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Lord Stoddart of Swindon: My Lords, that is for a family of four. Four times 1,700 is 6,800, I believe. The service is paid for and people ought to know that they are paying for it, not be told that it is free of charge. If we are going to get pressure for better services and better administration, people should know how much

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they are paying. It is about time that we gave serious consideration to showing on people’s payslips exactly what they are being charged—in other words, a health contribution.

I agree with the noble Baroness, Lady Knight, that patients should be treated with courtesy and respect. She is right that when people of an older generation go into hospital they expect to be treated with dignity; they should be called “Mr” or “Mrs” and not by their Christian name—their first name, rather—without their consent. I have had a lot of complaints about that, and it is time that that was understood in hospitals.

The same goes for mixed-sex accommodation. In 1995 this House passed a Bill to outlaw mixed-sex accommodation. I moved it, as a matter of fact, and it went through this House without dissent. Fourteen years later it has still not been got rid of. I welcome the announcement, although not in this place or the other place, that the Secretary of State is going to take stern action to see that mixed-sex accommodation is phased out, but he then went on to threaten those hospitals that do not do it with having money withdrawn from them. That means money withdrawn from patients—absolutely the wrong thing to do. He should say that if they cannot do it themselves, the Government will bring in another trust to manage that particular trust or hospital. I hope that that will be considered instead of penalising patients by withdrawing financial support.

We have promises of continuous improvements in the National Health Service. I hope that that will continue in spite of the economic and financial difficulties we have. It is essential that some services, anyway, are improved. I also hope that the operation of the EU working time directive, which restricts hours worked to 48 per week, will not adversely affect the work of doctors, nurses and other staff in the National Health Service. Perhaps I could have that assurance from the Minister.

How are patients to be informed properly of their rights? That needs further consideration. They need to know their rights; they should be informed of them when they go into hospital, if not before. Perhaps, generally, the population should know anyway.

Part 3 of the Bill covers the prohibition of tobacco displays in shops and on the internet. That really is going too far. Such a provision ought not to be in this Bill. This is a health Bill, and restraint of trade ought to come under another department, perhaps the Department of Trade and Industry, or whatever it is called these days. This is a restraint of trade; it is preventing purveyors of tobacco displaying their wares. If you did that in any other industry which poses health problems, you would be getting rid of a lot of food, for example. We have heard a lot of talk about sweets and chocolate. They would be banned. You would not be able to display them to children in case their teeth were damaged or there was some other complaint. Would McDonald’s be able to display or advertise its products? You could go through everything and, before very long, nothing would be on display because of being dangerous in some way.

This is yet another witch hunt against smokers and the people who provide tobacco products. There is a huge risk, as we have already heard, that many small

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shopkeepers will be put out of business. The legislation reaches a new height of authoritarianism by banning shopkeepers from displaying their wares. There may be a hint of racism about this, as well.

Noble Lords: Oh!

Lord Stoddart of Swindon: Yes, my Lords, a lot of small shops are run by people from the Commonwealth who provide a good service throughout the country, which might not be provided otherwise, to help the country and help families. We ought to take all these things into account when we consider banning the display of a legal substance. As we have heard, these provisions will also encourage sales of illegal cigarettes and rolling tobacco.

This nasty piece of legislation, wrapped up as a means of discouraging children from taking up smoking, will not achieve its objective. The greater the temptation and the greater the danger perceived by young people, the more they want to do it, just for the hell of it.

The noble Baroness, Lady Howarth, who is not in her place, referred to the health aspects of smoking. She said that there were 87,000 deaths from so-called smoking-related diseases. Most of those deaths did not involve people who smoked. Some 75 per cent of those people never smoked in their life. We have to put that figure into perspective. There are 620,000 deaths per annum; as a proportion of that figure, so-called smoking-related deaths make up only 14 per cent. So there are 533,000 deaths from other causes. Furthermore, most deaths from so-called smoking-related diseases occur among people over 65; indeed, a big proportion of those people are over 75. When we talk about the health aspect, we really should put it into its proper perspective.

We shall be debating these matters in Grand Committee, when we will be able to explore them in more detail. However, I am most concerned and unhappy about a Bill of this importance being relegated to Grand Committee. It should be taken on the Floor of the House. I made Independent Labour representations about it to the usual channels, but of course they have not taken any notice. I made representations to both the Leader of the House and the Leader of the Opposition to say that I, along with a lot of other people, was unhappy that this Bill should not be taken on the Floor of the House. But I have no doubt that the Grand Committee will be well attended and that we will have great debates there. Perhaps we can make some decent amendments so that smokers and those who sell and provide this service are not victimised further.

7.17 pm

Baroness Masham of Ilton: My Lords, I have great admiration for the hard work that the noble Lord, Lord Darzi, has undertaken with his review and reports, resulting in this Bill. I welcome the constitution and its accompanying handbook, and the fact that the Bill ensures that every organisation and staff member working with or on behalf of the NHS will have to adhere to them. Will the National Health Service’s contractual arrangements with the private sector also have to adhere to them? I hope so.

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It seems wise that the constitution will not be reviewed more than once every 10 years. There have been so many changes to the National Health Service that people working within it so often say, “Not change again!”. I am pleased that the constitution puts responsibility on patients too. When patients miss appointments without a good reason and do not call to cancel, it is deplorable.

There has been considerable interest in the Bill from many organisations. As a long-term supporter of the National Health Service, I have some questions for the Minister which I hope he will be able to answer. I consider two of the most important aspects of healthcare to be good quality of care and safety. I am sure the Minister will agree with me on these points. I am exceedingly pleased that they are in the constitution and the handbook. However, what will happen if staff do not adhere to good quality of care at ground level with the patients? Let me give your Lordships three examples. Since Christmas, three patients were to be transferred from Scarborough hospital to Bridlington hospital. One of the patients was over 90 years old and the others were also elderly. The transfers were to take place at 10 am. In the end they were transferred at midnight. They found Bridlington hospital cold. The food was cold, the patients got confused and the staff were found to be chatting round the nursing station and not caring for the patients.

Recently, another elderly patient of 93 had a fall and was taken for an X-ray to Scarborough hospital. It was found she was only bruised and shaken. At 3 am she was told to go home. There was no transport so an elderly nephew had to fetch her and drive her home at 3 am. On a third occasion an elderly man had a fall and it was found he had serious cancer of the bladder and had to have an emergency operation. As there was no available bed on a ward, he had to stay in a holding ward in A&E.

I am told there are real problems in Scarborough and Bridlington hospitals and, when I heard of these incidents which have occurred since the Healthcare Commission’s worrying report, I thought I would ask your Lordships if you thought this was treating the elderly with dignity and good-quality care. I thought it worth mentioning in the hope that there will be some improvements. These were only three cases told to me personally. How many more have there been, I wonder?

I quote from the Handbook to the NHS Constitution, on page 14:

“You have the right to expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary”.

The NHS provides access to “specialised services”. I declare an interest—of course, unpaid—as president of the Spinal Injuries Association. A short time ago I met the doctor in charge of the intensive care unit at the Royal London Hospital. He told me he had five tetraplegic patients who were on respirators and waiting to be transferred to a spinal unit where they have specially trained staff but there were no beds. His beds were being blocked. This is a very serious matter and everyone concerned is most frustrated. Some of the spinal beds in the specialist units are also being blocked

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as some of the patients do not have suitable housing and their home circumstances mean they cannot be discharged.

The spinal consultants and the Spinal Injuries Association agree it is essential to enable optimum access. A national bed bureau should be set up, both for first-time admissions and urgent readmissions, like pressure sores. One can have as many constitutions written down as the Government like but if the NHS cannot deliver, which is the case with spinal injuries at the moment, the constitution will be worthless. I hope the Minister will look into this urgently.

I agree so much with the statement in the handbook:

“Quality of care is personal to each individual patient—you have the right to high-quality care that is safe, effective and right for you”.

It would be impossible for me not to mention the importance of page 28 of the handbook, which says:

“Requirements are also made clear in the duty to provide and maintain a clean and appropriate environment for healthcare, as set out in the Code of Practice for the Prevention and Control of Healthcare Associated Infections”.

The Healthcare Commission should be congratulated on what it has done, but it is an ongoing challenge as staff can so easily get lax. I hope, therefore, that the Care Quality Commission will have this as its top priority.

I am pleased that the constitution encompasses the recommendations of Professor Mike Richards’s review, Improving Access to Medicines for NHS Patients, which ensures that NHS care is not withdrawn from patients who choose to purchase private drugs. This was so cruel; you will do anything to relieve suffering and prolong life when that is wanted.

It may be because I am a canny Scot that I have some reservations about direct payments for the health services. The Department of Health’s own 2006 White Paper Our Health, Our Care, Our Say unequivocally ruled out direct payments. I believe in the founding principle of the NHS that care should be free at the point of need. It has been the envy of many countries. Could direct payments become something like managed care in the USA? Could it lead to means-testing? Could there be greater barriers to services for those who most need them? What happens if the money runs out? What happens if the patient spends it on non-healthcare? What happens if the patient has a long stay in hospital and does not use it? What happens if other family members make use of it and make the patient hand it over? Would it not become a bureaucratic nightmare? What safeguards will there be? How will the pilots be chosen? I hope the Minister will be able to answer some of these questions, as many noble Lords have asked the same.

I would be grateful if the Minister would explain how the innovation prizes will work. How will they directly benefit patients and the public? Will they be like merit awards or will they be like targets?

I have always known how dangerous smoking is and it has been a great relief to now have so many places smoke-free. With this Bill before us, I have been surprised how much material your Lordships have been sent from all sides of the smoking or non-smoking lobby. I welcome the Government’s initiative to try to

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prevent young children smoking. It is worth repeating that each year in England deaths attributable to smoking total more than suicide, road traffic and other accidents, diabetes, drug- and alcohol-related deaths put together.

I would like to query one of the ideas, which is to remove the brand names from the packets. Will this not make it easier for the evil market of counterfeit cigarettes, which seem to be a growing problem? Some young people seem to like to challenge anything which seems to harm them and it is awful to see such young children smoking.

I welcome the fact that people who pay for their social care will have the right to complain to the ombudsman. They can be just as much as risk as anyone else. I look forward to the Minister’s reply.

7.30 pm

Lord Faulkner of Worcester: My Lords, it is a real pleasure to follow the noble Baroness, Lady Masham of Ilton. I think that I speak for all your Lordships when I say that it has been a great privilege to be able to listen to speeches not only from her but also from my noble friend Lady Wilkins and the noble Baroness, Lady Campbell of Surbiton. We are fortunate to have them present when we debate health issues and to hear their powerful and effective speeches. I intend to speak on the subject of tobacco control and the Bill’s related measures. In doing so, I declare an unpaid interest as a trustee of Action on Smoking and Health and as a patron of the Roy Castle Lung Cancer Foundation.

Like most other speakers, I warmly welcome what the Government are proposing in the Bill. I congratulate them again on securing such overwhelming popular support for the measures that were taken in the Health Act 2006 to protect workers and non-smokers from the dangers and discomfort of second-hand smoke. It is perhaps hard to recall now what it was like to have a drink in a pub or a meal in a restaurant in a smoky environment, and it is great that one country after another around the world is following the lead that we in the British Isles set—I say the British Isles because Ireland was first and Scotland was second—in passing comprehensive legislation.

Since the publication of the tobacco control White Paper, Smoking Kills, a decade ago, progress has been remarkable. Your Lordships will recall that it started in this House, when we passed the Tobacco Advertising and Promotion Act as a Private Member’s Bill in 2002, which brought the vast majority of tobacco advertising and sponsorship to an end. That legislation in addition to a wide range of stop-smoking services and the subsequent measures in the Health Act 2006 have succeeded in persuading 2 million fewer people to smoke compared with 10 years ago. Millions of people are now protected from exposure to second-hand smoke in the workplace, and in the first year since the introduction of the smoke-free legislation, many thousands more smokers have given up the habit. So this is clearly the right moment to consider how we can build on that progress and address the need to tackle the problem of children and young people thinking about starting to smoke. That is behind the measures in the Bill, which I hope will be part of a wider tobacco-control strategy.

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Let us be clear what we mean by this. Every day, hundreds of children try smoking for the first time. Eight out of 10 smokers become addicted before they turn 19. As other speakers have said, smoking remains the single biggest preventable cause of death, killing more people than alcohol, obesity, illegal drugs and road accidents put together. This debate is about protection—the protection of children and young people from a deadly addiction. One in seven 15 year-olds is a regular smoker. As we know, since the introduction of the Tobacco Advertising and Promotion Act, the tobacco industry has worked hard to produce smarter and innovative measures to target and recruit “new customers”. One example of this is tobacco point-of-sale displays which have become more elaborate and eye-catching.

I am delighted that the Government have based their proposals in the Bill on research. Some of the most important research has been carried out by Professor Gerard Hastings, director of the Centre for Tobacco Control Research. He investigated the complex relationship between tobacco marketing at the point of sale and young people’s intention to smoke. He found that:

“In 2006, almost half —46 per cent of UK teens—were aware of tobacco marketing at point of sale”.

Moreover, the likelihood of a young person stating an intention to smoke may increase by 35 per cent with each brand that they can recall having seen at the point of sale.

Bans on point-of-sale displays have been introduced in a number of jurisdictions. A useful case study is Iceland, which introduced a ban on point-of-sale displays in 2001. The result, which is contrary to the misleading briefing sent to some noble Lords by the Tobacco Manufacturers’ Association, is that prevalence in 15 to 16 year-olds dropped from 18.6 per cent in 1999 to 13.6 per cent in 2003. This rate of drop was twice the rate of decline in the prior four-year period. There is similar evidence from other countries. I am sure that the Minister will be able to elaborate on that when we discuss these issues in Committee.

Can the Minister outline how it is intended that trading standards officers will be involved in the enforcement of the point-of-sale legislation? When the Criminal Justice and Immigration Bill was debated last year in this Chamber, the Minister committed to giving to Parliament a report on the effectiveness of orders in preventing under-age tobacco sales. Will he monitor the enforcement and impact of the prohibition of point-of-sale displays and in due course report back to Parliament?

I turn briefly to tobacco smuggling, to which a number of noble Lords have referred and which resulted in an estimated £1.7 billion loss of revenue to the Exchequer in 2006-07. The supply of cheap illegal tobacco is severely undermining other tobacco control measures. I would welcome comments from the Minister on how trading standards officers will play a part in enforcing the age restrictions and can be empowered to play a greater role in tackling smuggling. The case for a positive licensing system, where each local authority is required to keep a list of all retailers and establishments which sell tobacco and apply for a licence, is very strong. It would be a proportionate measure to tackle

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smuggled tobacco. Local authorities are already obliged to keep a list of all establishments that sell fireworks and alcohol. Why is there not a similar case for selling tobacco? If the Government are serious about taking action against smuggling, why not give our trading standards officers the strongest framework in which they can operate?

We must remember that the personal cost of smuggling is very large: 22 per cent of all UK smoked tobacco products are smuggled. If we were to eliminate it, the result could be a 5 per cent reduction in tobacco consumption, which in turn could lead to 4,000 fewer deaths each year in the longer term.

As the Minister said at the beginning of our debate, there are no UK-specific laws which govern the use of vending machines. While only 1 per cent of all cigarette sales are from tobacco vending machines, there is a disproportionate number of sales to under-18s. An estimated 17 per cent of 11 to 15 year-olds who regularly smoke get their cigarettes from vending machines.

A recent test-purchasing survey by the local government regulatory authority, LACORS, to which the noble Baroness, Lady Howarth, referred earlier, found that, on average, young people were able to buy cigarettes from vending machines on more than four in 10 occasions. Indeed, a number of councils reported that test purchases by young people failed to be prevented on any occasion. It is clear, therefore, that young people obtain their cigarettes from tobacco vending machines and that the current voluntary restrictions on their location do not guarantee protection for young people.

I know that the Government are thinking in the short term of age-proofing the machines. I hope that that they will not; I hope that they will go for an outright ban from the beginning, because age-proofing was tried in Japan and did not succeed in preventing young people buying tobacco. It would make much better sense if they were taken out of establishments or converted to sell other goods rather than tobacco.

Several noble Lords have referred to something that is not in the Bill, namely a provision to force the industry to introduce plain packaging. My view is that that would reduce the appeal of cigarette packets to young people. Again, if we look at Professor Hastings’ research, we find that the proportion of young people who are aware of new pack designs increased from 11 per cent to 18 per cent between 2002 and 2006. The Government are already committed to further research; I know that they have already carried some out into the impact of plain packaging. I wonder whether my noble friend will, in Committee, consider taking advantage of this Bill by giving the Secretary of State an enabling power to introduce plain packaging at a later date when more evidence is available. We need to bear in mind that the WHO framework convention on tobacco control has agreed guidelines which define retail displays, vending machines and tobacco packaging as forms of advertising and promotion. It would seem sensible for us to fall in line with what others are doing.

Finally, I remind the House that the measures on tobacco control proposed in this Bill are overwhelmingly popular with the public. Over 50,000 people signed Cancer Research UK’s “Out of Sight, Out of Mind”

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petition calling for the prohibition of tobacco point-of-sale displays and tobacco vending machines and the introduction of plain packaging. Over 80 per cent of the 96,000 responses to the Department of Health consultation also supported these proposed measures. I wish this Bill well and believe that it will make an important contribution to reducing the number of children and young people who take up smoking, and thus further significantly improve public health.

7.41 pm

Lord Palmer: My Lords, I take part in today’s debate on this Bill with a degree of trepidation. As a resident of Scotland, I am more likely to use the services of NHS Scotland, for which I have the highest possible praise, although my wife and I have recently had superb service from accident and emergency departments in two London hospitals.

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