My Lords, I beg to move that this Bill be now read a second time.
It is a privilege to have the opportunity to bring such an important and indeed historic Bill before the House. The Bill contains a diverse range of provisions aimed at protecting the health of the public both inside and outside of hospital as well as improving the management and efficiency of the NHS.
I will start with the smoke-free provisions. We have come a long way in recent years, but smoking is still the principal cause of premature death in England. An estimated 85,000 people die every year from smoking-related illnesses, including lung cancer, respiratory illness and heart disease. The estimated cost to the NHS in England alone of treating people with smoking-related diseases is between £1.4 billion and £1.7 billion per year. Only last week research published in the European Heart Journal showed that the UK spends the highest proportion of its healthcare budget on treating cardiovascular diseases of any country in the European Union.
However, we are tackling head-on the problem of smoking. We have already banned tobacco advertising. We have strengthened health warnings on cigarette packets and we have introduced NHS stop-smoking programmes that in 2004–05 alone helped almost 300,000 people give up smoking. With this Bill, from the summer of 2007 virtually all workplaces and enclosed public places, including all licensed premises and membership clubs, will be smoke-free. This will be a major step forward. Not only will we be protecting people from the well documented dangers of second-hand smoke, we will be creating an environment in which smokers will find it easier to give up.
Of course noble Lords will be well aware of how the smoke-free provisions in the Bill have evolved during its passage through the other place. Indeed, no doubt many of your Lordships will see the changes made by the other place as an interesting reversal of roles. I do not intend to dwell on that point other than to say I hope that this House will respect the divisive—I mean, the decisive—vote—
These always creep in, my Lords.
I hope that the House will respect the vote—indeed, it was a free vote—in favour of extending the smoke-free provisions to both licensed premises and private membership clubs. I believe the comprehensive smoke-free legislation that the House will now consider was not just the best outcome in public health terms but also the best outcome in terms of representing the strong public support there is for a total ban. A December 2005 opinion poll commissioned by Cancer Research UK and the public health charity ASH revealed that over 70 per cent of respondents supported a total ban on smoking in public places and workplaces.
Noble Lords will no doubt also be aware of the strong support the full ban has with those who see at first hand the harm that smoking causes. For example, Professor Dame Carol Black, president of the Royal College of Physicians, said:
"The ban will lead to up to a million people quitting smoking and in the long term thousands of lives will be saved. The UK now recognises smoking as one of our greatest avoidable threats to health and accepts the need to manage it effectively. There are still more measures to be taken and we urge the Government to continue along the path of effective tobacco control. We shall be with them at every step".
The BMA's head of ethics, Dr Vivienne Nathanson, said:
"Every day around 30 people die in the UK as a result of second hand smoke. Yesterday's vote will mean the beginning of the end to these frightening statistics".
Professor Alex Markham, Cancer Research UK, said:
"This is the most important advance in public health since Sir Richard Doll identified that smoking causes lung cancer 50 years ago".
Lastly, I quote Mr Peter Cardy, the chief executive of Macmillan Cancer Relief, who said:
"We are delighted that Parliament has seen sense and has taken the single most effective step it can to cut horrible, painful lung cancer deaths. As Macmillan Cancer Relief knows only too well, smoking and passive smoking cause nine out of 10 lung cancers. This move will, quite rightly, protect the health of staff working in pubs and membership clubs as well as their patrons".
This is truly an important and historic Bill. Through the smoke-free provisions, thousands of lives will be saved every year and many thousands more people will be spared the misery of watching friends and family die prematurely. Hundreds of thousands of people will be helped to give up smoking and to take back control of their own health. And millions more will be protected from the dangers of second-hand smoke in virtually all enclosed public places.
Before moving on to the other important provisions in this Bill, I turn briefly to Chapter 2 of Part 1 of the Bill. Here, we have taken a power to enable us to raise the minimum age for sale of tobacco products through secondary legislation. On
Part 2 of the Bill reinforces the measures that we have taken to tackle healthcare-associated infections. I know that this issue remains a key public concern and patients quite rightly expect to be treated in a clean and safe environment. Not all of these infections can be prevented, but minimising healthcare-associated infections is a top priority. That is why we have set a target to halve MRSA bloodstream infections by 2008. We were the first government to require surveillance for MRSA and we are using this data to help drive down infection rates. These actions are beginning to have an effect and some specialist hospitals have shown particular progress. But we are not complacent. The provisions in this Bill build on the progress to date and will further sharpen the focus on infection control in the following ways.
First, the new provisions will enable the Secretary of State to issue a code of practice on healthcare-associated infections which will be legally binding on any English NHS body. The code is based on existing best practice, and a draft was well received when it was consulted on earlier this year. Copies of the latest version of the draft code are in the Library.
Secondly, we will back this up by giving the Healthcare Commission new duties to ensure that the relevant NHS bodies observe the code. Thirdly, where the commission feels the code is not being properly observed, it will have the power to serve an improvement notice where it judges that this is the most appropriate course of action.
Finally, if there are significant failings in the provision of healthcare involving performance against the code, the commission will be under a duty to report this to the Secretary of State, and to monitor in the case of NHS foundation trusts. The commission may recommend that we take special measures to remedy the situation. The measures we decide to take in response to a report could range from practical assistance, such as drawing on the support of a trust that has successfully implemented the code, to more formal intervention at board level.
The provisions in the Bill will build on existing good work to give a firm statutory footing to good practice in infection control and hygiene practice in the NHS. We will have clearer direction and tough sanctions for trusts that fail to deliver. I am confident that the code and the new powers for the Healthcare Commission will ensure that patients receive the quality of care in this important area that they rightly expect. I note that the Opposition health spokesman in another place, Andrew Lansley, emphasised at Third Reading the necessity for the measures described in the code.
Part 3 of the Bill deals with drugs, medicines and pharmacies. This includes provisions to strengthen the management of controlled drugs throughout the UK, in response to some of the shortcomings identified by Dame Janet Smith in the Shipman inquiry's fourth report.
Many improvements in clinical governance have already taken place since Shipman was practising, but this legislation will bring a greater focus to the management of controlled drugs in particular.
The Bill gives every healthcare body a duty to appoint an "accountable officer" to take personal responsibility for the use of controlled drugs within that organisation. There will also be a new duty on all NHS bodies and relevant local organisations to share intelligence and agree joint action where there are concerns about the misuse of controlled drugs. I am confident that this legislation will strengthen the safeguards against that very small minority who would divert these drugs for personal abuse, financial gain or, in a few rare but extreme cases, criminal purposes.
The remainder of Part 3 and Chapter 1 of Part 4 of the Bill deal with pharmacies. It has long been recognised that we are not making best use of the pharmacy workforce, particularly in community pharmacy. To address this, the provisions in this Bill will free pharmacists throughout the UK from the dispensing bench so they can expand the range of services that can be provided from the pharmacy. There are services that can add real value to the health of the community, such as advice on smoking cessation or medicines-use reviews for patients with long-term conditions. And we know from our "Your Health, Your Care, Your Say" consultation just how well regarded our community pharmacists are, and that many people really appreciate the advice and help pharmacists can give.
At the same time as freeing up the pharmacists, we are also reforming the entry requirements for the provision of pharmacy services across England and Wales. The Bill implements the final elements of a balanced package of reforms for England in response to the Office of Fair Trading's 2003 report on the restrictions on NHS pharmacy applications known as "control of entry".
I read with interest the debate in the other place on the ophthalmic provisions in this Bill. Quite rightly, there was acknowledgement that we have some of the best ophthalmic services in the world. But there was some concern and misunderstanding that the provisions in this Bill are seeking to tamper with this excellent service. This is not the case. What we are seeking to do is remove restrictions on whom PCTs can contract with to provide the sight-testing service to reflect the reality of service provision and help to facilitate market entry.
Secondly, the new framework for ophthalmic services will also permit the commissioning of enhanced services or additional services—the type of services that are often available only in the less convenient secondary care setting, but doing this within the community setting. That is what our review of ophthalmic services is looking at: how we can make better use of the skills and resources in the primary care setting. The provisions in this Bill simply provide a new framework for such services to be provided. While PCTs have some powers to commission enhanced services, we think that a more coherent and flexible framework, such as that used for other primary care services, will support that activity and help PCTs to deliver better care for patients. In particular, there will be powers to require the provision of additional ophthalmic services across England. The new framework clearly provides opportunities for primary ophthalmic providers to provide a much wider range of services. Currently, the 1977 Act provides only for the commissioning of the sight-testing service.
I know that there are concerns about whether the new framework will mean that we move away from the current nationally negotiated contract and central funding arrangements for the sight test. On that point, I reiterate what my colleague, Caroline Flint, said in the other place. We have no intentions to move away from how the sight-testing service currently operates; in other words, patients will be able to choose their general ophthalmic services contractor and contractors will be able to have a general ophthalmic services contract, provided that they meet agreed national criteria, subject, as now, to local decisions on matters such as quality of service. We also plan to continue to have a centrally negotiated and funded sight-test fee with access to sight tests not being constrained by individual PCT budgets. These provisions will help PCTs to deliver better outcomes, more choice and even more convenient ophthalmic services for patients, and provide a real opportunity for providers of primary ophthalmic services.
I turn to the protection of the NHS from fraud. The Bill will give the NHS Counter Fraud and Security Management Service modest new powers to continue to fight fraud in the NHS and to make it a safer place to work. The counter-fraud service has been highly successful in ensuring that money provided for provision of healthcare services in the NHS is spent as intended and not lost to fraud. By the end of the last financial year, it had produced a financial benefit of £675 million, which represents a 13 to one return on its total budget since 1999. Its role in deterring fraud is considerable. The new provisions in the Bill will simply enable the counter-fraud service to require the production of documents relating to specific investigations, such as asking for the pay records and duty roster of a private care home when an NHS employee has been working while also claiming sick leave from an NHS trust. It will not include powers of entry, search, seizure or arrest. In that respect, the counter-fraud service will continue to be supported by the police.
The last substantive part of the Bill is Part 5, which will establish a new non-departmental public body, the Appointments Commission, to replace the current NHS Appointments Commission. These provisions respond to the Public Administration Committee report in 2003 on Government by Appointment. The committee found that the NHS Appointments Commission was working well and that other government departments could benefit from using its services. This Bill provides the legal framework to do just that and reconfirms our commitment to an independent appointments process.
There are also a number of minor and technical provisions in the Bill relating to the administration of the social care bursary scheme; the audit arrangements for special health authorities; the injury cost recovery scheme in the NHS; the transfer of criminal liability in the NHS; and provisions to remove out-of-date references to Welsh health authorities. I shall not go into any further details here.
In conclusion, this is an important and wide-ranging Bill that will have a tangible impact on the health of the public both inside and outside the hospital setting. It will remove tobacco smoke from virtually all the country's enclosed workspaces, leading to an estimated 600,000 fewer smokers, more lives saved, and up to £100 million per year in savings to the NHS. It will better protect patients from healthcare-associated infections; modernise the provision of pharmacy services, ensuring we make best use of pharmacists' skills; give our counter-fraud service enhanced powers to target those who defraud the NHS; and it will make a number of technical changes to improve the working aspects of health and social care. I commend the Bill to the House.
Moved, That the Bill be now read a second time.—(Lord Warner.)
My Lords, I declare an interest: I chair St George's, University of London, I am a trustee of Cancer Research UK, and am involved in a number of health-related organisations and charities through my company, Cumberlege Connections. I start by thanking the Minister for his very clear exposition of this Bill. It is a complicated Bill. He described it as "diverse", and I agree. It has something like nine component parts. Sadly much of what is in it is to be left to regulation. Like him, though, I believe there are elements in the Bill that will have a tangible impact on the positive health of the nation, but of course there are other elements that will need robust scrutiny and debate. As is customary in this House, we will seek to amend and improve in weeks to come.
Sir George Young, when a junior health Minister, coined the memorable phrase that a decision at the Cabinet table could do more to improve the nation's health than an incision on the operating table. Yet the Cabinet has had real problems in reaching a decision on smoking. It has been for individual Members of Parliament to decide, and I have no quarrel with that. It is right that in this House we should also have a free vote.
It is perhaps surprising that it has taken over 50 years of compelling research to bring Parliament to consider whether smoking should be banned in workplaces. For me the hero in all this has been the remarkable Sir Richard Doll, who sadly died last year. This is neither the time nor the place to laud the great man, but I remember his survey of family doctors when I was a child. My chain-smoking father was a participant. He was so convinced by the results that he quit smoking. He urged his patients to follow suit, but the majority were totally unconvinced, and did not.
The medical profession believed the research was so compelling that the public would need no further persuasion; they would be convinced and stop of their own accord. Some did, of course, and the reduction from 45 per cent of the population who smoked in 1974 to today's rate of 25 per cent is progress, albeit small. What is a concern, however, is the number of teenagers who smoke: 26 per cent, and their number is increasing. Teenagers are not worried by their own mortality, a distant concept, but are obsessed by image, which is of immediate concern. We know that once they have started, it is very hard for people to stop. This Bill, with its emphasis on banning smoking in workplaces, turns smoking from a social activity into an activity for loners—hopefully not a cool image, but one to be rejected by teenagers.
Having read the brief from FOREST, I have no doubt there will be a debate on the legitimacy of the science. That is inevitable, and robust questioning is healthy. To my mind, however, the two reports of the Department of Health's Scientific Committee on Tobacco and Health are overwhelming in both their evidence and conclusions. I am convinced that second-hand smoke kills; ventilation does not work; smoke-free legislation helps reduce smoking prevalence and does not increase smoking in the home; a comprehensive law would reduce health inequalities; private members' clubs are workplaces too; exemptions discriminate against workers and could lead to legal challenges; partial legislation is unfair, unjust, inefficient and unworkable; a comprehensive smoke-free law will provide an even playing field for business; the public supports going smoke-free; and a smoke-free UK makes sense. My reservations in this part of the Bill are purely aesthetic: they concern the rash of notices that will deface every building. I hope that we will be able to enforce the law with a degree of consent and without plastering every available building with another, bossy, unsightly notice.
Part 2 is entitled "Prevention and Control of Health Care Associated Infections". Traditionally hospitals have been seen as places for cure, treatment, therapy and respite; places of compassion and care. Today they are seen by some as frightening places, places that harbour hospital-acquired infections. For some people, hospitals are now scary places, to be avoided if at all possible. MRSA is probably the best-known of the superbugs, but we should not ignore the other organisms, such as Clostridium difficile, VRE and Acinetobacter which are causing increasing problems. These and other infections have been emerging over recent years at the same time as initiatives have been under way to try and combat the spread. The Government have been slow to act and the problem has got and is getting worse.
We have some of the highest rates of MRSA in Europe. The financial cost to the NHS is estimated to be in excess of £1 billion a year. But the cost to individuals and their families is beyond measure. In 1978 Clostridium difficile—C.diff—was first linked to making the elderly sick in hospitals. In Canada, about five years ago, C.diff mutated and started to kill patients, younger people. This new hyper-virulent strain has spread down the east coast to the US and has also arrived in the UK. Stoke Mandeville Hospital was the first British hospital to admit publicly to having the strain, which was linked to a number of deaths. This C.diff mutation should be a salutary lesson to us. If a similar mutation was to happen to MRSA and if it were to become resistant to Vancomycin, the antibiotic used to treat MRSA—if VRSA were to get a hold as MRSA has, in the vernacular, we would not have seen anything yet and there would be widespread deaths in hospitals.
One of the contributory factors to the spread of hospital-acquired infection has been bed over-occupancy. My recent experience when visiting a relative in a private hospital was that every bed was left empty for 24 hours after the patient was discharged and then thoroughly decontaminated. Not so in the NHS, where beds are "hot beds", re-occupied while still warm, which means that the waiting list targets are met in the short term, but it builds problems in the longer term. The Government should view the wider picture and relax some of their targets in the interest of safety and good clinical management.
I welcome the introduction of a code of practice and the involvement of the Healthcare Commission in its enforcement but I hope that the Minister will take into account the continuing concerns of the RCN as to the scope of the code and give organisations a further opportunity to debate and improve it before the Bill receives Royal Assent. Likewise, the definition of a healthcare-associated infection needs reconsideration.
Parts 3 and 4 of the Bill have proved controversial. The Royal Pharmaceutical Society has concerns, as do optometrists. I would like to leave the pharmaceutical issues to Committee stage, but regarding the changes to the General Ophthalmic Services the question is: why do the Government want to change an arrangement which works so well at the moment? I have listened to what the Minister has said, but there is still a strong belief that, if the Government allow primary care trusts the powers to limit the availability of NHS sight tests, there is every likelihood that the service will be put at risk. As the Minister has quoted, during the Commons Committee stages, clear promises were given that regulations would be introduced to effectively stop the Bill damaging the service. But it still begs the question why these clauses are in the Bill at all. They put at risk genuine choice for patients, no waiting lists and an opportunity to increase standards.
Alongside the negative aspects of these clauses there is also a positive side. The Bill allows for an expansion of the service to deliver in England what Scottish and Welsh patients can already enjoy, and I really welcome that.
Those are not the only aspects of the Bill that I think need consideration; as always, other parts require amendment and improvement. I look forward to a lively Committee, a stringent Report stage and a crunchy Third Reading debate.
My Lords, I too thank the Minister for introducing the Bill. At last your Lordships have the opportunity to consider in detail the Health Bill—not the Health Improvement and Protection Bill as it was originally entitled. Clearly, the part of the Bill that has attracted the most attention in the other place is Part 1, dealing with the ban on smoking in enclosed public places. More observant noble Lords will have noticed that my noble friend Lord Clement-Jones, who is part of our DCMS team, is back on a free transfer to the health team because he took the tobacco advertising Bill through this House very successfully and therefore has some form on the subject. I should like simply to make two points and to leave most of the other matters to my noble friend.
The first is that the smoking ban is a matter of considerable public interest and one on which there has been extensive and well informed public debate. Public opinion, not least as it is reflected by the number of commercial companies that have already introduced voluntary bans, is quite clear and in some respects ahead of Parliament. Should there be a difference between the two Houses on the matter of a ban, I believe that the views of the elected Members of another place should take precedence. I do not believe that this is a matter on which this House has the right to overrule those down at the other end.
Secondly, this is a matter of public health. The role of government should be to protect individuals who for whatever reason cannot exercise free choice about whether to work or to be in a smoke-free environment, and to address health inequalities. That will be the basis of the Liberal Democrat contribution to this debate and it reflects our policy on the matter.
I too wish to concentrate on the other parts—the anorak parts—of the Bill, which have received very little attention. However, these parts have important consequences for primary and secondary healthcare.
The most substantial part of the Bill, as the noble Baroness, Lady Cumberlege, said, is the introduction of a code for infection control. The incidence of infection in healthcare settings has been the subject of extensive political debate, not least during the previous general election, which proved conclusively that the public were not thinking what the Conservatives were thinking. The second national prevalence survey of infection in hospitals, in 1996, estimated that 9 per cent of all inpatients had a healthcare-associated infection. The National Audit Office report in February 2000 reported that healthcare-associated infections were possibly responsible for up to 5,000 deaths per year and the associated cost was £1 billion per annum. Since then there have been a number of initiatives, mostly information and education materials for healthcare professionals, such as Fighting Infections, Winning Ways, Towards Cleaner Hospitals and, in June 2005, the NHS Modernisation Agency's infection control initiative Saving Lives
Given all that activity, the fundamental question which the House has to ask is what difference will be made by a code of practice that, by the Government's own admission, will place on the NHS a regulatory burden of £34 million annually. When making up their minds, noble Lords might like to consider that the Bill's regulatory impact assessment makes clear that the data on which the code are built is from 1997. Moreover, in the intervening period there has not been a fully reliable system of surveillance of incidence of infection, nor of the implementation of infection control practice within hospitals.
Perhaps the greatest concern is that there is a dearth of information about the effectiveness of different infection control measures. There is evidence that infections transmitted by hand can be countered by the use of alcohol rubs, and infections in catheter care, which are extremely prevalent, can be reduced by the introduction of aseptic non-touch techniques. In addition, programmes such as UCLH's screening of all patient admissions has worked well, in that it has identified the prevalence of MRSA in other environments such as care homes. One wonders whether greater investment in pilot projects such as that and the eventual roll-out of successful infection control techniques would represent better investment of resources.
Furthermore, one must ask whether the penalties for non-compliance with the code of practice will simply lead trusts to divert their resources from other means of fighting infection—such as high standards of laundry, ensuring that staff have changes of uniform and facilities in which to change, and 24-hour cleaning services. The noble Baroness, Lady Cumberlege, gave an example; I shall give another. A few years ago, a friend of mine who was in a major London teaching hospital went for a bath and returned to find that her bed had been given to, and was occupied by, another patient. Bed occupancy rates are extraordinarily high in some of our major hospitals. We do not want another lot of centrally set targets that are of no use to front-line staff in trying to combat problems as they meet them.
A number of organisations have commented on the limitations of the proposals. The RCN has criticised the definition of healthcare-associated infection within the code of practice. That organisation states:
"The definition as currently drafted appears to confuse what a HCAI is with how you come to acquire such an infection".
That is an important distinction when one is attempting not just to identify but to control infection. Many organisations have criticised the fact that the code of practice will not apply to non-NHS facilities such as independent care homes. That is remarkable, given the incidence of MRSA among care home residents.
Our policy has been to give those in the front line the support and freedom of action to do what is necessary to fight infection where it occurs. We would ensure that information and training would be available to all staff to enable them to implement effective good practice. Staff would have discretion to close wards or set up isolation units as necessary. We would also ensure that effective systems of feedback and monitoring were in place, so that a sound evidence base of practice could be built.
In 2003, the Government gave £12 million of pump-priming money to pharmacists to set up a system of surveillance of the use of antimicrobials. That money is coming to an end and I would like to know whether that extremely successful project will be extended.
Our view is that a code of practice, which is to be introduced immediately, whether trusts are ready or not, and which focuses on processes rather than outcomes, is likely to be of limited use; but we accept it as far as it goes.
The new measures on supervision and management of controlled drugs are to be welcomed in that they incorporate many of the findings of part four of the Shipman inquiry. No system should be designed on the basis of the actions of one extraordinarily evil man; however, reform is necessary. We welcome the proposals in the Bill to the extent that responsibility for medicine management remains within organisations but wish to ensure that there are clear lines of accountability. We note the responsibility placed on the Healthcare Commission to review performance of each NHS organisation. However, I would also like to ask what role the Royal Pharmaceutical Society inspectorate will have in monitoring and policing the actions of NHS bodies. After all, that is the body with the relevant experience.
The proposals to change the control on supervision of pharmacists, as the Minister has said, are the subject of some concern. Pharmacists do not simply fulfil prescriptions; they play a very important role in talking to patients and checking for adverse drug reactions, which are often not obvious until repeat prescriptions have been issued. To do that, pharmacists need face-to-face interaction with the people they serve. The proposal that registered pharmacists may oversee more than one pharmacy has caused some concern.
We seek to scrutinise in detail the provisions on the review of general ophthalmic services. We are concerned that the Bill may limit access to general optometry, which is vital not just for eye care but for diagnosis of conditions such as brain tumours or glaucoma. Furthermore, we seek to probe exactly what constitutes additional and enhanced services under the GOS contract. Will conditions such as glaucoma be part of those additional and enhanced services?
I have one minor question to the Minister. The administration of the social care bursary scheme is to be moved to NHS bodies. I am not clear from the limited statements in the Explanatory Notes why that is possible or necessary. Why should one discipline issue bursaries for another?
With the exception of the smoking ban, this is not a strategic Bill. The noble Lord, Lord Warner, called it a diverse range of provisions. I would call it a collection of bits and pieces. It needs improvement and bits of it may well need protection during its passage through this House. Overall it has our support, but we will seek to strengthen it as it passes through your Lordships' House.
My Lords, I thank the noble Lord, Lord Warner, for explaining this Bill so clearly. When the Health Bill appeared in the Printed Paper Office just before the half-term break, I thought, as I suspect others did too, "Not more changes to the National Health Service". But some of the additions in this Bill, such as restrictions on smoking, will be of great benefit to many people. Changes of membership of bodies and appointments to bodies, however, always seem to take the concentration away from direct patient care.
Part 4 of the Bill deals with pharmaceutical services and makes changes to enable PCTs to consider, in their assessment of applications from pharmacists to provide NHS services over the counter, medicines and other healthcare products. It is the other healthcare products that I query. There is great concern that the Department of Health, having conducted a consultation exercise, is considering options for changing Part IX of the Drug Tariff. There are concerns about the proposals for change in the consultation on arrangements for the provisions of dressings, incontinence appliances, stoma appliances, chemical reagents and other appliances to primary and secondary care.
The Patients Industry Professional Forum consists of medical professionals, patients and patient representative groups. Representatives from industry have been in touch with me. They say the consultation fails to acknowledge the demand for, and the necessity of, the essential services currently provided for patients by companies in this sector. Such services include the home delivery of appliances required by stoma and continence patients and the provision of specialist stoma care nurses, who care for patients by providing bespoke services such as the measuring and fitting of their appliances.
The thrust of the Government's approach appears to be based on the opinion that the payment received by member companies that provide such essential services—known as dispensing appliance contractors, or DACs—should be the same as that received by high-street pharmacists, who do not provide such services. The members of the Patients Industry Professional Forum recognise that within the patient population will be many patients who wish to obtain their necessary prescriptions over the counter. However, for a large number of patients, such a service is impractical and inappropriate. Unfortunately, my husband is one such patient. The services provided by member companies in this area bring significant benefit to a sensitive part of healthcare, which much of the population does not understand and still finds embarrassing to talk about. New patients are recovering from the mental stress involved in facing up to serious illness, as well as the physical stress involved in recovering from major surgery. The support given by the specialist nurses is invaluable to carers, too.
The Continence Foundation has also been in touch with me. It says that it hears that some PCTs are trying to make significant savings to the budget for continence products and that they are trying to withdraw delivery to people's homes and care homes. In a rural area, that would be totally impractical. On
"Thousands threatened by oxygen shortage. Woman dies as 'chaos' follows privatisation of vital NHS supplies".
Surely we cannot continue with the Government telling us that it is up to individual PCTs. The public are worried about the fragmentation of these vital services. Do the Government and the Minister not want to protect these most vulnerable patients? We need some amendments to protect them and to make PCTs realise that they have a duty of care to provide these vital services.
I am delighted with the progress in this Health Bill in making many premises smoke-free. All my life, I seem to have been trying to dodge smokers. For years, I have served on the board of visitors of a young offender institution. I have always felt that not enough has been done in health promotion in the Prison Service, especially with regard to the dangers of smoking. I ask the Minister to clarify the exemptions to smoke-free premises in Chapter 1, Clause 3. Will the Secretary of State for Health be able to make some specified areas in prisons and other institutions smoke-free? If prisoners who are non-smokers are banged up in a cell with a heavy smoker for long periods, that must be totally wrong now that the health evidence is so clear. Would it not be possible to make smoke-free wings in prisons and ban smoking in all eating areas and also in visiting areas, where there are often children and where staff are always on duty?
I often interviewed young people who were non-smokers. Those who are trying to stop smoking should be given as much encouragement as possible. I hope that the Secretary of State will make appropriate regulations. I hope, too, that in care homes people who do not smoke are given a smoke-free environment to eat and socialise in if they so wish.
Part 2 of the Bill introduces new provisions on prevention and control of healthcare-associated infections. I am pleased that this important part of healthcare is in this Bill. On
The Secretary of State will have the power to issue a code of practice, which I hope will include some basic needs. Only on Sunday evening, I was telephoned by a carer of a very disabled man. She said that his wife would not be given gloves that had been supplied to the carer for cleaning up the patient. He has 24-hour care, and has had MRSA twice. He has a peg in his stomach to feed him. To stop supplying such aids used for the prevention of infection seems unwise.
I was told by a GP receptionist a few days ago that the NHS did not supply sterile swabs. Knowing that to be untrue, I told her that the NHS might be short of money but it had not yet reached that desperate state. GP practice receptionists should not be giving out false information. Otherwise people will not realise the importance of sterile procedures for vulnerable patients.
There must be more training on infection control for everyone. I give those examples to illustrate what can happen at the grass roots. There are several areas in the draft code of practice requiring much greater clarification and definition. They include hospital design, staff to patient ratios, bed occupancy rates, isolation facilities, the timely management of patient care, clean air environment, hand-washing, and the correct clothing for medical and nursing staff—no rings, no ties—cleanliness of wards, beds, trolleys, curtains, door handles, and so on, and adequate laundry services. Clinical waste must be disposed of effectively and appropriately.
Often there is a problem in the community. Infections can set in on a Friday or at the weekend. Doctors have to give a wide spectrum antibiotic instead of the most sensitive one for the infection, but the problem is that GP surgeries close on a Friday evening. If there were more testing facilities for infections of all sorts, with quick test results, fewer infections would become resistant to antibiotics.
I am pleased that the Bill is trying to address the horror of Shipman, but with the increase in the number of elderly patients, there will be plenty for the accountable officer to do. There have been some disturbing cases in the north, with nurses abusing vulnerable patients with controlled drugs. The recent report on care homes and abuse through administering incorrect medication needs urgent attention. With so many demands and an increasing amount of patients of all sorts, I hope that the Government will not rob the most severely disabled people of their vital services. I hope that the Government will not forget that some patients need looking after even though the current message coming down from on high is that people should be capable of looking after themselves. There are some very concerned patients and carers who need reassuring. I hope that the Minister can give them that today.
My Lords, I speak today on only one aspect of the Bill—the subject of smoking. One important factor of the Bill is its timeliness. Perhaps it has even come a little late. When I stopped smoking, almost 30 years ago—I had gradually become a 40-a-day woman—I did so not because I was made ill by my addiction, but for social reasons and because, remarkably, I foresaw that at some time in the future—possibly many years, as turned out to be the case—smoking would become unacceptable and ultimately disappear from this country. I say "remarkably" because that is the only long-term prediction that I have ever made which looks like coming true.
I remember saying to like-minded people that the time would come when only a few very old people would remain smokers. This no longer seems like a fantasy. The idea of a total ban on smoking no longer seems unreal; indeed, the media are already commenting on it as a fact, although the Bill has yet to pass through your Lordships' House. Will a total ban discourage addicts from smoking? The Department of Health has estimated that almost 700,000 will give up. A British Medical Journal survey concluded that workplace smoking bans reduced numbers by 4 per cent as well as cutting the number of cigarettes that people smoked—by no more than 1.3 a day, it is true, so my 40-a-day would have been reduced to only 38.7. To reduce through price, the British Medical Journal has estimated that the cost of cigarettes would almost have to double. Most of us who have no use for cigarettes will have noticed that, generally speaking, it is only non-smokers who comment on the cost. Smokers grit their teeth and pay.
Smoking bans work. It seems, too, that they work without much of an outcry. Scandinavia has always seemed to me as if it would be the last bastion of smoking in western Europe, yet the Norwegians banned it in 2004, their aim being to protect those non-smokers among their citizens from second-hand smoke. Last summer, Sweden banned it, while allowing smoking rooms. The bans happened in both countries with scarcely a ripple of fuss. Ireland's ban, which the rest of Europe gloomily predicted would be unworkable, has been a distinct success. Since the 1960s, when I first began going to the United States, I have seen whole swathes of that vast country abandon smoking without fuss, so that it is possible to spend a week in a city there and neither see nor smell a single smoker. Bans were easy to enforce in New York and in California, and Montana saw a 40 per cent decline in the number of hospital admissions for heart attacks during a six-month smoke-free period.
It is said by some that smoking should be left to people's personal choice. Leaving aside the question of whether someone under the sway of an addiction has any choice, what of the non-smokers? Until now, people with respiratory conditions or allergies have been denied all choice. The good done by a total ban will not be against their will nor will they grouse and grumble about a nanny state. Four-fifths of the country's 5 million asthma sufferers say that second-hand smoke makes their condition worse. Where are the civil liberties in compelling people to suffer others' smoke? In restaurants and pubs and clubs it has been compulsion for those who wish to keep their jobs.
Smoke is not simply in the atmosphere that non-smokers breathe. A friend of mine who is a doctor of medicine told me that while he was working in the Royal National Throat, Nose and Ear Hospital the children with asthma and other respiratory problems almost invariably had a parent or parents who smoked. He could smell the smoke on those children, the result of their being hugged by loving parents who had perhaps been careful not to smoke in their children's company but whose hair and clothes still harboured the results of the smoke that they had absorbed. This is an aspect of passive smoking to which public attention has not previously been drawn.
In one respect, the ban does not go far enough. When it comes, it will not, as we know, extend to royal palaces, prisons or residential care homes. Anyone who has been convinced of the reality of passive smoking will ask why not. Maybe those who live or work in the royal palaces—including this Palace—prisoners and elderly or incapacitated people approve of that exemption, but what of the staff? Choice is denied to them. Because of the relatively small spaces where smoking is allowed, one can be sure that there will be a concentration of smoke in the atmosphere. Librarians and catering staff in the case of your Lordships' House, prison officers and nurses and carers in residential care homes will be affected by it and, as we now know, will have their health damaged by it, but they need their jobs.
More than 600 people die each year in the United Kingdom from second-hand smoke. Long before passive smoking was recognised as dangerous, a friend of mine in New York died of lung cancer. She was in her 50s. She had never smoked a cigarette, but had spent every day of her working life in a newspaper office where most people smoked. The ban will one day, I am sure, extend to these exempted areas. Perhaps it should even extend to people's homes if we remember asthmatic children, for whom normal breathing is difficult as a result of being hugged by their parents. We have been told that people's right to smoke in private places should be respected, but the health of children who have to live there and have no choice should be respected more.
It has been said that when the ban comes into force more people will smoke at home than at present. That presupposes that those who now smoke in pubs and clubs will stay at home more. But people do not go out in the evening to smoke; they go out in the evening because they like going out in the evening, largely to enjoy eating and drinking in a convivial atmosphere. It is hard to imagine them giving up that habit to remain in an environment where they can smoke. On my way here this afternoon, my taxi driver told me that he did not smoke, but that his wife smoked heavily, which is a cause of dissent in the household. I asked him whether he thought that a ban in pubs and clubs would encourage her to smoke more at home. He said that it would have rather the reverse effect because of the opposition in his house to her smoking anywhere but out of doors.
On the question of passive smoking, the rights of children are perhaps even more important than those of workers. Most of us would agree that children should have some say in the environment in which they are brought up, though few do. They should at any rate be protected, as they are in other areas of life, from activities which are now known to cause them harm. An all-embracing ban including people's homes is, however, a matter for the future, not the here and now.
A ban with exceptions and exemptions, as we know, leads to abuses. Most of us know about pub licensees who, when licensing hours were heavily restricted, contrived ways of serving drinks to regular customers long into the night by establishing a "lock-out". So it might be with a partial prohibition on smoking, as those unwilling to give up their habit seek loopholes in the law. Moreover, ventilation is ineffective unless it is increased to gale levels, which would be unacceptable to most people.
Scotland will go smoke-free at the end of this month, the National Assembly for Wales wants a comprehensive ban and comprehensive smoke-free legislation will be introduced in Northern Ireland. Medical opinion has for many years been in favour of the habit of smoking being abandoned and doctors will always tell patients that the most important step that they can take towards better health is to become non-smokers. Like the noble Baroness, Lady Masham, I ask my noble friend for some clarification on the exemptions to the ban.
My Lords, a Bill of seven parts should encourage me to examine each of the parts with equal vigilance. In this case, I am sure that noble Lords will accept that it is not unsurprising that an ardent campaigner for a total ban on smoking in public places would spend most of the time considering Part 1, Chapters 1 and 2. This is not to say that the other six parts are neither fascinating nor interesting, or that they do not give rise to many questions. However, those of us who take part in Second Reading debates in your Lordships' House usually concentrate on the issues they feel most passionately about. As the Bill progresses through your Lordships' House, there will be opportunities to raise issues on other matters, not least, in my case, Part 2, which is on healthcare-associated infections, and Part 5, which is on the Appointments Commission.
The Minister graphically described the effects of smoking on the health of our nation—600,000 deaths per annum from passive smoking is one—and he is right to say that the Bill will make a tangible difference. It has been a very long haul to convince the Government that we need—
This is a pretty good trade-off for some limitation on smokers' freedom to smoke. Part 1 is entitled "Smoking", and contains little of which we are not aware. Members of the other place comprehensively made their views felt on a free vote, and many congratulations are due to them on placing the health of the whole nation before any sectional interests.
This has been a long battle, but praise where praise is due. The events of
This will be a short contribution. All I want to do at this stage is to flag up the issues which I think need further explanation and those that I think have been overlooked. First, will the Minister explain to us, either today or later in the passage of the Bill, what safeguards will be put in place under Clause 3(2) to ensure that the residents of care homes who do not smoke will not be subjected to passive smoking arising from the actions of residents who do smoke? The noble Baroness, Lady Masham of Ilton, mentioned this, as did the noble Baroness, Lady Rendell of Babergh.
Similarly, what would be the position of visitors to care homes? Would they be subjected to the effects of passive smoking? Some visitors go to care homes to see their loved ones many times a week and sometimes spend many hours there. How will they be protected? Still on the same subsection, will university halls of residence be included as an exemption? I hope not. There must be sympathy for elderly folk in care homes who have smoked all their lives. When their lives are drawing to a close, it would be most unkind to deprive them of what they think is their only pleasure, or probably addiction. But students? No.
Secondly—the noble Baroness, Lady Rendell of Babergh, also mentioned this—will the Palace of Westminster be an exempt area, or will every part of the Palace come under the law? Let us push for it. Finally, I have just three general points to make. I congratulate the Government on the provision in Chapter 2, at Clause 13(2), that the age specified in an order under subsection (1) may not be lower than 16. The Minister rightly mentioned this in his opening speech and I hope that the consultation will be even more positive.
I heartily commend the Government for allowing a free vote on the subject of a partial or total smoking ban. I sincerely hope that we shall also have a free vote in this House. May I make a plea that we look again at the Irish experience and avoid one of the unforeseen consequences? When entering a restaurant, a café, a coffee shop or a pub in Ireland, one must inevitably go through a wall of smoke, a most nasty experience, which results in one's entrance being accompanied by coughing and watering eyes. There should be some way of putting a cordon sanitaire around the entrance to public places.
I look forward to the Committee and further stages of the Bill and hope and pray that, on the issue of smoking, sanity will prevail.
My Lords, I, too, thank the Minister for introducing the Bill. I strongly support it and, unusually, congratulate the Government, particularly on bringing in comprehensive legislation prohibiting smoking in all enclosed public places.
I declare an interest: I am vice-president of the charity QUIT, which has helped thousands of people to give up smoking. Today's legislation will help hundreds of thousands more to give up and will go a long way towards meeting government targets for reducing the incidence of smokers in the population.
I agree with the scientific evidence cited by the noble Baronesses, Lady Cumberlege, Lady Rendell and Lady O'Cathain. Anybody who does not agree with the overwhelming scientific evidence of the damaging effects of second-hand smoke has his head in the sand or is confused by facts.
I am pleased that the Bill was amended in the other place to remove the opportunity to exclude private membership clubs and any licensed premises. All public places should be smoke-free, including all areas of the Palace of Westminster. I would go further: Parliament should set an example, as have hospitals, and ban smoking in all parts of the Palace of Westminster, including offices. I support these measures.
Part 2 relates to the prevention and control of healthcare-acquired infections. I welcome and support this part of the Bill as well. Again, I declare an interest. I am chairman of the National Patient Safety Agency, an organisation that has done a considerable amount, particularly with its "clean your hands" campaign, to help to reduce healthcare-related infections, as the Minister is aware.
I have some questions about the scope of the code of practice, which others have mentioned. The code is not available to us now, but it would have been better to have had it to enable us to comment on it when debating the Bill. I hope that the Minister will comment on that and that we will have the opportunity in Committee to probe further on the scope of the code of practice on healthcare-acquired infections.
I also have concerns about the definition of healthcare-associated infections. The definition in the Bill refers to any infection which an individual "may be" exposed to. The definition used by the Health Protection Agency is much better and does not include the words "may be". Again, we will have an opportunity to explore this further in Committee.
I support Clause 15 on the functions of the Healthcare Commission in relation to the code of practice, as the body which ensures compliance with the code. There are, however, issues to be discussed with regard to improvement notices—for example, the length of the specified period which an organisation must meet to comply with the notice, the redress open to the Secretary of State if the organisation does not comply, and so on. What are the likely effects of the code of practice on the training of health professionals, and will it require more resources to implement them?
Part 3 of the Bill refers to drugs, medicines and pharmacies. This part of the Bill is in response to the fourth report of the Shipman inquiry and relates to the safe management and audit of controlled drugs. It is right that an accountable officer should be responsible for ensuring the safe use of controlled drugs and for best-practice guidance on the handling of controlled drugs. We have examples reported to us by the National Patient Safety Agency in relation to the harmful effect of some controlled drugs, which will soon be out as an alert to the service.
As I said in the beginning, I welcome the Bill. Apart from some areas requiring further clarification, I shall support it. In bringing in Part 1, which relates to smoke-free premises, the Government have made a greater contribution to public health and health gain than any government in decades.
My Lords, I wish to speak in support of the Bill as it has emerged from its passage through the other place. In particular I wish to talk about two aspects: namely, the provisions to make enclosed public places and workplaces smoke free; and the clauses related to the Appointments Commission. I welcome the smoke-free provisions; they are health and safety measures. They do not represent a ban on smoking as some have sought to suggest. What the provisions do represent is the freedom for people not to be forced to inhale potentially lethal second-hand smoke in enclosed public places or in their place of work.
Inevitably the measure has been opposed as an attack on the liberty of the individual to, in this case, smoke. The requirement to wear a seat belt was also opposed on the same grounds, but I do not think there are too many people now campaigning against that measure, which was also a health and safety one. Others—namely, many representatives of the tobacco industry—continue to deny the overwhelming evidence of the adverse effects of second-hand smoke, just as for many years the industry maintained that smoking itself was not a cause of concern, even though it has now emerged that it had known about the consequences of direct smoking for some years. If there is anyone who believes that all captains of industry are beacons of integrity and honesty they should take a close look at the tobacco industry in that regard.
Second-hand smoke does kill. The Scientific Committee on Tobacco and Health, which advises the Government, has said that exposure to second-hand smoke increases the risk of lung cancer and heart disease to non-smokers by about a quarter. That exposure in the workplace has led to some 600 deaths a year; or three times the number killed in industrial accidents. It also causes illness and not least asthma attacks at work. It is precisely because this is a health and safety issue at the workplace that it was not acceptable, as originally proposed, to exempt membership clubs and pubs not serving food, neither of which could be regarded as having any similarity to places of residence.
In the Irish Republic, where similar measures to those in the Bill have been introduced, one person in three used to smoke; this has now fallen to one person in four, which suggests that the measures will have a favourable impact on levels of smoking. Government figures suggest that the measures contained in the Bill will lead to hundreds of thousands of people in England giving up smoking to the benefit of their own health, differences in life expectancy between social classes and the National Health Service.
Neither are the measures in the Bill likely to have an adverse economic effect. Bar sales in Ireland rose by more than 5 per cent in the year to October 2005 and I understand there was a similar trend in the year following the introduction of New York's smoke-free air act. The case for these measures in the Bill is overwhelming, and once they have been brought in I am sure they will quickly be accepted as the norm and not subsequently be reversed.
I also wish to talk about the measures in the Bill relating to the Appointments Commission. Under Clause 57 the Secretary of State will be able to direct the Appointments Commission to exercise all or part of her power to appoint, among others, non-executive members of strategic health authorities, primary care trusts, NHS trusts and special health authorities. I am sure that the Secretary of State believes that non-executive members have a vital role to play, and are not there just to be seen but not heard in order to give the necessary veneer of respectability to governance arrangements. If I am correct about the Secretary of State's view, and I have every reason to believe that I am, it will be necessary to make sure that her view about the importance of non-executives and the need to support them in their role is reflected in the culture of her department and throughout the health service.
The reason for my raising this issue is an example which has been brought to my attention, and over which my noble friend Lord Warner has been extremely helpful, of non-executives being treated effectively as peripheral figures in a health service organisation. That organisation is one of those that now have problems with their finances.
We will neither attract nor, equally significantly, retain the calibre of person we want as non-executive members if they are left with the feeling that they are wasting the time they are prepared to give, in what are already full and busy lives, because they are either being thwarted in carrying our their role through being ignored or have repeatedly to fight and press to have any sort of meaningful involvement. People of ability who have something of real value to contribute will not accept that kind of treatment. Either they will not apply or, if they are already in post, they are liable to walk away.
Perhaps the case that I have had drawn to my attention is the one exception to the rule. If my noble friend can assure me that it is, I will of course accept his word. However, if, like me, he has a feeling that this is not the case, I hope that he will make sure that the general issue of the level of involvement in practice, rather than in theory, of non-executives, and their role in the effective running of the National Health Service, is pursued. Otherwise, the appointments commission referred to in this Bill will be wasting much of its time in making such appointments.
My Lords, I have no interest to declare in this Bill and I certainly have never smoked in my life. It is clearly an important Bill and one should assess it in the total context of health policy, cost, and priority of health need.
The National Health Service is probably at an all-time low in terms of its management. We are told that it is running at a loss of £750 million a year, which is still rising. I note that the Minister in introducing the Bill did not, to the best of my knowledge, tell noble Lords the costs of each part of the Bill. When he winds up, I hope that he will be in a position to tell us the cost of implementing each of the varying parts of this important Bill.
This is clearly a very strong anti-smoking Bill, but it is very much in contrast to the Government's health policy overall. I mention, first, alcohol policy. Though too much alcohol is detrimental to health, the Government have extended drinking hours and made alcohol easier to obtain. Secondly, we see a continual easing of the policy on the taking, using and obtaining of drugs, be it cannabis or the new dance drug. Thirdly, I mention gambling. Gambling is very much a social ill, yet we see in the Government's policy a provision to increase the opportunities for families to gamble. Most of us, who have either served in the other place or seen a bit of life, know what a tragedy and a disease gambling can be, and how terrible can be its consequences.
Fourthly, a report placed in all our boxes today points out that the Government's obesity policy at present is in complete tatters. It is an obesity policy which should be implemented properly and one which has come to the fore particularly in the past seven to 10 years.
That is the background. I now consider the science. Perhaps I may say to the noble Lord, Lord Patel, that I do not have my head in the sand. He is a scientist; I am not. During my national service, I learnt to fly in the Royal Air Force. The science of aviation used to be crystal clear in relation to sonic travel: everyone said that it was fundamental and definite. That was changed dramatically when they discovered the real effect of going through the sonic barrier. Noble Lords will remember the problems of Concorde and others. Science changes with further information. I do not say that it will change necessarily in relation to smoking. The evidence is quite clear and fundamental about the person who smokes. But I have yet to be convinced about passive smoking. I may be wrong, but others have been wrong—not least in the example I have given. To get a little nearer to the world about which the Minister knows, the same comment would apply to vitamins and minerals. Twenty years ago the medical world scoffed at the role of vitamins and minerals. Today that has all changed and most people—the Government included—recognise that there is some role for some vitamins and some minerals.
In considering the 1998 and 2004 reports of the Scientific Committee on Tobacco and Health—SCOTH—noble Lords, myself included, and interested parties should have the right to see the evidence, debate and minutes of that organisation. With the greatest will in the world and seeking to be objective, that scientific committee appointed by the Government does not have the most balanced membership. It does not have that degree of balance for me as an individual to have total faith in it. However, I find it strange that at this point in time SCOTH has not allowed its minutes to be made fully available. They are not yet in the public domain. In addition, I am informed that the papers which have partially been provided have been redacted. Some would say another word for redacted is censored. That may be going a little far; I do not know. If the evidence on passive smoking is so clear—I have an open mind—why is that evidence not made available to interested parties? Perhaps the Minister will cover that point when winding up.
I do not know why there was not proper debate in another place about ventilation and air conditioning. My noble friend Lady O'Cathain says that she is totally convinced; that that subject is irrelevant. But looking at the world of air conditioning, extraction and so on, is not irrelevant.
My Lords, I thank my noble friend for giving way. I never once said that ventilation or air conditioning was irrelevant. I never used the word "irrelevant". In fact, a study showed that in Ireland it proved useless.
My Lords, my noble friend has now added to her speech and anticipated that she meant to say it and forgot to say it but now believes that what I am saying is totally irrelevant. Either way, it is not helpful and a little bit over the top, for the other place to totally ignore developments in this area. If we take it that some people want to smoke, cannot stop smoking or get enjoyment from smoking, and if ventilation is sufficiently improved so that the effect of passive smoking is negligible, that is particularly relevant. It is not acceptable in a society in which one-quarter of our population want to smoke—okay, it is a minority, but it is one-quarter—for those means that make it possible for them to do so to be totally pushed aside and ignored.
I turn to the nature of the ban itself. I read the Labour manifesto, as I suppose that all those of us who are interested in politics read our opponents' manifestos—I even bought a copy; and I have noted what the Labour Party's policy was on smoking, because we have had debates in your Lordships' House on that subject, in which I have taken part. I noted the public consultation Choosing Health; indeed, I read it. That document came forward with some exemptions. There is only one that I want to focus on: the situation of genuine membership clubs, which are not commercial clubs but are controlled by the members, who set the policy of the club and have annual general meetings in which they can change the policy, if they do not like it. The Secretary of State, on the morning of the Second Reading in the other place, recommended that membership clubs should be exempt; by the evening she had changed her mind and voted in the opposite Lobby. I am not sure that too many members of the public can have much faith in a Secretary of State who is such a will o' the wisp.
Licensed members' clubs, in relation to the debate in the other place, were simply rolled up. There was a sort of euphoria from the health people, who wanted to ban all smoking and anything to do with smoking—and out of the window went the licensed clubs. Nobody was worried about the liberties or freedoms of people in those clubs and what they wanted to do. Nobody recognised or remembered the genuine nature of those clubs; they were all totally ignored and swept into prohibition. The Government are totally ignoring what the public wants, which is a smoking policy that provides a choice of facilities for smokers and non-smokers alike; they seem to forget all about that and ride over the nature of those clubs.
Those clubs hold a certificate, as noble Lords will know, and are run by and for the benefit of the members. They can decide, as members, what they do, at their annual general meetings. Even the Under-Secretary of State in another place said:
"Private clubs are exempted on the basis that their members are adults who choose to sign up to the regulations of that club. They have a say in . . . whether smoking should be allowed at all or in certain areas. Many clubs already apply rules in that area, including no smoking in bars".—[Official Report, Commons Standing Committee E, 8/12/05; col. 87.]
I shall table amendments in Committee to restore the right of membership clubs to choose whether they wish to ban smoking.
In passing, rural pubs seem destined to be lost to us all. I shall not develop the point now, but I may do so in Committee.
I listened to the Minister trot out statistics and forecasts and have heard other statistics bandied around in the Chamber. I think that the Minister said that the BMA quoted a figure of 30 people a day dying from smoking, but the age at which they were dying was left undefined. Naturally, everybody dies, so it is not a very meaningful statistic. We are told that thousands of lives will be saved, which is very emotive. Given that we are down to 25 per cent of people smoking, that figure seems to me a bit questionable and highly unlikely. Again, although I am sorry to come back to my noble friend Lady O'Cathain, I thought I heard her say—I shall hurriedly give way to her if I got it wrong—that 600,000 people would be saved from dying if we got rid of passive smoking.
My Lords, I think that the noble Baroness has subtly missed the comma in my concluding remarks. I actually said that 600,000 was the estimated number fewer smokers; there was then a comma after that, and I went on to say that there would be many lives saved. Noble Lords may have elided the "600,000" with the "many lives saved".
No, says the noble Lord, but he does not know the press and he certainly does not know the health lobby. But at least we have now established that it is not 600,000 people dying from passive smoking, although the noble Baroness clearly thought it was, otherwise she would not have said it—or perhaps she was not listening properly and she wished it was. But, either way, let us move on.
I am not sure whether the Minister was totally clear on the saving to the NHS. I am not sure whether he said £100 million or £100,000 million, but perhaps he could clarify that in his winding-up speech, as he has already given the figure. If he would be kind enough to say what the savings to the NHS actually are, we would take that at face value, and it would help the debate.
I conclude by saying that as someone who has taken an interest in this subject, I will listen to objective science, but I am not willing to listen to science with a twist on it. Noble Lords who are scientific need to recognise that science is not always totally accurate—and I have given two examples. If government policy is taken to its logical point, the Government should be banning smoking—but they know that they cannot do that because 25 per cent of people want to smoke. Furthermore, what possible trust can people have in the Government when they state one thing in their manifesto and then go and do almost the opposite in reality?
My Lords, noble Lords may be relieved to know that I am not going to talk much at all about the smoking business. My views, both as a doctor and a chairman of a strategic health authority are so predictable that you could almost take them as read. I congratulate the Secretary of State, Patricia Hewitt, on finally voting against her own department's original proposals—although I was sad to see that one health Minister did not support the healthiest option of smoke-free public premises. I hope that that particular Minister will not be around monitoring the performance of my authority on our smoking cessation targets.
I add my voice to the voices of the noble Baronesses, Lady Rendell and Lady O'Cathain, who raised the issue of providing better protection for residents of care homes and nursing homes, who often have to suffer the smoking of other residents and staff. I have regularly witnessed that in registered care homes and nursing homes, and we must find some better way in which to protect those individuals.
As the noble Lord, Lord Patel, said, this is probably the most important public health measure proposed in the past few decades, and I strongly support the Government's current proposals.
I turn to the new pharmacy regulations, and hope that the Minister will be able to put my mind at rest on a few points. First, I want to say how much I welcome the new pharmacy strategy and the new proposed wider role for community pharmacies in primary healthcare, and to support the increased contribution that they can make to public health and possible practice. We have 37,000 pharmacists in the UK; highly trained, skilled professionals whose talents are often underutilised under the current arrangements.
Those noble Lords who have visited Italy, France and many other European countries will know that the local pharmacist often plays a key primary care role, and is expected to give advice and guidance on a wide range of healthcare matters relating to medicines and products and on public health issues. It is enormously beneficial and easy to be able to consult a high street pharmacist on the spot, and to widen access to pharmacy services must be a good thing.
On the face of it, the current proposals make a good deal of sense. There will cease to be an obligation for a pharmacist to be physically present at a pharmacy while medicines are being dispensed. There will be a designated responsible pharmacist in overall supervision, but not required to be present at all times. The supervision of the pharmacy may be by remote mechanisms, by robotics, video links, electronic means of viewing prescriptions and so on. But it seems to me—and this has been raised by the Pharmacists' Defence Association too—that the provisions, if not properly implemented, may have the unintended consequence of lessening the public's access to a community pharmacist in more deprived areas and provide fewer safeguards for patients in terms of supervision of their medications.
The primary role of the pharmacist is to ensure the safe sale and supply of medicines in the pharmacy, and he or she is uniquely qualified to do that. The PDA deals with the many dispensing errors and near-misses, and knows, even though now 80 per cent of medicines are pre-packed and bar-coded, that drug errors still occur, and that technicians and dispensing assistants are not equipped to cope with an unexpected incident where an intervention may have to be made quickly to avoid harming a patient. The prolonged absence of a pharmacist will undoubtedly leave many decisions to assistants and technicians.
It looks as if it could be possible under these proposals for a pharmacist to supervise more than one pharmacy at once, by being officially in one pharmacy and providing cover remotely as a supervisor at another. I fear that companies with several pharmacies will simply reduce the number of qualified pharmacists they employ in some areas. The commercial reality of the pharmacy industry in inner-city areas, and in some remote rural areas where there are already recruitment problems and great difficulty in finding locums, could lead to the creation of a two-tier system of well staffed and poorly staffed pharmacies.
I do not want to downplay the skills of our valuable registered pharmaceutical technicians, nor our dispensing assistants, but the fact is that they are at their most useful when they work directly with, and are learning from, an expert pharmacist in a close-knit multi-disciplinary team. How many hours will a pharmacist have to spend in the pharmacy per day or week or month in order to be designated as a responsible pharmacist? Has that been considered with regard to patient safety? Will the Minister explain how regulations can be, as it says in the Government's Health Bill information paper, tightly drawn to ensure that the absence of a pharmacist will be permitted only in specific and defined exceptional circumstances, yet designed to ensure the responsible pharmacist has sufficient time and flexibility to offer other services away from the pharmacy? How can a pharmacist supervise a remote pharmacy over extended periods without compromising safety? How long might he be away for?
What about pharmacies that open 100 hours a week or more to satisfy the exemption from control of entry regulations to NHS prescribing status? Can we be reassured that there will be one responsible pharmacist for every community pharmacy? Will the Minister clarify under what circumstances a responsible pharmacist could supervise more than one pharmacy? Finally, what is the remote pharmacist permitted to do when he or she is away from the pharmacy? I hope, because this is one of my fears, that it will be providing healthcare rather than simply driving around town between his six other pharmacies.
My Lords, I think it was last week that an article was published in what we used to call a broadsheet about climate change and global warming, which was followed by an assessment by a television presenter who drives fast cars. He said that while there was still one expert who says climate change is not taking place, he would not believe it. I would love to know whether this gentleman has found an expert who says that smoking does you good.
I have to declare an interest. My hospital records show that I have severe acute allergic brittle asthma. What does this mean? I can become very ill indeed—at worst, within 20 seconds—following inhalation of one or more of numerous chemicals. What has this to do with the Health Bill? There are many chemicals that lead me to being ill that cannot be quantified, nor indeed controlled, but I can become ill with one inhalation of certain types of tobacco smoke, with that from cigars being the worst. I am not alone in that respect.
The noble Lord, Lord Naseby, talked about passive smoking. I will give him two examples. First, the noble Lord, Lord Brougham and Vaux, had to relieve me a couple of weeks ago when I became ill while chairing the Grand Committee because tobacco smoke came up a ventilation shaft. Secondly, I will have an asthma attack if I am driving up a motorway with my windows closed and someone else is smoking a cigar. It will not be a bad attack, but I will have to take some medication.
All those who smoke have a perfect right to do so, but there are many people like me who should have the right to inhale smoke-free air. Exposure to second-hand smoke is the second most common asthma trigger in the workplace, and working where others smoke doubles your risk of developing asthma. Indeed, there are many non-smokers without any illness who would like to breathe clean air—like me. That includes employees in the hospitality industry, where one person so employed dies every week. To make matters worse, the BMA published research last year that showed second-hand smoke is likely to be responsible for the deaths of more than two employed people for each working day of the year. Everyone has a human right to work without being exposed to poisonous and life-threatening substances, and many people, including those with asthma, are currently excluded from many social environments because of the damaging effects of second-hand smoke.
Comprehensive legislation benefits health. Smoke-free laws prevent ill health and second-hand smoke, and encourage smokers to quit, as has happened in Ireland. They motivate smokers to protect their families from second-hand smoke in the home.
What would this country be doing if Sir Walter Raleigh had introduced cannabis, not tobacco, into this country all those years ago? Probably not very much. But, in general terms, cannabis does not affect other people, but tobacco does, and its smoke should be rigorously controlled. I welcome this Bill.
My Lords, I have enormous sympathy with the noble Viscount, Lord Simon. He put his finger on the point: those who do not wish to smoke should not suffer from second-hand smoke, but those who wish to smoke should be allowed to. That is the essence of what we are talking about. I declare an interest as a proud member of the Lords and Commons Pipe and Cigar Smokers' Club, although I smoke neither pipes nor cigars.
Like my noble friend Lord Naseby, I wish to concentrate on Part 1 of the Bill, particularly Clause 3, which deals with private membership clubs. Clause 3 gives the illustrative example of homes and places of permanent or temporary living accommodation, including hotels, care homes—as the noble Baroness, Lady Rendell, mentioned—and prisons, as places that may be exempted by regulation. As an aside, I can see a farcical situation developing in prisons, where the prisoners concerned can smoke, as they are exempted. But what about the prison warders? That is their place of work. Are they allowed to smoke? Perhaps the Minister could clarify that.
Clause 3 continues specifically to prohibit the exemption of premises having a premises licence or club premises certificate under the Licensing Act 2003, which includes of course pubs, bars and private membership clubs. There is a special case for genuine private membership clubs. The licensing regime recognises that genuine membership clubs are significantly different from licensed premises. There is a technicality on the two different types of licensing, but I will not bore your Lordships or take up their time on that one. As my noble friend Lord Naseby rightly said, clubs holding a club premises certificate—that is the difference between a normal licensing certificate and one that affects clubs—are run by their members, who choose freely to associate with each other. They are run principally for the benefit of their members, and under their rules there is accountability to the members of the club who determine how the club is managed and operated. Surely a private institution like that can make up its own mind. No one is obliging anybody to become a member of such a club, but if you are a member of a club why can't you indulge in smoking if you so wish?
I have done quite a lot of trawling of press reports. I do not normally rely that much on what the gentlemen of the press say, so I have tried to give as wide a spectrum on this as I could. I shall quote extracts in no particular order. There was an interesting comment on
"MPs think they have the right to stop us smoking, if we wish to do so, on private premises in the company of friends . . . It is an invasion of private freedom; it is an abuse of power of Parliament, none the better for being carried on a free vote of the House of Commons. They use their free vote to take away our personal freedom".
I then found one in the Yorkshire Post—not exactly the same as the Mail on Sunday—of
"The smoking ban agreed last night is an illiberal piece of legislation that severely restricts freedoms of choice and the rights of publicans and club owners to run their businesses as they see fit".
Then from the Sun—normally a periodical or newspaper that I would have thought supported the present Government:
"We always knew New Labour were a bunch of control freaks. Now, with this ludicrous and unnecessary smoking ban, they stand as out-and-out fascists".
Switching slightly now, in political terms, to the Times—or maybe not switching; I do not know which way the Times leans nowadays—of
"The pettiness of this official persecution of smokers (who are not prevented from paying a lot of tax) can hardly be exaggerated".
My final quote is from the Daily Mirror, again not known to be a supporter of this side of the House, whose correspondent said:
"What riles me is that as part of this government's manifesto, the deal was a partial ban. They lied. Secondly, we, the British public, have laid down, rolled over and allowed our liberty to be taken away".
I would now like to concentrate on that last point: the manifesto. Again, my noble friend Lord Naseby has done a great service in bringing that to the fore. Let me just quote the relevant sentence in the Labour Party manifesto and then elaborate slightly on that. The manifesto said:
"In membership clubs the members will be free to choose whether to allow smoking or to be smoke-free".
The Government have been increasingly praying in aid their election manifesto. As recently as two days ago the noble Baroness, Lady Amos, the Leader of the House, in a slightly testy 10 minutes just after Question Time, prayed in aid with relevance to the reform of this House. That is not the point, but the subject matter is. The point that I submit is that she said:
"My Lords, government policy on House of Lords reform was set out in a manifesto on which this Government won an election last year".
In the space of 10 minutes, she used that argument three times. The last of them, chronologically, was:
"The Government's policy on House of Lords reform remains as set out in our manifesto last year".—[Hansard, Lords, 27/2/06; cols. 11-13.]
The Government cannot have it both ways. I suggest that there is a certain amount of cherry-picking going on here. When it suits, the manifesto is called in aid; when it does not suit, it seems to be torn up. Other noble Lords may have got the letter that I received this morning. It is on the subject of ID cards, which indeed is coming back to your Lordships' House next Monday, if I remember correctly. It is nothing to do with this Bill at all, but with the point of the manifesto:
"I believe that Tony Blair and his Government, by stating in their manifesto that ID cards would be voluntary, have created a sense of apathy among the general public, myself included".
I repeat: either the manifesto is adhered to or it is not, and it was made very clear in the Government's manifesto in May last year that private clubs would be exempted. I certainly will be supporting my noble friend Lord Naseby, if he sees fit to put down an amendment on that subject.
Just one final comment: it is a personal one and to me rather surprising. My wife is vehemently anti-smoking. She hates my smoking and tells me so on numerous occasions. But when the ban on private clubs was passed in another place some 10 days ago, she went incandescent with rage and said, "How dare they invade the right of private individuals to do what they want on their own premises?" I give that as one illustration and I do not believe that it will be unique.
My Lords, I will confine my remarks to Chapter 1 of Part 1 of the Bill, which legislates to ban smoking from public buildings and workplaces. This of course was not the Government's original intention but, since the Cabinet was divided, the matter was left to a free vote of the Commons.
My opposition to Chapter 1 of the Bill is based on a single point. It is grossly disproportionate and off target relative to the harm, such as it is, caused by passive smoking. I thought that I would be in a minority of one after listening to the debate, but as it is I am glad to follow the powerful interventions of the noble Lords, Lord Naseby and Lord Geddes. If there is a rational basis to the Bill, it seems to be this: the Government are determined to stamp out smoking or at least heavily reduce it from its present level of 25 per cent of the adult population. I am told that the Department of Health has a target for reducing smoking to 21 per cent by 2010. I do not know whether that is true, but it seems plausible. Since banning smoking outright would seem to be too gross an interference with liberty—there are still too many smokers around—the idea is to reduce it by claiming that it harms others. If there are fewer places in which people are allowed to smoke, it seems to follow that fewer cigarettes will be smoked. That seems to be the rational basis for this Bill.
What is wrong with that basis? If the attack on passive smoking helps to rid society of tobacco, is that not a good aim? The answer is that it is corrupt. The quality of information that the public receive is vital to the proper functioning of a democracy. I fear that we have got into the absolutely appalling state where it is widely accepted that the end justifies the means. We saw it with Iraq: it did not matter whether Saddam Hussein had weapons of mass destruction, we got rid of him, and wasn't that a good thing? The same attitude seems to be prevailing here. It does not matter whether passive smoking actually does do that much damage provided that the end result is a reduction in smoking.
There is also the not insignificant matter of the assault on freedom. An office with two persons is designated a smoke-free zone even if both occupants want to smoke. A group of smokers will not be able to form a private club. As far as I can make out, even private dwellings and private motor cars may at some time in the future be designated smoke-free zones on the order of the Secretary of State. So this Bill is not the end of a process; it is part of a process which may result in a much greater interference with liberty than is at present contemplated, grave though that is.
I refer noble Lords to the Explanatory Notes on Part 1 of the Bill, which state:
"The Bill will also give the Secretary of State for Health the power to make regulations specifying places or specified areas within them that do not have to be smoke-free. These will include premises where a person has his home".
The Englishman's home will for the time being remain his castle by permission of the Secretary of State.
I do not deny for a moment that smoking is dangerous to one's health. How could one? Some 100,000 people a year are said to die of smoking-related diseases, 30,000 of them from lung cancer. But even here we must be careful. What does it mean to say that smoking kills? Everyone dies. What the statement must mean is that it causes premature death. What the statement that 100,000 people a year die from smoking-related diseases actually means is that 100,000 smokers die on average somewhat earlier—up to five year earlier, it is said—than non-smokers.
The question then is: how dangerous is passive smoking? Before trying to answer that, I have a health warning of my own. The interpretation of smoking statistics is fiendishly difficult. That is why they tend to give way in legislative assemblies to anecdote or general statements. And I do not blame politicians for not understanding statistics; very few people understand statistics. What I blame them for is being too careless of liberty.
So the question is: how dangerous is passive smoking? There have been more than 50 studies of passive smoking over 25 years. The firmest conclusion is that non-smokers exposed to environmental tobacco smoke at work and at home show an increased risk of lung cancer of about 20 per cent—it may be a bit more or a bit less. How many extra premature deaths is that? If we assume a 20 per cent risk, the answer is about 650 extra deaths a year.
Earlier this year, the House of Commons Select Committee on Health said:
"It is currently estimated that SHS"— inhalation of second-hand smoke—
"causes at least 12,000 deaths each year in the United Kingdom".
That is deaths from all smoking-related diseases, not just cancer. However, I have to emphasise that 12,000 is not a robust figure. The US Environmental Protection Agency estimates that there are 3,000 environmental tobacco smoke-related deaths in the United States, which has five times the population of the United Kingdom. Even in Britain the estimates range from several hundred to 12,000.
If you assume that passive smoking causes a 20 per cent increase in the risk of lung cancer and that there are as many deaths from other causes relating to passive smoking as from lung cancer, which is not unreasonable, the rough estimate of premature extra deaths on the basis of available data is about 1,300 a year. That is roughly consistent with the British Medical Association's estimate, which is 1,000. So that is the sort of order of magnitude of the premature deaths caused by passive inhalation of tobacco smoke.
Another approach to the question—a more intriguing one, I think—would be to ask by how much life is shortened by exposure to environmental tobacco smoke. Obviously it is less than by the five years' shortening suffered by the active smokers. The US Center for Environmental Health has estimated that the mean cotinine level of non-smokers exposed to ETS—that is, the level of toxic substances in tobacco smoke—is 1/500th that of active smokers. If we assume that the increased risk of premature deaths from environmental tobacco smoke relative to smokers is reduced in proportion, then 1/500th of five years works out at about four days. So whether the number of premature deaths caused by passive smoking is 12,000 or 100,000 or 1,000, if we assume that on average smoking reduces life expectancy by five years, then passive smoking reduces average life expectancy by four days per person.
As the House of Commons Select Committee recognises, most deaths from passive smoking are caused by domestic exposure to second-hand smoke; that is, living with a smoker. Various studies, including one by Professor Konrad Jamrozik of Imperial College London, imply that only about 15 per cent of deaths from passive smoking are caused by exposure to environmental tobacco smoke in public places—the places which the Bill proposes to make smoke-free zones. Thus we are talking about between 150 and 200 premature deaths a year from passive smoking. That means that the maximum decrease in average life expectancy from exposure to ETS in public places is about 15 hours per person. Now, I am just trying to lead you on to what statistical manipulations can achieve if you want to follow the logic of these matters. And, after all, we should not entirely dispense with logic in framing our legislation.
These numbers are impossible to prove statistically. This is because the increased risk from passive smoking is too small to determine given the quality of the data. To say that passive smoking would lead to an increase in the incidence of lung cancer from 10 per 100,000 non-smokers to 12 per 100,000 is statistically meaningless. The cautious experts refuse to commit themselves to a number.
"I think that passive smoking has to be causing some risk", one expert recently told the House of Lords Select Committee on Economic Affairs, of which I am a member, but he refused to name a number when pressed several times. He said that it must have some effect.
So what conclusion does one draw? The part of the Bill dealing with passive smoking seems to me to be based on a false prospectus. It relies on a manipulation or lack of understanding of the statistics. At best, it is using a sledgehammer to crack a nut and it is grossly careless of liberty. It does not deal with the main risks from passive smoking, which arise from the home, and whose biggest, non-lethal impact is on young children. Indeed, the smallness of the risk of dying from passive smoking has caused the argument to shift to the non-lethal damage done by passive smoking rather than the lethal damage.
I am deeply sympathetic with the plight that the noble Viscount, Lord Simon, movingly described in his speech. I would simply say that the legislative response must be proportional to the damage. Not only do we have very little data on non-lethal effects, but the response must be much more nuanced than it is in the Bill.
If the Government honestly want to reduce smoking, they have two legitimate weapons—education and taxes. Both have already had a big effect, not a negligible effect. Only a minority of adults now smoke. Pressure from the majority of non-smokers has led to most working places and many hotels and restaurants becoming non-smoking zones. Public opinion is already achieving what the Government aim to do by legislation, without trampling on the liberty of smokers to choose where they want to work and relax. I am saying this as an ex-smoker.
If governments want to accelerate that movement, there is no reason why they should not continue to raise taxes on tobacco to the point at which smoking becomes the vice of the rich rather than the habit of the many. It will be claimed that that approach would disproportionately hurt the poorer sections of the population who smoke more. But those groups will also gain disproportionately from the improvement in their health. Rather than using the price mechanism, or "sin taxes", which is the natural thing to do if you want to reduce the quantity demanded, the Government prefer that all smokers should suffer an equal loss of liberty. Equality of deprivation has always been more attractive to some people than freedom of choice.
We are faced with a demand to legislate which, although I believe it to be unnecessary, is almost certainly unstoppable. Therefore, I will be looking to introduce or support amendments in Committee that exempt private clubs from this legislation, and in other ways to modify the blanket prohibition of smoking in public places.
My Lords, although I have an interest in several areas of the Bill, I intend to concentrate at Second Reading on smoke-free public places. I am still trying to work out which of the gods placed me after the noble Lords, Lord Skidelsky and Lord Geddes. In no way will I try to tackle the statistical analysis, although there were moments when I thought that the noble Lord made my point for me. I am grateful that he made more suggestions about how we can reduce smoking.
This House has already demonstrated that it puts the health of the community first by voting for the London and Liverpool Bills, which await the outcome of this legislation. Noble Lords also voted for smoke-free areas in virtually all parts of this House, showing that they care for their own staff—that is the issue about private clubs—as well as their own health. I had the privilege of taking a leading part on both those Bills and now speak in support of this Bill, so that the legislation can be enacted at the earliest opportunity in 2007 to ensure that all workers have the same level of protection. Although the noble Baroness, Lady O'Cathain, is not in her place, I would join her in trying to ensure that the whole of the Palace becomes smoke-free.
The BMA has written expressing its delight that Members of the other place opted to put the lives and health of their constituents first and vote for a total ban. Although there were moments when the leadership on the issue looked a little shaky, we were all delighted when the ban went through. That showed that we have a listening Government that can look at the facts and change their mind. Whatever is in the manifesto, I thought that listening meant that you were capable of changing your mind during the course of a Parliament. For that I am grateful—after all, you may change your mind about other things, too.
A partial ban on smoking in public places would have brought nothing but unworkable chaos and the most disadvantaged in our society would have continued to be at the greatest risk. Therefore, I hope that Members of this House will not try to introduce amendments to raise sectional interests—although I understand now that they will. I have no sympathy for the arguments on behalf of private clubs. I have talked to workers who work in private places. Of course they say, "Yes, I think it's alright", until you ask them privately. They say it is alright because they know that they will lose their jobs if they say that it is not alright. I have examples.
It would be inappropriate for me to repeat the vast array of evidence that we outlined in the London and Liverpool Bills, but some facts bear repeating. The research published by the British Medical Journal last year—and I hope that these are the right statistics—showed that second-hand smoke at work is likely to be responsible for the deaths of more than two employed people in the United Kingdom every working day. That is 617 deaths a year. If you start to divide that up into tiny proportions of hours and days it may seem small compared with the whole population. But I thought that in areas such as this we worked on the precautionary principle—that we care about our community. It is, I hope, the same attitude that we took in relation to BSE and vCJD. Certainly, there are not thousands of people dying from vCJD, but I hope that we continue the precautionary principle to ensure that people do not die that terrible death any more than the terrible deaths I have seen from diseases such as cancer that have resulted from smoking and, I believe, secondary smoking.
Professor Vivienne Nathan, director of professional activities at the BMA, wrote me a telling letter. She stated:
"The health evidence that second hand smoke kills is beyond dispute"— that is the view of the BMA—
"but doctors' knowledge does not just come from scientific papers—we see the evidence in the lives of our patients and their families. We see that the least affluent patients bear the heaviest burden of the disease from smoking and second hand smoke, and know that this suffering is preventable".
I know that the positive effect on bar sales has already been mentioned, and maybe some of us have views about alcohol in relation to that, but it shows that business has not been particularly affected by a ban. What about compliance? In the debate on the London Bill, noble Lords said that no one would do anything about it. People will not comply, they said.
However, in March 2005, a report, Smoke-Free Workplaces in Ireland, A One-Year Review, contained the following key findings. Compliance with the smoke-free workplace legislation was very high—94 per cent of all workplaces inspected under the National Tobacco Control Inspection Programme were smoke-free; 92 per cent of all workplaces inspected by the Health and Safety Authority were smoke-free; 93 per cent of all hospitality workplaces were smoke-free. There is in Ireland overwhelming support for the law, with 98 per cent of people believing that workplaces are healthier and 96 per cent of people considering that the smoke-free law is a success. In addition, air quality in pubs has improved dramatically and more people like to go to them.
I know that the issue of ventilation has been raised and I was not going to speak about that, as I talked about it in the debate on the London Bill. However, I have to tell the noble Lord, Lord Naseby, that an atmospheric physicist, James Repace, looked at the need for ventilation in smoke-filled rooms and what recycling that smoke would require. He said that it would take an air recycling rate of tornado-like force to remove all the effects of secondary smoking. I thought that it might be worth the expense of watching some people try to light up in that situation. But that is what the physicist said—and we are talking about physics, not chemistry, anyway.
My Lords, I am grateful to the noble Baroness for giving way. I said that it would remove, not all, but the majority of, the problem. The majority, given the speech of the noble Lord, Lord Skidelsky, would indicate that the incidence would drop dramatically. Also, will the noble Baroness comment on why tobacco consumption is back on the increase in Ireland?
My Lords, I do not have the facts on that, but I am prepared to look at them and come back to the noble Lord. However, I will probably leave it for the Minister to answer, as I have learnt from the noble Baroness, Lady O'Cathain, that that is the best approach.
There is another positive aspect to this legislation. Critics have pointed out that the main smoking problem may be in the home. Maybe this is what the noble Lord, Lord Naseby, is relating. Clearly we cannot legislate at the moment for that, however much we hope to do so. However, passive smoking is a danger to vulnerable adults and to children, especially children with health problems. As patron and trustee of Little Hearts Matter, a charity which works with families of children with single-ventricle heart problems, I am particularly aware of this. There is a myth that this Bill would increase smoking at home, but in fact the opposite would be likely, as it encourages smokers to quit. I understood that cigarette sales in Ireland had, in fact, fallen by 16 per cent. But again I look to the Minister for verification of that fact. Moreover, such a law increases public understanding of the risks of second-hand smoke. It raises a debate and therefore discourages smoking around children. Finally, it helps to prevent seeing smoking as a normal, even desirable, adult activity. I am so glad that so many of your Lordships have given up—maybe that is a good example, too. It is a real incentive to prevent young people smoking, which is a major problem in society. That is why I welcome the Government's plans to consult on raising the age for sales of tobacco to young people to 18.
We also need to look at the problem of glamorising smoking. Television and theatre glamorise smoking and, when I mentioned it before, the noble Baroness, Lady McIntosh, accused me of not getting out enough. On reflection, and with my workload, I thought she might be right. But there is a real issue about how smoking is portrayed, particularly to the young.
Other noble Lords raised the issue of smoking in residential homes, secure units, prisons and other long-stay settings. The problem might have been addressed had the London and Liverpool Bills gone to Committee. The Joint Committee on Human Rights has argued that smoking should not be completely banned from such establishments where people live "akin to their own abode". But where staff provide care, or where domiciliary workers visit people who smoke in their homes, much more thought is needed about the balance of protection and service delivery. What consideration is being given to the issue? The ALG and SmokeFree London encourage a blanket ban and I have heard that some unions have concerns for staff. I declare an interest as president and trustee of John Grooms, a charity providing residential care for severely disabled adults. I know that the sector is looking for a framework in which this clash of interests can be addressed.
Perhaps I may mention three colleagues whose voices would have been heard could they have been here today. My noble friend Lady Finlay of Llandaff, president of Ash in Wales, asked that I remind noble Lords of the work she has done in introducing the Smoking in Public Places (Wales) Bill. She would have wished to contribute from her wealth of knowledge of the issue had it not been St David's Day—she is required to be in the land of the Bards. She would have spoken from her knowledge and about the increased risk of developing lung cancer and heart disease in those exposed to secondary smoke. Another supporter would have been Lord Stratford, Tony Banks, who made his maiden speech on this issue, and whose loss continues to be felt in this House. And, of course, my colleague Lord Chan, who spoke in favour of the London Bill. I think both would have raised their voices in this debate.
The other place has set us a good example by a massive majority. It is time for England to come into line with Scotland, Wales and Northern Ireland, in protecting our workforce. Many bitterly resent the potentially fatal damage to their health from working in a smoke-filled environment. This is an opportunity for legislation to do real good. I hope your Lordships will give it the measure of support it so richly deserves.
My Lords, I declare my usual wholly non-financial interest as president of the Society for Individual Freedom and a supporter of FOREST, although, of course, neither of those offices affects what I am going to say in any way. The fact that I am also a light smoker may do so to some extent—although I would hope that, even if I were not a smoker, I would stand up for individual freedom in the same way that the noble Lord, Lord Naseby, has, and the noble Lord, Lord Stoddart of Swindon, will do shortly.
When this Bill received its First Reading in another place, I suppose it was correctly titled. It contained many inconsistencies and illogicalities, and was illiberal in many respects—but then illiberalism is par for the course where much recent government legislation is concerned. However, the legislation that has emerged from the Commons can be better described as a health fascism Bill and a slap in the face for the Labour manifesto on which this Government set such store. It embodies a puritanical zealotry we have not seen in this country for 350 years. As the noble Lord, Lord Rees-Mogg, wrote in the Mail on Sunday on
"The House of Commons is full of busybodies . . . looking around eagerly for [any] . . . opportunity to bite into personal liberty . . . The ban on smoking in enclosed public spaces and workplaces . . . is an invasion of private freedom . . . [and] an abuse of the power of Parliament . . . They [MPs] use their free vote to take away our personal freedom".
It is interesting to know how many of those who voted to shackle traditional English freedoms represent Scottish, Welsh or Northern Irish constituencies.
We can all agree on one thing: when people's eyes, ears or nostrils are irritated by other people's habits, as so often happens, they normally have to suffer in silence through gritted teeth. So, if just one of those habits can be deemed not merely irritating but positively lethal to bystanders, it is only natural that the sufferers should take the opportunity to press for the habit in question to be heavily curtailed in their presence—however little truth there may be in the mortality claims. The operative words here are "in their presence". To a very large extent, this has already happened. For example, by 2004, smoking in the workplace for 92 per cent of the population was either banned or confined to segregated smoking rooms. Those who are especially sensitive to smoke, like the noble Baroness, Lady O'Cathain, will surely concede that life is very much more agreeable for people like her now than it was even five years ago, let alone 25 years ago.
As the general public is much more tolerant than the current House of Commons, only 31 per cent of people want a complete ban in public places. Five per cent want no restrictions and a majority is entirely happy with separate smoking and non-smoking rooms in pubs and suchlike. According to the Office for National Statistics—and who could be more impartial?—this contradicts the claim made by the noble Baroness, Lady Cumberlege. But as the noble Lord, Lord Skidelsky, has already hinted, the long-term and indeed the medium-term, aim of the zealots is to turn all smoking into a shameful, outcast activity, indulged in furtively by men at street corners with their coat collars turned up as if they were peddling hard drugs or pornography. In other words, it is a form of psychological warfare directed against smokers. No matter that most of the men who fought in the trenches of Flanders in the first world war were smokers and honourable men. No matter that most of the men who fought in the second world war across the north African desert, up the spine of Italy, on the beaches of Normandy and in the jungles of Burma were smokers and honourable men, as were those who fought in the Battle of Britain. No matter that Winston Churchill, Clement Attlee and Harold Wilson all enjoyed their pipes or tobacco, as the case may be, and lived to the ages—note this carefully—of 90, 84 and 79 respectively. No doubt their pleasures will soon be literally airbrushed out of history, as Franklin Delano Roosevelt's perpetual cigarette holder has already been airbrushed out of history in the United States. Judging by what the noble Baroness, Lady Howarth, said, she would be quite happy if airbrushing took place in this country.
The zealots hope to achieve their aim by claiming, which Professor Sir Richard Doll and Professor Sir Richard Peto never did, that second-hand smoke is so lethal that anyone entering a room, or indeed a company car, which the last smoker vacated possibly several hours previously is in mortal peril—indeed, the noble Baroness, Lady O'Cathain, claimed that 600,000 people a year die from passive smoking, but that figure is larger than the total number of people who die in Britain every year from all causes.
If that were the case, virtually none of us would be here today. Anyone born before, let us say, 1955 necessarily, whether they liked it or not—and most of us did not like it—spent their formative years wreathed in other people's exhaled smoke, since, even if neither of their parents smoked, smoking in public places was ubiquitous. Yet our generation—or perhaps I should say "generations"—have statistically lived much longer than anyone predicted, much to the dismay of annuity providers. Incidentally, have any death certificates listed passive smoking as a cause of death? I think not.
Anyone who doubts the draconian nature of even the original Bill should scrutinise Clause 11 and Schedule 2. By comparison, Clause 13 is relatively mild—albeit wholly inconsistent. It is inconsistent because five and a quarter years ago, on
One recognises that the Bill has not reached this House as the Government originally intended, but that is largely the Government's own fault, partly because some Ministers changed their mind at the last moment—indeed, some of them changed their mind several times in the course of a day—but partly because, as Terence Blacker pointed out in an excellent article in yesterday's Independent, which I commend to your Lordships,
"government by anxiety has become a favoured New Labour method of dealing with its more intractable problems. At the first sign of sustained opposition to proposed legislation that would infringe civil liberties and free speech, for example, ministers spoke in apocalyptic yet general terms about security and the threat of terrorism. The right to life was the greatest human right of all became the mantra of the moment".
Of course, that applies to all sorts of things. It is implied that if Olympic pistol shooters are allowed to practise using .22 pistols in this country, the murder rate will shoot up, and if we were to leave the EU, there would be millions of unemployed and mass starvation, and so on.
If you consistently frighten people into believing that their safety is in peril, it is bound to rebound on you as a government at some point. Let us hope that in this House we can at the very least restore the Bill so that it goes no further in eroding our freedoms than what was proposed in the Labour manifesto.
My Lords, when I saw that the noble Baroness, Lady Howarth of Breckland, had put her name down to speak in this debate—which of course she would, given her acknowledged expertise in this area—I got an unpleasant sense that she would return to my very disobliging remarks about her when we both spoke in the debate on the London and Liverpool prohibition of smoking Bills last summer. So, first, I want to take this opportunity to apologise to the noble Baroness for casting aspersions on how she conducted her private leisure activities. Despite that, I am not deterred from raising the issue that she observed I probably would raise, and have raised in the past, in respect of this Bill: the impact of Part 1 on the theatre industry.
I start by declaring my interests, which include being an ex-member of the board of the Society of London Theatre and a current member of the boards of both the Almeida Theatre and the Roundhouse, which is shortly to reopen. I should also say that I entirely support the Bill. I want to make that very clear from the outset. In particular, I support the aspects of it that relate to the restriction of smoking in public places. However, some difficulties arise from it concerning the presentation of live theatre events, and I want to outline them. Before I do so, however, I should like to associate myself with the remarks of the noble Baroness, Lady Howarth, about our late colleague Lord Stratford. I had wanted to refer, as she did, to the fact that he spoke in the debate that she and I both participated in last summer. It was the occasion of his maiden speech, and it seems to me terribly sad that he was not with us long enough to see this issue, about which he felt so strongly, brought to fruition through a government Bill. We shall continue to miss him.
Three aspects of Part 1 have a direct impact on how theatre presentations can be brought about. First, the definition of "smoking" in Clause 1 is as follows:
(a) . . . smoking tobacco or anything which contains tobacco; or smoking any other substance; and (b) smoking includes being in possession of lit tobacco or of anything lit which contains tobacco, or being in possession of any other lit substance in a form in which it could be smoked".
That definition would, therefore, include the smoking of herbal cigarettes—a matter to which I shall return.
Secondly, the definition of smoke-free premises in Clause 2 is drawn widely enough to encompass not only the public areas of theatres and other places of entertainment, such as auditoria and foyer spaces, but also rehearsal spaces and all indoor stages or other performance spaces, although I note the potential specified in Clause 3(5) for regulations to allow certain exemptions.
Thirdly, the requirements set out in Clause 6 for the provision of "no smoking" signs could, as drafted, result in such signs having to be displayed on stage during performances. At this point, I agree wholeheartedly with what the noble Baroness, Lady Cumberlege, said earlier about the necessity to be scrupulous about how we go forward with the issue of signage. It can be a very heavy-handed way of dealing with the obviously necessary provision of information.
All those requirements put together could seriously interfere with the production of theatre work within which smoking is either specifically indicated in the text or necessary to convey a particular period, atmosphere or character. I think, for instance, of John Osborne's seminal play "Look Back in Anger", with which I am sure many of your Lordships are familiar. It was written in 1956 and, briefly, it deals with the marital difficulties of a young couple in that era. The main character, Jimmy Porter, smokes a pipe. If he were not to do so, not only would a significant element of the play be lost, as many of your Lordships will know, but the author's copyright would be infringed because he specifies that. It would be improper for anyone to remove from the play that aspect of his writing without the permission of those who act for him now—unfortunately he is no longer with us.
There are many other similar examples but I will not detain the House by repeating them. I simply reiterate the point that I made on the earlier Bill:
"The Bill as drafted gives powers . . . both to inhibit the process of creating work for the stage and to compromise the integrity of performance".—[Hansard, 20/07/05; col. 1568.]
I do not think that it is the Government's intention to place unreasonable restrictions on the presentation of live theatre performance. Indeed, I believe that they are already considering the matter. My honourable friend Caroline Flint, in reply to a Question from the Conservative shadow Health Secretary, Andrew Lansley, on
"We received representations from the theatre industry to exempt theatrical performances and will take them into account in drafting regulations"—[Hansard, Commons, 17/01/06; col.1307W.]
Will my noble friend confirm this intention and say when it is anticipated that draft regulations will be available? Perhaps I could further encourage him by pointing out that in New York—a city now notorious for the draconian way that anti-smoking regulations are enforced—actors are permitted to smoke herbal tobacco on stage and in rehearsal, subject only to the proviso that if there is smoking on stage, the public must be alerted in much the same way as they are alerted to the use of strobe lighting or explosive sound. It surely cannot be impossible for this Bill to be amended to create similar flexibilities with appropriate safeguards.
In case it should occur either to my noble friend or any other of your Lordships—the noble Baroness, Lady Howarth, in particular—that perhaps this suggestion is an evil plot by wicked theatre producers to force their hapless employees into unhealthy practices against their will, I should record that Equity, the actors' union, has also raised these issues with the Government.
On the question of glamorising smoking, I have some sympathy with the noble Baroness, but there is a difference between an active wish to glamorise the act and simply representing the act as part of a theatre performance.
I recognise that this is a relatively minor matter in the great scheme of things, but it is not insignificant. The move to end smoking in public places is a hugely important step in promoting public health, as many of the previous speakers have said. It has my full support. None the less, as I have said before, smoking, though dangerous and undesirable for many reasons, has been part of our own and other cultures for hundreds of years and its presence in, and impact on, art cannot be ignored or legislated away. We need to find acceptable ways of allowing it to be represented. I hope that the Government will feel able either to bring forward suitable amendments in Committee, or to consider sympathetically suggestions from others.
My Lords, at this stage of a debate there tends to be some repetition, particularly of statistical evidence. However, I welcome the Bill and the changes that have been made in the other place. The other place has been discussing dentistry this afternoon. Normally, when speaking on a health Bill I can steer it round towards dentistry. The Minister will be delighted to hear that that has not proved possible this evening.
Although most smoke-related deaths are caused by passive smoking at home, about 500 each year are due to exposure at work. This exposure is particularly high in the hospitality industry and is likely to affect bar workers and, indeed, musicians. Perhaps I have been lucky, having played my trumpet for more than 40 years in smoke-filled bars, clubs, hotels, and marquees without—as yet—a smoke-related problem. I commend the work of the Roy Castle foundation on this particular issue. Roy died from lung cancer at an early age, and passive smoking was thought to have been the major cause of his disease.
Although I dislike any nanny-state regulations and the restriction of freedom of choice, I did think that the provision of smoking areas and smoke extraction could go a long way to lessening the risk. It was a regular subject for discussion during my time as chairman of the Refreshment Department, and the committee tried to accommodate the wishes of all members. I am sure that the matter is still being discussed regularly. However, my medical training and the statistical evidence has convinced me that the introduction of smoke-free policies will improve public health, or generate long-term health improvements and reductions in health social inequality. These benefits must override the issues relating to freedom of choice.
I am proud to have been present for one of Sir Richard Doll's early lectures on the association of lung cancer and smoking many years ago and, like the Minister, I pay tribute to his work on this subject. At one time, I thought that a ban in public places would increase smoking at home, but the evidence now shows that where smoke-free workplaces and enclosed public places are accepted, there tends to be less smoking at home. That is clearly the case following the ban in Ireland. The legislation could lead to a million people quitting smoking. Thousands of lives will be saved and the economy will benefit by about £4 billion.
I shall now stress some of the points made by the noble Baroness, Lady Murphy. For many years I have thought that there should be changes in working practices in community pharmacies to allow pharmacists to make best use of their skills and experience for the benefit of the public. I was attached to Boots via the Industry and Parliamentary Trust when it widened its policy to build consultation areas into its pharmaceutical outlets for direct patient advice. Doctors should not have to spend time on minor illnesses and infections when practice nurses and pharmacists are equipped by their qualifications to deal with this important aspect of primary care.
The Bill deals with many of the issues of concern relating to supervision and responsibility in a pharmacy. Pharmacists will be allowed more freedom to begin to provide some of the other services set out in the newly negotiated community pharmacy contract. A responsible pharmacist will have professional accountability for all processes in the pharmacy and will be able to carry out other duties, such as visiting patients and meeting local GPs, when pharmacy activities can be delegated to appropriately trained pharmacy technicians. That is to be welcomed.
When I first read the Bill, I was concerned that it might affect the regulations currently applied to the way drugs and medicines are stored and dispensed by groups of general practitioners who effectively run small pharmacies within their practices. This issue is not covered by the many pages of briefing notes that I have received, so I assume that there will be no change in the current situation. But will the Minister specifically confirm that the Bill will not affect this vital and essential service, and that suitably trained doctors' dispensers will continue to dispense without the supervision of a pharmacist? That is particularly important in rural areas, where pharmacies can be many miles from the doctor's surgery. I ask for confirmation as I am aware that the relationships between community pharmacies and doctors' dispensing outlets are not always ones of mutual agreement, yet they are essential for the efficient management of many practices.
I also welcome the provisions in the Bill relating to healthcare-associated infections. This is a major problem that is not under control, and I am concerned that the final version of the code of practice will be unnecessarily delayed by the decision that it should not be published until the Bill receives Royal Assent. The latest figures for MRSA reveal that the NHS will not achieve its goal of cutting rates by 50 per cent within the next two years. The number of deaths linked to MRSA has risen by 22 per cent. Research has shown that up to 100,000 patients admitted to hospital each year were unknown carriers of MRSA. I should have thought that identification of those carriers should be fairly straightforward and an absolute priority.
The need for the code to be relevant to all health care, and its relationship to hospital design, staff-patient ratios, bed occupancy, isolation facilities, and a clean air environment, must be addressed urgently. Finally, a brief comment on the supervision of management and the use of controlled drugs, as that directly affects my own work when I have to order drugs, store them, carry them with me, and prescribe and use them in different situations. I hope that the Minister can confirm that this legislation will not affect the right of healthcare professionals to prescribe these drugs.
I welcome the response to the Shipman inquiry and the fact that routine monitoring and inspection of controlled drugs in community pharmacies is likely to become a role undertaken by the pharmacy inspectorate of the Royal Pharmaceutical Society.
Clause 19 refers to,
"A constable or an authorised person", being able to enter premises. Pharmacy bodies have been negotiating on the inspection of controlled drugs in England, but not in Wales or Scotland. Given the preparations for the transfer of this role to the Royal Pharmaceutical Society inspectorate, I know that they are keen to receive clarification on this issue.
While welcoming the Bill, I am concerned about the sheer volume of detailed provisions that will be enacted through regulations that will have little scope for amendment once made. I hope that the Minister will be able to set out as much detail as possible in the Bill.
I am delighted to be followed by the noble Lord, Lord Walton. The last time he followed me was at the Macmillan concert, when he performed in a Geordie accent, but I shall not tempt him this evening.
My Lords, I am a fervent believer in the rights of the individual and in personal freedom. That leaves me free to indulge in a habit, if I so wish, such as smoking, if I am alone, but it does not give me the right to indulge in a habit such as smoking in the presence of other individuals who thereby could be seriously harmed. That is one of the core principles underlying the Bill as amended. I am very glad to see the noble Lord, Lord Naseby, back in his place because the attitude of the medical profession has undergone a sea change over the past 50 or 60 years on this issue.
Many years ago, when I was a medical student, the professors of anatomy and physiology recommended that we should all smoke, particularly in the dissecting room, as it would help to dispel the odours. More than 60 years ago, when I was in the Army as second in command of an army hospital ship in the Royal Army Medical Corps, I used to buy a 50-can of Senior Service every other day and I got through it in two days. It cost one shilling and eight pence and I smoked 25 cigarettes a day. Then, when Sir Richard Doll produced his first paper, with Bradford Hill and others, I began to see that there were some risks in smoking. However, the evidence at that time suggested that pipe smoking was less dangerous than cigarette smoking, so I moved on to a pipe. In another 10 years' time, the risks associated with pipe smoking of tobacco—indeed all tobacco consumption—became increasingly clear and I gave up nearly 40 years ago. For a time I had that feeling, like Lady Macbeth:
"Is this a [pipe] I see before me, its handle towards my hand? Come, let me clutch thee! I have thee not, but yet I see thee still".
I give that personal history because, since that time, the evidence on direct, personal smoking has accumulated steadily and progressively, not only in relation to cancer of the lung or cardiovascular disease, but also in relation to many other cancers. I can quote to my noble friend Lord Skidelsky, although I shall not tonight, the massive volume of statistical evidence that has clearly underlined the facts relating to this matter.
Some 20 years ago, I chaired a conference at Green College, where I followed Sir Richard Doll as the warden, on the effects of passive smoking. We took a lot of evidence from skilled individuals, such as statisticians, doctors, scientists, and from members of the public. We came to the conclusion that there was anecdotal evidence suggesting that perhaps passive smoking might be harmful. In the past 20 years, the statistics have steadily accumulated and the evidence is now absolutely cast-iron. There is a very large body of scientific literature that makes that point clear. As my noble friend Lady Howarth said, the BMA published evidence last March showing that second-hand smoke is likely to be responsible for the deaths of more than two employed people every working day—more than 600 deaths a year—and at least one employee in the hospitality industry dies each week—54 deaths a year—from passive exposure to tobacco smoke.
I appreciate what was in the Government's manifesto, but I congratulate the Members of another place on their good sense in introducing the amendments to change the Bill from what had originally been in the manifesto to enact a total ban on smoking in public places, including private members' clubs. I would be delighted if the Bamburgh Castle Golf Club, of which I am president, enacted a ban on smoking. The noble Lord, Lord Geddes, who is not in his place, won a competition there a few years ago. I believe that will be very important because everyone, including those working in private clubs and pubs that do not serve food, has the human right to work without being exposed to poisonous and life-threatening substances. For that reason, the provision relating to private members' clubs is very important.
On the points made by the noble Lord, Lord Naseby, on ventilation, I commend to him the parliamentary brief from the British Medical Association with a series of very precise references to scientific research studies in Europe, which demonstrate that,
"displacement ventilation technology cannot remove the gases and particles from the air".
Perhaps that can be done partially, but it certainly cannot be done to an extent that will be really effective.
"there is nothing that this Government could do for health that would be better than to bring in this ban—absolutely nothing".
I agree with her entirely. The Royal College of Physicians estimates that some 12,000 deaths per year occur from passive smoking, but the great majority of those occur in the home. The figures for the workplace are very much smaller, at 500 to 600. Most of the deaths are caused by passive smoking at home, but exposure is particularly high for some workers in the hospitality industry. Preventing passive smoking at home, particularly for children, is, therefore, a public health priority. Home exposure is prevented only by encouraging parents and carers to quit smoking completely by making homes completely smoke-free. I agree entirely with what the noble Lord, Lord Colwyn, said. There is a widespread misconception that banning smoking in public places will lead to an increase in tobacco consumption in the home. In fact, the reverse is the case. There is now growing evidence that where smoke-free workplaces and smoke-free enclosed public places are the norm, parents report that they are more likely to try to prevent smoking in the home. In Ireland there has been a significant increase in the percentage of smokers who ban smoking in their own homes. I firmly and warmly support Clause 1 of the Bill as amended in the other place. I believe it will make a massive contribution to public health.
I shall comment briefly on Parts 2 and 3. The Royal College of Nursing welcomes the action that is now proposed to tackle healthcare-associated infection. But they have some specific concerns, which the Minister may be able to allay, relating to the scope of the code of practice, the timetable for introducing the final code of practice and the need to ensure that the code for acute settings is not just transferred to the primary and independent care settings without consultation on its impact. That is particularly important in relation to care homes, as other noble Lords have said. Others have pointed out the concern expressed by the Royal College of Nursing about the definition of healthcare-associated infection. They much prefer the definition of the Health Protection Agency and not the one in the Bill. I hope that the Minister will be able to comment on that.
I turn to Part 3 and the anxieties expressed by the Royal Pharmaceutical Society of Great Britain, which wants assurances that it will be an active participant in the drafting of the regulations which, as the noble Lord, Lord Colwyn, said, are likely to come thick and fast once the Bill has become law. The legislation should clearly define those activities that can be undertaken only when the responsible pharmacist is present and should include clear lines of accountability, provisions for the responsible pharmacist to be contactable when absent and in a position to return without undue delay, and provisions for the responsible pharmacist to justify any absence from the pharmacy.
Clause 19 refers to,
"A constable or an authorised person" being able to enter premises. Given the preparations for the transfer of that role to the RPSGB inspectorate, it believes that the role of the Royal Pharmaceutical Society in inspecting pharmacies should be stated on the face of the Bill, over and above the role of the constable.
Those are the points that I wished to make at Second Reading. I hope that your Lordships will give warm support to the Bill in general, but will be prepared to look at some of the points that I have raised when it comes to Committee stage, in particular the strong support that we have heard from all sides of the House for the ban on smoking in enclosed public spaces.
My Lords, the noble Lord, Lord Walton, mentioned Sir Richard Doll. I distinctly remember hearing the late Sir Richard saying on the "Today" programme that he would not favour a ban on smoking in public places. We should keep that very much in mind in view of the fame that he has in relation to smoking. I must declare an interest because although I am not a smoker—I have not smoked for many years—I am a member of the Lords and Commons pipe and cigar smoking club. I find the company I keep there very congenial indeed. The second-hand smoke of the other members does not worry me one bit.
Going home last night in my car, I was thinking about my life in politics. I have been in politics virtually all my life: I joined the Labour Party in 1947, which was a long time ago. I well remember the late Lord Shawcross, when he was Attorney-General, getting up in the House of Commons and saying, "We are the masters now". There was outrage at that statement because it was just after the war and people had memories of the master race. But it was not only that, because at that time the people who represented other people in the House of Commons believed that they were there not as masters of the people, but as the servants of the people. Elected representatives forget that at the country's peril. I believe that that is what has happened in the House of Commons in relation to this Bill.
The duty of elected representatives is to ensure justice and fairness to all citizens, even minorities. Indeed, we hear a lot from the present Government about safeguarding the rights of minorities, except, of course, smokers. If you are a minority smoker, then you are everybody's butt and the order is to get rid of you as soon as possible, to get rid of the awful habit. That is not democracy; it is autocracy at its worst. I regret that the House of Commons rejected the just and fair way to deal with smoking in public places, which is separation to give consideration both to smokers and non-smokers, and instead used the most vicious authoritarianism and divisiveness to deal with the problem of so-called passive smoking.
What about the manifesto commitment that was referred to by the noble Lords, Lord Geddes and Lord Monson, and perhaps by other noble Lords as well? The noble Lord, Lord Geddes, referred to what the Leader of the House said in relation to the future of this House two days ago. However, we have a more up-to-date comment than that. Yesterday, in the debate on Commons amendments to the Terrorism Bill, the House was told that it must abide by manifesto commitments. The noble Baroness, Lady Scotland, said:
"the manifesto said:
'we will introduce new laws to help catch and convict those involved in helping to plan terrorist activity or who glorify or condone acts of terror'.
I respectfully suggest that that could not have been clearer. We should demonstrate to our electorate that we take its views seriously".—[Hansard, 28/02/06; col. 137.]
There could not be a clearer statement than that that the Government wish to honour their manifesto commitments—except, apparently, in respect of smoking because, as we have heard, the manifesto has not been adhered to. Yesterday, we were being told that we must honour manifesto commitments; today, we are being told to ignore a manifesto commitment. The Government cannot have it both ways.
Of course, the Government think that they have got out of it by having a free vote, which is a government device to get around the manifesto. But every Labour Member of Parliament was bound by that manifesto. They went to the electorate on it and they fought the election on it, so they have the same duty as the Government to ensure that it is carried out. Labour MPs cannot ignore manifesto commitments with impunity while everybody else apparently has to comply with them to the letter. I am afraid that Britain becomes more like a one-party state every day when this sort of thing goes on.
This legislation is being claimed as a measure to protect the health of people in areas where people smoke. All sorts of figures—we have heard some of them this afternoon—have been bandied about on the numbers involved. As has already been said today, in November last year, Patricia Hewitt, the Secretary of State for Health, said that 54 people from the hospitality industry and 617 from other workplaces die in Britain every year from the effects of second-hand smoke. That is statistical evidence. The noble Lord, Lord Skidelsky, dealt very well with the statistical part of this matter this afternoon. He will be quoted all over the world, make no mistake about that. The figures that he gave were very significant and came from an expert source. However, no clinical evidence has been produced, only statistical evidence. We are still waiting for clinical evidence. The figures are simply estimates.
Those figures pale into insignificance compared with the number of deaths from alcoholism. That number is many times greater—and I have not mentioned fights and killings outside public houses and the injuries that they cause, or wife and child beating. People who are interested in social affairs should consider the wives and children who are beaten up by drunks when they go home after drinking too much every Saturday night, and perhaps every night of the week. What about them? And, of course, there are the millions of days that are lost through overindulgence in alcohol and the damage that that does to the country's economy.
On the basis of actual harm, not simply of statistics—and it is actual harm; we know about the children and the wives who are beaten, and the people who are knifed outside the pubs—it would be more sensible to ban alcohol, rather than smoking, in public places. But, of course, no one would suggest that, would they? Well, not at the moment, although that time may come under this Government. If they can get away with a ban on smoking in public places, who knows where they will ban it next? The noble Baroness told us today what the next step is—a complete ban on smoking at home or wherever else. Just think of the problems that that would cause with policing and people interfering in people's homes.
My Lords, I did not want to intervene, but that suggestion has been made twice. I simply said that I hoped that we could stop people smoking around children in their own homes. I said earlier—if the noble Lord cares to read my speech—that that was one of the things that we could not do. I believe that I was the one who was referred to twice. I think that there is freedom, but freedom means being conscious of the damage that you are doing, particularly to your own children.
My Lords, may I interrupt the noble Baroness? I did not quote her; I am sorry if she misheard what I said. I quoted the noble Baroness, Lady Rendell of Babergh. I am sorry that she took my remarks amiss, but they were not addressed at her.
Then, of course, there are the dangers to health from vehicle emissions; estimates of deaths in the United Kingdom vary from 10,000 to 30,000 a year. According to the Mayor of London—he is still there for the moment—1,000 people in London alone die from vehicle emissions, not to mention from diseases such as asthma, which are exacerbated by traffic fumes. People will step out from smoke-free pubs and so on into the foul atmosphere of traffic-congested streets, and also risk being one of the 3,500 killed and 45,000 seriously injured on the roads each year.
The whole anti-smoking campaign has been driven to the present situation through the creation of fear and hysteria among people that second-hand smoke is one of the greatest health risks, although I have just given two examples to show that it most certainly is not. But people tend to accept the myth of greater danger from second-hand smoking because the medical profession embraces it. We all respect medical practitioners and listen intently to their views, but we need to ask ourselves whether it is more dangerous to go into a smoke-filled bar or a hospital. There are roughly 5,000 cases of medical negligence every year and, according to the BMA, there are at least 5,000 deaths per annum from MRSA. Some 300,000 patients pick up an infection in hospital each year, some of which leads to death or permanent disability. Those are not my figures—they come from a report published by the BMA's Board of Science and Education on
Then there is the new scare of obesity. When I was a lad growing up in the Rhondda Valley during the depression, we were not worried about obesity; we were worried about almost skeletal children. Now, the new problem, in addition to smoking, is obesity. It is said to be costing the NHS £6 billion a year—that is three and a half times more than the Government say smoking costs the NHS every year. So why are we talking about passive smoking? Obesity is also supposed to shorten the life span. Perhaps House of Commons man will introduce a Bill soon to ban eating in public places.
I quoted these figures to try to show that we have got our priorities wrong, that the evidence for a ban on smoking in public places is tenuous and based on estimates rather than clinical certainty, and that the whole argument about smoking has been whipped up by assertions from witch-hunting bigots who pretend that smoking is the most dangerous activity in the world, which it is certainly not. I think that it is a national disgrace that we have a House of Commons that, in a debate of only three hours to discuss this great matter, has stripped people of rights that they have enjoyed for hundreds of years, despite a manifesto commitment not to do so. Separation and good ventilation would produce a solution satisfactory to most reasonable people and, with others—at least, I hope that there will be others—I will seek to achieve this at least by amending the Bill to the limits included in the Labour Party manifesto.
My Lords, it is a pleasure to follow the noble Lord, Lord Stoddart of Swindon, although it is a difficult act to follow on this occasion. I, too, would like to thank the noble Lord, Lord Warner, for introducing this Bill. I feel very humbled to be taking part in the debate among such a distinguished line of speakers, most especially my colleagues on the Cross Benches from the medical world.
As the last speaker, I have three very brief points that I would like to make, and I propose to introduce amendments to two of them under Part 6 of the Bill. The first is prescription charges. I used to correspond with the noble Baroness, Lady Cumberlege, on this point when she was at the Department of Health. I have always felt very strongly that all prescription drugs ought to have their value clearly printed on them, so that patients know exactly what they are getting for the prescription charge. I have always thought that this was a particularly good idea, because some of these drugs are outstanding value for money.
My second point is also an old hobbyhorse of mine. In order further to reduce the waiting lists and the heavy load on the National Health Service, I have long advocated that insurance health premiums ought to be allowed against income tax. For those of us in this House who have health insurance, it is a very large proportion of one's expenditure, particularly if one has a wife and, say, three or four children.
Finally, I turn to the vexed question of smoking. My views are well known and are certainly well documented in Hansard, from when we last discussed smoking. I echo the views of my noble friend Lord Monson, and the noble Lords, Lord Geddes and Lord Naseby. Particularly bearing in mind what the noble Lord, Lord Stoddart, said, I find it difficult to believe that a party in power can go so directly against its manifesto commitment.
If you own a restaurant, you have to staff it and pay all the financing. Therefore, if you want someone to work in that restaurant you can, after all, explain, "I am sorry, this is a restaurant where smoking is allowed. If you want to work here, you will have to accept that". There are, of course, plenty of other places where that person could work.
In theory, I applaud the Government for wishing to limit the amount that people smoke. For years and years I have thought that the only way to stop people smoking is to have a blanket ban on the sale of all tobacco products. I know that we would have a bit of a problem because at the moment, 27 per cent of tobacco products sold in this country are smuggled in. However, I believe that if the Government really want to stop people smoking, the only alternative is to ban the sale of all tobacco products, and I intend to produce an amendment to that effect in Committee.
My Lords, I thank the Minister for his succinct introduction to the Bill. I also thank my noble friend for her trailer, football metaphors included, although in this House, being on the Bench has a rather different meaning.
I am tempted to start with the words, "As I was saying July 2004". I have a strong sense of déjà vu when I look at some elements of the Bill. The Government claim to have been fighting the battle against MRSA and now VRSA and C. Difficile over the past few years. Every year they use a new set of targets or guidelines or launch a new campaign and assure us that the battle is nearly won in the face of all the available figures.
The latest bright idea is a legally binding code of practice incorporated in the Bill. I am extremely sceptical whether the legislation will make the situation any better. This is a basic management and infection control issue in our hospitals. I commend the analysis and prescription of my noble friend Lady Barker in this respect.
As regards Part 1, I have no sense of déjà vu, unless you count some of the hyperbole being displayed by some of its opponents and the massed ranks of the Lords and Commons Pipe and Cigar Smokers' Club, who were present when I was lucky enough to sponsor the Tobacco Advertising and Promotion Bill. Part 1 is the product of the other place at its very best—a bold legislative step to ban smoking in public places, including all pubs and private clubs, taken as a matter of individual judgment by MPs on a free vote.
Despite the claims of tobacco company spokesmen and organisations such as FOREST, it is, as the noble Lord, Lord Walton, made clear, no longer a question for serious debate that second-hand smoke is harmful and leads to premature death. The key issue is the estimated number of deaths caused by inhaling other people's smoke. I listened to the noble Lord, Lord Skidelsky, with mounting incredulity—his use of statistics was quite extraordinary, and I hope that the Minister will demonstrate the proposition against.
The paper in the British Medical Journal by Professor Jamrozik of
My Lords, if you read the paper, as I am sure the noble Lord has, there are deaths that are earlier than might have been anticipated. The professor has presented a very respectable piece of work, it is peer reviewed, and we can argue about the definitions. The fact is that it refers to a minimum number.
The noble Lord will no doubt have read many other papers—the noble Lord, Lord Walton, referred to a number of them—which give far higher estimates. The Greater London Assembly has a printed document that refers to 10,000 individuals in London alone. The figures are very high and it is only responsible to use the latest ones, as many other speakers, including the noble Baroness, have. On the basis of that minimum number, we argue in favour of Part 1. We are not talking in hyperbolic terms but in a responsible, level-headed way on the basis of research that has been carried out. This minimum figure is three times the numbers killed each year in industrial injuries.
My Lords, this is a matter of statistical analysis. I am perfectly willing to rely on the contents of the paper. If the noble Lord has read it, I am sure he will challenge me further down the track.
My Lords, it is not the question of months or years that is relevant; that is why I could not understand the argument of the noble Lord, Lord Skidelsky. It is the fact that people died from smoking-related diseases who would otherwise have died from something else.
My Lords, I am content to rely on the analysis of the noble Lord, Lord Walton.
To return to the fray, the analysis of the noble Lord, Lord Skidelsky, is that it is an average of 15 minutes per person. It all depends, I suspect, on who you are. If the finger points at you, it is not a question of 15 minutes—you are subject to passive smoking and you are dying prematurely.
My Lords, I am quite content to rely on Hansard when the time comes and see whether it was four days or 15 minutes in a different context. I will certainly look at that. Four days is pretty hyperbolic in my book.
The BMA's 2002 report concluded that there are at least 1,000 preventable deaths every year as a result of passive smoking. The side effects include lung cancer, heart disease, respiratory disease, middle ear disease and asthma attacks. We have heard that both the BMA and the Royal College of Nursing support a complete ban in enclosed public spaces and we on these Benches agree. Alone among the parties, we included that in our manifesto at last year's general election. A partial smoking ban would have continued to leave workers at risk of the effects of second-hand smoke. That is why we welcome Part 1 as it left the other place.
If an exemption had been left in place for pubs not serving food, pubs currently serving food might well have stopped that facility if so doing would have allowed them to qualify as exempt. Various noble Lords have waxed lyrical on the virtues of licensed clubs. Exempting licensed clubs—there are some 20,000 of them—would have driven a coach and horses through the Bill. Why should workers in pubs be entitled to be protected but not those in private licensed clubs? I see no logic in exempting licensed clubs.
A further advantage of a total ban is that as lower-paid workers such as bar staff are exposed to higher levels of second-hand smoke than other workers it will help to reduce health inequalities. Furthermore, under the previous provisions, 45 per cent of the pubs in the most deprived areas would have been exempt compared to 14 per cent in the least deprived. There are strong issues in addressing health inequalities derived from Part 1 as well. Having visited Ireland, as the noble Baroness, Lady O'Cathain, mentioned, I am convinced that the issue of compliance and enforcement will not loom large. If Ireland can enforce the law and publicans and others can ply in the way that they do to a large extent, then, frankly, in England, Scotland and Wales we will be able to do the same.
I turn to ventilation systems, which the noble Lord, Lord Naseby, mentioned. While removing the smell of smoke, they cannot effectively remove the harmful chemicals in smoke. Recent research from Australia has shown that designated no-smoking areas in hospitality venues provide at best partial protection and at worst no protection at all against the effects of second-hand smoke. Ventilation is not affected and any smoking indoors will continue to pollute the air. Indeed, the paper's summary says that tornado-like qualities of ventilation are needed to have any effect. To rely on ventilation as a panacea is relying on something that is not a reality.
It is even clear that a ban on workplace smoking, including pubs and clubs, is popular, as the YouGov poll taken last December showed. The arguments for a total ban are founded on health and safety grounds, as many noble Lords have made clear. For reasons of protection of the workforce and fellow residents or inmates, I also favour a complete ban on smoking in care homes and prisons. I hope that during Committee we will be considering that matter, which was also mentioned by the noble Baronesses, Lady Rendell and Lady Masham. I also wholeheartedly take on board the points made by the noble Baroness, Lady McIntosh. We cannot simply airbrush out of our artistic culture the fact that over many years people have smoked; whether it is represented on the stage, in films or in other forms of art. On these Benches we are sympathetic to that point, particularly in my role as a DCMS spokesman; I am only here on loan, as my noble friend made clear.
This is a basic health and safety issue. A smoke-free environment should be the norm where non-smokers work. They should have the freedom to work in an environment free of damaging substances. That is where I believe that the freedom issue lies; not in the freedom to smoke in the presence of others, but being free of other people's smoke that can damage one's health. The Government do not and should not seek to legislate over individuals' smoking habits in their own homes. By the way, noble Lords who said that there would not be displacement were entirely right. None of the evidence demonstrates that there will be displacement as a result of a public smoking ban. It is the Government's role to provide a safe environment in enclosed spaces in the public sphere and where people work.
In addition to the immediate effect on employees and customers, there are of course wider benefits to be reaped in banning smoking. Such a ban would clearly help to reduce smoking in the population at large. That can only be a good thing. No-smoking laws have been shown to support smokers to quit. In Ireland, a survey by the National Smokers' Quitline service revealed that about 10,000 smokers reported that they had reduced their consumption since the ban came into force. According to the Irish Revenue Commissioners, cigarette sales fell by nearly 16 per cent in the first six months of the ban. I am sure that the noble Lord, Lord Naseby, will have views on those facts, but they are the facts that I have to hand.
Similarly, in New York City there are now an estimated 200,000 fewer smokers than when a ban was introduced in 2002—a 15 per cent decrease. Smoke-free laws have also reduced smoking rates across all population groups. Surely a similar effect in England would be good news for the nation's health. As we have heard, the Government's own estimates suggest that a smoking ban would encourage some 600,000 to 700,000 people to give up smoking.
Crucially, research by the Chief Medical Officer has shown that fewer young people would take up smoking if their workplace was smoke free, possibly reducing smoking rates by a third among the 300,000 16 year-olds who start work each year. Opponents have raised spurious economic figures to show the damage to the hospitality sector, but if we take the Irish experience, which is close to what we expect ours to be, the volume of sales in beer, wine, spirits and food in pubs rose by 5.3 per cent in the year to last October, and the value of sales by 4.2 per cent; which reverses a longstanding decline in sales of those products in previous years. The same is true in New York according to the New York City authorities. In fact, estimates by the Chief Medical Officer are that a ban could benefit the British economy by up to £2.7 billion; an impressive figure.
Finally, we should note the words of the BMA's head of science and ethics, Dr Vivienne Nathanson:
"The medical profession is united in its calls for a total ban on smoking in all enclosed public places and workplaces. Recent research reports that second-hand smoke kills 30 people each day. The situation in New York, Ireland and other cities and countries that have gone smoke-free show that these policies do not harm business, they do not cost jobs. The policies are popular, they encourage people to quit and they protect health and save lives. What possible argument is there for not implementing a total ban?".
The Bill also has the benefit of bringing England in line with Scotland, which has passed legislation introducing a ban on smoking in all enclosed public places that will come into force on
My Lords, will the noble Lord, Lord Clement-Jones, clarify one point before he sits down? He said that noble Lords on his Benches would be supporting the Bill as it emerged from the Commons. However, in the other place seven Liberal Democrat honourable Members voted for an exemption for private clubs. Is he saying that unlike in the Commons, Liberal Democrats in this House will not be permitted a free vote?
My Lords, that is an interesting point. I will rely on the usual ministerial response that I will have to ask the usual channels. I cannot commit our Whips to any such thing, whether it is a free vote or not. I can speak only for myself and the health team. I believe that we will have a rousing vote for Part 1, especially since it is a manifesto commitment. We might indeed wish to go further, as I indicated in my speech, in terms of banning smoking in care homes, prisons and so on.
My Lords, this has been a very good debate, which has generated a good deal of what this House enjoys and is good at: well-informed opinions trenchantly articulated. It has been far from the damp squib that some of us thought it might be a couple of days ago when the list of speakers was extremely short. As all the contributions have demonstrated, the Bill presents us with a variety of disparate themes thrown together inside a single wrapper. There is nothing wrong with that, but in any job of summing up such a debate, seamlessness will not be an attribute much to the fore. My initial comment to the Minister is that the greater part of what the Bill contains is uncontroversial and that a great deal of it deserves a welcome and a fair wind. Those parts that do not fall within those descriptions are perhaps self-evident from speeches today.
I wish to start with the positive. All of us were aware, as the details of the Shipman case emerged, that an official inquiry into it would be a near certainty and that recommendations would ensue that probably would require legislative change. I am very pleased to see provisions in Part 3 of the Bill that respond to the concerns expressed in Dame Janet Smith's fourth report about the use and monitoring of controlled drugs. The measures proposed appear in the round to be sensible and proportionate, even if they are not quite what Dame Janet recommended. I am not sure what led the Government to favour the idea of creating accountable officers ahead of Dame Janet's concept of an inspectorate. If we were looking at an inspectorate, the most obvious candidate, certainly in the case of community pharmacies, would be the Royal Pharmaceutical Society of Great Britain, which already has an inspectorate. It would be helpful if the Minister commented on this.
Setting that matter aside, if we table amendments on this part of the Bill, they are likely to relate to issues of detail and practice, rather than principle. That comment applies in equal measure to the provisions in Part 4, relating to fraud, and to the whole of Parts 5 and 6, which are not contentious.
I listened carefully to what the Minister had to say in relation to Clauses 25 to 32, covering medicines and pharmacies. We shall probably wish to probe these issues in Committee, because while we all subscribe, I am sure, to the notion of a wider role for community pharmacists in delivering patient care, it would be wrong to try to achieve this at the expense of patient safety. I should like to be quite confident that allowing drugs to be dispensed by unsupervised pharmacy staff will not open up such risks. We also need to be clear about precisely what activities a pharmacist needs to oversee and how wide his empire of responsibility ought properly to be. The issue boils down to what is entailed by the phrase "responsible pharmacist" and exactly how the current rules are to be varied. These are matters to be explored. It is regrettable that so much is to be left to regulations.
I listened carefully to the Minister's explanation of the proposals relating to ophthalmic services. He will know that there is considerable disquiet among optometrists about the implications of these proposals. We have had a system that has worked perfectly well up to now, so why change it? And why change it without consultation and in advance of the review of general ophthalmic services? If we change it, and give PCTs the responsibility for commissioning services, the fear is that budgets will leach away into other patient services where funding is under pressure, that PCTs will be tempted simply to go for the cheapest option and that, as a result, the quality and range of ophthalmic care will diminish, with possibly fewer officially approved practitioners for the public to go to for eye tests. That may not be the Government's intention, but the fear exists. We shall need to explore the rationale and the practical implications thoroughly. What we all want to see, and what the profession is without doubt capable of delivering—if it is allowed to—is an even better and even more innovative service to the patient. That should be what we aim for here.
We have debated on a number of occasions in this House the vexed issue of healthcare-associated infections. I shall not make this an opportunity to bash the Government, but the Minister will know very well the number of initiatives that the Department of Health has already put in place to try to combat this problem during the past few years. I have no objection to the idea of a statutory code, but the question which we have to ask, and which has been asked a number of times today, is whether a statutory code will really make the crucial difference. What matters is that hospital staff should follow the proper procedures. The existence of a code is fine as far as it goes, but it will not affect behaviour; nor, I fear, will the issue of an improvement notice by the Healthcare Commission, which already has extensive powers to audit and criticise hospital practice. It is the extent to which staff—all staff, and not just doctors and nurses—are motivated to do the right thing and are held to account if they do not that will make the difference. Whenever corners are cut in hospital hygiene, it has a lot to do with time pressure, lack of access to washing facilities and high levels of bed occupancy. These are very difficult problems to overcome.
Where the Government are right is in making it clear that good hygiene is not, and can never be, an optional extra. It is a top priority. The BMA estimates that about 15 to 30 per cent of healthcare-associated infections are preventable. That figure surprised me, because a lot of hospitals in the NHS have done considerably better than that, but it tends to show that a code of the kind proposed here is not likely to prove to be a magic wand. Once again, we shall wish to test and probe the Government's intentions in this area in Committee. It would be very good if we could see a final draft of the code before then. I do not know whether that is possible.
I have left 'til last the Bill's most contentious ingredient, on which many noble Lords have focused their remarks today. A legal ban on smoking in the workplace and in all other enclosed public spaces, including bars, clubs and restaurants, is indeed a momentous step for Parliament to take. If the decisions taken in another place are accepted by this House, no government Minister will be entitled to claim credit for them. The Government have been all over the place on this issue. They were elected on a manifesto commitment which amounted to a partial ban on smoking in public places. There were to be exemptions for pubs and bars that did not serve food and for private members' clubs. After the election, the Government had second thoughts. The Cabinet deliberated whether it would be better to go for a more comprehensive ban. Following weeks of discussion, it was decided to stick with the original policy. The Bill was published. The Secretary of State introduced the Bill in another place and defended the policy. Among other things, she stated her firm belief in the right of private clubs to decide on their own smoking arrangements.
Then, all of a sudden, the policy disappeared. It was goodbye to the manifesto commitment and to the Cabinet decision. The whole issue would be subject to a free vote. On Report, the Secretary of State, along with the Prime Minister and the Chancellor of the Exchequer, did something quite unprecedented, which was to vote against their own Bill, against their own manifesto and against the policy that had been thrashed out in Cabinet and so stoutly defended at Second Reading. The Secretary of State did something even more extraordinary, which was, without warning, to vote against an exemption for private clubs, which she had previously declared as being right. One has to ask what kind of leadership that is from a Secretary of State for Health. Whether or not you agree with government policy, you expect there to be a policy on a matter as important as this and you expect a Secretary of State to give a lead in promoting it. The handling of the Bill, on this major issue, has been woeful.
Your Lordships face a decision about what to do. My own view, though painful for a number of noble Lords, is that the decision is straightforward. The majorities recorded in the other place, on a free vote, in favour of a complete ban were substantial. For this House to overturn those decisions would not be right. We can, and we should, debate the detail of those decisions and test their practical implications, but I suggest that that is, bearing in mind the role and powers of this House, as far as we should go. I say that with due respect—
My Lords, it will be a free vote as far as my party is concerned.
I have reached my conclusion with due respect to my noble friends Lord Naseby and Lord Geddes and other noble Lords who spoke in the same vein, as well as to the 100 or more men and women from Whitefield in Manchester whose petition on the subject reached me today.
Perhaps I could also express a personal view. A few years ago, any discussion about second-hand smoke revolved mainly around arguments about its nuisance value. That has changed. The medical evidence set out by the Scientific Committee on Tobacco and Health is unequivocal. Second-hand smoke kills people. It kills a lot of people. It is not simply the increased risk of lung cancer.
My Lords, my noble friend says that the evidence is totally conclusive. In that case, why is that evidence not made public? Why are the minutes of the meetings currently redacted?
My Lords, I cannot answer for the committee or its proceedings, but there is no shortage of evidence either from the committee or from published papers in medical journals that reach exactly the same conclusion. Those were papers that the committee itself reviewed.
My Lords, I have not been able to read the study to which the noble Earl refers. Can he say whether it is based on statistical or clinical evidence? Is there a body of clinical evidence to support the figures that he has given us?
My Lords, I take as my brief what expert medical people tell me. I am in no position to second-guess what they tell me, and I would not dream of doing so. Where we have an authoritative body that advises the Government such as the Scientific Committee on Tobacco and Health, I take it as read that it is composed of people who know what they are talking about. If someone wishes to challenge that, I am ready to listen, but I do not feel sufficiently qualified to do so myself.
My Lords, I am most obliged to the noble Earl for again giving way. Would he therefore urge the organisation to publish all the evidence and methodology that it used?
My Lords, in so far as I have any leverage with that committee, I should be glad to do so. I am not sure whether I am the best person to urge that course, but it is one that I would endorse wholeheartedly.
It is not simply the increased risk of lung cancer. It is also the significant increase in the risk of coronary heart disease from quite modest exposure to second-hand smoke. In other words, there is a non-linear relationship between dose and risk. Once one accepts the evidence—it is endorsed by every reputable medical body around the world—one has to accept that it is no longer a nuisance issue; it is a public health issue. If it is a public health issue, it is obvious that there is no acceptable halfway house. The Government's manifesto policy to exempt some pubs and bars, but not others, made no sense whatever. The risks from smoke are the same, whether the pub you are in does or does not serve food. In fact, it is worse than that because the areas of the country where the largest number of non-food pubs are to be found are those where there are already poorer than average levels of health. That is why the Chief Medical Officer stated that a partial ban was worse than no ban at all. That is also why I am so critical of the Government. For many months, they led up us a blind alley that was very obviously a blind alley and one that would actually have worsened health inequalities.
At the last general election, my own party was quite clear: we wanted to bring about a situation in which non-smokers in enclosed public places and at work should not be exposed to second-hand smoke. We would have done that by a different route—by voluntary self regulation and by promulgating a beefed-up health and safety at work policy. The end in view was broader than under the Government's previous policy. However, that is now past. Now that a legislative solution is in prospect, we need to make sure that its full implications are debated in a constructive spirit and understood. That, I suggest, will be our task in relation to this and other issues in the Bill when we reach Committee stage to which I, for one, look forward.
My Lords, I thank most noble Lords for their support for the Bill. I also welcome back the noble Lord, Lord Clement-Jones. Long may he continue on this free transfer. We look forward to our discussions at later stages of the Bill. I also gently remind noble Lords, such as the noble Lord, Lord Monson—who described it graphically as a health fascism Bill—that there were 47 fascist Conservatives and 47 fascist Liberal Democrats who also joined members of the Government and Labour Back-Benchers in the other place in voting for a comprehensive ban.
My Lords, I seem to recall that the noble Lord described this as a health fascist Bill, but we shall let Hansard speak for itself.
We could spend a long time debating the figures. I think that the figures are in the public arena. I shall not go over them again. Noble Lords can interrupt me as much as they like, but I shall not go over the figures again. We spent a lot of time on that issue. The information is in the public arena. If people have a thirst for knowledge they can read the documents. They are well set out in the public arena.
I wish to clarify any confusion over what I said at the end of my opening speech—I do not think that I confused people—about 600,000 lives. I did not say that 600,000 lives were saved. I apologise if I confused people. What I said was what was in the regulatory impact assessment: smoke-free provisions will lead to 600,000 smokers giving up, not lives saved. That is a 1.7 per cent reduction in prevalence. What that suggests—as I also said—is that many lives will be saved in the long term.
With regard to some of the issues raised by the noble Lord, Lord Skidelsky, and others, this is not a debate about statistics, about how many people died and to what extent their lives were truncated. I ask the noble Lord and others who shared his views to think about how many people will also have the quality of their life affected as they have their life shortened. Many people are in the position of my noble friend Lord Simon. They may have conditions that are adversely affected. There is a quality of life issue and deteriorating health for many people who are afflicted and have to subject themselves to the experience of second-hand smoke.
The noble Lord, Lord Naseby, is concerned about the SCOTH report and whether information is being withheld from the public. SCOTH has reported twice in the past eight years, in 1998 and 2004. Both reports have been published. They are in the Library. Their case has been set out. People can read it. They can consider whether they accept or reject it. In addition, the World Health Organisation reported in 2002 classifying second-hand smoke as a known carcinogen.
My Lords, I wish to continue with my speech.
Let me respond to some other points that were made about the issues around ventilation. I think that the noble Lord, Lord Clement-Jones, put the points in that area very well. There is a total lack of good evidence that ventilation provides a real solution to the health risks associated with second-hand smoke and we do not want to require expensive and potentially useless ventilation equipment, as that would be burdensome to many of the people involved.
A lot of concern has been raised about the impact on the home of the ban on smoking in public places and the workplace. The evidence from New York suggests that 100,000 people have quit smoking since the ban was introduced there; in Ireland, cigarette sales in 2004 are 15 per cent down on 2003 and, after the first six months of the ban, an estimated 7,000 more smokers have quit than would otherwise have been expected to. That evidence is also in the public arena for the sceptics to consider as they wish.
Issues have been raised about exemptions. We shall no doubt go into those in considerable detail in Committee, but I should like to clarify one or two points. The noble Baroness, Lady Masham, raised the issue whether exemptions would extend to prisons. Prisons are exempted due to human rights issues, as prisons are a person's residence. However, I can say to the House—and I shall put this in more detail in writing to noble Lords—that the Prison Service management board has set up a working group with the Department of Health to review all the implications of the smoke-free provisions of the Bill with a view to achieving smoke-free prisons, so that certain safeguards are made for prisoners who do not want to be exposed to the smoke.
Residential care homes are also to be exempted on human rights grounds, as they are the residences of those living in them, but we shall issue guidance to homes on how best to provide protection from second-hand smoke for other residents and for staff. It is not intended to exempt student halls of residence as such; however, an individual student's private rooms would be exempted, as they are the individual student's residence.
The noble Baroness, Lady Cumberlege, raised a number of issues around teenage smoking rates. What I can say to her is that the prevalence of smoking among children aged 11 to 15 steadily increased between 1988 and 1996, from 8 per cent to 13 per cent, but that since 1996 the rate has fallen. In 2004, 9 per cent of pupils aged 11 to 15 were regular smokers. We seem to have peaked, and the percentages are coming down.
The issue of smoking in the Houses of Parliament is a matter for the House authorities, not the Government. It is down to the House whether it wishes to set a good example to other people. My noble friend Lady McIntosh raised the issue of the impact on the theatre industry of the smoke-free provisions. We are still considering representations from the theatre industry; we are aware that in those countries that have already brought in smoke-free legislation there are a number of different approaches to smoking on stage. That will be covered in the public consultation on the regulations to be made under the Bill.
I turn to some of the issues raised around healthcare-associated infections. I would gently say to the noble Baroness, Lady Cumberlege, and remind the House that MRSA took root in our hospitals between 1993 and 1997. There is good evidence on that and we have put that evidence in the public arena. As a Government, we introduced mandatory surveillance, which has now been extended. I shall give further and better particulars on conditions other than just MRSA. We believe that the code will improve hygiene. The fact that we do not know everything about tackling healthcare-associated infections does not mean that we should not codify what we do know to improve public safety in this area. We know that there is variation across hospitals in the extent to which they have been able to tackle healthcare-associated infections, and we believe that the code will achieve greater uniformity and help to bring up the standards of the less good to the standards of the best. We do not believe that there is any evidence that targets to improve health services have actually had an adverse impact in that area.
The noble Baroness, Lady Barker, asked why the code did not apply to the independent sector—to residential care and nursing homes. Enhanced standards of infection control should in our view apply in all settings in which healthcare is provided. We will accomplish that through the legal framework of the Care Standards Act 2000, which forms the foundation of the regulation of the private and voluntary healthcare sector and care homes. In other words, the relevant elements of the code will be applied to the independent sector under regulations made under the Care Standards Act.
The noble Lord, Lord Colwyn, asked whether the healthcare-associated infection code should be delayed until the Bill gains Royal Assent. We obviously want to get this into operation as quickly as possible, but we need to wait until the Bill gains Royal Assent before the new powers given to the Healthcare Commission kick in. But the draft code is already available to all NHS bodies.
The noble Baroness, Lady Barker, raised some issues around the social care bursary scheme. The transfer is administrative; there is no more significance in it than that. It was a result of the recommendations of the arm's-length body review.
I turn briefly to a number of issues raised in relation to the Bill's provisions on pharmacy and other areas. I am happy to give the noble Lord, Lord Colwyn, the assurance that the Bill does not affect the work of dispensing doctors. The noble Baronesses, Lady Barker and Lady Murphy, raised concerns about the extent to which people might be put at risk in circumstances in which a pharmacist had responsibilities extending beyond more than one pharmacy. We are trying to ensure that there will be a responsible pharmacist in charge of every pharmacy, even those open 100 hours a week. That pharmacy is expected to be their main place of work. There will be exceptions to the "one responsible pharmacist" rule only in exceptional circumstances. An example already in use in Australia is a pharmacist-controlled vending machine, where the pharmacist safely controls the supply of medicines from another place.
It would not be sensible to require a responsible pharmacist in that situation to stand by the vending machine on the registered pharmacy premises. The responsible pharmacist will be required to set down procedures and determine which staff are competent to undertake them safely. There are a number of other specifications that would ensure patient safety in this area, and I am happy to put those in writing to noble Lords after this debate.
I can confirm to the noble Lord, Lord Walton, that we will consult widely on the regulations, and will expect to work closely with pharmacy organisations such as the Royal Pharmaceutical Society of Great Britain, with which we have already been working in preparing this legislation. In those regulations we will clearly define the activities that pharmacists must undertake themselves and those that can be delegated to other competent staff.
The noble Baroness, Lady Barker, mentioned inspection. It is intended that Royal Pharmaceutical Society inspectors will inspect controlled drugs management in community pharmacies as part of their routine inspections of community pharmacies. That will build on their expertise and minimise disruption.
I tried to give reassurance in my opening remarks about ophthalmic services. This is not the occasion to go into great detail, but I will try to extend those reassurances in a letter to all noble Lords. The noble Baroness, Lady Masham, raised some concerns about stoma service changes. The consultation on that finished on
My noble friend Lord Rosser raised an important set of concerns about support for non-executives and the role they play in the running of NHS bodies. He is quite right to raise those concerns, and I assure him that my right honourable friend Patricia Hewitt and I are pursuing the issue energetically.
I have tried to cover many of the points noble Lords have raised. I am sure we will go into considerable detail on some of those issues, and I have no doubt that we will be batting around figures about second-hand smoke in a very happy manner, but tonight is not the time to re-enter that fray. I will be pleased to write to noble Lords on all the points I have not managed to cover.
My Lords, the code is still in draft form, but we have put the latest version of it in the Library because it is also available in the NHS to help improve standards, even in its non-final form.
On Question, Bill read a second time.