern Europe are impaired by the fact that drug-resistant testing and treatment services are broadly unavailable at the majority of healthcare facilities.
Of greater concern was that of the estimated half a million cases of multi-drug-resistant TB around the world only 136,000 were officially diagnosed. It is perhaps more dire to note that 9% of those with MDR are estimated to have extensively drug-resistant TB or, in other words, that close to 50,000 people worldwide have a form of the disease that we do not currently have the necessary tools to treat.
TB is caused by bacteria. It is airborne and infectious, transmitted when a sick patient coughs or sneezes. TB has been estimated by the Lancet to be the deadliest disease in the world. The World Health Organization estimates that TB kills 1.5 million people every year. Like many other bacteria, TB is increasingly resistant to our best drugs.
We must not be complacent here in the UK. We have many demands on our NHS, but infections need controlling and preventing whenever possible. It is much easier to treat an infection in the early stages. Here in the UK, there were 7,982 cases of TB in 2013. This is a reduction of 10.6% over the previous two years. London, however, has the highest rate of any capital city in western Europe. Birmingham’s rate is even higher. Both are near the World Health Organization’s definition of a high-risk area. Before 2012, rates of TB in the UK rose steadily from the year 2000. Only 15% of TB cases in the UK occurred in people who had entered the UK in the previous two years. TB remains concentrated among the most deprived populations. In 2013, 70% of cases were resistant in the 40% most deprived areas. Nearly half of cases were among the unemployed, while 10% had social risk factors, including a history of alcohol and drug misuse, homelessness and imprisonment. More than a quarter of patients with TB in their lungs started treatment more than four months after the onset of symptoms. On average, patients in the UK wait 72 days between the onset of symptoms and diagnosis with TB. This increases the severity of symptoms and increases the likelihood that patients will transmit the disease.
There are two main reasons for this problem. Healthcare professionals in the UK often do not consider TB in the first instance. Thus, patients can be misdiagnosed. Patients can be reluctant to come forward due to stigma, lack of awareness of the disease and reluctance to access healthcare. In London, the Find and Treat service has overcome some of the challenges on the patient side. Find and Treat is a service based around a mobile X-ray unit in the back of a van which travels to hostels and other homeless places across the capital to screen marginalised and high-risk groups. I have visited this unit at work and I can tell your Lordships that it is run by enthusiastic, dedicated people. I assure your Lordships that if you had time you would find a visit most interesting. The unit even has access for a wheelchair, which is unusual. Most units for screening breast cancer do not have this facility.
The service frequently employs previous service users to offer mentoring to current patients, offering all-important social care and helping previous service users develop employable skill and experience. Find and Treat accordingly has a higher treatment completion rate than the UK national average, despite working with hard-to-reach, marginalised populations. The draft collaborative TB strategy for England recommended the scale-up of Find and Treat to become a national outreach service. This is welcome, but it must be done correctly.
TB is just one of several interlinked conditions across the UK that suffer from delayed and incomplete diagnosis. Some 30,000 people in the UK with HIV do not know their status. Half of all those with hepatitis C do not know their status. Some 630,000 people with type 2 diabetes do not know their condition and 11.5 million people are considered to be at high risk of developing type 2 diabetes. These conditions are linked. People with HIV are 20 to 30 times more likely to develop TB. People with diabetes are three times more likely to develop TB. Hepatitis C and HIV infection are connected by similar methods of transmission. All these conditions are found predominately in areas of high health inequalities. Many of these people are unaware of their status and are not accessing healthcare. HIV, hepatitis C, diabetes and TB can all be screened for in less than 15 minutes.
I must declare an interest, as among the all-party health groups I serve on, I am a member of the All-Party Parliamentary Group on HIV and AIDS, the All-Party Parliamentary Group on Global Tuberculosis, the All-Party Parliamentary Hepatology Group and the All-Party Parliamentary Group for Diabetes. Therefore, I agree with scaling-up Find and Treat to include these conditions. This would maximise the efficiency of the outreach service, making the most of a single contact with an individual to screen for multiple conditions. It would reduce stigma related to any single disease by making such tests part of routine health screening. It would target areas of high health inequalities, adapt a preventative approach to health and, most importantly, save money. The Find and Treat budget is under £1 million a year. The lifetime cost of HIV treatment in the UK has been estimated at over £300,000 per person, so an outreach service would need to help prevent only three cases of HIV to break even. Most importantly, an outreach programme such as this would save life.
We must do more to prevent these infections. I hope that in the next 10 years there will be a vaccine and more new drugs for TB, but I also hope that the Minister will commission her department to explore the possibilities of an integrated national outreach service for HIV, hepatitis C, diabetes and TB across the country. I look forward to the Minister’s reply.
My Lords, I thank my noble friend Lady Suttie most sincerely for giving us the opportunity to debate this important subject. I acknowledge an interest in that my husband is chairman of the board of the Whittington Hospital, which is one of the hubs for the innovative TB Service North Central London, which I will mention later. I thank Dr Helen Booth, a consultant thoracic physician and TB clinical lead for that hub at the Whittington, for briefing material. I also appreciate the briefing from Results UK, the NGO that my noble friend mentioned. I also draw on evidence from the London TB clinical leadership advisory group.
I have no health background or expertise except some involvement in diabetes, but the more that I briefed myself on this subject, the more interested and alarmed I became. Having formerly had the privilege of being the elected representative for London in the European Parliament for 15 years, I was naturally very impressed with the fact that London, as has been mentioned, has the highest rates of TB of any capital city in western Europe—indeed, I believe, in the developed world—that the London Borough of Newham has rates equivalent to Nigeria, and that England is set to have a higher rate than the United States in 2015. These statistics are all very impressive. Unlike other major cities such as New York, Barcelona and Paris, London has not seen a reduction in TB rates, and accounts for almost half of the approximately 8,000 cases nationally. As a Londoner, I find this topic very important, and I am grateful to my noble friend for drawing attention to it.
The evidence suggests that in London the majority of new cases, around 75% or 80%, are due to the reactivation of latent infections after TB has been acquired in a high-risk country outside the UK, but of course if that latent infection is reactivated it acts as a source of infection for those in close contact with that person, including their family and children.
I mentioned the North Central London TB service, the NCL, which is an innovative service providing holistic care to TB patients. It has seen reductions in TB rates. It includes the outreach service, mentioned by the noble Baroness, Lady Masham, of the mobile X-ray and Find and Treat team based at University College Hospital, as well as a TB link project, which demonstrates the importance of an integrated social care team. It has introduced a cohort review into London and the UK, based on a New York model of TB control, and since 2007 it has had a united nursing, social care, outreach and administrative team. Lastly, it has concentrated non-in-patient services to two hubs in north central London—that is, the Whittington and the North Middlesex—instead of previously having had five sites. So this is a concentrated focus with consistent nurse leadership, avoiding the fragmentation of the nursing team and better able to tackle inequalities in the provision of care.
It has been mentioned that the national TB strategy is in preparation and I am advised that this needs to result in changes to the current model of fragmented care. However, as other noble Lords have said, it is important to acknowledge that success in TB control must involve agencies other than the health service and must address the social factors involved, which have also been mentioned. Homelessness is probably top of the list. It increases the likelihood of exposure to TB and also makes managing the care and treatment of patients very difficult. Treatment is quite arduous and requires a sustained commitment from the patient, which may be difficult in adverse social circumstances, particularly homelessness. It is a good illustration of why a co-ordinated approach between health and social care is vital.
Other factors include overcrowding, poor housing, poverty, poor access to health care, drug or alcohol dependency, HIV/AIDS and the social stigma which exists in certain individuals, cultural groups and society in general. This can lead to people having great difficulties with treatment compliance.
The rates of TB among the homeless community in certain parts of London have been recorded as up to 35 times higher than the national average. As the disease attacks people with reduced immune systems, the impact of rough sleeping, poor nutrition and chaotic lifestyles increases the chances of developing TB in the first place. Members of the homeless community are less likely to present to primary healthcare when experiencing symptoms. It is a vicious spiral because they are likely to remain infectious and transmit the disease to others, develop more severe and difficult-to-treat symptoms and increase the likelihood of developing drug resistant strains. Again, this is an illustration of the importance of taking a holistic view.
As I understand it, once a person is admitted, hospitals cannot discharge people without a home address, and a patient who cannot be discharged might cost the NHS more than £100,000 in bed fees alone. Not only is this expensive but it blocks access to in-patient treatment for other patients. One estimate that I have been given is that the cost of providing a hospital bed for a week would provide secure accommodation for all patients without housing for a year. So provision of housing can help break the cycle.
My noble friend mentioned the Olallo project in Euston, which is able to provide, on a more cost-effective basis, food, room, training, language skills and social support for TB treatment which helps the patient to recover. I am invited to invite the Minister to visit this project if she has not had the chance to see the positive impact of specialist accommodation.
Not only do we need a focused approach in the health service but a multiagency approach between the health service, housing authorities, the health and well-being boards of local authorities and other agencies. This approach goes a long way to account for the success in New York, Barcelona and Paris, which have achieved impressive and sustained reductions in infection rates. Not only do these cities recognise the problem but they have a unified, city-wide strategy to identify, treat and prevent transmission of TB.
That is the challenge in London, which is starting to be met. Significant progress has been made and now that the NHS and social care changes are bedding down there is a good prospect of success. A London TB control board has been established—I believe it has been suggested that control boards should be established nationally—which has on it all representative stakeholders. It is important that London, as the highest prevalence area in the UK, is an integral part of the national TB strategy.
Finally, I quote from Dr William Lynn, who is the clinical lead for TB and chair of the London TB Clinical Advisory Group, he said,
“health and social care (including housing) must work towards common, agreed London Wide service delivery and make the resources available to establish the detection and treatment of latent TB as the benchmark standard of care. Without this we fear that we will continue to fail the population of our Capital City and TB rates will not fall”.
My Lords, I, too, congratulate the noble Baroness, Lady Suttie, on securing the debate and on her comments. I associate myself with her remarks about praising the work of the all-party group on TB, which does excellent work. I am grateful to it for a specific briefing on issues in Birmingham, which I am particularly interested in. We have always had excellent briefs from Public Health England and the Local Government Association and it is credible that so many experts are now thinking about how we are going to address what are clearly very important problems.
Like the noble Baroness, I thought that TB had been virtually eradicated. It clearly has not been and we need to do something about it. Noble Lords have mentioned that the UK has one of the highest incidences in western Europe but if your Lordships look at the local authorities most affected, including my own Birmingham, there is a strong correlation between TB and general poor health. For instance, if you look at the list of the 20 local authorities with the highest rates of TB per 100,000 population, which I think gives a safer comparator, many of them have other very real health issues as well.
I say to the noble Baroness, Lady Jolly, that there is also an uncanny correlation between that list and the local authorities that have been affected worst by the funding formula switch. I ask her to reflect on this. It is rather ironic that if you read down this list of local authorities, which includes Manchester, Birmingham, Southwark and Hackney, many of them have taken huge hits in the changes to the local government funding formula. I know that some of this resource will obviously come from the Department of Health and that it has been ring-fenced, although health experts tell me they think that not all the money has actually reached public health. We can begin to see why; because of the squeeze on other resources in local government. The substantive point I put to the noble Baroness is given that, how can we ensure that the public health resources being allocated to local authorities are going to be spent on important issues such as TB?
The LGA and PHE produced a report called Tackling Tuberculosis—Local Government’s Public Health Role. It is an excellent piece of work and I endorse the fact that it should be the local authority that leads this work. The report has a lot of very good recommendations, such as that the scrutiny work of local government could address TB issues. There are also substantive recommendations, such as driving improvement through the overview and scrutiny committees and health and well-being boards. The report then says that:
“Local health service commissioners should prioritise the delivery of appropriate clinical and public health services for TB”,
and that local leadership should be promoted at all levels, with a senior co-ordinator being appointed,
“perhaps from the public health team”,
to take responsibility for TB. It recommends that local authorities:
“Encourage and empower the voice of people affected by TB”.
“‘TB cohort review’ and other methods to collect data to inform local needs assessment”.
It also says that they should:
“Facilitate appropriate access to information and services for underserved populations, such as homeless populations … Assist with supporting an individual’s social needs … Review how third sector organisations can help improve access to services and patient support”,
“Ensure information about TB is cascaded into key teams—for example Children’s Services, Adult Services, Housing and Benefits, Citizen’s Advice”.
These are great recommendations.
At the heart of this is a recognition that if we are going to tackle TB effectively—to pick up the point the noble Baroness, Lady Ludford, made about London—you have to have one plan, an integrated programme and one body accountable for delivering it. Can the noble Baroness, Lady Jolly, see a way through to getting that single point of accountability through the local authority where it is absolutely clear who is responsible for reducing TB rates in the area?
This is very relevant to Birmingham. Unlike London, we have only one local authority, so it ought to be easier to get that kind of integration. None the less, we have three clinical commissioning groups, at least three NHS acute trusts which collectively provide a lot of clinical and preventive services, many GP practices and, because education plays such an important role in this, a lot of schools, academies and free schools as well as the local education authority. It is clear—the all-party group has also commented on this—that although the director of public health is taking this very seriously and giving leadership, at the moment it has not been pulled together into one plan with a commitment from everyone to sign up to it. That is really what is missing. There is a lot of good work with lots of outreach programmes. Working with sex workers in the city is one example. TB professionals have also conducted screening and health education in English as a second or other language, and through this route they have screened high numbers of people quickly and raised awareness of the disease among high-risk populations. So lots of good work is being done, but it does not quite hang together at the moment.
I want to put two other questions to the noble Baroness, Lady Jolly. The noble Baroness, Lady Suttie, mentioned the report published this morning on dealing with antimicrobial resistance. Of course, this is very relevant to TB. I have just glimpsed the report. Can the Minister say a little bit about any steps that the department is now going to take to find new treatments to tackle multidrug-resistant TB? Finally, the Collaborative Tuberculosis Strategy for England 2014 to 2019 was launched in March at a meeting organised by the all-party group. The strategy aims to learn from successful TB programmes internationally and adapt the learning to our specific circumstances in the UK. Will she give noble Lords a report on progress with the strategy and how she thinks it will be implemented?
My Lords, I am grateful to my noble friend for securing this important debate, which has proved to be fascinating, and to all speakers for their informed and thoughtful contributions. I, too, commend the work of the APPG on TB and declare that a couple of years ago I, too, went courtesy of RESULTS UK to see TB in Zambia. I have many questions from noble Lords. Should I run out of time, I will write and post a letter in the Library.
There are considerable inequalities in the distribution of TB cases in England with respect to age, ethnicity, sex, location and socio-economic status. TB today is largely a disease of poverty and inequality. Underserved and marginalised members of our communities have the highest rates of TB and the greatest risk of onward transmission. The Chief Medical Officer has identified the inequalities associated with TB as an important priority for England and the Health and Social Care Act 2012 has placed a duty on local government, clinical commissioning groups, Public Health England and NHS England to reduce inequalities.
In response to the high rates of TB, Public Health England and NHS England will launch the Collaborative Tuberculosis Strategy for England 2015-2020 in January. The draft strategy was widely consulted on in the summer of 2014, with the active input and participation of a wide range of stakeholders and partners across the Department of Health, the NHS, local government, Public Health England and the third sector. It is jointly developed to improve national TB control, with the aim of achieving a year-on-year decrease in TB incidence and a reduction in health inequalities, with a particular emphasis on bringing improvements in the areas with the highest rates of TB. NHS England and Public Health England are committed to resourcing the implementation of the strategy, and precise funding mechanisms are currently being finalised. The strategy will establish clear lines of responsibility for TB control at a national and local level, and provide a framework for the commissioning of TB services that takes into account all aspects of the patient pathway.
Most cases of TB are found in large urban areas: London, West Yorkshire, the West Midlands, Greater Manchester, Leicester and Luton. The noble Lord, Lord Hunt, inquired about the situation in London. I have just asked my officials what role the London Assembly and the mayor have in all this, because that is the overarching body for all boroughs. Public Health England London advises the mayor on all health issues via the Public Health England London director, who also chairs the London TB control board, so there is someone who has a handle on all this.
To follow up on the issue of funding, there is no TB weighting in either the local authority or the NHS funding formulae, but there are special TB tariffs for TB care within the NHS tariff system. The majority of cases are in deprived areas. TB is more likely to occur among settled migrants, those with connections to high-incidence countries, ethnic minority groups, the elderly and those with social risk factors including homelessness, a history of imprisonment or drug or alcohol use. The lifestyles of those most at risk often mask the symptoms of TB, which can cause problems accessing and completing appropriate care. This in turn creates inequality in outcomes.
The noble Baroness, Lady Masham, inquired about providing accessible health services to the homeless. This particular group can face great inequalities in accessing health services, yet their health can often suffer just from being homeless or living in poor quality temporary accommodation. Poor health, whether physical, mental or both, can also cause a person to become homeless in the first place. Homeless people may often leave health problems untreated until they reach a crisis point, and then present inappropriately.
My noble friend Lady Suttie asked about the response from global health R&D and the licensing of newly approved TB drugs. In 2012 Ministers of Health called on the WHO to develop a post-2015 global TB strategy in order to have a world free of TB and zero deaths, disease and suffering caused by TB. This is in recognition of the need to address the disease globally; in 2013 it affected nine million people around the world. As my noble friend has already told us, it has killed 1.5 million. To achieve this reduction, the strategy sets out ambitious global targets for the reduction of TB incidence and mortality and the individual costs of illness, with targets and milestones up to 2030.
The collaborative TB strategy contains 10 areas of action which will underpin local prevention and control services. It makes provision for a whole-system, evidence-based approach across the whole health and care system. Implementation will be supported by a small team working with local and regional experts ensuring delivery through existing structures. This structure will provide accountability, reinforced by national oversight provided by NHS England and Public Health England. A formal monitoring framework will be put in place with effect from 1 April 2015. It will monitor performance at local and national levels. Public Health England will provide annual monitoring reports on a suite of indicators relevant to the control of TB at geographical and organisational levels.
My noble friend Lady Ludford was talking about comparisons with major cities across the world. The TB strategy will address this issue. It should bring organisational change and funding improvements, focusing on TB control. There is a focus on public health in England because incidence is more than four times as high as in the US.
The noble Baroness, Lady Masham, inquired about the incidence of multidrug-resistant TB in the UK and asked why it was lower in other European countries. The incidence of MDR TB in the UK is not higher than in the rest of Europe. However, the proportion of multidrug-resistant TB cases in the UK has increased from 0.9% to 1.6%.
My noble friend said that London is regarded as the TB capital of western Europe. London has 35% of the UK total, with 2,965 cases reported in 2013—a decrease from the 3,403 cases reported in 2012. This concern is being recognised and work is currently under way to draft the implementation plan for London that meets London’s needs. A number of CCGs and local authorities with the highest TB rates are already working with Public Health England and NHS England (London) to implement latent TB case finding, and with TB Alert, a third sector organisation, to raise awareness within their communities. London has a TB service specification with key performance indicators that are being used to ensure that TB service providers are able to meet local population need. London is also looking in depth at the mortality of TB patients, scoping BCG provision and accommodation for “no recourse to public funds” TB patients and those with chaotic lifestyles.
My noble friend Lady Suttie inquired about general prison awareness issues. Much is being done to raise awareness of TB in prisons in the UK and to help to educate prisoners. This awareness-raising is arranged locally by health protection teams.
My noble friend made reference to the work of Find & Treat. My honourable friend Jane Ellison MP, the Minister for Public Health, met representatives of the Find & Treat service when they visited Parliament in March this year. Dr Alistair Story, the service’s clinical lead, has been involved in the development of the TB strategy and its plans for the expansion of an outreach service, similar to Find & Treat, for the rest of England. I would be happy to join any noble Lords on a visit to Find & Treat and Olallo.
The vast majority of TB cases can be cured when the medicines are provided and taken properly. Active, drug-sensitive TB disease is treated with a standard six-month course of four antimicrobial drugs with the support of specialist healthcare staff and additional support, as required, from social care support staff. Without such supervision and support, treatment adherence can be difficult and the disease can spread or manifest in drug-resistant form.
With regard to the issue of delayed diagnosis and what is being done to tackle it, poor access and late diagnosis result in more advanced and complex disease, with greater morbidity, mortality and cost. The Royal College of General Practitioners has an e-learning programme—which is available to all primary care staff—to raise awareness of TB, especially the signs and symptoms of TB disease.
As to R&D, the UK Government support a range of research programmes to promote the development of new diagnostics, drugs and vaccines. The MRC is one of the main agencies through which the Government support medical and clinical research. It receives its grant in aid from the Department for Business, Innovation and Skills and supports a wide portfolio of research, including the current UK-based research into new TB drugs.
Through effective localised commissioning of TB treatment services, we are able to place patient safety at the forefront of the work in the UK. The collaborative TB strategy paves the way for this to happen. The measures contained in the strategy are comprehensive and far reaching. To ensure that they are brought to fruition, PHE and NHS England will oversee implementation, monitor progress and publish reports. The strategy will set out what needs to be done both at a national and local level. It will be aimed at a range of key partners, including in health and social care and the third sector at a local level, which will be empowered to ensure that the clinical priorities affecting their communities are effectively addressed.
Committee adjourned at 5.51 pm.