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Bread and Flour Regulations (Folic Acid) Bill [HL]

Volume 773: debated on Friday 8 July 2016

Second Reading

Moved by

My Lords, my Bill concerns a measure of preventative medicine designed to reduce the number of children born with a lifelong serious disability and reduce the high level of terminations of affected pregnancies following antenatal screening and diagnosis. Some may think the number is small. We are talking about approximately 1,000 pregnancies per year in the UK, of which 80% are terminated. We can do something about this, and in my view we should act.

In 1991, UK research by a Medical Research Council team discovered that a deficiency of vitamin B9, folic acid, is the cause of neural tube defects. The defect is that, just after conception, the neural tube does not close as it should. This leads to defects of the brain, spine and spinal cord leading to spina bifida and other serious, lifelong disabilities. The neural tube closes at 27 days, which for most women is before they know they are pregnant.

In all health matters, it is wise for Parliament and government to take expert advice. Following the 1991 ground-breaking UK research, in 2000 the then Committee on Medical Aspects of Food and Nutrition Policy gave advice to government to improve the blood folate status of the UK population through the mandatory fortification of flour with vitamin B9, folic acid. This advice was repeated by the Scientific Advisory Committee on Nutrition in 2006 and in 2009. The Food Standards Agency gave similar advice in 2007 and 2009.

Further research was requested by one or more of the Chief Medical Officers, and it was conducted by various scientists. Several aspects were looked at, including a possible male colon cancer rise due to folic fortification, but a peer-reviewed study of 50,000 cases published in 2013 found no evidence. The National Diet and Nutrition Survey was requested in particular to check the blood folate levels in the whole population, especially among women of child-bearing age. This took some years and the results were published in March 2015. The results showed that the blood folate levels for UK women are below the WHO thresholds.

By October 2015, the Scientific Advisory Committee on Nutrition had collated all the latest evidence, and on 20 October wrote to all four Health Ministers in England, Scotland, Wales and Northern Ireland. Its eight-paragraph letter alerted Ministers to the recent information, the WHO studies, evidence from the USA and the blood folate levels, as well as concerns that the UK food industry was actually reducing amounts of voluntary folic acid in its products. In summary, the letter repeated the advice of 2006 to go for the mandatory fortification of flour.

My Bill would effectively put that advice into legislation. Drafting a Bill like this was easy. As the UK already fortifies flour on health grounds, vitamin B9, folic acid, can simply be added to the list.

To date, the policy in the UK has been that women planning pregnancy should take folic supplements. Health is of course a devolved matter, but there are two problems here. First, the UK has the second-highest number of unplanned pregnancies after the USA. Secondly, the use of supplements is in decline. Taking supplements after becoming aware of pregnancy is too late, as this will be after 27 days. A preventative medicine strategy to cut the numbers of affected pregnancies has to take these facts into account. It cannot be that 80% of terminations after the 20-week scan is a preventative strategy.

Recent peer-reviewed research published in February 2014 by a team led by Sir Nicholas Wald, the leader of the 1991 Medical Research Council study, showed that in a 10-year study of 500,000 women in the UK the policy of advice regarding supplementation was not working. The study showed a decline in women taking supplements from 40% in 1999-2001 to 28% in 2011-12. It showed that women under the age of 20 were five times less likely to take folic supplements than women aged 30 and over. Even among women who had previously had a neural tube defect pregnancy, only half were taking supplements. The conclusion was stark: the current government policy was,

“failing and has led to health inequalities”.

On average, 69% of women of child-bearing age are not taking supplements. Half the pregnancies are unplanned. It cannot be right there is no proper strategy.

In my view, saying that it is individual responsibility is unacceptable. Department of Health officials have been known to say that terminations after the 20-week scan identifies the defect are how the issue is managed, and have stated that dealing with neural tube defects via folic fortification is “not a vote winner”. This was told to a public meeting in Parliament last year, and the Minister is aware of the source.

Based on the 1991 UK research, over 80 countries have introduced the mandatory fortification of white bread flour with folic acid, vitamin B9. There is abundant evidence of efficacy and no suggestion of any harm. It reduces the abnormality by up to 50%, though I have seen some research giving an even higher figure than this. The USA mandated the fortification of flour in 1998, based on the 1991 UK research. Recent American published research showed a significant reduction in neural tube defect births there, and they have a Folic Acid Awareness Week. There has been a large saving in America both in human misery and public expenditure. The US expenditure saving on averted medical costs alone for surviving babies is put at $600 million. It spends $4 million on fortification.

No country which has introduced fortification has reversed the decision. The various countries that have introduced it include America, Australia, Iran, Chile, Iraq, Canada and Saudi Arabia. In July 2015, a report on preventable spina bifida in Europe reached the conclusion that Europe has an epidemic of spina bifida compared to countries that apply mandatory fortification. The prevalence of neural tube defects per 100,000 births in the UK, Denmark, France and Germany is in general twice the level in the United States of America, where flour has been fortified for nearly 20 years.

There is a need for a strategy on neural tube defects rather than a campaign for fortification. It is not mass medication, as only white bread flour has ever been involved, so the argument about mass medication does not apply. Research galore has shown no ill effects on the male population. The principle of flour fortification in the United Kingdom is not at stake. The UK has fortified flour on health grounds since World War II with four substances: two vitamins and two chemicals. That was last reviewed in 2013 and a decision to continue that was made by the coalition Government. Industry pays for the fortification, by the way, so it is not a question of public expenditure. People will say that the numbers are not huge, but they are bound to grow as supplement-taking declines and as industry reduces voluntary fortification.

I am in favour of a woman’s right to choose, but I reject the Department of Health view on managing neural tube defects by termination. That is quite unacceptable. The human tragedy, much of which could be avoided by a science-led policy, should be the reason for a push on policy change. There are too many terminations, and too many babies are born with a serious lifelong disability. Mandation is needed to reduce this human distress and misery, to save lives by avoiding terminations, and to prevent lifelong disability and significant public health costs.

During the many times I have raised this matter over the last few years, I have never used any real-life examples, because the science tells the story. However, yesterday I found a letter from a colleague, who is absent from the House at present due to poor health. Although we knew each other for many years before we joined your Lordships’ House, they have never mentioned their family history to me. Our colleague’s letter said that before our colleague was born,

“my parents lost three children to spina bifida: one was still-born, one lived for a year and another for 6 weeks. The grief caused by these deaths cast a very long shadow over my parents’ lives and indeed over my own—I felt an obligation to live for the three of them. The point is that this degree of suffering is largely avoidable by measures like your proposal”.

We have the means, not for a complete cure but vastly to decrease this harm and misery. I cannot see how we can stand by and do nothing when we have the chance to reduce the human misery caused by neural tube defects. I beg to move.

My Lords, the House owes a debt of gratitude to the noble Lord, Lord Rooker, for his persistence in pursuing this case. I should tell the Minister at the Dispatch Box that I was a colleague of the noble Lord, Lord Rooker, in the days when we were both young MPs in a hurry, and he is a formidable opponent. We are, in our later years, perhaps old Peers in a hurry, but that does not mean that we are any less determined on this issue. Today, the noble Lord has provided the House with irrefutable evidence of the case for supporting his Private Member’s Bill, and in fact I think he has done more than that. A Private Member’s Bill is not the way to implement a measure that is so self-evidently important for public health. He argued for a change in government policy, and I hope that the Minister will not be put in what I know to be the profoundly uncomfortable position on the Front Bench of once more defending the indefensible on this issue.

Last night I was telephoned by my son, who told me of his frustration over the length of time it was taking to get the Government to respond on a completely different, although equally important, issue. It is an issue supported by five Select Committee chairs and committees and over 90% of parents—that of making PSHE a statutory subject in the national curriculum so that all our young people are given the means to protect themselves in today’s world. I fear that, when I explained to him that today I would be talking about an issue on which I had been campaigning for 25 years, that did not add to his optimism or enthusiasm. However, I also told him that one thing I had learned in politics was never to take no for an answer, and that applies to this issue and to his.

As I said, I first became aware of this matter in 1991. I was involved then, as I am now, in the ethics of medical research. The MRC trial, to which the noble Lord, Lord Rooker, referred, was the first trial I had ever known to end early. That was because the results were so clear that it was considered to be unethical to continue to allow one half of the group—the control group—not to receive the folic acid supplement which the other half was getting. The evidence that has had such a profound effect in the rest of the world, but not in the UK, is based on that trial.

A second reason for my concern was that in the preceding years I had helped to found an organisation called the Maternity Alliance. It was particularly involved in pre-conception care—in the health of mothers and babies. It was absolutely clear that the fortification of flour with folic acid was the most effective mechanism for delivering pre-conception and early pregnancy care, as has been demonstrated by the ineffectiveness of the supplement route, as the noble Lord, Lord Rooker, has demonstrated.

However, the main reason for my interest was that I had been having babies myself. I knew the intense anxiety of waiting for antenatal checks and then the birth, worrying about whether the baby was healthy, and thinking through what I would do in the case of an in utero diagnosis of an abnormality and having to face up to the question of whether to undergo a late termination.

A generation has gone by; I am no longer having babies, but I am having grandchildren and I see my sons, their wives and partners going through exactly the same anxieties. It is no wonder that the British Pregnancy Advisory Service says that this one measure would ensure that some of the saddest cases it sees would not need to come through its doors, and women in the devastating situation of ending a wanted pregnancy because of foetal abnormality would no longer have to do so. Beyond that, many families would not have to deal with the devastating and heart-breaking situation described by the noble Lord, Lord Rooker, of one of our colleagues and of having to support children who endure short and painful lives because of the burden of preventable disease.

In those 25 years, we have had the opportunity in this country to see not just pilot schemes of fortification of flour with folic acid but mass implementation of it. We have had the opportunity to see the effect—an up-to-50% reduction in the incidence of the neural tube defects—and to see that the theoretical risks of the policy have been investigated and not come to fruition.

The question for the Government now is how they can in all conscience continue to ignore the evidence before them and not accept what their own Chief Medical Officer, the Scientific Advisory Committee on Nutrition, the other Administrations of the United Kingdom and the rest of the world accept. I cannot believe that they maintain their position given the conclusions of every piece of research—ending with that which found in December last year:

“Failure to implement folic acid fortification in the UK has caused, and continues to cause, avoidable terminations of pregnancy, stillbirths”—

and permits “serious disability in … children”. That situation should not be allowed to continue. This Bill would not solve every instance of it, but it would do a great deal. Not to do what we can do is a dereliction of duty.

My Lords, I join the noble Baroness, Lady Hayman, in paying tribute to our mutual friend, the noble Lord, Lord Rooker, for bringing forward this Bill and I certainly hope he succeeds. The three of us, the noble Baroness, Lady Hayman, the noble Lord, Lord Rooker and I, were in the other place for some years together. I can testify to the noble Lord’s capacity for identifying a public policy that needs to be taken up and his tenacity in seeing it through. He is perhaps best known, at least among the three of us, for the so-called Rooker-Wise amendment—an unlikely duo—which was successfully introduced to a Finance Bill to make national allowances subject to the rate of inflation. He annoyed the then Chancellor of the Exchequer, Denis Healey, no end. Such tenacity is worth having and it certainly makes us in your Lordships’ House proud.

The issue of adding folic acid to flour has been around for a long time, because we share knowledge of the suffering of families who have had children aborted, who have lost children early or who have had children born with defects that last for years of their lifetime. The question must be asked: why are the Government so reluctant to move in the face of such indisputable evidence about the efficacy of adding folic acid to bread when there are certainly no signs at all of any detrimental effects in doing so? I do not know and I hope the Minister can answer that question.

At Question Time in the House—I say this without malice—the Answers given by the Minister for not doing so have been rather flimsy. He has cited the fact that health problems are improving in women, and there is no doubt about that. But beyond that, there is no reason why the Government cannot move. As my noble friend Lord Rooker said, many countries in the world already do this. The Scottish Government are considering moving on their own and have the power to do so as health is a devolved matter. It would be a great shame if that were to be the case.

Why is there such opposition? I know from personal experience how difficult it is to argue against those who, possibly for genuine reasons, are opposed to vaccination or fluoridisation of the water. I still have the scars on my back from trying to persuade Aberdeen Town Council to adopt that when I was the convener on the welfare committee there. I do not know whether it is a matter of prejudice. It cannot be ignorance because the facts are very well known. But the fact is there is huge opposition to any move to what is called public health medicine. The worst example of that is adding fluoride to the water. I emphasise absolutely what my noble friend said. Adding folic acid is not mass medication. That argument might be made in the case of putting fluoride in the water but this is a different matter altogether. This is a simple and straightforward measure that has been well documented as being successful and safe and for making people’s lives much better.

As my noble friend said, this is not a panacea. It will not eradicate NTDs, but the fact that 50% of women may be beneficially affected by this is a prize that makes it worth doing. The only slight disagreement I might have, although I may have misheard what my noble friend Lady Hayman said, is whether this is the right way to go about getting the legislation. I may have misunderstood what she was saying. But in the face of a Government unwilling to move on their own account through lack of time—and goodness knows what the Government will face in terms of time in the coming months and years—it is absolutely essential that those who have the opportunity to bring forward a Private Member’s Bill should do so.

I would be more than content were the Minister to say today that the Bill in the name of the noble Lord, Lord Rooker, be taken forward with all speed and support by the Government in another place.

Hear, hear to that. But in the event of that not being the case, it is the duty of this House to pass this legislation through all its stages and send it to the other place to deal with. That is imperative and essential and I am pleased to give my support to my noble friend Lord Rooker.

My Lords, I thank the noble Lord, Lord Rooker, for his very clear and forceful statement about adding folic acid. We cannot say that this should not be done. From what he said, there is no doubt that this should be taken up: adding folic acid to flour should take place very soon. If we can save any children from disability, it is our duty to do so. Since many other countries relied on UK research to bring in their own legislation on this, it is pretty pathetic that we have not. The US, Canada and Australia have done this using our research so it is very strange and pathetic that we have done nothing. I cannot understand what the negative is here. What could be the reason for not doing this? If there are, say, 50 births with defects, that is 50 people—human beings—who will not see a good life, or even see life at all. A friend had a daughter with spina bifida. It wrecked that girl’s life and it wrecked the lives of her parents. It is not just the child—if they live—who suffers but the whole family.

I got up to say something else as well. It may not be the right moment—but then, when is the right moment? If folic acid is to be added to flour, I would like to make a case for adding vitamin D as well. People who have come from the subcontinent suffer greatly from vitamin D deficiency. There are now cases of rickets even in adults. There is a lot of evidence that vitamin D deficiency affects people from the subcontinent. Again, it will not hurt or harm anybody to add it. It is particularly necessary, if it is not to be added to all flour, that it be added to chapatti flour, the atta, which most Asian families use. This is a serious matter for Asian families and their children, as they, too, have rickets. When I was teaching many years ago, in the 1960s and 1970s, it was not unusual to see children who came from India in the classroom with rickets. There is no vitamin D around us here. In India or Pakistan, it is all round everybody. There is a new problem, too, because we now say to people, “Don’t sit in the sun; you might get skin cancer”. People are not keen to sit in the sun. It is a real issue. Many families from the subcontinent suffer from vitamin D deficiency.

As has been said, why can they not take supplements? We know that people are not good at self-medication of any kind. It is not medication but it is still something for their health. We get medication and all sorts of things, including advice. Do we take it? I think 90% of people are quite slack about it. That is why I make the case for adding to the Bill the vitamin D deficiency aspect. We will probably never get another chance to do this. If it can be done by an amendment, that would be absolutely wonderful. On the other hand, I have no intention of detracting from folic acid by putting this forward. Clearly, that is absolutely a must, must, must. But vitamin D deficiency is beginning to grow in this country and it would be a very good thing if that were taken on board.

My Lords, the usual folate aficionados speaking in this debate do not need me to talk about all the nasty effects of neural tube defects, spina bifida and the impact on children’s lives and that of their parents, or repeat that folic acid given early in pregnancy is an extraordinarily effective preventive measure akin to vaccination and immunisation. There is no argument anywhere against that. We also know that if it is to work, folic acid must be taken before a woman knows she is pregnant because the neural tube forms in the first 28 days. Taking it when she confirms that she is pregnant is just too late. All that is accepted.

The argument for fortification has been made many times and, indeed, as we have heard, has been accepted in very many countries. Now many millions of people across the world have been eating bread made with fortified flour for very many years, and it seems that Scotland is about to follow. So what are the arguments against fortification in the UK? These rely on two major premises. First, this would be a case of mass medication and we should avoid that whenever possible. That is not unreasonable. It is a type of philosophical argument about free will and freedom of choice, and I understand that. However, I cannot accept it in this case. We already fortify our flour with iron, calcium and Vitamin B1—thiamine—without a peep from anyone.

I hope that I do not offend noble Lords if I say that I have just had a sandwich in the Bishops’ Bar, and that I do not scare them when I tell them what was in the sandwich. In the white bread there was some wheat flour—that was useful—with added calcium, iron, niacin and thiamine. There was water, yeast, salt—that is reasonable—emulsifier, E472e, soya flour, preservative, E282, rapeseed oil, flour treatment agent—whatever that is—and a smidgen of E300. We add these things, and many others, despite the fact that the case for these sorts of fortification, especially of vitamin B1, are not nearly so compelling as that for folic acid. Vitamin B1 deficiency was something we saw in concentration camp victims. In normal life and normal diets, it is as rare as hen’s teeth. Folate deficiency, on the other hand, is common, and its potential to cause devastating disease is there for everyone to see and accept.

The second argument against fortification is that folic acid, when taken in excess, can cause unpleasant side effects. That, too, is a rather specious argument. The amounts we are talking about, and the form in which it is added to flour, have been shown to be perfectly safe. Just look at the control trial in which the whole population of North America—many millions of people—took fortified flour for 10 or more years. You might have expected some of the threatened changes and dangers to have emerged, but there has been none. Large doses of folic acid may possibly be problematic, but then large doses of iron are also dangerous, yet we have carried on with iron fortification. Large doses of almost anything are dangerous. However, what we are talking about here is a small dose—a minute dose—that would pose no conceivable danger to anyone else and would prevent a very nasty disease.

I strongly support this Bill and am grateful to the noble Lord, Lord Rooker, for his persistence and tenacity. I hope that the Minister will think again about this whole thing.

My Lords, I strongly support the noble Lord, Lord Rooker, in putting forward the proposal that the UK mandates fortification of white flour with folic acid or vitamin B9, and I congratulate him on his Private Member’s Bill and his persistence in promoting this measure. Twenty-five years ago when I first stood for Parliament, I was given the advice by my noble friend Lord Maclennan of Rogart to never take no for an answer. The noble Lord, Lord Rooker, is doing exactly that. It is good advice.

There have been mountains of scientific evidence that this fortification works in preventing foetal neural tube defects, prevents a great deal of disability and distress and causes no harm, as we have heard. When will the Government stop stalling and take action? I do wonder whether they would have taken the same attitude if it was a matter of men’s health rather than that of women and babies. I wonder whether a woman Prime Minister would have a bit more understanding of the level of distress that is caused to women affected by this issue. Perhaps we should start a petition of all the thousands of women who over the years have had to have terminations for this reason, or given birth to children with terrible disabilities. Perhaps that might have some effect.

To my mind, five facts make the case. First, currently the folate levels in the blood of women in the UK of child-bearing age are below WHO recommended levels and risk NTDs.

Secondly, supplementing the diet with vitamin B9 can protect against neural tube defects that can be caused by a shortage of this vitamin. Thirdly, there are 1,000 cases—that is a lot of people—of NTDs in the UK every year, of which 800 are terminated and 200 are live births. The terminations and the live births cause parents great distress and cost the NHS a great deal of money, both for the terminations and for the lifelong services needed by the children. Fourthly, supplementation needs to take place, as we have heard, before the 27th day of gestation—long before most women know that they are pregnant. It really is nonsense to rely on the suggestion that women planning a pregnancy should take supplements when we know that half of all pregnancies are unplanned and so, if followed 100%, that would prevent, at most, only half the cases. You cannot rely on women taking supplements, because only 28% of women of childbearing age take vitamin supplements and, for women under 20—the age group least likely to plan their pregnancies—it is even lower, at 6%. Fifthly, the UK has the second-highest rate of unplanned pregnancies, behind only the USA. However, as we have of course heard, there they fortify their flour and have half the relative incidence of NTDs compared to us.

The problem is getting worse. The number of abortions due to NTDs has risen 40% in England and Wales in the four years to 2013, which is the latest figure that I have seen. The availability of terminations free on the NHS is not a cost-free option. Termination is not in the best interests of women, because it can cause great distress and present dangers to the woman’s health. It is also a very bad strategy for the NHS, because terminations cost money and, of course, there are some women who would never choose a termination, no matter what. It is like controlling conception with the morning-after pill. It is even worse than closing the stable door after the horse has bolted; it is closing the stable door after the horse has bolted, broken down hundreds of fences and broken all four of its legs.

On the other hand, it would cost the Government nothing to insist that, along with calcium, iron, niacin and thiamine, manufacturers must fortify flour with folic acid. As we have heard, the principle of fortification has been established since World War II. I think that the case is made. At a time when prevention of disease is more important than ever before to ensure the sustainability of the health service because of the growing demand and rising costs, it is perverse to resist the call of the BMA and all the other medical and scientific experts, as well as the noble Lord, Lord Rooker, to agree to this small but important measure. I hope that the Government will stop procrastinating and will act by supporting and giving time to this Bill.

My Lords, it is a great pleasure to wind up for the Opposition and to congratulate my noble friend Lord Rooker on bringing this Bill here. As the noble Baroness, Lady Hayman, said, my noble friend is not giving up. I am delighted about that; I hope that he will carry on with force to press the case.

The argument is overwhelming. It is not just a matter of regret in relation to the women and babies who have been so affected by the failure to implement an entirely rational decision. What is striking is that it was British research, led by that brilliant scientist Sir Nick Wald, which found the link and recommended as a result of the MRC work that flour be fortified—in 1991. This Government have an accelerated access review and have adopted a number of initiatives to speed up the introduction in the National Health Service of proven new technologies and medicines. Yet here we have a brilliant piece of British research that this country—unlike many other countries—has ignored. I think that is a matter of great regret.

The Government have clearly been prevaricating for a number of years. When the noble Earl, Lord Howe, was the Minister a few years ago, there was a clear indication that the Government were prepared to go with it. Then there was a step back and prevarication by referral to any number of scientific bodies. Finally, the noble Lord, Lord Prior, made it clear in one debate that the Government had decided not to go ahead.

That was followed up in his letter of 7 June 2016—I am very grateful for a copy of it—confirming that decision. In it, the noble Lord, Lord Prior of Brampton, said that,

“whilst we will continue to consider emerging evidence, the Government currently has no plans to take forward the mandatory fortification of white flour with folic acid in England”.

So, essentially, the Government have made their decision, Like the noble Baroness, Lady Walmsley, and my noble friend Lord Hughes, I hope that the Minister will say exactly why they have done so. What happened to change the Government’s view? Is it to do with the nanny state argument? What is it to do with?

If it is to do with the nanny state argument, I remind him of our debate earlier this week on the recommended number of units of alcohol. The Government took the CMO’s advice to reduce the level—I am not sure it is right to call it the “recommended” level, but the Minister will understand me—from 18 units to 14 units per week for men. As I told him earlier in the week, I looked at the department’s website to find out what the change in risk would be of keeping it at 18 units per week—but the website simply talks about risk.

I also went back to the main research in relation to cancer on which the decision was based and looked at the lay summary. Again, there is no quantification of the change in risk. Going through the paper, I encountered a lot of scientific terminology that, as a layman, I could not work out. My suspicion is that the actual change in risk is quite small. Yet the Government are quite prepared to accept that they should take action in that area. That is why I find it so puzzling that the Government will not take action in relation to folic acid in white flour. It is beyond comprehension.

Finally, I will mention the other issue raised in the Minister’s letter. He is very gracious in agreeing to meet organisations that noble Lords ask him to meet, and he should know how grateful we are to him for that. But my noble friend Lord Rooker asked whether the Minister for Public Health, Jane Ellison, would meet Sir Nicholas Wald, and obviously she has turned down that request. I must say that it is outrageous for a Minister to turn down a meeting with Sir Nicholas Wald. He has huge scientific advances to his credit, and he was the leader of the research in 1991. Given that the Government have decided not to go ahead with fortification, it is really a bit much that the Minister concerned is not even prepared to tell Sir Nick to his face why they are not going ahead with it.

We know that the noble Lord, Lord Prior of Brampton, is a great servant of this House. I hope that at the end of this debate he might at least be able to open the door to some further dialogue on this matter.

I, too, congratulate the noble Lord, Lord Rooker. I think he has raised this issue in the House—I wrote this down—10 times in the past three years, as well as in a great many Written Questions. I have been a Minister for just over a year, and he has certainly raised it three times with me. You could say he hopes that doing so will be a triumph of hope over expectation, but it reflects his real passion and genuine heartfelt concern about such tragedies. He mentioned a letter he had received from a colleague whose mother had lost three children from spina bifida, and other noble Lords have brought home to the House what the impact can be. We can sometimes have rather arcane debates in this House, but that impact is very profound not just on the children but on the parents and families of those children. Far from being an irritation to those of us on this side of the House, his single-minded determination to keep this issue before the House has won him a great deal of admiration and respect in all parts of the House.

Perhaps I may start with the science, although frankly my argument will not be with the science. The noble Lord and others have argued that the science is absolutely black and white; I would say that it is clearly strong but there are still some residual issues.

The SACN has advised that the fortification of white bread flour with folic acid should be introduced only if it is accompanied by a number of preconditions: for example, action to reduce folic acid intakes from voluntary fortified foods, to ensure that individuals do not substantially exceed their safe maximum daily intake of folic acid. The noble Lord, Lord Turnberg, addressed that in his speech so it is perhaps questionable how strong that argument is. It also told us that there is inconclusive evidence on several possible adverse health effects of the mandatory fortification of flour with folic acid. For example, for people aged 65 and over, folate fortification of flour may result in cases of vitamin B12 deficiency not being diagnosed and treated.

However, there is no doubt, certainly in my mind, that the scientific evidence is strong. Regarding other countries, the noble Lord, Lord Rooker, mentioned the huge controlled experiment in America. I certainly would not feel comfortable standing here today and arguing with him on the science. Mine is a different argument: fundamentally, it is not a scientific dispute but more of a philosophical dispute. The science is to inform policy but not to determine it. For policy, we must look more to philosophers than scientists, more to moral choice than scientific experiment, and of course to Parliament and not the laboratory.

The nub of the question is this balance between state and individual responsibility. I know that when we bring it down to this issue, it may be felt to be beside the point but that balance is important because it is fundamental to the kind of society that we choose to live in. It is perhaps especially important now, when lifestyle behaviour is becoming such a big driver of healthcare demand. It is such a big driver that unless it is addressed, there is a serious risk that no healthcare system anywhere in the world will be able to afford the level of healthcare that we expect. I know that a special committee of the House of Lords is looking at this now.

My Lords, can the Minister explain whether his argument on philosophy applies only to this measure? Does it apply to the treatment of water for safety purposes or to vaccination? It is equivalent to saying that vaccination should not be compulsory in any sense of the word. Where does the line fall as to where the philosophy overcomes the practicality of the matter?

The noble Lord makes a very good point and I hope to address that issue as I go through this, because where the line is drawn is critical to the debate that we should be having.

The ways in which we live our lives—what we eat or drink, how much exercise we should take and how we should look after ourselves and one another—all directly impact on the likelihood of getting cancer, a stroke or diabetes, or premature death. In this case it directly affects the health of children, so prevention has never been more important. I am sure everyone in this House would agree. The question, as raised by the noble Lord, is then: what are this Government or any Government to do? At one extreme, the answer is to do nothing and, at the other, it is to be highly prescriptive: to determine how we should all live and what we should eat and drink.

The noble Lord, Lord Hunt, referred to alcohol, which I will take as an example. The Government could have washed their hands entirely of that issue and left it to individuals—the classic, John Galt, libertarian approach, which he may have read about in Atlas Shrugged in his youth. Alternatively, they could have opted for some form of prohibition, as tried in the USA and as we do with certain drugs today—although with profound unintended consequences, I might add.

In the UK, as in most democracies, the balance as to where responsibility lies has shifted over the years. It has not shifted seismically or even consistently—there have been ebbs and flows of where that line should be drawn over the years—but it has shifted away from government intervention towards the individual. That is not surprising: you would expect that shift as the population becomes better educated, better informed and better able to make good decisions.

I will in a minute but will just finish this point. That is not to say that the Government have no role—far from it—just that the role is different. It is to inform, to educate, to persuade, to nudge, to incentivise, to influence and to cajole but not, I would argue, to dictate, except in the most extreme and difficult circumstances.

What amazes me is that we are talking about nudging and not doing this or that, but we often have research on issues which are of great importance not only to the individual—as we have been talking about—but to the family and to the country. When a child needs lifelong care, surely it is not a good idea to not do anything about that. We seem to be going round and round, saying that we cannot be led by research, while the Government must have their policy. But what is the policy based on?

The noble Lord has just read out a list of the functions of government. Would he not add protection to that? We chlorinate all our water to protect people from water-borne diseases. Why not put folic acid in flour?

I will continue with the example that the noble Lord, Lord Hunt, gave, of alcohol. Clearly, the Government have the responsibility to put the science into the public domain. But should they ban people from drinking more than 14 units of alcohol a week or should they leave it to people to make that choice themselves, on the basis of the information that they have? That is the philosophy that lies behind the Government’s position on folic acid. It is also our thinking on how we address the scourge of obesity and lies behind the way we deal with our smoking and alcohol problems and behind all our prevention strategies. It is about doing all we can to help people make the right choice, but ultimately accepting, outside of extreme circumstances, that the final choice has to be made by them and not by the Government.

This is why the Government agree with the statement made by my honourable friend in the other place, Jane Ellison, when she said that the Government consider that a broad approach to the promotion of good pre-conception health needs to be taken to make sure every child gets the best start in life. On balance, the Government have decided that mandatory fortification is not the right way forward and therefore have no plans to introduce it in England.

We know that good pre-conception health, of both future mothers and fathers, can lead to healthier pregnancies and good infant health. By contrast, poor pre-conception health—for example due to diabetes, poor diet, obesity or smoking—can lead to poor pregnancy outcomes, including gestational diabetes, NTDs, premature births, and poor perinatal and infant mental health.

Many parents make few preparations to improve their health before pregnancy. That is why a more proactive approach which promotes good pre-conception health to reduce the risk of poor pregnancy outcomes for women and their families should be adopted. This is why my colleague Jane Ellison has set up a ministerial round table. She held her first meeting with interest groups on 13 June to help identify additional measures to promote good pre-conception health.

I recognise the tragedy of neural tube defects. I recognise the urgency and passion that lies behind this Private Member’s Bill but, at this time, the Government have decided that, on balance, we are against mandatory fortification of white bread with folic acid and therefore have no plans to introduce it in England. Instead, all our efforts will be directed at promoting good pre-conception health. I realise that that is a disappointing but probably not unexpected reply to the noble Lord, Lord Rooker, and to his colleagues who support the Bill. Of course, that balance may change over time. As the noble Baroness, Lady Hayman, said, he is a formidable opponent and I have no doubt that he will carry on pushing the case for fortifying with folic acid. In time, who knows where that argument will go but, for the time being, the Government’s position is that we will not support the Bill.

My Lords, I do not propose to make a windup speech, but I thank all colleagues who have spoken—I am very grateful. I am grateful to the Minister as well, because we have had a little more time today than we get in Question Time exchanges. I understand where he is coming from. I do not accept it, but at least he has put things on the record about the philosophy argument that will be useful for the future.

It is a bit like somebody in South America at the moment finding a real cure for the Zika virus and not using it. We are standing by with a 100% cure and not using it. I used the example of the United States of America. They do not just do fortification, they have a disability child awareness month and a folic acid awareness week as well—we do not even do that; that is refused as well in Parliamentary Answers—that is voluntary, but they see the benefit of it. Basically, you are on your own, girls. That is a summation of where we are. The Government refuse to accept the fact that half of pregnancies are unplanned. Despite any pre-conception advice, half of pregnancies are unplanned. People will not be listening. That is one of the problems.

I tried to keep my speech devoid of all the scientific quotes, but the issue about the industry is important. I fully accept that the advice to industry from the Scientific Advisory Committee on Nutrition on mandatory fortification was, “Be careful what you do voluntarily”. Since its warning letter last October, industry has taken steps to reduce its voluntary folic acid fortification on the basis that the advice of 2006 would be implemented at some time—that is, there would be mandatory fortification. We have a problem. The industry is reducing voluntary fortification and we are not introducing mandatory fortification, so the position will be even worse. The blood levels will be even lower as a result. That is a cause for concern and I have not heard a solution to it.

I also avoided any reference to devolution. The English Government, for whom the Minister speaks—he does not claim to speak for anyone else—could well be faced, in the next couple of years, because these things take a while, with Scotland, Wales and Northern Ireland legislating for white bread flour fortification. The mills are in the wrong place when one looks at the borders. Industry wants a UK solution. As I said, during the general election, I wasted time knocking on doors, but I also spent time with Sir Nicholas Wald and Sir Colin Blakemore visiting the supplement manufacturers and others. It is quite clear that they want a UK-wide solution.

In September, the Cabinet Secretary for Health and Sport in Scotland and the Chief Medical Officer in Scotland had a meeting with myself, Sir Nicholas Wald and Sir Colin Blakemore to listen to the argument. They do not have all the solutions, and do not profess to have all the answers. Scientists do ask the question, which is why, when I left the Food Standards Agency, I said I would pursue this. The independent scientists were saying on this and on other issues that Government never pronounce about the advice. In this case, the Government have pronounced; they said no. I fully accept that; there is no doubt about that any more. We know where we stand, but I am not going away, and I beg to move the Bill be read a second time.

Bill read a second time and committed to a Committee of the Whole House.

House adjourned at 2.36 pm.