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The hon. Member for South Cambridgeshire talked about vending machines being banned from public areas—I assume that he was speaking on behalf of the Opposition Front Bench. When he said that, I was reminded a little of the argument that said, “We should ban smoking in public houses that serve food, but don’t ban it in public houses that don’t serve food,” but what happens if someone comes along with a sandwich or whatever? My view is that we should look seriously at banning vending machines full stop, so that there is no way that young people can access them. If we really want to help small retailers, that would be one way of doing so. I know that this proposal is not in the Bill, but I would be more than surprised if an amendment were not tabled on Report
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to ban vending machines altogether. There is no way that those machines can check anybody’s identification, whether they are in public places or elsewhere.

Greg Mulholland (Leeds, North-West) (LD): Does the right hon. Gentleman include in his comments nightclubs where there is a strict over-18s policy? Are not there some environments in which such machines could be placed? Does he think that there should be a blanket ban, or are there areas in which the machines could be properly policed?

Mr. Barron: That is a very good point. If there were a minimum age for admission to an establishment, that could be sufficient to prevent the under-age purchase of tobacco in those places.

We all know, however, that no one is asked their age before they use a cigarette vending machine. There is no ID check for anyone with a few pound coins who has access to a vending machine. On that basis, we ought seriously to look at their use. On the hon. Gentleman’s point, I will ask the powers that be in the Department whether an amendment could be made so that a ban did not cover all areas, but my instinct is that we will never be able to cover these machines with any form of licensing. Instead, we ought to consider banning them from public places.

I have asked the Minister a number of questions about how he sees the innovation prizes developing, and how much money would be involved. Perhaps he will tell us how they are going to encourage people in the national health service further to develop their skills to provide better services to our patients. I hope that the intentions behind the Bill will have the support of the House, although I think one or two matters will be contentious.

I would say to all Members that, if anyone sends them a briefing on any subject, telling them that something is right or not right, they should go to the source material to find out who is peddling these myths. We are all susceptible to getting a nice easy briefing from time to time and simply standing up and reading it out, but life is not like that, certainly when it comes to tobacco. Good evidence over many decades suggests that we need to treat with deep suspicion any briefings that support tobacco in one form or another.

7.2 pm

Sandra Gidley (Romsey) (LD): It is a shame that the Secretary of State has had to leave the debate, although he apologised for doing so. I should like to put on record my congratulations to him on his appointment. When I first met him, we were on the Health Select Committee together. I originally thought that he was just new Labour voting fodder, but I soon realised that he was more than capable of making up his own mind on the issues. He is independently minded, and the only Minister I have ever been able to persuade to change a clause in a Bill. He does think things through.

The broad thrust of the Bill is welcome. We have heard the outline of what it includes: the NHS constitution; quality accounts; direct payments; and a range of measures following the next stage review. However, if the interventions during the Secretary of State’s speech are anything to go by, the measures that will attract the most attention are those that deal with tobacco. I see that Labour
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Members are now dribbling back into the Chamber, so I assume that their meeting has finished and they can now concentrate on the real issues.

Many areas of the Bill deserve our consideration, and I will start with tobacco. I want to put on record my personal baggage in this regard. My father died of lung cancer. He had never smoked in his life, but he was surrounded by smokers. He was also a newsagent. In thinking through these issues, I have looked carefully at all sides of the argument, but when it comes to a clampdown on smoking, I sometimes have to restrain myself from being a fag fascist—although I am as nothing compared with the Chairman of the Select Committee, the right hon. Member for Rother Valley (Mr. Barron).

I welcome some of the Government’s actions so far, although I query whether enough has been done. The increase in smoking-cessation programmes is welcome, although the quality and outcomes framework needs to be tightened up. It should not be enough for GPs simply to mention the need to stop smoking; there should be real evidence that that has happened. I am not entirely convinced that it is a measure of success that someone has quit smoking for four or six weeks, as is the case in some parts of the country. However, I congratulate the Government on eventually getting round to banning smoking in public places.

The Bill also contains a hotch-potch of further proposals. Our big regret is the complete absence of a comprehensive tobacco strategy. If the Government were to produce such a strategy, we might be able to get an indication of their thinking. Instead, we are faced with a fairly random set of initiatives. The big idea is the prohibition of the display of tobacco products at the point of sale. It is not being sold as something that will reduce sales in general, however. It is seemingly to be being touted as a measure to reduce sales to children, but the evidence that it would have that effect is weak. If there were strong evidence that that could be achieved, we would be tempted to support these moves. The Government seem to demand an evidence base for everything else that they do, but the evidence base for that proposal is very weak.

There is evidence that children are influenced by advertising and encouraged to smoke, which provided the motivation for the Tobacco Advertising and Promotion Act 2002. Many of us have seen pictures of displays of tobacco products in newsagents and supermarkets that push the boundaries of the Act. I was on the Bill Committee that looked into the fine detail of that legislation, and I should not have underestimated the creativity of the tobacco manufacturers. They have come up with a lot of display material that makes their products stand out to people going into a shop. We should do more to amend that legislation and to tighten up the law on what can be displayed, rather than going for the measures in the Bill. That would be honest and within the spirit of legislation that is widely supported on both sides of the House.

David Taylor: I am grateful to the hon. Lady for giving way, particularly as I have only just returned to the Chamber. She cites a lack of evidence in relation to point-of-sale displays and prevalent traits of smoking in young people, but studies of groups of as many as 25,000 people have shown that the 15-year-olds who are
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most exposed to point-of-sale displays are three times as likely to smoke as the rest of that age group, and that the effect of such exposure is even stronger than that of parental smoking in the family.

Sandra Gidley: If the hon. Gentleman listens to the rest of my speech, perhaps he will rethink his argument. I do not think that the studies he cites are quite that large.

The bottom line is that, whatever we think about smoking, tobacco is a legal product that can be bought by consenting adults, yet we are planning to restrict its display even more than we restrict that of pornographic material. That seems to be a rather strange attitude to take. A compromise approach that would be worthy of consideration would involve the introduction of plain packaging, and we shall certainly table amendments on that in Committee.

If the aim of the proposed changes is really to reduce under-age smoking, the Bill is making the wrong proposals and missing a few tricks. For example, there should be greater penalties for shopkeepers who sell tobacco to under-age people, as the hon. Member for South Cambridgeshire (Mr. Lansley) suggested. It should also be an offence to buy cigarettes and pass them on to someone under the age of 18. It seems odd that the Government are proposing only one measure, when a whole basket of measures such as these would have a much greater effect. I do not understand the Government’s objection to such measures; it would be helpful if the Minister explained it in summing up.

The proposals on vending machines are weak. The Secretary of State said that if they did not work, the Government would consider a total ban. My hon. Friend the Member for Leeds, North-West (Greg Mulholland) mentioned places with a strict age restriction, and there may be a case for an exemption, but if we are serious about trying to stop under-age smokers gaining access to cigarettes, we should consider a ban on vending machines and restrict the sale of cigarettes in pubs to behind the bar.

The British Heart Foundation estimated that machines were the source of cigarettes for approximately 46,000 children in England and Wales, so if the Government were really committed to doing something about it, they would go a step further. Children are very clever in getting hold of tokens and other means of accessing the products. Other age-limited products can be bought only through a face-to-face, over-the-counter type of transaction, so why can we not have the same for tobacco products? I hope that the Government will consider the issue further. Many children obtain cigarettes from black-market sources, car boot sales and the like, so it is disappointing that the Government are not using the Bill to address smuggling, which would start to tackle some of the supply problems at source.

The concept of an NHS constitution has received widespread support from the British Medical Association and patient groups, and there even seems to be some agreement between the two main political parties. I agree with the comments of the hon. Member for South Cambridgeshire about whether the proposal really amounts to a constitution or whether much of it is new, but having all the rights and entitlements written down in one easily accessible format is helpful. The problem is how to prevent yet another motherhood and apple pie
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exercise and how to make the constitution meaningful so that it effectively becomes a bible of good practice for health professionals while commanding the trust and respect of patients.

It is important that we try in Committee to put some more meat on the bones. For example, it would be helpful to have further clarification of the duty to

and of how it might be challenged. To give a simple example, a person has the right to be treated with dignity and respect. We all know that there is a widespread problem with mixed-sex wards; they were supposed to have been abolished years ago, but that has still not happened. Older people, who are often from a private generation, object to being in a mixed-sex ward and are much more against such wards than younger people. If treated in a mixed-sex ward, the patient could understandably become upset, but could the trust then say, “Well, we had regard to the NHS constitution and the rights in it, but the physical constraints gave us no other option”? It is not clear whether the constitution will act as a driver for change and improvement in that area. If it does so, that will be a very good thing, but it is not yet clear how much in the way of teeth the constitution will provide.

Greg Mulholland: Does my hon. Friend agree that, as we are all committed to narrowing the artificial gap between social care and the NHS and we have created a NHS constitution, we now surely need a social care constitution alongside it? Otherwise, social care will be the poor relation once again. That is particularly important in view of the needs of elderly people.

Sandra Gidley: My hon. Friend makes a very good point. In many cases, the dividing line between health and social care is very hard to identify, so some thought needs to be given to circumstances where the balance between health and social care is a very fine one and it is difficult to unpick which is which. It would be helpful to know whether the Government plan to extend the constitution in that direction, given that, as my hon. Friend says, the current mantra from most political parties seems to be that greater joining up of health and social care services would be good.

I want to move on to discuss discrimination and to raise a concern about whether some matters might fall between two political stools. The constitution states that people have

on a number of grounds. Age is a particularly controversial criterion, but it is clear that the Government are also using the Equality Bill to try to provide some clarity. However, I am not clear about how the Equality Bill and the Health Bill will join up in practice or whether there is any capacity for some issues to be dealt with less than fully by either Bill. When the Minister responds, will he describe what conversations are going on between the various Bill teams working on aspects of the NHS constitution and equality issues to ensure that that cannot happen?

To provide one small example of the sort of problem I mean, the constitution also provides the same

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on the grounds of disability. Research by the Royal National Institute of Blind People shows that many visually impaired people do not receive information in a form that they can read. Depending on which part of the NHS they want to access, anything from 69 per cent. to 81 per cent. of those people cannot read it. The RNIB tells me that a variety of Ministers have said that the Equality Bill provides the best opportunity to deal with the problem of making the information accessible, but a recent letter from the Solicitor-General stated:

It would thus be helpful to have some idea of how that issue will be dealt with and which legislation will enable people with visual impairments to access the relevant information.

I was intending to go on to deal with issues surrounding health and social care, but we have already covered that, so I will make one final point on the constitution. There were welcome moves in the other place to improve the reviewing of the constitution, but the patient voice seems to be lacking in the review process. There seems to be some resistance to the idea of involving patients and the public on the grounds that that might make the process too long-winded. That seems somewhat ironic, given that page 52 of the good old handbook on the NHS constitution gives patients the right to be involved in the planning of health care services. On one hand, we are giving people a right in a constitution, but on the other we are not giving anybody a right to be involved in its review, which seems to be a major omission.

We very much support the idea of direct payments for health care and we very much support the idea of pilot schemes, too. I have often been against pilot schemes in the past, because they seem to have been used as a mechanism for delaying the implementation of policies that have a good evidence base. In this case, the pitfalls are real, so it seems right to pilot the schemes. I welcome the commitment properly to scrutinise the pilot schemes before going a step further.

Direct payments are aimed at long-term medical conditions and I believe the pilots are going to start later this year. There is also great potential for such payment schemes in maternity care and mental health, so I hope we can pilot those areas, too. Women often have quite specific ideas about what maternity care they want for the birth, and it would help them if they were free to shop around a little more.

There are number of fundamental questions, however. The Secretary of State said earlier that the plan had to be signed off by the care manager. That struck me as potentially problematic. What if there is a disagreement? Many social care direct payments have given the recipients complete autonomy over the way in which the money is spent and the way in which they lead their lives. It seems to me that there ought to be approval of some kind. It could reasonably be argued that care managers should sign off the payments, because we would then know that approved treatments were being given, but that too would reduce patient choice.

I am not sure what benefit would be conferred by direct payments. What is the difference between deciding what people should do and giving them the money to do it, and deciding how patients are to be treated and
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making all the payments for them? I do not see much difference in either outcome or process or increase in flexibility. A legitimate question to be asked is “What will happen if patients underspend?” Will they be able to keep the money? I suspect that that is very unlikely. We should also ask what will happen if patients run out of money. The measure is intended to apply to long-term conditions, which are usually fairly stable. However, people may deteriorate. Another condition—a co-morbidity—may render the treatment of a patient much more complex. Will someone suffering from two or three long-term illnesses have to undergo three different assessments and add up the payments, or will that person be treated as a single patient? A number of answers will have to be teased out in Committee.

How will it be possible to calculate the amount that patients will need in order to receive the care that they want? We have all seen comparisons between the amounts spent by PCTs in different health areas, and we know that there are great differences. Will there eventually be a national tariff? Will there be some smoothing mechanism to ensure that people in PCTs that do not fund some services very well are not disadvantaged? The answers to those important questions may not be provided by the pilot schemes if they are conducted on a strategic health authority basis.

The Secretary of State said that if a patient chose a treatment that was not regarded as clinically effective, it would probably not be signed off. However, an equality issue arises as well. Is this a bit middle-class? Research shows that some demographic groups benefit from direct payments much more than others. Can the Minister assure me at this stage that equality will be a consideration in the evaluation, so that we can be sure that we are not hitting only certain sections of society?

All providers will be required to produce and publish quality accounts. I fear that the process will be time-consuming, and that the ultimate benefit will be limited. It reminds me of the time when standard assessment tests were introduced. My children were quite young then. I remember the headmaster saying “These are standard assessment tasks. There is no way they are tests, and there is no way they will ever be used to compare children or to compare schools.” When we consider what has happened to SATs, we have to worry about the way in which the quality account data will be used and analysed and the comparative purposes to which they could ultimately be put.

I did not intend to say much about pharmaceutical services, but I want to reassure the hon. Member for South Cambridgeshire. I am not sure whether he was involved in health at the time—he may have been involved in education—but at one stage the Office of Fair Trading proposed that pharmacies should be subject to a complete change in the control of entry regulations. There was a move to allow them to open anywhere, to allow a free-for-all and to see what happened after that. We ended up with a bit of a fudge, but a fair number of people argued at the time that pharmacies were not like sweet shops or toy shops, and that their provision should be planned as part of the primary health care service. The proposal was considered by the Select Committee, of which the Secretary of State was a member, and he seemed to be persuaded by the argument that control of entry could be used to ensure the provision of better services.

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