Sir George speaks out on smoking and direct payments
8 Jun 2009
This is the speech which Sir George made in the House of Commons on the second reading of the Health Services Bill

Sir George Young (North-West Hampshire) (Con): It is a pleasure to follow the hon. Member for North-West Leicestershire (David Taylor), who is chairman of the all-party group on smoking and health, in which I am a humble spear carrier. Where he leads, I follow. I want to return in a moment to the points that he made about tobacco.

May I pick up on a point that my hon. Friend the Member for Basingstoke (Mrs. Miller) made about clause 34, which caps the private income that can be generated by a foundation trust? When the Bill setting up foundation trusts was going through the House of Commons, I remember objecting to that provision because it would freeze the activity of a hospital such as Basingstoke hospital at what had been its historic level. The whole thrust of the foundation hospital movement was to enable a hospital to develop its specialities, to expand in the areas in which it had a competitive advantage and to generate more income that it could then plough back into increasing its NHS activity. That is exactly what has happened in Basingstoke and I endorse the eloquent plea from my hon. Friend and neighbour that the clause should be allowed to stay in the Bill and should not be axed.

I welcome the Secretary of State to his new post. He could not have known five days ago that he was going to be moving the Second Reading of the Health Bill on this particular Monday and he did so with remarkable skill.

I want to touch briefly on two points, the first of which is chapter 3 and the provision for direct payments. I believe that the most radical element of this Bill is the provision for direct payments, and it has been touched on briefly in the debate by my other neighbour, the hon. Member for Romsey (Sandra Gidley). It is the manifestation within the NHS of a social policy that has already made good progress in adult services where it trades under the name of personal directed support. Direct payment potentially represents a very radical move from an inflexible, institutionalised response to a client’s or patient’s needs to a much more flexible, user-friendly response, and I welcome it. When we had a debate about this policy in the social care context, the Minister said that it would mean that people would have a life, rather than a set of services. Indeed, the Minister who said that might well have been the Minister of State, Department of Health, the hon. Member for Corby (Phil Hope), who is sitting on the Front Bench. In the social care context, that summed it up rather well.

I understand that the proposal is only for a pilot and that only a limited range of services can be funded by direct payments, but there are potentially enormous implications for the NHS. When services have been provided by a monopoly supplier, a new market for different suppliers is opened up. At the moment, the NHS is the funder, the prescriber or advocate, and the supplier. As direct payments come into play, the NHS will remain the funder, but the role of advocate and supplier will become available to others. For that to work in the social care context, independent advocacy services need to be available. As I looked through chapter 3, it was not absolutely clear to me who would provide that role for the NHS. If the NHS is the advocate, it is not clear that the patient will get the best value from direct payments because the patients might not be told what is available outside the NHS. If someone else is to do the advocacy, as they probably should, who will do it and who will pay for it? Will the cost of the advocacy have to come out of the direct payment?

I accept the point that choice is less of an issue in health than it is in social services, because it is by its very nature a more prescriptive service, but I think that patients want choice. Although they want choice, they do not want the hassle of contracts, of employing people, of insurance and all the rest. One reason why so few people took up direct payments in social services—initially, only 5.4 per cent. of those who were eligible did so—was the paperwork. We have to make it absolutely clear that the advocate or the NHS can handle the paperwork once the patient has decided on the package. The proposed new section 12A to the National Health Service Act 2006, which appears in chapter 3, makes provision for that, I think.

If direct payments are to work, the supply side of the health care market will have to respond and it might need some pump-priming. There will be demand for a totally different range of services as patients invest in packages of care that they have selected. Over time, the market might change as resources are shifted from institutionalised provision, on the one hand, to much more individualised provision on the other. There might be fewer block contracts, there will need to be much more transparency on costs and, crucially, we will need more trained providers who can provide the packages that people want.

The question of resources has been touched on. The issue of what I call calibration is crucial: how much money should be allocated for the direct payments or the individual budgets? There is a risk that the whole policy could not take off if unrealistic provision is made and people then find that they cannot buy the range of services that they need. At the moment, a PCT can prescribe through the GP or consultant a range of treatment and there is little transparency on cost—it will probably get lost in a block contract. With direct payments, however, the costs are of enormous importance and are very transparent. In some cases, experience with direct payments in social care was that the sum allocated simply was not enough to purchase the care that was needed, which may explain why take-up is low. We need realism in pricing if direct payments are to work.

We need to know how the direct payments policy set out in chapter 3 relates to the parallel policy of allowing primary care trusts to top up individual budgets from social services. For example, when a patient is also a social services client, will the PCT simply put the direct payment into that pot, or will it set up a separate one with its own NHS rules?

Top-ups are allowed in social care. I understand that, because they are means-tested, but apparently they will not be allowed under direct payments for the NHS. I cannot find a provision in the Bill that says top-ups are banned, but the King’s Fund briefing says that top-ups will not be allowed. There is a risk of confusion, because we are moving towards toleration of co-payments in the NHS—we had a debate about cancer drugs, for example—and if we are to allow people to top up their social care payments but not their NHS payments, and all the money is put in the same pot, I can see a philosophical problem. I hope the issue of top-up payments will be kept under review.

We have already heard about risk. How do we reconcile the right of an individual to determine how he or she spends the direct payment with the obligation of the PCT to ensure that public money is spent wisely and to discharge its responsibility to look after vulnerable people? We heard from the Secretary of State that there will be some safeguards, in that the PCT will have to validate the plan, but there will inevitably be an element of risk although I do not think it is necessarily a killer argument against going ahead. The same argument was deployed in the social care field, but in the event there has been little abuse of funds.

Finally on this point, I have a philosophical question. Why do the Government stop here? Does the logic of direct payments not imply that they could be extended elsewhere—to adult education or indeed to school-age provision? Perhaps the Minister who winds up the debate will explain the difference between an NHS direct payment and an education voucher. With that controversial question hanging in the air, I shall move to my second and final point, which relates to part 3 and the clauses on tobacco.

My first job as a Minister—30 years ago almost exactly to the day—was to renegotiate the voluntary agreement on advertising with the tobacco manufacturers. Because of my aggressive stance, I was transferred to another Department, but I have long taken an interest in measures that reduce the damage done to the nation’s health by smoking, so I welcome the Bill, which makes further progress in the right direction. However, I find myself a little ahead of my Front-Bench colleagues on the issue, and indeed of some of my other colleagues. I hope the Government will resist attempts to water down the Bill’s provisions.

The Bill includes two important measures that will help to protect children from smoking and help smokers who are trying to quit. It also includes measures to restrict or prohibit cigarette vending machines and to put an end to the tobacco industry’s powerwall promotional displays. I agree with all those who say that the measures need to be seen in a broader context—as part of a comprehensive strategy
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to reduce the incidence of smoking and a proper plan to reduce the terrible burden of tobacco-related death and disease.

The measures in the Bill are wholly consistent with the ban on smoking in public places and the ban on advertising. They are trying to change the climate in which smoking was seen as a socially acceptable behaviour. As advertising was prohibited, so that changed the environment. As smoking in public places was prohibited, that too changed the environment and the measures in the Bill to restrict the display of tobacco packs will make a further change in the environment, to discourage the activity.

Very few smokers start as adults, and if the Government were to succeed in preventing under-age smoking, the tobacco industry would be out of business in a generation. The fact that the industry is so against what is in the Bill sends me the clear message that we must be on the right track and that the Bill must be good for public health.

The health and medical communities are united; the research clearly shows that tobacco displays increase awareness of brands and prompt purchases among young people. Jurisdictions that have put an end to such displays have seen youth smoking fall. A study of smokers published earlier this year shows that displays prompt sales where none have been planned and tempt smokers who are trying to quit. Indeed, one in four smokers says that a display ban would make it easier for them to quit.

I take the point that has been made about the impact on retailers of introducing these measures during a recession, but that is not what the Secretary of State is proposing. Whatever inconvenience small shopkeepers encounter will not occur for four years, by which time we will—we hope—be out of recession. Tobacco displays are typically replaced every three to five years, which would give ample opportunity to plan ahead for low-cost compliance.

The Secretary of State may have noticed that both speeches from the Government Back Benches advocated much faster action on vending machines, as have speeches by Opposition Members. I hope the Secretary of State gets the message that there is an appetite in the House for faster progress than is proposed. The tobacco vending machine market is worth £1 billion and is dominated by Sinclair Collis, a subsidiary of Imperial Tobacco. As has been said by a number of Members, the purchases are unsupervised, young smokers are rarely challenged and in some cases staff even offer assistance. Vending machines compete with small retailers, and a ban on them would help the smaller retailer because sales would be transferred to local retailers who are open all hours. An outright ban on vending machines would provide health gains but, as I have just said, it would also offer a benefit to hard-pressed small shopkeepers.

Smoking is the largest cause of preventable death and disease in the UK, causing more premature deaths than alcohol, obesity, road accidents and illegal drugs combined. The provisions could reduce those burdens on our children, so I hope the House will resist any attempt to water down the provisions and I hope Ministers will be encouraged by the debate so far to build on what is already in the Bill and take the argument and the debate a stage further.

 
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