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House of Lords

Thursday, 6 October 2011.

11 am

Prayers-read by the Lord Bishop of Derby.

Railways: Brighton to London Line

Question

11.06 am

Asked By Lord Berkeley

Earl Attlee: My Lords, there are no current plans to issue safeguarding directions. However, the former Uckfield to Lewes route is safeguarded by both Wealden and Lewes district councils in their local plans.

Lord Berkeley: My Lords, I am very grateful to the Minister for that Answer. Is he aware that East Sussex County Council has plans to build a road across the formation outside Uckfield which would, of course, completely prevent the line being reopened? Furthermore, is he aware that British Rail Property Board, which, as the House will know, is being abolished, is trying to sell off all its surplus land, which includes the land of the old Uckfield station, which, again, is essential to the reopening of this line? Will he instruct the property board not to do that and to keep this and other similar pieces of land for future reopening?

Earl Attlee: My Lords, the noble Lord raised two points, the first of which is the road. One of the benefits of the proposed scheme is that it allows for the building of a bridge at a later stage should that be necessary. In fact, the scheme makes it easier to open the line, should that be necessary, because to the west of the proposed road crossing is a level crossing, which would be unacceptable if you wanted to open the railway.

The noble Lord asked about the BRPB and whether we would give it directions. No, we will not. It is not necessary. We are absolutely confident that nothing has been done that will compromise the ability to open the railway at some point in the future, should it be desirable to do so.

Lord Bradshaw: Will the Minister widen his consideration just beyond this line. There are a number of noble Lords who have in their areas of interest railway lines that could be reopened with advantage in the future. Surely the land concerned should be vested in Network Rail, which in July last year pronounced the Uckfield to Lewes line of strategic importance. There are many other such lines, of which one example is Oxford to Cambridge. This has been made almost impossible to open between Bedford and Cambridge because of building.



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Earl Attlee: My Lords, it is important to ensure that disused railway lines could be reinstated if it was necessary. The difficulty with my right honourable friend the Secretary of State issuing safeguarding directions is that he can do so only if it is intended to reopen the railway line, not to make it possible. In addition, if he does give safeguarding directions, it can result in compensation to developers.

Baroness Whitaker: My Lords, does the Minister accept that his words "at some point in the future" are not very consoling to south-east commuters, of whom I am one, who regularly have to stand on overcrowded trains at certain times of the day?

Earl Attlee: My Lords, the noble Baroness makes an extremely important point. We all know that at peak periods, the commuter railway lines south of London are all running at peak capacity. One difficulty is that we cannot easily increase the capacity to the main line terminals. In the case of Uckfield to Lewes, one of the bottlenecks is East Croydon, so even if we increased capacity in that area on the south of the line, you would still encounter the bottleneck at East Croydon, and there is very little we can do about that.

Lord Dubs: My Lords, does the Minister agree that many people believe that the Beeching cuts represented an act of terrible vandalism in the previous century? There are local campaigns to bring back many small railway lines up and down the country that have fallen into disuse because of Beeching. Can the Government at least say that they will encourage local initiatives to help us restore those railway lines? They have environmental benefits and tourist benefits. If the Government were to say that that is their policy, many of us would be very grateful.

Earl Attlee: My Lords, it is great that there are local initiatives to reopen lines-to make my department think carefully about that-but there has to be a good business case.

Lord Dholakia: My Lords, does the Minister accept that Gatwick Airport is a very popular destination for those travelling between London and Brighton? The number of passengers has increased. Secondly, does not the maximum use of the line between Victoria and Brighton demonstrate the need to preserve an alternative method, especially when this expansion of the Brighton line is exhausted?

Earl Attlee: My Lords, I fully accept that the Brighton line is running at capacity, but this particular scheme will do nothing to relieve the bottleneck. For instance, the path between Sevenoaks and Orpington is just twin track and there are no more train paths available at the peak period.

Lord Rosser: Nearly all line reopenings that have taken place have proved successful and have more than met projected passenger figures. Can the Minister say whether other lines are being considered for reopening? In particular, what is the current position with the reopening of the Skipton to Colne route and the safeguarding of that route?



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Earl Attlee: My Lords, the Skipton to Colne route is a little far from Uckfield and Lewes. I can point to the dualling of the Swindon to Kemble line, which is very expensive but will bring many benefits. I see the Leader of Her Majesty's Opposition nodding her head enthusiastically.

Lord Berkeley: My Lords, I am very grateful to the Minister for the answers that he has given to various colleagues on my original Question. Lewes-Uckfield is in Network Rail's route utilisation strategy, which was published last year, so a lot of people in Network Rail must think that there is demand there.

The Minister said that if the Secretary of State was asked to give some assurance or make some designation on certain routes, the developers might try to claim compensation. Given the time that it takes to develop any of these new railway lines-noble Lords have given different examples-surely there is a case for looking at the policy again so that routes can be safeguarded even for 10 or 20 years. It may take that time to get a new project off the ground.

Earl Attlee: My Lords, we do not think that that route will need to be opened within the next 20 years.

Legislative Timetable

Question

11.14 pm

Asked By Lord Soley

The Chancellor of the Duchy of Lancaster (Lord Strathclyde): My Lords, like every other Government before us, we intend to enact the legislative programme set out in the Queen's Speech by the end of the Session. We have no plans to review that objective.

Lord Soley: Does the Leader of the House accept that there is concern in all parts of the House, including among his own Back-Benchers, about the amount of ill-drafted legislation being presented, resulting in Bills being withdrawn or changed? The situation has been made increasingly complicated, in ways which we all understand, by deals that have to be done within the coalition, which makes it more difficult to compromise after the event. However, does that not mean that it is vital that the Government go the extra mile to liaise with the other political parties and Cross-Benchers in this House to deliver an outcome that gets us through? Otherwise this House will be sitting on Christmas Eve, and we all know it.

Lord Strathclyde: My Lords, I was not aware of the noble Lord's concerns. However, he is entirely right that the Government wish to go the extra mile with our own Benches, with coalition partners, Cross-Benchers and, indeed, with members of Her Majesty's loyal Opposition, and that is precisely what we do. That is one reason why we spend so much time on legislation. Noble Lords will remember the 20 days in Committee that we spent on the PVSC Bill earlier this year. I wonder whether they feel that that time was well spent.



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Lord Ryder of Wensum: Exactly two years ago, on 5 October 2009, at the Conservative Party conference in Manchester, the then shadow Leader of the House of Commons, now its Leader, Sir George Young, stated:

"Conservatives will legislate less, but we will also legislate better. So today I can announce that we will abolish the practice of automatically guillotining government bills".

Why have Sir George and the Government broken those two promises?

Lord Strathclyde: My Lords, on the first point, I am delighted to tell my noble friend that in the first Session of the last Labour Administration, in 2005-06, 4,005 pages of legislation were enacted. So far this Session, which is longer than the 2005-06 one, we have passed only 1,392 pages of legislation. As for automatic timetabling in another place, that is up to the procedures there. However, I understand that most of that timetabling is agreed with the Opposition, very often without a vote.

Baroness O'Neill of Bengarve: Does the noble Lord the Leader of the House consider that it might help both Houses if legislation were drafted at an earlier stage? At present, I understand that departments of state receive a budget for parliamentary counsel to start drafting only when they have a guarantee that such legislation will be in the forthcoming Queen's Speech. That is too late, and I believe that we might have better drafted legislation that we could deal with more expeditiously if that were changed. It does not require legislation to change it.

Lord Strathclyde: My Lords, I broadly agree with the noble Baroness. She will welcome the fact that the Government are committed to promoting other forms of scrutiny and have already published a number of Bills for pre-legislative scrutiny in this Session alone. We are currently scrutinising in pre-legislative scrutiny some six Bills, including clauses relating to individual electoral registration and electoral administration.

Baroness Royall of Blaisdon: In relation to the PVSC Bill, I suggest that noble Lords may wish to look at comments made recently by the noble Baroness, Lady Warsi, and the noble Lord, Lord Rennard, on the boundary proposals. Many noble Lords, and certainly colleagues down the Corridor, might think that we did a jolly good job in this House.

Does the Leader of the House agree that it is preferable for this House to sit in the same weeks as the House of Commons? We are two Houses but one Parliament. Can we have the noble Lord's assurance that next year we will not sit during party conference weeks? To do otherwise is not good for the smooth running of business, not good for Parliament and not good for politics. Some of us in this House are proud to be politicians and we wish to participate in our party conferences.

Lord Strathclyde: My Lords, I have received a number of representations from noble Lords all around the House who are very opposed to sitting in September and would infinitely prefer to sit earlier in October and sometimes even later in July. That is something that it is right for the usual channels to discuss. Of

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course we are one Parliament. We are also two Houses. We have different rules and regulations and are not the same in that respect. We deal with legislation very differently.

Lord Maclennan of Rogart: My Lords, can my noble friend the Leader of the House give some indication of the progress of his consideration, and that of the Government, of the recommendations of his group on the working practices of the House, which gave some consideration to the programming of Bills in another place and made some suggestions that might help to ease the pressure and enhance the careful deliberation on these Bills?

Lord Strathclyde: My Lords, I am glad to say that the Procedure Committee will be meeting on 24 October and a number of the proposals made by my noble friend's group, the Leader's Group on Working Practices, will be debated and then brought to the House, hopefully for agreement.

Lord Grenfell: My Lords, would the noble Lord the Leader of the House agree that it would be a very good idea if the usual channels would not do what they did recently over the Armed Forces Bill and make an agreement that matters discussed on Report would not be voted on until Third Reading? This is not in keeping with what the Companion says, nor is it particularly acceptable that we should be told that this is a one-off that does not set a precedent. When you do something you set a precedent and the only question that is open after that is whether it is going to be followed. My fear is that this could be followed because we have opened a door that should have been kept closed.

Lord Strathclyde: I agree with the noble Lord: I have never accepted this line that something is not a precedent when it so clearly is, and I would not have used that argument. Of course, usual channels make agreements on a whole range of matters in relation to how we deal with business on a daily basis. That is for the benefit of the House as a whole and for good order in the House, and I think that was so with the recent decision that took place earlier on this week.

Apprenticeships: Dyslexia

Question

11.21 am

Asked By Lord Addington

Lord Addington: My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and draw attention to my declaration in the register of interests.

The Parliamentary Under-Secretary of State, Department for Business, Innovation and Skills (Baroness Wilcox): My Lords, the Government recognise that there are issues with delivery that can make it difficult for people with dyslexia to get the English qualifications that apprenticeships require. We want to ensure that all learning providers offer the right provision

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and support, and are challenging these providers' representatives to see what more their members can do to make this work. I know that assessment arrangements for key skills are a particular concern to my noble friend Lord Addington and I assure him that this qualification will be phased out of the apprenticeship by the autumn of next year.

Lord Addington: I thank my noble friend for that Answer. I am sorry to have to return to this subject yet again. I hope the Government can give us an assurance that they are looking at finding a way through this and give us some sort of timescale. With that in mind, could the Government please tell us whether any precedent that is set in other parts of the education department is appropriate to be taken as a whole to this area? If you can get through the A-level system and to university, surely you should be allowed to get through the apprenticeship system.

Baroness Wilcox: My noble friend rightly repeats a worry and a question that he has over the fact that using the key skills system for the apprenticeships is extremely difficult. We are looking, as he knows, at how we can improve access. There is no doubt that to encourage employers to take as many apprentices as possible is good for our country and we want to use all the talents that we have. That means harnessing able and disabled students wherever possible.

Lord Martin of Springburn: My Lords, would the noble Baroness consider the fact that when I was an apprentice those who were most helpful to the apprentices in the factory were normally the journeymen over the age of 50 who had more patience and tended to mentor the young people, not only in their trade but in their behaviour and other matters? A large number of men and women are unemployed and retired and could be used for mentoring apprentices. Could this be considered by the Government? By the way, I welcome the Government's action in encouraging apprenticeships.

Baroness Wilcox: I agree with the noble Lord. My father was an apprentice and he, too, became a journeyman, which is a wonderful thing. Perhaps we can find a use in that way. I will take this back and discuss it, and will come back to the noble Lord.

Lord Young of Norwood Green: Can the Minister guarantee that, given the importance of assisting all disabled people, especially the young, and the record levels of youth unemployment, there is sufficient budget to achieve this objective? If the Government have found a spare £250 million to spend on weekly bin collections, would it not have been better spent on encouraging more than the current 4 per cent of employers to provide apprenticeships?

Baroness Wilcox: I think the noble Lord knows that we are taking forward the work that he started and I hope that he is pleased with the way we are doing that. We are allowing the money that is needed to do this work, which is so important to us. There is no question that the bins come first.



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Scotland: Civil Service

Question

11.25 am

Asked By Lord Foulkes of Cumnock

Lord Wallace of Saltaire: My Lords, the Cabinet Secretary is also the head of the UK Civil Service, including those parts supporting the devolved Administrations in Scotland and Wales.

Lord Foulkes of Cumnock: I thank the noble Lord for that clarification. Is the Minister aware that the Conservative, Liberal Democrat and Labour leaders in the Scottish Parliament have all made official protests over Sir Peter Housden, the Scottish Permanent Secretary, advising the SNP Government on tactics and policy in relation to the break-up of the United Kingdom? Surely it is the responsibility of Sir Gus O'Donnell to say to Sir Peter Housden that he should be advising the SNP Government only on devolved areas and not on matters which are reserved to this Parliament, particularly those which are politically sensitive.

Lord Wallace of Saltaire: My Lords, I should of course declare a family interest. A relative of mine campaigned actively for Scottish independence and was executed by the English. I do not think that it is appropriate for a Minister to comment on the behaviour of a senior civil servant. I have read the Scottish press for the past week and I am well aware that the leaders of the three opposition parties in Scotland have written to the Cabinet Secretary. I will ensure that a copy of his reply, when it is ready, is placed in the Library of the House.

Lord Lang of Monkton: My Lords, is it not one of the strengths of the United Kingdom Civil Service that it is a United Kingdom body? In the past, great advantage has arisen for both sides when Scottish civil servants have served in United Kingdom departments and vice versa. Will my noble friend ensure that he makes every possible effort to prevent any diminution of this historic trend which might undermine the union?

Lord Wallace of Saltaire: My Lords, there are civil servants in Scotland working for the UK Government as well as civil servants in Scotland working for the Scottish Executive. This is a single Civil Service and there is extensive interchange. Indeed, the Permanent Secretary in Scotland about whom these complaints have been made has worked for a number of other institutions within the UK. Perhaps I might read the relevant parts of the Scottish version of the Civil Service Code, which was first issued in 2006. I shall quote from the 2010 version. It states:

"As a civil servant, you are accountable to Scottish Ministers, who in turn are accountable to the Scottish Parliament".

A footnote adds:

"Civil servants advising Ministers should be aware of the constitutional significance of the Scottish Parliament and of the conventions governing the relationship between the Scottish Parliament and the Scottish Executive".



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Perhaps I may add that the next paragraph states that,

Lord Sewel: To go a little further on this, generally, would it be proper for any Permanent Secretary at the Scottish Executive to give policy development advice to Scottish Ministers on constitutional matters when the constitution is clearly and explicitly a reserved matter? Secondly, is it proper for the Permanent Secretary of the Scottish Executive to make clear in public his personal views on a matter of controversial policy?

Lord Wallace of Saltaire: My Lords, on the second of those two questions, my understanding is that this was an internal blog. Noble Lords will have their views on the advisability of blogging. It was leaked to the Scottish edition of the Daily Telegraph. There might be a certain lack of wisdom there.

On the first question, once we have a devolved Government, although constitutional matters are reserved to the UK Government they are bound to be discussed within the Scottish Government. How far civil servants should offer advice is an important question. There is also a director-general for constitutional reform in the Cabinet Office.

Lord Butler of Brockwell: My Lords, will the Minister confirm that, just as it is the duty of the rest of the Civil Service to support the policies of the Administration that it serves, so it is the duty of the civil servants in Scotland to advise on the policies of the Scottish Executive?

Lord Wallace of Saltaire: My Lords, I entirely agree with that. It is important that the Civil Service working for the Scottish Government commands the confidence of Scottish Ministers of the day, regardless of their political complexion, just as it is for civil servants in Whitehall working for the UK Government.

Lord Forsyth of Drumlean: My Lords, I recall being given a wigging by the noble Lord, Lord Butler, when he was Cabinet Secretary and I was Secretary of State for Scotland, for issuing an official press release from the Scottish Office in which I used the term "tartan tax". Although my Permanent Secretary approved it, the then Cabinet Secretary told me that it was inappropriate for a Scottish Office press release to contain something that might be politically contentious. I accepted that advice: he was quite right and I was in the wrong. So what on earth is going on when the Permanent Secretary for the Scottish Executive circulates what is described as an internal blog-a newsletter-to civil servants in the Scottish Office, which, among other things, advised going to see a play about an army of occupation in 11th-century Scotland which he said,

What on earth are this Government doing in standing aside? Surely it is the absolute duty of the Cabinet Secretary to maintain the impartiality of the Civil Service, which is a centrepiece of our constitution.



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Lord Wallace of Saltaire: My Lords, the noble Lord will recall that on an earlier occasion the SNP strongly recommended that the population of Scotland go and see that dreadful film "Braveheart", one of the most historically inaccurate films that I am aware of.

Lord McFall of Alcluith: My Lords, the Minister says that he should not criticise civil servants' actions or behaviour. Why is that the case when the Permanent Secretary crosses a line that he should not? Will the Minister ensure that the Cabinet Secretary writes a letter to him, which is then placed in the House of Commons Library so that we can ensure that the proper constitutional arrangements are maintained in this country?

Lord Wallace of Saltaire: My Lords, I have already said that the Cabinet Secretary will write a letter in response to the three opposition leaders in Scotland. As the noble Lord knows well from the press, the Cabinet Secretary has already visited Edinburgh and a copy of the letter to those opposition leaders will be placed in the Libraries of both Houses.

Lord Stephen: My Lords, I first thank the noble Lord, Lord Foulkes, for raising this important and controversial issue. Is the Minister aware that most people in Scotland would far rather that senior civil servants, particularly such highly paid ones, spent their time improving the education system, health service and transport networks in Scotland, than pandering to the party political objectives of our First Minister? This is a serious issue. The core issue should not be the independence of Scotland but the independence, neutrality and objectivity of our civil service. When that is struck at, as has clearly happened in this instance, it is very worrying not just for Scotland but for all parts of the United Kingdom.

Lord Wallace of Saltaire: My Lords, I hesitate to get too embroiled in current political arguments in Scotland. The coalition Government do not agree with the SNP Administration on Scotland's future but they are an elected Administration with a policy programme that their Ministers wish to pursue. In delivering that programme for Ministers, all civil servants must comply with the appropriate ministerial code.

Lord Soley: Does the Minister accept that there is a need for a policy on the United Kingdom? Many of us in this House are concerned that no one is speaking up for the advantages of keeping the United Kingdom united. If we are not careful, the arguments for splintering, dividing and breaking away will get very strong. The Government need a policy that advances the arguments in favour of keeping the United Kingdom united. Let us put our heads above the parapet and defend it.

Lord Wallace of Saltaire: My Lords, I entirely agree with that. This Question, however, was about the division between what is political and what is administrative; what it is appropriate for the Civil Service to do and what it is appropriate for politicians to do. I am a strong supporter of the union myself, although I am not a unionist fundamentalist, as the Scottish newspapers are apparently alleging some are. We are finding a new balance between the devolved

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Administrations and the London Administration. It is very important that we all engage in the active debate on what that balance should be, but that is a political activity.

Lord Selkirk of Douglas: Would the Minister accept the principle that it is extremely desirable that civil servants should remain impartial, especially in the context of a referendum on whether the United Kingdom should or should not remain in existence? Is it not extremely important that individual civil servants should be like Caesar's wife-above suspicion?

Lord Wallace of Saltaire: I am never sure about Caesar's wife. One of the things I have learned in government is that special advisers-political advisers-are a very useful way of maintaining the distinction between what is political and what is impartial Civil Service advice. That is a distinction that I think everyone here-and, I hope, everyone in Edinburgh-wishes to maintain.

Lord Hughes of Woodside: This is asking the wrong question. The question is not whether there should or should not be a political debate. We are all agreed on that. The problem is that of civil servants entering that political debate. That should not happen, ever. The Minister should make that absolutely clear.

Lord Wallace of Saltaire: I entirely agree with that. Discussions are under way to ensure that the Civil Service remains impartial.

Financial Services and Markets Act 2000 (Exemption) (Amendment No. 2) Order 2011

Medicines Act 1968 (Pharmacy) Order 2011

Freedom of Information (Designation as Public Authorities) Order 2011

European Union (Definition of Treaties) (Second Agreement amending the Cotonou Agreement) Order 2011

Public Services Reform (Scotland) Act 2010 (Consequential Modifications of Enactments) Order 2011

Incidental Flooding and Coastal Erosion (England) Order 2011

Electricity and Gas (Internal Markets) Regulations 2011

Motions to Refer to Grand Committee

11.37 am

Moved By Lord Strathclyde

Motions agreed.



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Procedure of the House

Motion to Resolve

11.37 am

Moved By Lord Strathclyde

The Chancellor of the Duchy of Lancaster (Lord Strathclyde): My Lords, the second Motion in my name on the Order Paper is largely self-explanatory but perhaps I may give some background to it. We are conscious that, if there should be a Division in the House while the Grand Committee is meeting in Committee Room 4A, and many Members with restricted mobility are taking part in that Grand Committee, it could be challenging for them all to make their way to the Chamber in order to vote within the eight minutes allowed. The Motion therefore seeks to address that concern by allowing Members of the House with restricted mobility to vote in their place in Committee Room 4A during sittings of the Grand Committee on the Welfare Reform Bill, subject to certain conditions, and only if they so wish.

A paper in my name setting out the proposal embodied in this Motion was circulated to the Procedure Committee during the Recess and received the unanimous support of the members of that committee.

I should emphasise that this entitlement would be a one-off, limited to the Grand Committee on this particular Bill, and deviating from the normal practice of the House in the conduct of Divisions only on account of the potential concentration of Members with mobility restrictions participating in the proceedings.

A Grand Committee on the Welfare Reform Bill presents a unique set of circumstances, in the light of which I believe that we should make what adjustments we can to allow all noble Lords, including those with mobility restrictions, to play a full part not only in the work of the Grand Committee but also in any Divisions

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that take place in the Chamber. That is what the Motion is about and I hope that the House will support it today. I beg to move.

Lord Foulkes of Cumnock: I hesitate to try the patience of the House, having had such a useful discussion earlier in relation to Scotland. I welcome this Motion from the Leader of the House, as it will be of great help to people of reduced mobility in the Grand Committee to enable them to vote in the House. However, it is unfortunate that we have had to go this way. It has happened only because the Government, and the government Chief Whip in particular, saw fit to force on this House that all sittings of the Welfare Reform Bill Committee should be held upstairs in Committee Room 4A. That has resulted in what I understand to be substantial expenditure of many thousands of pounds on that Committee, when a number of the sittings could have been held here in the Chamber of the House. That would have been much more convenient for all of us, much better for the public, much better for people of reduced mobility and much better in every way.

I was in the Grand Committee the other day and the possibility was raised, as it has been raised elsewhere, that if the Grand Committee itself were to ask that certain parts of the Bill be held on the Floor of the House, particularly those that relate to people with disabilities, the House might reconsider the question and have at least one or two sessions dealing with these particular items on the Floor of the House. There appears to be some time. On Monday, the House rose before six o'clock; on Tuesday, it rose before eight o'clock; and there are in the forthcoming programme days on which there are no matters of any great substance to debate compared with the Welfare Reform Bill. Therefore, it would be really helpful to all of us if issues of particular contention could be taken on the Floor of the House and if the House could be given an opportunity to reconsider this matter.

Lord Strathclyde: My Lords, I am very grateful for the noble Lord's support of this Motion. I am glad to have that, but I cannot agree with him on most of the rest of what he said, mainly because the House has already decided that the Committee stage of the Bill should be in a Grand Committee. Earlier today we had a Question from the noble Lord, Lord Soley, about the amount of legislation that we have. It was decided a long time ago that, if we are to try to close at 10 o'clock at night, we need to put Bills into Grand Committee. There are many important Bills before us and the principle of Grand Committee has been well established.

I understand that there is also an advantage in going to Committee Room 4A. More Members can participate overall compared with the Moses Room; more members of the public who wish to view the proceedings can get in compared with the Moses Room; and, indeed, there are more places for wheelchair-using members of the public to view proceedings than in either the Moses Room or the Chamber. Moreover, there are more places for Peers in wheelchairs to listen to the proceedings in Committee Room 4A than there are in the Moses Room or, indeed, in the Chamber of

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this House. Therefore, at every level there is an advantage to being in Committee Room 4A and this added Motion will be of extra benefit to those who have mobility issues.

Motion agreed.

Health: Non-communicable Diseases

Debate

11.43 am

Moved By Lord Crisp

Lord Crisp: My Lords, it is a privilege to open this debate on such an important issue, which sadly affects, or will affect, the lives of all Members of your Lordships' House, either directly or indirectly through family members. In talking about non-communicable diseases, I am talking about diabetes, cancer, cardiovascular disease, respiratory diseases and mental health. You may ask why I am drawing attention to this at this time, because these diseases have been with us for a long time. The reason is that this is a growing problem. It is now the biggest set of health issues globally and the fastest growing set of health issues in every continent, including those afflicted by HIV/AIDS. We are ill equipped to deal with them, and we need a new and concerted effort to confront them.

When I put forward this proposal for a debate, I actually wrote, "To draw attention to the worldwide epidemic of non-communicable diseases". Somebody in the Table Office, quite rightly I guess, chose to change that to "incidence of non-communicable diseases", reasoning that an epidemic is something that is spread and communicated. In the ordinary sense of the word, however, we are dealing with an epidemic. As far as we know, these diseases are spread not by infection or biological process but they certainly are spread by social processes. Diet, the availability of food-healthy and unhealthy-smoking, alcohol, lack of exercise, stress and social pressures, which may in turn lead to overeating, alcohol, smoking and so on, are all key factors in the major spread of these diseases. They are sometimes called the diseases of affluence but, as I will say later, they also strike the poorest in the world.

I am very grateful to the distinguished noble Lords who are taking part in this debate and I know that they are bringing great expertise and knowledge in the fields of mental health, diet, cancer and coronary heart disease. I am particularly delighted that my noble friend Lady Hayman is returning to speaking in the House. My task is to set the scene, identify some of the key strands and ask just a few questions of the Government. Let me start with the context of the diseases.

I am not going to give your Lordships a lot of statistics but will try to limit myself to a few which scope and shape the problem. Now, 60 per cent of deaths in the world are due to these diseases-twice the number due to communicable diseases. This has

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changed markedly in recent years and is growing fast. While these diseases are associated with ageing, as they are with affluence, it is noticeable that a quarter of the deaths from them globally are in people under the age of 60. If we look at the UK, a quarter of the deaths from these diseases are in people under the age of 70. They are what we in the Department of Health and elsewhere would tend to call, or have called, preventable deaths. If I might take one example to show the pace of growth, diabetes is one of the fastest growing diseases and there are now 300 million people in the world affected by it. It is estimated that there will be 500 million by 2030. The numbers are vast: in India, it is 52 million people; here in the UK, it is something like 2.8 million people and growing fast. I believe that the noble Lord, Lord Kennedy, will have more to say on this.

These diseases are often called diseases of affluence. Indeed, as societies develop more of these diseases become more prominent. In Europe, 85 per cent of deaths are now due to these diseases but they hit the poorest population in a society worst. If we think of those causal factors such as smoking, diet and so on, we can understand that. Globally, Africa is the fastest growing area for non-communicable diseases. This is not just about death. It is also about disability and dependency, and the long-term and economic impacts in both the treatment of these diseases and lost productivity. This has been authoritatively estimated as being of the value of $47 trillion over 20 years. One-third of that is in mental health and I am sure that my noble friend Lady Murphy will have more to say about that. What is also noticeable about those costs is that $7 trillion of them are in low and middle-income countries-in other words, it is disproportionately hitting their economies.

I have already alluded to the fact that perhaps the most significant issue here is prevention. Up to 40 percent of cancers, 80 per cent of type 2 diabetes and much of heart disease and stroke are preventable or can be delayed to the advantage of both patients and of costs. I have already mentioned the causes which, again, your Lordships can see in one simple statistic: 7 per cent of UK hospital admissions are due to or related to alcohol, diet, exercise, smoking and, of course, obesity. I know that the noble Lord, Lord McColl, will be talking more about obesity and diet but in the UK 25 per cent of people are now in the category labelled as obese. In India-this may be much more surprising- 45 per cent of children in its cities are underweight and 25 per cent are overweight, so they are being affected by both aspects of the problem. I read an extraordinary story in the newspaper, perhaps reminding me that I should not always believe what I read there, that something like half of the Indian Cabinet has had gastric bands fitted-in other words, surgical devices to restrict the size of their stomach to prevent overeating.

So we have here a picture of a set of diseases that are distinguished by applying to us all, rich and poor, in every country in the world. They are driven by social factors as well as others, require a massive focus on prevention and, crucially, cannot be handled in the same way as the diseases of the previous century. Diseases have changed since health systems were set up. Our systems in the UK, for example, based on

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hospitals and doctors, were set up largely around episodes of care coming in and being dealt with-being killed or cured, if you like-whereas another way of thinking about these non-communicable diseases is to talk of them being long-term conditions. Those conditions last, and we live with them, for many years. Over those years a typical patient will have some acute episodes where maybe they need to be in hospital, they will have a lot of self-care and they will get care from neighbours and social services as well as from health services. They need a completely different pattern of care from the ones that our systems deliver.

The South African Minister of Health, Dr Aaron Motsoaledi, says that incentives in all our systems are in the wrong place. In talking about diabetes, he asks why we pay only a certain amount to the people who prevent diabetes, much more to the people who treat diabetes and the highest amount possible to those who deal with the complications of diabetes. We have a system that incentivises the highest level of treatment as opposed to one that incentivises prevention. I know that there are no simple answers, no one has the answers and the situation is changing all the time, but here is a real opportunity for global learning and working with others around the world on how to deal with this growing epidemic.

This debate is timely. I was extremely fortunate to be successful in the ballot because two weeks ago, on 19 and 20 September, there was a UN summit on non-communicable diseases, which was attended by virtually every country in the world and 34 heads of state. This got very little reporting in the UK, which was understandable, given what else was going on at the time, including the economic situation, but I am pleased to have the opportunity with this debate to draw a little attention to this set of issues and to what happened at that summit.

The summit was important; it was part of a process of the world, as it were, starting to agree what will replace the millennium development goals when they come to fruition in 2015. As noble Lords will know, those goals were set in 2000 for reducing deaths from TB, HIV/AIDS and malaria, as well as reducing child and maternal mortality. These are wholly admirable and there has been a lot of progress. We always need priorities. However, one of the negative impacts of priorities is that other things are deprioritised, and over these years we have seen that as more money has gone into communicable diseases and, rightly, into child and maternal care, systems and resources have moved to those areas at the cost of non-communicable diseases. We have seen systems broken up as priority has been given to those areas. In due course, we will need to move beyond the MDGs and think about global targets and priorities for non-communicable diseases. I suspect that over the next two or three years there will be other debates in your Lordships' House around these issues as the collective will moves towards some target-setting.

The UN summit identified six strands of action. The first was that this is not purely a health problem; it is a problem for the whole of government and society-industry, civil society and NGOs as well as health.



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The second area was about reducing risk factors and creating health-promoting environments. Of course a lot of this is about individual responsibility for what we eat and drink but there is a lot that can be done through regulation and nudging, through lateral thinking and creativity. To take one terribly simple example, it is about how we design our buildings. Somebody drew to my attention the other day that, in most of our schools, children now stay in the same classroom all day. I was used to a system where I moved from one classroom to another, sometimes quite considerable distances during the course of the day. That meant that, just through the act of being at school, children were doing a certain amount of exercise. The design of a lot of our public buildings and spaces is important.

The second area is about reducing risk factors and creating health-promoting environments. The third is about national policies and systems. The fourth is about global collaboration on regulation, trade and development policies. The fifth is research and development, and the sixth is monitoring, evaluating and learning. The outcomes from that summit are that, by the end of 2012, the Secretary-General must report back to the United Nations Assembly on what is happening. This is starting to move.

The UK has a proud record in development, with what was achieved under the previous Government and, indeed, during the current Government. I am a great admirer of the work of DfID and the priority that has been given to it by this Government. The UK played an enormous role in the development of the millennium development goals. It is globally influential and can play an enormous part in giving this new agenda the priority that it needs.

The Minister knows that I am not, however, an admirer of the NHS Bill, in part because it does not put these long-term conditions and non-communicable diseases absolutely at the centre of priorities. If it had, integration of services would not be an add-on. We would see much closer integration of health and social care, and all the carers together. Nevertheless, there are many good policies in the UK on treating non-communicable diseases and dealing with this problem. I look forward to hearing the Minister say more about that.

I have four questions and challenges for the Government if they are to play this leading role. The first is aimed more at DfID than the Minister's department, and I will understand if a reply comes later. There is a problem not just of prevention but of access to treatment. In Zambia, for example, 90 per cent of people with diabetes do not have access to insulin. This leads them to a major problem. The World Trade Organisation agreed in 2001 that, in the event of a public emergency, countries could apply for exemption to international patents relating to essential medicines so that they could be produced generically and, therefore, much more cheaply.

In the run-up to this high-level summit, the EU and the US and the pharma-companies argued that this should apply to non-communicable diseases. What is the Government's position on this? What is the

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Government's policy on the use of these exemptions of essential medicines relating to real crises and public emergencies in low-income countries?

The second question applies both to the UK and to the global situation. What do Her Majesty's Government believe is the role of industry in non-communicable diseases, specifically the food industry? It must be involved, but I note that it is being given quite a prominent position. How will self-regulation work and what evidence is there that self-regulation will have the desired effects? Thirdly, what are the Minister's views on the research that is required here, and how we can link together non-communicable and communicable diseases?

Finally, I notice that DfID uses MDGs as a method for determining what funds are awarded. Given that people in DfID understand as well as I do that this is the coming epidemic, what will be their role in exercising greater flexibility on this issue, and paying more attention to these diseases in the future? I beg to move.

11.59 am

Lord McColl of Dulwich: My Lords, I thank the noble Lord, Lord Crisp, for introducing the debate. As he has indicated, I intend to speak only about the terrible epidemic of obesity. It is the worst epidemic to affect this country for 100 years. It is killing millions, costing billions and the cure is free: eat less.

What a strange world. Half the world is dying of starvation; the other half is gorging itself to death. Obesity is a disease which wrecks the human body; it causes an enormous amount of distress, disease and suffering. In the United Kingdom there are over 2 million people suffering from diabetes as a result of obesity and a further 750,000 have diabetes but do not yet know it. So-called adult diabetes has reached epidemic proportions and now affects teenagers and young children. Parents seem to be unaware and unconcerned that their children are obese and there needs to be a great deal of education in this field.

Sport, of course, is important, but green spaces and sports centres do not influence the physical activity of children. Social inequalities are no longer a major factor in obesity. All children are at risk, regardless of family income or postcode, as the noble Lord, Lord Crisp, mentioned. Obesity leads to inactivity rather than the other way round. Obesity comes first. Reducing the intake of calories, rather than physical activity, is the key to weight reduction. Most obesity starts before children go to school; Professor Terence Wilkin and Linda Voss, of the Peninsula Medical School, have done a lot of work on the subject and found that 90 per cent of excess weight in girls and over 70 per cent in boys is gained before the child ever gets to school.

What else does obesity cause? The arteries become silted up with fatty material, called atheroma. As noble Lords know from their Greek studies, atheroma means porridge. It may be Greek porridge, but it is not Scottish porridge. It silts up the arteries and can cause heart attacks, strokes and blockage of the arteries of the leg, leading to amputation. Blindness is another result, as are high blood pressure and cancer. The excessive weight wears out the joints, so people need their knees and hips replaced. Obesity leads to cirrhosis.

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We always think of cirrhosis in terms of alcohol poisoning, but now the commonest cause seems to be obesity, so we have a big problem.

An even greater problem with this epidemic is that politicians refuse to admit that the cause of obesity is overeating. The Minister stated in Question Time on 12 September that his reason for refusing to believe that overeating was the main cause was that he was following the advice of NICE. Indeed NICE stated that:

"A person needs to be in 'energy balance' to maintain a healthy weight-that is, their energy intake (from food) should not exceed the energy expended through...exercise".

This obsession that Ministers have had for some years that it is a balance between what you eat and how much you exercise is the crucial mistake. The real balance is between calorie intake and the total expenditure of energy in the body. We have to run miles to get rid of a pound of fat and, bearing in mind that as little as 25 per cent of the calories we eat go on exercise, where do the other 75 per cent go? They go on the numerous activities of the body over which we have no control. The heart beats several million times in a lifetime, the kidneys filter a vast quantity of blood-about 360 pints over 24 hours-and there are myriad other activities in other organs, such as the liver, pancreas, bones and the alimentary tract. Where do those who believe that the energy from food is all used up in exercise imagine the energy comes from to run the heart, the pancreas, the liver and so on? Perhaps they imagine they run on air-perhaps hot air.

What could the Government do to encourage the food industry, canteens and restaurants to serve smaller portions of food? There is a company called Cook, which has 50 outlets and prepares meals of the right size-meat, two vegetables and gravy. They are cooked, frozen and then stored. They can be heated in five minutes, giving an instant meal of the right size, the right quality and the right price.

During the war, we had no obese people. We had the right quantity of food and the right kind of food. The only people who were obese were those who used the black market, and we children used to point our accusing fingers at them. Surely most mothers who are making their babies and children obese do not realise the terrible damage that they are doing, condemning them to a life of hardship, suffering and early death.

Bearing in mind that most obese people cannot exercise because they are so overweight, all they have to do to lose weight is eat less. The noble Lord, Lord Soulsby of Swaffham Prior, has given me permission to tell your Lordships the following story. As you know, he cannot exercise because he is confined to a wheelchair, but he decided to take three stone of weight off. He used a really revolutionary technique: he took three stone of weight off by eating less. There are no mysteries, only mysterious people.

Telling obese people that they have got to exercise is demoralising because they cannot. Most of them realise that it is nonsense to say so. What hope is there of dealing with this very serious epidemic if Ministers deny its cause? Exercise is of course very important-it is ideal for the functioning of the heart and control of cholesterol, and it gives one a sense of proportion and well-being-but it does not deal with the obesity epidemic.

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Of course I recognise that it is not the job of politicians to tell people how to live their lives, but it is surely the duty of government to speak the truth and give a lead. By continuing to stress that exercise is the answer, politicians are misleading the public.

The message is absolutely clear: this is the most serious epidemic to affect this country for 100 years; it is killing millions and costing billions; it will wreck the NHS for sure. The answer is simply to eat less. When obese people reduce their weight, then they can begin to exercise to keep fit-but not to solve the obesity epidemic.

I have been to see the director of NICE to reason with him, and he has now admitted that its advice is wrong. I have also been to see the Chief Medical Officer, and she has admitted that the advice is wrong. So the Minister is out on a limb. When will he listen to the Chief Medical Officer and NICE?

12.09 pm

Lord Kennedy of Southwark: My Lords, I congratulate the noble Lord, Lord Crisp, on putting down this Motion for debate today. He has had a distinguished career in health and related fields, culminating in serving as the chief executive of the NHS and Permanent Secretary at the Department of Health. It is a timely Motion that allows us to reflect on the four major chronic non-communicable diseases and the enormous problems and suffering that they cause. I agree wholeheartedly with the thrust of the points that the noble Lord has made.

The four major non-communicable diseases are, of course, cardiovascular disease, type 2 diabetes, cancers and chronic lung disease. As the noble Lord, Lord Crisp, said, 6 per cent of deaths in the world is a truly shocking statistic. I will speak briefly today about type 2 diabetes.

For many years I felt stressed, agitated, tired and run down at work. You could say that if you work for the Labour Party for 20 years, what do you expect? But in reality, I was an undiagnosed diabetic, having symptoms and developing complications but not getting the treatment that my body desperately needed. The point made by the noble Lord, Lord Crisp, about how we have an about-face, with more money going into dealing with the complications than the prevention, is absolutely right. I hope the noble Earl can address that in particular in his response.

Undiagnosed diabetics are an even more at-risk group. Enabling people to spot the signs, have a proper test, and seek medical care at as early a stage as possible, thereby offsetting some of the complications that can develop, is important for us all. Annual eye screening, regular checks on feet, and regular visits to a diabetes nurse are all welcome measures to deal with complications and enable sufferers to deal with the problems. They enable people with the condition to have a better quality of life and save the NHS considerable sums of money in treating otherwise preventable complications.

Complications such as heart problems, strokes, amputations and blindness are all things that we can work together to eliminate and to improve people's quality of life. I am sure the noble Earl, in his response,

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will tell the House how much better prevention is than cure for sufferers of type 2 diabetes. Bearing in mind the huge number of preventable amputations that are still taking place today, something must be done to improve on this situation.

I am delighted that my noble friend Lord Collins will respond to the debate for the Opposition. Like me he has type 2 diabetes. In our previous lives, mine as the director of finance for the Labour Party, and that of the noble Lord, Lord Collins, as general-secretary, we worked and sat closely together. Having been diagnosed some time earlier, I saw the signs in my noble friend and was not surprised when he told me the diagnosis from his GP. Getting the diagnosis, advice and treatment has certainly considerably improved how I feel and enabled me to take positive steps to control the condition.

Soon after I was diagnosed, I joined Diabetes UK. I am sorry that my noble friend Baroness Young of Old Scone, who is the chief executive of Diabetes UK, cannot be with us today. She is at a board meeting, or otherwise would be taking part in this debate in your Lordships' House. Diabetes UK is a great charity and has given me great advice, help and support.

I want to say congratulations and well done to Diabetes UK for winning the healthcare and medical research award at the charity awards this year for its diabetes roadshow, which goes out into communities to make people aware of the risk they are at. Through its campaigning and briefings, the research that it is funding, and the awareness and support that it gives, working with the Health Department, it is leading the way in ensuring that people can live fulfilling lives and avoid the problems and complications that diabetes can bring. Diabetes UK also has a fantastic care line, the only dedicated helpline in the UK, which enables sufferers to get advice and guidance when they need it.

I also pay tribute to another diabetes charity, Silver Star, which my right honourable friend, Keith Vaz, the Member for Leicester East, was instrumental in setting up. It raises awareness of diabetes and its complications, particularly in the Asian community, both in this country and on the Indian subcontinent. Diabetes is one of the conditions where prevention is the key. Proper information is needed to allow people to make informed choices about their lifestyle. Better diet, losing weight, and more exercise all contribute to dealing with what has become an epidemic across the globe but that can be avoided.

Again, I thank the noble Lord, Lord Crisp, for initiating the debate and look forward to the response by the noble Earl.

12.13 pm

Lord Roberts of Llandudno: I thank the noble Lord, Lord Crisp, for introducing such a revealing and fascinating debate. I think I will need a consultation with my noble friend, Lord McFall, very soon.

At the meeting in New York in September, just a week or two ago, the interesting thing was that 192 countries were represented there. There were 30 world leaders and 100 Ministers, who all came because they thought this was such an important subject. Is it not great that we are able to have international

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consultations that bring in the most vulnerable countries as well as those who have the most ability and knowledge? Anything that hinders international discussion and co-operation is very unwelcome. We support all these international efforts and must continue to do so. Many people from the UK attended that event. I was interested to read that not only were representatives present to discuss the four main areas but that discussions covered many other areas that affect many people. The noble Lords, Lord McColl and Lord Kennedy, referred to those areas. Diabetes can lead to blindness, for example, so there was representation from organisations representing blind people. Palliative care bodies, Catholic medical missionaries, Help the Aged, the Alcohol Policy Alliance and neurologists were also represented. These areas all touch on the core of non-communicable illnesses that we are discussing. We have heard these described as western diseases. However, as the third world develops, these diseases are becoming more prevalent there, although in Africa diseases such as AIDS still cause the most concern.

The risk factors in the UK comprise tobacco consumption, excessive alcohol consumption, an unhealthy diet and a lack of physical activity. As has been said, these factors cause poverty, disability and death. However, they can be regulated, even though we often have battles with those who benefit from the sale of alcohol or tobacco. We need to find a balance. Perhaps we do not want to return to the prohibition era in the United States, but how far should regulation go? Drink is sold not only in one part of my local supermarket but in several parts. How can we regulate that? Binge drinking can result from such practices. Are we too sensitive and nervous about regulating alcohol?

I declare an interest as a teetotaller. Perhaps I should not be speaking in this debate. People say that drinking is acceptable as a social activity, but in many cases it is harmful, especially when it involves excessive alcohol consumption. We are engaged in a battle over tobacco sales and displays and warnings on cigarette packets. However, these industries provide employment. Do Parliament and the Government have an adequate dialogue with these people? They might respond more positively if we could discuss the problem with them in a different manner. There are still problems to be tackled. Once problems are tackled, you see a great change. My grandfather on my father's side was a quarryman in Blaenau Ffestiniog. He and many of his friends died from silicosis and pneumoconiosis, as I note when looking at cemeteries in the Conwy valley. These diseases are caused by inhaling quarry dust and mining dust, but they can be prevented.

People have mentioned the need to monitor the content of food and the availability of various fitness opportunities. The forthcoming Olympic Games and Paralympic Games provide an opportunity to encourage and engender enthusiasm for keeping fit among people of all ages. They could increase participation in physical activity. However, we have not only a responsibility to ourselves as individuals but a responsibility to provide role models and examples to other countries to enable them to avoid making the mistakes that we have made in the past. The relationship between poverty, deprivation and ill health can be seen very clearly.



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We have raised standards and improved lives and life expectancy. In Swaziland the life expectancy is 31.8 years and in Japan 82.6. So much could be done, and I am delighted-and I will stand by it all the way-that our overseas aid budget is not to be tampered with and that we will, I hope, reach 1.7 per cent of GDP for overseas aid during the lifetime of this Parliament. I can assure noble Lords that we on these Benches at least will not consider any diminution of that particular part of our budget.

I am a past chairman of Wales Water Lifeline. We were on the border of Iraq and Iran during the war there, and the children just wanted safe drinking water. That was all they wanted. There was also a high death toll in Rwanda due to unsafe drinking water. As I think I have said before in the House, Wales Water Lifeline provided water-purification plants and well digging in these places when cholera, diarrhoea and so on were rampant. One morning a fax came telling us that we had stopped cholera dead in our patch because of safe drinking water. That was wonderful.

I used to say, although I am not sure whether it is true or not, that if we could stop the manufacture of armaments just for two weeks, the money saved could provide pure piped drinking water for every family in the world. Is there a way of doing it? I am an eternal optimist and I would like to think that, if only we could take the measures that have been outlined by others and that I have touched upon in an inexpert way, we could in our lifetime halve many of the deaths caused by preventable diseases in the world today.

I thank the noble Lord, Lord Crisp, for introducing this debate.

12.22 pm

Baroness Masham of Ilton: My Lords, I thank my noble friend Lord Crisp for bringing up this most important topic today in your Lordships' House. He is an important ambassador, taking expert knowledge to the World Health Organisation and the United Nations and bringing information back to the UK. This is a timely debate for your Lordships as we will be debating the Health and Social Care Bill next week and non-communicable diseases need to be highlighted. They are a huge part of the health agenda.

My husband, who was a Member of your Lordships' House and for a time Deputy Chief Whip, sustained several non-communicable diseases. He had several strokes, diabetes, Parkinson's disease and a cancer tumour of his lower bowel. After 10 years of living with these conditions, he died of a respiratory disease-pneumonia-in an A&E department on a Sunday evening. My father died of coronary heart disease on a Sunday morning in Scotland when I was 18. The locum doctor thought he had a chest infection. He died half an hour later. Perhaps your Lordships will understand why I am so passionate to see correct diagnoses, care facilities improved, and the prevention of and research into the hundreds of different NCDs high on the agendas of countries across the world. In the mean time, however, the correct drugs should be available to help with the different diseases.

The UK, as a so-called developed country, has many improvements to make. Many people who watched the recent "Panorama" programme on the treatment

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of vulnerable people living in a care home near Bristol are still reeling from the horror of what they saw. Many people are surprised to learn that care assistants can get a job with no registration. They can be nurses who have been dismissed for dangerous and disgraceful practices and then be taken on as care assistants with no registration and no control. Surely all patients with non-communicable diseases who are vulnerable should feel safe and protected. I hope that the Government will take the safety of all patients very seriously. There have been far too many unkind and unacceptable incidents in recent years. That just cannot go on.

The Global Status Report on Noncommunicable Diseases 2010states:

"Noncommunicable diseases (NCDs) are the leading global causes of death, causing more deaths than all other causes combined, and they strike hardest at the world's low- and middle-income populations. These diseases have reached epidemic proportions, yet they could be significantly reduced, with millions of lives saved and untold suffering avoided, through reduction of their risk factors, early detection and timely treatments".

The Global Status Report on Noncommunicable Diseases is the first worldwide report. It shows ways to map the epidemic, reduce its major risk factors and strengthen healthcare for people who already suffer from NCDs.

It is important that the World Health Organisation gets support from Governments worldwide. Of the 57 million global deaths in 2008, 36 million-or 63 per cent-were due to non-communicable diseases, principally cardiovascular diseases, diabetes, cancers and chronic respiratory diseases. As the impact of NCDs increases, and as populations age, annual NCD deaths are projected to continue to rise worldwide. Accurate data from countries are vital to reverse the global rise in deaths and disabilities. At the high-level UN meeting this September, world leaders unanimously adopted the political declaration on non-communicable diseases, agreeing that the global burden and threat of NCDs continues to be one of the major challenges for development in the 21st century, undermining social and economic development throughout the world. The director-general of the World Health Organisation, Dr Margaret Chan, told the meeting that NCDs are,

Recommendation No. 6 is of the utmost importance. It is to:

"Recognize the urgent need for greater measures at global, regional and national levels to prevent and control non-communicable diseases in order to contribute to the full realization of the right of everyone to the highest attainable standard of physical and mental health".

There are thousands of non-communicable diseases across the world, but there seem to be clusters in different parts of the UK. Two such conditions are spina bifida and leukaemia. Why should that be? There is a vital need for ongoing increased research into all non-communicable diseases. The health department, universities, pharmaceutical bodies, specialised units of experts and voluntary associations should all be working together to address the multitude of needs.

Diabetes has become a serious global emergency. The epidemic is now imposing a heavy dual burden of infections and non-communicable diseases on already

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under-resourced health systems. To date, no country has succeeded in turning around the figures. There are 50.8 million people with diabetes in India and 92.4 million in China. Africa will have the highest percentage increase in the number of people with diabetes over the next 20 years; 80 per cent of people with diabetes in Africa are undiagnosed. It is encouraging that countries are working together to try to find ways to stem that ever-increasing problem.

The Neurological Alliance is the collective voice of 80 brain and spine charities, representing the 8 million people in England with a neurological condition. They are often called the neglected 8 million. I hope that the Minister will see that every person diagnosed with a neurological condition has access to high-quality, joined-up services and good information.

Being a member of the all-party group on cancer and rarer cancers, I must make your Lordships aware of the great concern that exists about late diagnoses, especially of rarer cancers. The Government must be congratulated on setting up the rarer cancer fund, but research from the fund on the diagnosis of rarer cancers revealed that GPs are failing to diagnose almost a third of people with rarer forms of cancer at an early stage, damaging their chances of long-term survival. Late diagnosis is the major reason why cancer survival rates in England lag behind those in other developed countries. GPs should be rewarded for identifying the signs and symptoms of cancer when they are at an early stage and for referring patients for investigation; they should not be encouraged to delay referrals, which seems to be a worrying trend. I hope that the Minister will help over this serious matter.

I hope that the specialist voluntary associations which bring members' needs to the Government's and the public's attention, and which lobby for better conditions, will be listened to. I have experienced at first hand with my husband's condition the value of specialist nurses when they are involved in the treatment of patients. They support patients with conditions such as diabetes, strokes, Parkinson's disease, MS, rarer cancers, and so many others. Not having specialist care would downgrade treatment and care.

Many improvements can be made for adults and children with non-communicable diseases here in the UK. I refer to services such as wheelchairs and prosthetics. Assessments of patients and the supply of aids and equipment can take months, if not years. Someone with a condition such as motor neurone disease needs help immediately. Sometimes patients languish in hospitals far longer than necessary due to the inefficiency of the system.

I end by asking the Minister whether he is satisfied with the training of doctors in pain control for thousands of patients with non-communicable diseases, such as arthritis, when pain can interfere with employment and the quality of life. Is it not the case that several pain clinics have had to close down for lack of funds? I hope that this debate will highlight some of the needs of people living with non-communicable diseases.

12.33 pm

Baroness Hayman: My Lords, I have a double reason to be grateful to the noble Lord, Lord Crisp, for his introduction of today's debate. Not only is it timely

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and important, it gives me the perfect justification for reversing my intention of keeping a dignified silence in your Lordships' House until 2012. Instead, I shall use the opportunity of today's debate to make my first speech after leaving office as Lord Speaker. This is also my first speech from the Cross Benches. In my 15 years in your Lordships' House I have led a peripatetic life. I have spoken from the Front and the Back Benches, and from the opposition and government Benches. I fear that there is nowhere left for me to go. I look across to the Bishops' Bench but the obstacles to that are many and insuperable, so I will probably have to stay where I am.

The reason why I feel justified in abandoning that intention of not speaking is because today's debate chimes with so many of my interests-past and present. For four years I was the founder chair of Cancer Research UK. Having the privilege to do that made me aware of the burden of non-communicable diseases in the UK, particularly cancer, but also the growing threat and damage that those diseases cause in middle-income countries. The issue has already been raised today of their being in a way diseases of growing affluence. One needs look only at the increase in the incidence of lung cancer in China with the increase of smoking there. The noble Lord, Lord McColl, made us very aware of the dangers of diet leading to ill health in those major non-communicable diseases. It is important to recognise the role of public health in countries that are developing their health systems-public health in terms of surveillance, of education and of prevention.

There are often debates on whether health interventions in the developing world should be in terms of programmes or systems but, when DfID is looking at investment, the knowledge that we have gained in this country in terms of public health systems-based very much on having a comprehensive and truly national NHS-is an important gift that we can share with other countries. Another past interest as trustee of the Tropical Health and Education Trust also made me aware that it is not a one-way street when we talk about exchanging knowledge and healthcare professionals and practices with other countries. There is much that we can learn from the developing world in attitudes to medical problems and innovation. You need only look at the recent reports of how technology is being used in Tanzania to transfer by mobile phone the bus fare needed to women who have obstetric fistula. For them the problem is not the cost of the operation, because that is provided through charitable support to hospitals in that country; their problem is not having the bus fare to access that treatment. The innovations in technology being used through mobile phone networks can at a stroke end that problem. In that and many other areas there are possibilities to learn from other countries.

I should declare not a past interest but the only responsibility that I have taken on since leaving office in your Lordships' House, which is as a trustee of the Sabin Vaccine Institute in the United States. That institute has as its mission:

"To reduce needless human suffering from infectious and neglected tropical diseases through innovative vaccine research and development; and to advocate for improved access to vaccines and essential medicines for citizens around the globe".



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Some noble Lords will have noticed that word "infectious" and perhaps considered that in another place I might be out of order because the debate introduced by the noble Lord, Lord Crisp, is about non-communicable diseases. I shall return to that in a moment because there are links between NCDs and NTDs that need to be explored.

Neglected tropical diseases are a tremendous scourge of the world's poor. They are diseases of poverty. Of the bottom billion-the 1.4 billion people in the world who exist on less than $1.25 a day-virtually every man, woman and child will be afflicted by one or more of the seven most common neglected tropical diseases. These diseases have been disabling, disfiguring and blinding their victims for centuries. They have enormously debilitating effects on individuals and economies because they cause a lack of growth and well-being, not only for the patient but for the nation concerned. That is an important point to make to follow on from the noble Lord, Lord Roberts of Llandudno, in the argument about investment in overseas aid. At a time of global economic crisis, we need those middle and lower-income countries to be growing their economies, not for them to be ravaged by the effects of the diseases that make many of their citizens unable to contribute economically.

I said that I would deal a little with this interaction between communicable and non-communicable diseases. In many ways, neglected tropical diseases behave like chronic non-communicable diseases. They are chronic; their clinical manifestation-the weakening of the immune system and the resulting long-term disability-is very much the pattern of non-communicable disease. They have the same effects and therefore it is important that we recognise the interactions between them and the fact that those interactions are not only in the parallels that I have made but are in co-morbidities and often in the neglected tropical disease being the catalyst for the non-communicable disease.

There are many examples. Schistosomiasis is one of the areas in which the Sabin Institute is working on the production of a vaccine. We also know that urinary schistosomiasis is a leading cause of bladder cancer in Africa and the Middle East. Significant numbers of cases of anaemia are because of hookworm infections, and liver flukes account for a number of cancers. That connection is there and my plea today is that we do not only look at vertical programmes of health but look at the health systems that we are supporting in the developing world; and at the interaction of the sorts of social factors that have already been described, and of the communicable and the non-communicable diseases, in our attempt to end the scourge and the pain and suffering that are caused worldwide.

12.44 pm

Lord Rea: My Lords, I congratulate the noble Baroness on returning to the Benches; she has shown that it will be greatly beneficial to all of us by the quality of the speech that she has just given. I would also very much like to congratulate the noble Lord, Lord Crisp, on securing this debate so soon after the recent high-level conference on NCDs that we have been talking about. If your Lordships will forgive me, I am going to use the abbreviation for brevity and to save tongue-twisting.



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This topic has been growing in importance for more than 50 years, since communicable diseases came more under control. NCDs are now the major public health problem of the developed world. More recently, as the noble Lord, Lord Crisp, has pointed out, there has been a major increase in these diseases in the developing world, where they now cause around 60 per cent of deaths, which in total numbers greatly exceed NCD deaths in developed countries because of their greater populations. A higher proportion of these deaths in developing countries occur in people under 60 than in the developed world. The rapid increase of NCDs in the developing world was the main stimulus for the UN conference two weeks ago.

I come to this debate from a background in UK general practice but with a particular interest in public health. This was triggered by a three-year stint working with children in Nigeria where I came face to face with the importance of the environment and particularly nutrition in giving rise to childhood disease and high mortality-of course, in that case from communicable disease. I declare an interest as current chairman of the all-party Associate Parliamentary Food and Health Forum and as a trustee of the respected National Heart Forum, an NGO that brings together more than 50 organisations with an interest in the prevention of heart disease. Because the risk factors which lead to cardiovascular disease are very similar to those underlying most NCDs-smoking, faulty diet and lack of exercise-the National Heart Forum has recently widened its remit to embrace NCDs other than heart disease. It has published numerous reports, tool-kits and interactive programmes to help NCD prevention activities throughout the world, and two members of the National Heart Forum team were delegates at the New York conference.

NCDs are age-related diseases; they are degenerative in nature, but they do not affect everyone. Some people and populations develop these diseases much earlier than others. Some of these differences are due to increased genetic susceptibility; for instance, people of South Asian origin are particularly prone to diabetes and heart disease and those of West African origin are more likely to have high blood pressure when exposed to the typical Western diet of high salt, sugar and saturated fat. The external risk factors that favour their development are well known, as many noble Lords have pointed out, and affect many more people than the genetic causes. As has also been pointed out, these can be reduced or eliminated-in other words, these diseases are largely preventable.

Apart from the basic three risk factors I mentioned earlier-physical inactivity, faulty nutrition and smoking-other conditions that result from these factors are themselves risk factors; for example, as well described by the noble Lord, Lord McColl, obesity results from a combination of faulty diet with, to a lesser extent, lack of exercise. Obesity is a risk factor for some forms of cancer and particularly for type 2 diabetes, which often leads to cardiovascular, kidney and other diseases; high blood pressure can lead to stroke and heart disease. In the developed world, mortality rates from NCDs have come down considerably, partly through preventive measures, particularly tobacco control legislation, but also because it is now possible to

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palliate and control many of these conditions, though not to cure them, because of their degenerative nature. So we are left with many if not most of our older citizens, including quite a high proportion of your Lordships' House, on some form of medication or living with a prosthetic limb or organ. This is very expensive and a major reason why the costs of the National Health Service continue to escalate.

In the past, heart attacks and stroke-or apoplexy, as it was known-were the preserve of the well fed and wealthy: but not any more-in fact the reverse is the case. The better off and better educated you are, the less likely you are to suffer from an NCD. If you do, it will hit you later in life than those at the other end of the social scale. They provide a prime example of health inequality.

This is even more the case in low and middle-income countries where diabetes and its complications are probably the most common form of NCD. There, the costs of treatment are borne mainly by sufferers themselves or their families as state health budgets are meagre. NCDs are therefore important contributors to poverty, as well as vice versa, and have a major economic impact. The reasons for the rapid escalation of these diseases in the developing world are well encapsulated in the words of Jean Claude Mbanya, the new Cameroonian president of the International Diabetes Federation. He said:

"We have moved away from our traditional cultures towards a Western lifestyle associated with prosperity. It is good, but it brings a trend to be more sedentary, not eat the right foods, not exercise enough, and to drink and smoke more".

The political declaration agreed by the UN summit two weeks ago describes the problem with impressive thoroughness as well as the action needed in its 65 paragraphs and 36 sub-paragraphs. It correctly concentrates on prevention, emphasising the need for a comprehensive approach and, as the noble Lord, Lord Crisp, said, the need to create "equitable health-promoting environments". It draws attention to the WHO's framework convention on tobacco control, its global strategies on diet, on physical activity and health, and on reducing the harmful use of alcohol and its recommendations on the marketing of foods and non-alcoholic beverages to children. To my mind, its main benefit is that it flags up the importance of NCDs and puts them firmly on the international agenda. What I regret is that it does not come up with any suggested targets to stimulate action, such as the millennium development goals. That is put off to a future date. Some of the action suggested could well be taken to heart by our own Government-of course, some of it is. For instance, paragraph 43(f) includes the words:

"Research shows that food advertising to children is extensive, that a significant amount of the marketing is for foods with a high content of fat, sugar or salt and that television advertising influences children's food preferences, purchase requests and consumption patterns".

That research was carried out in this country by Professor Gerard Hastings at the request of the Food Standards Agency.

Another paragraph suggests that Governments should:



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"Promote ... interventions to reduce salt, sugar and saturated fats, and eliminate industrially produced trans-fats in foods, including through discouraging the production and marketing of foods that contribute to unhealthy diet".

Unfortunately, under pressure from industry, it does not mention how these interventions are to be made. Long experience in public health, backed by research, shows that voluntary agreements with industry or commerce to act in this way are usually ineffective. But our Secretary of State, Andrew Lansley, appears sincerely to believe that bringing industry on board through Responsibility Deals is the way to do it. This is a course of action that one delegate likened rudely to "letting Dracula advise on blood bank security".

12.54 pm

Lord May of Oxford: My Lords, I join with others in expressing my appreciation to the noble Lord, Lord Crisp, for initiating this debate, which, as others have noted, is very timely. I also think that I can confidently speak for the Cross-Benchers collectively in saying how warmly we welcome the noble Baroness, Lady Hayman, to our ranks. We are honoured and delighted to have her.

Five years ago I had the privilege of giving the opening address of the international meeting on parasitology. In that, I joined with others in emphasising the need for communicable diseases to go beyond their then focus on the big three-tuberculosis, HIV and malaria-to move on to the neglected communicable diseases of poorer countries; that is, diseases of poverty. There has been welcome progress in that area.

As this debate reminds us, the fact remains that roughly two-thirds of annual deaths today come from non-communicable diseases, 80 per cent of which are in poorer or middle-income countries-that is, four in five deaths. The recent high-level summit is the UN's first meeting on non-communicable diseases. Perhaps more interestingly, it is only the second meeting it has ever had on diseases, the first being several years ago on HIV.

The meeting emphasised many of the complexities and issues. There is no question that non-communicable diseases are a big problem in poorer countries but just how big they are is not quite so clear. For one thing, the number of deaths from NCDs, which is emphasised by the World Health Organisation and many earlier speakers, tells only part of the story. Perhaps more relevant is the age at which disease strikes, the morbidity or mortality. Whether they are communicable or non-communicable is a more important statistic. When one looks at that statistic, the fact remains that communicable infectious diseases, especially HIV/AIDS in sub-Saharan Africa, remain the biggest burden in most poorer countries.

Several speakers parsed the word epidemic. To talk of an epidemic of NCDs clouds the fact that the rise in such deaths derives more from demographic changes- from populations increasing and people living longer-than from other factors, such as obesity and smoking, important though they are. Fifty years ago, the average life expectancy on this planet of a child born was 46 years. Today, it is a little more than 64 years. We cannot relate intuitively to the notion that average life

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expectancy is 46 years because half a century ago the gap between the developed and the developing world in life expectancy was 26 years, whereas today it has shrunk to a still disgraceful 12 years.

In this time, that shrinking simply means more older people, which means more deaths from NCDs. Projecting the trends we have today into the future is not easy. In a moment I will express some rather harsh opinions on the outcome of the summit, but one of the useful things that it did-at least, I hope it has-was to call for better monitoring and better data collection, which is welcome and appropriate.

Despite all these complexities and uncertainties, many people have pointed out some of the effective and important things that we could and should be doing to diminish the surge of non-communicable diseases in poorer countries. For one thing, the noble Baroness, Lady Masham, called for more research on NCDs. As a researcher, I would never fail to endorse a call for more research. One of the interesting facts about NCDs is that essentially all biomedical research is on diseases of the rich. A rough estimate is that some 90 per cent is on non-communicable diseases. The good thing is that as a result we have many drugs that are both cheap and effective against some NCDs. Particularly for heart problems, statins and aspirin have made a big difference in the developed world and are little used in the developing world. That is one opportunity.

We have heard some good and important facts about risk factors and what can be achieved by banning smoking in work and eating places. Taking such successes from the developed world into the developing world is not easy. In the lobbying that preceded this meeting, it was distressing to find tobacco lobbies from the developing world opposing implementation of the sorts of things that, despite their protests, we have managed slowly and haltingly to implement here. The active promotion by elements of the food industry of eating habits that lead to obesity-and thus increase the incidence of NCDs such as diabetes, heart problems and the things we have heard about-is already proving a rather intractable problem in the developed world. The noble Lord, Lord Crisp, was right in expressing some satisfaction in the good examples that we have set and our proud record of helping not just ourselves but others, but even in our own country encouraging self-regulation of the food industry is simply not working.

I amplify some of the good remarks made by previous speakers, particularly the noble Lord, Lord McColl. There is an authoritative recent book by a chap called David Kessler, who was the head of the United States Food and Drug Administration-the FDA-and dean of the medical school at Yale. It is rather a gloomy book with an upbeat title, The End of Overeating. I recommend it. With forensic precision, it documents some of the ways that the high levels of salt, fat and sugar in processed foods have come about and the consequent damaging effects on health, and even suggests that, like smoking, there are elements of addiction in some of these additives. It also documents how the attempts to address this problem are opposed

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by skilled lobbies, using many of the techniques and indeed some of the organisations that battled against regulating smoking.

Coming back to the UN summit, I will read a brief account of what went on before it convened from the journal Science:

"The game plan was for diplomats to craft a political declaration that their leaders would endorse in New York City, spelling out the extent of the problem and concrete actions".

It goes on to say that what has emerged is,

It then goes on to say that, leading up to the meeting, the World Health Organisation identified four priorities, as we have heard: cancer, diabetes, cardiovascular disease and respiratory disease. It continues:

"The report also named four major risk factors: smoking, unhealthy diet, lack of physical activity, and alcohol abuse. Health advocacy groups called for the world's governments to address them by ... committing to targets such as reducing salt consumption or instituting tobacco taxes by a certain date ... But a leaked 5 August draft of the declaration showed other interests getting in the way. According to sources who saw",

it, including,

and others, the successive modification shows how any,

by the developed countries, including our people. It goes on:

"They were replaced with 'vague intentions to "consider" and "work towards"'".

In summary-I will read so as not to make it more verbose-we certainly need to move beyond the encouraging successes in the campaign against the big three infectious diseases and the promising extensions to other neglected diseases of the poor. We must include action against the incidence of avoidable deaths from non-communicable infections in the developing world. As others have emphasised, international summits and aid are important. Ultimately, it will devolve to national Governments.

1.06 pm

Lord Kakkar: My Lords, I, too, join noble Lords in congratulating the noble Lord, Lord Crisp, on securing this important debate so soon after the United Nations summit on the problem of non-communicable diseases. In making my contribution, I remind noble Lords of my declarations of interest as professor of surgery at University College London and director of the Thrombosis Research Institute in London. Both institutions have active research programmes globally in the area of cardiovascular disease, the non-communicable disease that I will concentrate on.

As we have heard, non-communicable diseases now account for 63 per cent of all deaths-of the 57 million people who died in 2008. By 2020, some 52 million individuals around the world will die of non-communicable diseases. In 2008, some 25 per cent

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of the 57 million deaths were due to two important cardiovascular disorders: stroke and coronary artery disease.

We are making excellent progress in our own country in the management of patients with coronary artery disease and stroke. The national strategy addresses the 3 million of our citizens who suffer from cardiovascular disorders. That burden of disease was associated in 2006 with some 50,000 premature deaths in our country. It is estimated that by 2020 cardiovascular disease in the United Kingdom will be associated with some 58,000 premature deaths. Annually in our country, prescriptions for circulatory disorders cost the National Health Service some £2 billion. The total economic burden of direct and indirect costs associated with the management of cardiovascular disease in our country is estimated at some £30 billion a year. In the United States of America, the direct and indirect costs associated with the management of cardiovascular disorders come to some $400 billion a year.

It is in the developing world, in low and middle-income countries, that we see the fastest growth in cardiovascular disorders, one of the most important of all non-communicable diseases. Twice as many people in low and middle-income countries die of cardiovascular disease than they do of tuberculosis, HIV/AIDS and malaria combined. We can recognise the risk factors associated with the development of cardiovascular disorders in these developing countries. They are very similar to the risk factors that have been identified in our own population. High blood pressure, high cholesterol, lack of physical exercise, abdominal obesity, smoking and inappropriate diet are all important risk factors that can be recognised in these developing populations. As the noble Lord, Lord May, said, longevity ensures that populations are living longer in these countries, so they start experiencing cardiovascular disease.

The pattern of cardiovascular disease in low and middle-income countries appears to be quite different from the patterns seen in western countries. As we have heard, the onset of this disease is at a younger age in populations in India, in China, in Africa and in other important nations around the world. The pattern of disease in coronary artery disease, for instance, anatomically seems to be quite different, with disease more distally distributed in blood vessels, making it less amenable to the interventions that we provide for our patients successfully to treat coronary artery disease underlying coronary disease before it presents as a heart attack.

Of course, in addition to the pattern of disease and the early onset of disease, we also recognise in low and middle-income countries that the risk factors that are seen to be associated with the development of coronary artery disease are also associated with poverty in those countries. The high burden of cardiovascular disease in those countries is associated with increasing poverty in those populations.

If we look at the report by the World Economic Forum presented as part of the United Nations summit, we see that for low and middle-income countries over the period 2011 to 2025-a 14-year period-the economic loss to those communities associated with non-communicable diseases accounts for $7 trillion of

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lost economic output; for cardiovascular diseases it is some $3.76 trillion over that same 14-year period. That has huge impact in those nations in terms of avoidable economic burden.

If we look at this in terms of individuals, it is estimated that across Brazil, China, India, South Africa and Mexico, 21 million years of productive life are lost annually due to cardiovascular disease, a disease that is often attributed, as we have heard, to lifestyle choices, and of course to other environmental factors, but that is in many circumstances avoidable.

In driving economic benefit, therefore, there are important opportunities to be derived from targeting cardiovascular disorders and trying to promote strategies for prevention. Important public health strategies might be adopted around the world that could help reduce the risk of cardiovascular disease and its burden both for the individual and for society. Many of the strategies that have formed part of our national frameworks for targeting cardiovascular disease in the United Kingdom could usefully be adopted elsewhere in the world. We have heard during this important debate about the importance of prospectively collecting data to understand the distribution of risk factors for cardiovascular disease in low and middle-income countries, and in so doing better target our interventions that drive prevention on a population basis.

There are also some very exciting novel approaches to the prevention of cardiovascular disease at a population and an individual level. One of them is the concept of the polypill-identifying large populations and offering them; a pill that combines elements such as the statin that we have heard about from the noble Lord, Lord May of Oxford; aspirin, an agent that inhibits the activation of the blood cells in the circulation that come together to form small blood clots in the coronary arteries or the blood supply to the brain that result ultimately in a hard attack or stroke; an agent to drop blood pressure; and medications to control blood sugar. This polypill offered to populations, it is suggested, will reduce the impact of risk factors for the development of cardiovascular disease and therefore reduce the burden of that disease both clinically and, eventually, economically.

Another important approach is to target nutrition during pregnancy and in early life because it is well recognised that poor nutrition during pregnancy and in the first few weeks, months and years of life is associated with a heightened risk later in life for high blood pressure and the development of heart disease.

A third approach, which my own research institute is involved in, is the concept of vaccinating against atheroma, the disease pathology that was mentioned by the noble Lord, Lord McColl. The narrowing of the arteries is considered to be multifactorial, and there is some suggestion that an immunological response to the vessel wall as a result of chronic infection might play an important role in its pathogenesis, so vaccination across populations might be an alternative strategy to the prevention of cardiovascular disease. These are all novel ideas, with research being undertaken at many institutions here in the United Kingdom.

The research, whether conducted here and directed to populations elsewhere in the world, or conducted elsewhere in the world and directed to populations in

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our own country, is hugely important, because the burden of cardiovascular disease is a true global problem. In this regard, I ask the Minister what proportion of National Institute of Health research funding is directed towards the important problem of cardiovascular disease, both in improving the management for those with established disease and in the strategies targeted at risk identification and the development of biomarkers to understand better those at high lifetime risk for the development of cardiovascular disorders.

What proportion of our overseas aid budget is directed towards promoting research into cardiovascular disorders in low and middle-income countries? Potentially understanding the disease better in those nations, and therefore helping to prevent or treat it more effectively, could offer substantial economic benefits to those countries-benefits that are derived from such appropriate prevention and treatment of cardiovascular disease being directed to more beneficial areas of economic development.

Finally, I turn to the potential of using the Commonwealth-there was in your Lordships' House some weeks ago a very interesting debate on the ongoing role of the Commonwealth-to develop a network between our own country and those with whom we have strong emotional and economic ties to pursue research into this important, chronic, non-communicable disease to determine whether that would both help us serve the people of those nations and ensure that nations on whom our own economic growth in the future is going to be dependent through export could avoid the economic and medical toll of cardiovascular disease.

1.17 pm

Baroness Murphy: My Lords, I add my voice of thanks to the noble Lord, Lord Crisp, for securing this debate and for the opportunity that it gives us to talk about the scourge of these five chronic diseases. This is also an opportunity for me to express my personal admiration for his commitment in recent years to the cause of improving global healthcare through the improvement of the education of healthcare workers in developing countries. I wish all strength to his arm in that area.

Before I go on to talk about mental health-which will be no surprise to anybody because everyone knows that that is what I do-on behalf of the well rounded of this world I want to pick up on something that the noble Lord, Lord McColl, said. He is absolutely right that the obese should eat less and that we should all eat less-that is a message that comes over strongly-but I should like to point out that an obese individual losing weight permanently by eating less is as likely as a heroin addict coming off heroin. It is almost impossible. We must go back to the comments of the noble Lord, Lord May: we need population solutions; we need to support people to eat less; and we will need to tackle the food industry to do so. I am sure that the noble Lord, Lord McColl, will forgive me but it is an issue which is so easy to say but so difficult for many people to follow.

As we have heard, the World Economic Forum, which through the Harvard School of Public Health did the research on the anticipated costs of these five

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chronic diseases, found that mental health will account for one-third of the overall $47 trillion. I am not sure that I can take on board what a trillion is, but a huge amount of money-about one-third of the anticipated costs that NCDs pose-will be lost due to the dependence of people with mental health problems. As a result, countries and economies are losing people in their most productive years. About 70 per cent of lost economic output is due to mental illness and heart disease alone. That means that it is the largest burden of disease globally, measured by disability-adjusted life years; there is a greater economic toll globally from mental disorders than from any of the other major disorders. I suppose that that is not surprising, as the human brain is the seat of all higher intellectual, emotional and cognitive functions, which are essential for individuals to fulfil their fullest potential. Many of these disorders begin in childhood and adolescence-a critical period of life when an individual is being educated, establishing effective social relationships and laying the ground for a successful career.

Even in the least developed regions, where infectious diseases are prominent and still important sources of disorder and disability, mental and neuro-psychiatric disorders remain and are a growing source of disability. Suicide claims the lives of 800,000 people annually. That is clearly a gross underestimate; the way in which we collect suicide statistics is very poor. Over 90 per cent of the 24 million people suffering from schizophrenia reside in low and middle-income countries, and less than half those 24 million receive any treatment, even in developed countries. Some of the treatments available in near neighbours such as eastern European countries are pretty frightening. There are still some profound human rights abuses in some of our neighbouring and many developing countries, akin to the sorts of treatments that were available here in the medieval period. They are still happening in many countries. Countless millions of mentally ill people go untreated, suffer misery and poverty and, quite often, grave human rights abuses.

The World Economic Forum research was published just a fortnight before the UN meeting on non-communicable diseases, which was billed as a once-in-a-generation opportunity to tackle the predicted wave of the diseases. I cannot but express my disappointment that mental health was scarcely given a mention. It was not on the agenda and the final communiqué had three and a half passing mentions of it. Our Government were urged to promote mental health at this meeting but did not do so. How are we to get the countries of the world to take it seriously if our Government do not?

We can guess why these disorders were ignored. The problems of stigma, the rejection of mental health patients and the denial of how economically important they are, are all too frequent. But of course there are unique challenges associated with mental disorders because of the cultural influences in the manifestation of illness, the stigma which attaches to family and healthcare workers as well as patients, and pervasive misunderstandings about causes and appropriate treatments. Most diseases have straightforward diagnostic systems that are relatively impervious to the influence of culture and context, but mental disorders are hampered

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by shifting and imprecise diagnostic systems, a weak evidence base for their causality and a lack of awareness and resources for appropriate assessment. The treatment facilities for mental disorders are generally segregated from those for other health problems. That is a problem that goes back to the way in which European colonialists often viewed these disorders in the past two centuries and has resulted in very fragmented funding streams, haphazard training and care pathways. In many countries, the system of care is based around a single large, rare specialist facility, often in an old mental hospital-maybe one per country in an urban centre-which provides for a tiny fragment of the country's mentally ill and separates people from the care of the community where patients and families live. There is a need for decentralisation of services to scale up access to treatment and care. We now have evidence-based knowledge of very effective treatments and delivery systems that can be adapted to meet the needs of different cultures.

This morning I was talking to Professor Martin Prince, who is Professor of Epidemiological Psychiatry at the Centre for Global Mental Health at the Institute of Psychiatry. I asked whether he could give me some up-to-date good examples of where some new cost-effective delivery systems were in place. He particularly wanted me to mention two excellent services. One is in Goa and is being delivered by community mental health workers, picking up antenatal depression across large numbers of people in the community. I understand that the cost of treatment there is less than the cost of a loaf of bread a day, so it is extremely cost-effective. There is another one around Rawalpindi in Pakistan, where a system of community mental health workers provides basic community mental healthcare across a very wide area on an algorithm that reaches a primary care physician for those where the provision of community mental health workers is uncertain. Again, that is extremely cost-effective, and it is very well researched to show how effective it is in bringing sustained benefit over a number of years. There are many examples such as those.

To echo the point made by the noble Baroness, Lady Hayman, we have a lot to learn from some of the systems that have been put in place. There are some very cost-effective, economical and simple ways in which to pick people up and treat them early, using people trained with specific tools over short periods of time. Nevertheless, these are isolated good examples that I can quote-there is an enormous gap-and the time for global action has come.

Sadly, while we know that mental health is integral to achieving social, economical and health goals of development, it continues to get short shrift. It needs to be included explicitly and independently as a key component of discussions and recommendations. The World Federation for Mental Health has set up a convention of working groups to aid the United Nations in developing guidelines, goals, tasks and outcome measures-all those United Nations phrases which I suspect sometimes do not lead to much action. However, we have to start somewhere. There is much good work going on and it deserves government support.

Finally, can the Minister explain why the Government, whom I will praise for having done so much to foster mental health as a priority at home, have not given a

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vigorous lead at the United Nations? I understand that this particular meeting wanted to get some action on smoking, diet and exercise-particularly smoking-and that there was some hard stuff to be done. I understand the importance of that, but it does rather play into the hands of the ignorant, stigmatising mental health yet again by denying its crucial importance to suffering and national economies. What plans do the Government have for putting right that neglect of mental health on an international stage? It is really one of those disorders that we cannot stand by and ignore.

1.29 pm

Lord Collins of Highbury: My Lords, I, too, congratulate the noble Lord, Lord Crisp, on initiating this debate. I have huge respect for the work that he has done and continues to do in promoting better health here, and globally, through his experience of the National Health Service, his involvement as a fellow of the Institute for Healthcare Improvement and, above all, his leadership on global health. In his book, Turning the World Upside Down, the noble Lord highlights the most striking thing about health in the 21st century which is, he says, the way the world,

As we have heard, the UN conference has set out plans to tackle non-communicable diseases such as diabetes and heart disease, which now pose a greater global burden than infectious diseases. As has been said in this debate, lifestyle-related diseases are now the leading cause of death worldwide, killing 36 million people a year. Much of that toll, as we have heard, is in low and middle-income countries and that is where efforts must be focused.

However, as we have also heard, Europe today has a high prevalence of non-communicable diseases, such as cancer, diabetes, cardiovascular diseases, obesity disorders and musculoskeletal disorders, which together cause 86 per cent of deaths in the EU. According to the EU, the causes of these diseases can be attributed to the interaction of various genetic, environmental and, especially, lifestyle factors-including smoking, alcohol abuse, unhealthy diets and physical inactivity. Linked by these common risk factors, many of these diseases are, as we have heard, preventable. Spreading access to effective treatment more evenly across the EU would bring significant health and economic benefits to all EU countries.

At this point in my contribution, I feel I must declare an interest; in fact, I should say interests. When I read the WHO report on this subject, I realised that I was very much a victim of my own bad lifestyle. Five years ago, I stopped smoking and subsequently put on weight. As the noble Lord, Lord McColl, has said, I think that I ate too much. I then took on a very stressful job, as my noble friend Lord Kennedy said, as general secretary of the Labour Party. I discovered soon after taking that job that I had high blood pressure. As a result of further tests, I was told that I had very high cholesterol levels and to cap it all-my noble friend Lord Kennedy has already outed me in this respect-I was formally diagnosed as a type 2

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diabetic. Early diagnosis and the excellent response of the NHS means that I have a chance of avoiding the worst consequences of these diseases, but would it not have been better if I could have avoided them in the first place? Early preventive action not only saves lives, it also saves money.

This is where I also want to amplify the conclusions we have heard from the WHO report, which focused on affordable actions that all Governments should take. First, as we have heard, there should be measures that target the population as a whole such as high taxes on tobacco and alcohol, and smoke-free indoor workplaces and public places, as well as campaigns, more importantly, to reduce salt and dangerous fats. I very much understood some of the comments about some agencies that are trying to stop us making progress in this area. Secondly, there should be other actions focusing on individuals such as screening and early treatment, which I have already mentioned in my own case. As I said in my maiden speech to this House, the personal is the political. It was the smoking ban that prompted me to stop smoking, while my local swimming pool provides an excellent service enabling me to deal with some of the stressful elements of my life-I go swimming every morning-and that screening led to my early treatment for diabetes. These are the factors that influenced my health. Unfortunately, no one yet has found a cure for my addiction to chocolate but maybe that will come.

A telling fact for me in the WHO report, as the noble Lord, Lord Crisp, said, is that the total cost for adopting these strategies in all low and middle-income countries would be £7.2 billion a year. In comparison, the cumulative costs of heart disease, chronic respiratory diseases, cancer and diabetes in poorer countries are expected to top £4.4 trillion between 2011 and 2025-an average of nearly £316 billion a year-according to the World Economic Forum. Many countries have already adopted the public health interventions that have seen marked reductions in disease incidence and mortality. The WHO monitored the progress of 38 countries taking steps to address cardiovascular disease at both population and individual levels over the space of a decade. All recorded substantial decreases in exposure to the risk incidence of disease and death toll; proof, if we ever needed it, that there are affordable steps which all Governments can take to address non-communicable diseases.

It is also a fact, as we have heard, that men and women in low-income countries are around three times more likely to die of non-communicable diseases before the age of 60 than they are in high-income countries. In the 2008-2013 EU health programme, the main activities focus on raising public awareness, improving knowledge and reinforcing preventive measures. To support these actions, it proposes networks and information systems across member states to generate a flow of information along with analysis and exchange of best practice in the public health field. As the noble Lord, Lord Crisp, has said, we need to promote a strong global approach involving integrated action on risk factors combined with the efforts to strengthen health systems towards improved prevention and control. I therefore urge the Minister to support positive

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intervention on this important global health issue and, as the noble Lord, Lord May, said, to have action-not just words.

1.38 pm

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I thank the noble Lord, Lord Crisp, for introducing a debate on an issue of such global importance. Indeed, I am grateful to all noble Lords who have spoken so powerfully and I welcome in particular the noble Lord, Lord Collins of Highbury, to his Front-Bench responsibilities. Non-communicable diseases, or NCDs, kill millions of people across the world every year. Indeed, they are responsible for three in five of all deaths and bring illness and disability to countless more. People with NCDs are high users of health services worldwide. In England alone, around 70p in every £1 spent on health and care is spent caring for people with a long-term condition, the majority of which are as a consequence of the so-called four big killers: cancer, cardiovascular disease, chronic lung diseases and diabetes.

I listened with huge interest to the noble Baroness, Lady Hayman, and I am so glad that she gave way to temptation by joining our debate today. To pick up on what she said, non-communicable and communicable diseases combined can both devastate the lives of individuals and hinder the growth of whole countries. This is particularly the case in developing nations, which face the double burden of communicable and non-communicable diseases. The true prevalence of non-communicable diseases is often hidden in a number of countries, simply due to the lack of data. I shall come on to that in a moment.

The noble Baroness, Lady Masham, is right: the scale of the challenge is huge but it is not insurmountable. We start from a position of collective international commitment to act. The UK, along with other Commonwealth countries, has called for global action. The recent UN high-level meeting about NCDs, which a number of noble Lords referred to, raised awareness of the issue and culminated in a unanimous declaration by all member states stating their commitment to taking concerted action to prevent, manage and treat NCDs. There is a helpful practical focus on tackling the common risk factors and the WHO has introduced the idea of "best buys" that can be introduced by all countries at little cost.

My right honourable friend the Secretary of State for Health participated fully in that meeting. I take note of the disappointment expressed by the noble Lord, Lord May, but at the same time the meeting was an important first step and a sound basis for sustained action in the years and decades to come.

In reply to the noble Baroness, Lady Murphy, I say that mental health is referred to in the political declaration and the UK supported this inclusion, but we wanted to ensure support for the primary focus to be on tackling the common underlying risk factors and wider social and environmental determinants for the four big killers. We do not in the least underestimate the burden of mental ill health. I hope that the mental health strategy is evidence of that, but we believe that,

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once we see benefits from this initial focus, there will be positive impacts on health and well-being far beyond these four disease groups, including mental health. The linkages in risk factors were highlighted in the UN declaration.

Global health has long been a priority for the UK Government. I can tell the noble Baronesses, Lady Masham and Lady Hayman, that we are trying, working through both the Department of Health and the Department for International Development, to help developing countries to build health systems that can meet today's challenges, including the problem of NCDs but also all causes of ill health, especially for the poorest in society.

The UK also supports multilateral organisations. We are the third largest donor to the World Health Organization and we support initiatives such as the Global Alliance for Vaccines and Immunisations, GAVI, to which the UK is the largest contributor. Indeed, GAVI has immunised over 250 million children against hepatitis B and saved over 3 million lives as a result. I was interested in the work of the noble Baroness, Lady Hayman, in promoting vaccine uptake in the third world.

Whatever we do, though, I fear that we need to face one unpalatable fact: we will not be able to eradicate NCDs, unlike smallpox. There is no obesity inoculation. Prevention alone, important though it is, cannot be the sole answer either at home or abroad. Globally, we continue to work to strengthen health systems so that they can provide early, cost-effective care to all who need it, including the poor and vulnerable.

I mentioned that we are strengthening the capacity of countries to deliver improved health services. This is a key area of DfID's work. So, too, is the health partnership scheme, which facilitates links between UK health institutions and professionals from developing countries to improve health outcomes by sharing skills and capacity building. We are also supporting the medical training initiative, designed for doctors from developing countries to benefit from training in the NHS and foster exchange programmes. I pick up the point made by the noble Baroness, Lady Hayman, that we can learn from others overseas.

I can tell the noble Lord, Lord Crisp, that we also support research on global health. For example, DfID has recently launched PRIME, which stands for "programme for improving mental health care". That is a new multinational research programme that will focus on the development, acceptability and impact of mental health care packages for priority mental disorders. We have also supported research on tobacco, and I can let the noble Lord have further details on those programmes if he is interested.

The noble Lord asked me about access to essential medicines. This is a priority for us. We are supporting countries to develop domestic health financing mechanisms to ensure sustainable and long-term funding for cost-effective interventions to tackle NCDs, not just drugs but diagnostics and vaccines as well.

Health services have a key part to play in reducing health inequalities in terms of access and quality and working with others to improve health outcomes. We need health systems not simply to treat disease but to

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be reoriented towards preventative action. As ever, as the noble Lords, Lord Crisp and Lord Kennedy, reminded us, prevention is better than cure-preventing the onset of disease rather than merely treating the symptoms.

Our health reforms in the UK are designed to strengthen our approach to improving public health. On the Health and Social Care Bill we will debate how there is a new health improvement duty for local authorities, supported by a ring-fenced public health budget. This will allow local decisions on health improvement to be taken about the interventions that are most suited to local needs. We think that that will represent a very responsive system, more so than we have at the moment. We are committed to reducing health inequalities, which is why for the first time, subject to parliamentary approval, we are putting into legislation a duty on the Secretary of State for Health focused on the need to reduce inequalities. That makes this the strongest health inequalities duty we have ever had.

First and foremost in the UK, we focus on prevention through an integrated approach as the major non-communicable diseases share a number of common risk factors. We address the causes of the causes, the underlying wider social and environmental determinants. The conditions in which people are born, grow, work and age, their education, employment and housing-all these shape the health of individuals and communities. The Public Health Cabinet Sub-Committee, which we established, allows a wide range of Cabinet Ministers to agree how best to respond to the public health challenges. The importance of taking a whole-of-government approach is emphasised in the UN political declaration.

We are a world leader on collecting data on public health, and other countries draw on our approach to surveillance. WHO is looking now to strengthen global monitoring of the prevalence of NCDs and the common risk factors, which is essential if we are to establish the kind of meaningful targets referred to by the noble Lord, Lord Rea. In England we are putting in place a new strategic outcomes framework for public health at national and local levels-again, in an effort to benchmark these matters-which will be based on the evidence of where the biggest challenges are for health and well-being.

On the domestic front, we are making progress on some of the key areas of action highlighted by the UN and we stand ready to share those experiences with others. NCDs share common risk factors-tobacco use, unhealthy diets, physical inactivity and alcohol misuse. Our actions, particularly on tobacco control and reducing salt intake, have been highlighted by WHO as international best practice.

The noble Lords, Lord Rea, Lord May and Lord Collins, rightly lay particular emphasis on tobacco policy. The UK strongly supports the WHO Framework Convention on Tobacco Control, and we take it very seriously. Tobacco use is by far the biggest risk factor for NCDs, so effective policies to reduce smoking rates are essential. We urge all countries that are not yet parties to the treaty to sign up to it as quickly as possible, and equally we urge all those who are signatories to implement the treaty fully, as we have done in this country. The convention encourages parties to take

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comprehensive action on tobacco control. The Tobacco Control Plan for England, published in March, sets out a range of actions that will bear down on tobacco use.

The noble Lord, Lord Collins, mentioned salt. As he knows, we have made considerable progress in recent years by working in partnership with industry and others to reduce salt intake. It has gone down by about 10 per cent in the past few years, which has served to prevent over 4,000 deaths a year and saved the NHS a great deal of money. We are taking that work forward as one of the pledges contained within the Public Health Responsibility Deal.

As well as these initiatives, which aim to tackle population health here in England, we are working to strengthen our primary care system, putting the patient and their GP at the heart of service delivery. This will reduce the impact of non-communicable diseases through programmes such as the NHS Health Check, which I hope is of particular interest to the noble Lords, Lord Kennedy and Lord Collins. Our NHS Health Check programme assesses people's risk of heart disease, stroke, diabetes and kidney disease. It has the potential to prevent 1,600 heart attacks and strokes a year-so I am told-to prevent over 4,000 people a year from developing diabetes and to detect at least 20,000 cases of diabetes or kidney disease earlier. It is an important programme.

The noble Lord, Lord Crisp, asked me about the training and the DfID programme. He suggested that DfID was too rigid on this, and too focused on NGOs. Health system strengthening includes training as a key part of DfID's work. Globally, we provide training through a number of different organisations, including government organisations, NGOs and our contributions to multilateral organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. DfID estimates that 25 per cent of its aid to health supports human resources, including training.

The noble Baroness, Lady Hayman, spoke about neglected tropical diseases. I am pleased to tell her that, only yesterday, the UK announced that we would support the final push to eradicate guinea worm from the world. My honourable friend Stephen O'Brien yesterday issued a challenge: we will increase our support to guinea worm eradication and fill up to one-third of the financing gap, provided that others step forward and fill the other two-thirds. This funding would form a vital part of the push from former US President Jimmy Carter to ensure that guinea worm is consigned to the history books alongside smallpox. We have already committed £25 million over five years to tackle schistosomiasis, or bilharzia.

The noble Lords, Lord Crisp and Lord Rea, and my noble friend Lord McColl expressed doubts about engagement with the food industry in this country. We start with the recognition that people's lifestyle choices are affecting their health. The Government cannot address this challenge alone through central, top-down diktat. Everyone has a part to play, not just government but also business, industry, retailers, the third sector and individuals themselves. The Responsibility Deal is not a substitute for the development of government policy on public health; it complements it. We also

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know that businesses can reach consumers and deliver information in ways that other organisations, including government organisations, cannot.

My noble friend Lord McColl spoke very powerfully on obesity. I would like to think that he and I are not so far apart as he perhaps indicated. We are clear that the Government cannot tackle obesity alone. It is an issue for society as a whole. We all have a role to play. We will shortly be publishing our plans for how obesity will be tackled in the new public health and NHS systems in England, and the role of key partners. I could not help feeling, listening to my noble friend, that we might be talking at cross purposes. There is surely a distinction between keeping healthy people healthy-and the advice that goes with that-and helping obese people become less unhealthy. For the latter group, my noble friend's advice is surely spot on. The NICE advice, I suggest, is relevant and accurate for the former group. Diet has an important role, and we are indeed working to improve it, reducing the consumption of fat, sugar and excess calories. However, it is not tenable to suggest that physical activity is not important. I wonder whether my noble friend and I can agree that physical activity helps to balance the energy consumed. I look forward to a little conversation with him about that afterwards.

The noble Lord, Lord Roberts of Llandudno, spoke extremely convincingly about alcohol. Retailers, producers and pubs ought to promote, name, market and sell their products in a responsible way. We need to see leadership from them to produce a radical and better balance between business interests and social harm. I am encouraged to tell him that there has been a wide sign-up to the first set of collective pledges under the Responsibility Deal. Networks are already developing the next tranche of pledges. Again, by working closely with industry, we help it to shoulder its responsibilities and can go further and faster in developing the initiatives that we all want.

The noble Lords, Lord Kennedy and Lord Collins, referred quite rightly to diabetes. Our national diabetes service framework, begun in 2003, has been reinvigorated this year by a new NICE quality standard for diabetes against which future care will be measured. Our national diabetic retinopathy screening programme has been offered to 98 per cent of people with diabetes; that is a great record. A National Health Check programme for 40 to 74 year-olds in England includes an assessment for those at risk of developing type 2 diabetes as well as cardiovascular and kidney disease. That programme has real potential to identify people at risk of diabetes early and prevent its debilitating complications.

Now, I have a few apologies to make; first, to the noble Baroness, Lady Masham, who asked me about the training of doctors for pain control. I do not have information on that in front of me, but I will certainly write to her. I shall also write to the noble Lord, Lord Kakkar, who asked me about the proportion of NIHR funding on cardiovascular disease and any research network that there may be on that disease in the Commonwealth. He also asked me about UK funding for research on cardiovascular disease in developing countries, and I can tell him that the Indian Council for Medical Research is collaborating on several research

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topics related to NCDs; indeed, there is a collaborative research programme in Mumbai studying the impact of nutrition in pregnancy and early childhood on the risk of heart disease in later life, and its intergenerational effects.

I hope that what I have said will reassure the House that we are taking action on all fronts to prevent and manage NCDs both nationally and globally. However, concerted action is needed across Governments and industry to meet the challenges of NCDs. The human and economic consequences of inaction are too grave for us all to do anything else.

1.57 pm

Lord Crisp: My Lords, I said at the beginning that it was a privilege to introduce the debate, and it has certainly been a privilege to listen to it and to hear the wisdom, insights and wide range of interests of the noble Lords who have spoken. I think that we have all learnt something; I certainly have. It has been very good to have insights from the patients' perspective as well as from clinicians and everybody else.

This will be a continuing theme. The UN summit to which we have all referred was described as the end of the beginning. Non-communicable diseases will now be a major global theme of those sorts of global meetings. In due course, we will no doubt start to see some targets being set. For the time being, however, I beg leave to withdraw the Motion.

Motion withdrawn.

Building Stability Overseas Strategy

Debate

1.58 pm

Moved By Baroness Falkner of Margravine

Baroness Falkner of Margravine: My Lords, nearly 50 years ago, John F Kennedy spoke a simple truth:

"The basic problems facing the world today are not susceptible to a military solution".

He was speaking in the context of the Vietnam War. Since then, the United Kingdom has deployed its forces in the Falklands, Kuwait, Bosnia, Kosovo, Sierra Leone, Afghanistan and Iraq. In this century, we have seen the continuation of conflict in Iraq, Afghanistan and, recently, Libya.

It is right that I start this debate by paying tribute to our men and women in uniform who do so much to defend our country's interests. However, we should also note with relief that we live in a significantly safer world. Inter-state war has declined considerably since the end of the Second World War. It is estimated that 29 million people died in declared wars in the previous century. Civilian deaths caused by despotic Governments were on an even more horrifying scale. The Soviet Union and China alone account for nearly 100 million deaths. Joseph Stalin found that:



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"The death of one man is a tragedy. The death of millions is a statistic".

For us, that comment represented a collective failure of our humanity.

In recent years, civil wars, too, have become less numerous and less dangerous. According to the World Bank's world development report, there were 21 active major civil wars in 1991-92, but since then the figure has steadily fallen to less than 10 each year since 2002. Thankfully, the toll of battle deaths has also diminished. In 1988 there were more than 200,000 deaths per year, whereas in 2008 there were some 50,000. In the post-World War 2 settlement it has been the creation of institutions that has most powerfully militated against conflict.

Despite the rise in sovereign states from around 50 to nearly 200, the United Nations, the Bretton Woods institutions and the international judicial system have worked to diminish the violent resolution of disputes. The international community has succeeded in building institutions to cover the three essential characteristics for maintaining international order: an overarching body to maintain peace and security; a legal settlement system to adjudicate disputes; and an enforcement mechanism to carry out the will of the community should all else fail.

However, there are still too many states within the international system which lack the resilient frameworks that might safeguard against violence, hence the continuation of conflict. In fragile states, the Government are often illegitimate or weak, the rule of law absent and public institutions are at best ineffective or at worst partisan. To this mixture add poverty, ethnic, religious or ideological strife and chronic underdevelopment. When conflict breaks out, its spillover has consequences for all other countries in the region too, with the internally displaced and many millions of refugees in other countries.

Conflict's costs are borne disproportionately by women. A recent assessment shows that 80 per cent of those displaced are women and children. Some 75 per cent of the world's refugees are hosted by neighbouring states, with consequent destabilisation there, too. It is in this context that we can think about how a middle-sized European power such as ours can achieve the security of its citizens, as well as play a significant role in reducing the fallout from violent conflict for others.

We have started in the right place, with our commitment to reaching 0.7 per cent of GNI in development assistance. Committing resources to others at a time of austerity at home is a difficult argument to put to the public, but it is the right one. It is incumbent on the Government to find the most effective mixture of soft, smart and hard power that Building Stability can exploit. I am enthusiastic about this strategy's focus. It is predicated on a simple hypothesis: to work early on identifying areas of risk and, where we can, to work upstream to prevent conflict and maintain stability. Once a crisis has broken out, for whatever reasons, we should use our diplomatic and other resources for a rapid response to ameliorate the situation.

The strategy seems to hint at another important element: that of staying the course for the longer term. Too often when a crisis occurs, the attention span of both policy-makers and the public is too short. A

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classic example of this is Afghanistan in the late 1980s, where, once the mujaheddin had repulsed the Russians, our attention turned elsewhere. Civil war took hold, 4 million refugees became Pakistan's problem, while Afghanistan was seized by the Taliban and hosted al-Qaeda, with the subsequent war which has cost lives and treasure.

The World Bank's research shows that recurring civil wars have become a dominant form of armed conflict in the world today. Every civil war that has begun since 2003 was a resumption of a previous civil war: 90 per cent of conflicts initiated in this century were in countries that had already had a civil war. Peace is often not enduring: fighting has also continued after several recent political settlements, as we have seen in Afghanistan and the Democratic Republic of Congo.

With that in mind, let me turn to the work of the stabilisation unit which is the engine room for this strategy. Will the Minister assure me that while the strategic defence and security review, which establishes the roof under which the unit sits, is due to be reviewed or renewed every five years, the ongoing programme work of the stabilisation unit will have a longer horizon? Building stability is a long-term venture, which cannot be picked up and put down according to the vagaries of five-year electoral cycles. Partners tend to have little confidence in our staying the course with them if we are subject to changes in priorities every few years.

Sound analysis is also key to the effectiveness of the strategy. Above all, conflict is predicated on a failure to resolve political differences peaceably, whatever the root causes behind the political situations. As a former foreign affairs analyst, I know only too well that crises come in two forms: they often blow up where you could see them coming but were powerless to change things; or they blow up in places where, if you had anticipated them, you could have done something at an earlier stage. Improved intelligence and horizon scanning will no doubt improve our capabilities, but I want to know more about what criteria we would use to decide the level of our involvement.

Let me use the Middle East as an example. It seemed that in our desire to engage with the regime in Bahrain, we mistook assurances of reform for substance. As these assurances have evaporated like the morning mist-if only they had been as pure-we have been wrong-footed. In Syria, as in Libya, our previous Government courted regimes that are and have always been-there are no surprises here-every bit as venal as history had predicted. If our future analytical capabilities are to be more robust, which I hope they will be, I hope the Minister will take away the thought that henceforth our political and diplomatic priorities should be based on a longer-term strategic framework of alliances than those of the previous Government.

This brings me to the criteria for deciding which crises to respond to and how. I accept that in most cases this will depend on how much we can achieve multilaterally and bilaterally, and the extent to which our own interests are engaged. However, the lesson here must be that we need to lay the ground for multilateral action upstream, working with those who

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are willing at an earlier stage, in a preventive mode. It is in this area that the civilian stabilisation group can be most effective.

This pool of personnel with expertise in institution building, economic recovery, security sector reform and other practical state-building roles is commendable and I applaud its success in support of the National Transitional Council in Libya. However, one gets the impression that it is more of a reactive force than a preventive resource. I would argue that if it were to shift its focus to more preventive work, it would provide the skills and training for peacemaking and crisis management later in the day. Turning to skills and training, are the members of this group to be given regular skills updates and capability upgrades to keep them at the top of their game? Deployment is often too late to serve as a good training ground. Will resources be dedicated to this role specifically?

I also want to highlight the importance for the strategy's success of recognising the role of women. I acknowledge the references to United Nations Security Council Resolution 1325 and attempts to improve a gender focus. However, what is missing is a practical appreciation of how to mainstream gender. Women's active and meaningful participation must be central to all post-conflict and peacebuilding processes. For example, the use of stabilisation response teams should acknowledge that at least one member of the SRT should have the knowledge and skills to address sexual and gender-based violence.

At a more strategic level, the BSOS steering board could take a proactive decision to promote government co-ordination in longer-term thinking about gender impacts on decisions. In Afghanistan, a decision was taken to draw down our commitment by the next election, a decision which I fear will not be conducive to stability. In the political calculations, was any effort made to think through the impact on Afghan women, who I fear will be hung out to dry in a Taliban-ruled Government of the future?

In Libya, where we have leverage here and now, what steps are we taking to encourage the National Transitional Council to work with women towards a new political settlement? Can the Minister tell us whether talks have been held with the group Women4Libya to see whether we can assist its campaign for rights? Can he also assure us that our generous support for UN Women will continue and that we will work with that organisation to ensure that UNSCR 1325 is given practical effect?

I welcome the strategy for its attempts to improve the effectiveness of our efforts and to redefine our priorities in the period ahead. I am the first to applaud a "whole-of-government approach", as it is only when we pool our ample talent and our still-considerable resources that we can deliver best. My final concern, therefore, is one of accountability. When we have complex structures which are pulled together but remain autonomous, it becomes difficult to see where decision-making lies or where change can be effected. I would ask that one of the three contributing departments assumes overall responsibility for the strategy. We are talking here of work which will expend potentially billions of pounds, yet we cannot be sure whether we

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need to go to the FCO, the MoD or DfID for detailed scrutiny. My own preference would be for a named Minister to take ownership of the strategy-for a clear letter box to be identified and accounted for. I am delighted to see my noble friend representing the FCO in answering this debate, and I would be entirely happy for the FCO to be the lead department, but I am pragmatic in this regard as long as we have that accountability in a named Minister.


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