HC Deb 12 June 1978 vol 951 cc659-792

3.32 p.m.

Mr. James Boyden (Bishop Auckland)

I beg to move, That this House takes note of the First Report from the Expenditure Committee in the last Session of Parliament (House of Commons Paper No. 169) on Preventive Medicine and of the relevant Government observations (Command Paper No. 7047). This inquiry of the Social Services Employment Sub-Committee took 14 months. There were 23 sessions of oral evidence from 33 interested groups of witnesses and visits were made to medical premises and ICI. There are two volumes of evidence—

Mr. Robin Corbett (Hemel Hempstead)

Good stuff.

Mr. Boyden

As my hon. Friend says, it is good stuff, and I hope very much that those who are specially interested in the subject and in health services generally will take the trouble to look at some of the evidence from the witnesses and at the documents.

One of the features of the Expenditure Committee is that very busy and very important experts are prepared to come to the House and give evidence and to assist the Sub-Committees in every way that they can. Very often they supply written evidence which takes them considerable thought and effort. The appendices and the volumes of evidence are not to be ignored.

When I was a member of the Newcastle Regional Hospital Board, I must confess that I would have welcomed very much the kind of report that the Sub-Committee has produced. I can remember being inundated with reports on special services and special aspects of curative medicine, but I do not recall ever having any very constructive information on preventive medicine. The report before the House today would have given me rather more to do on the hospital board than I found in the atmosphere prevailing at the time. So I congratulate the Committee on having produced a practical document which will be of considerable use to lay members of the various hospital authorities and of course to the lay public as well, to say nothing of general practitioners and a good many specialists.

Looking at the high and increasing costs of the National Health Service, the Committee noted that the vast majority of that expenditure appeared on the surface to be for curative services and that a very small sum proportionately was spent specifically on preventive services. In a way, this picture is not entirely fair, because the line between curative and preventive medicine is not all that easy to draw, and the White Paper refers to this in a number of places. In any event, the general practitioner practises both. But by and large, the Committee was right to say that the preventive side had been neglected in various ways and that some effective prevention could in the end free resources of medical skill and facilities to tackle diseases which could not be prevented at present.

This was the main reason why the Committee began its inquiry. The inquiry was partly the result of growing public interest in preventive medicine, and this interest was shared and fostered by the Department of Health and Social Security. But the inquiry has provoked further discussion, on the whole at a very high level.

Ministers say in their White Paper that they are indebted to the Committee for adding to the public discussion of these matters. The Ministers concerned have throughout been most co-operative with the Committee. It is fair to say that the tone of that co-operation was set by my right hon. Friend the present Foreign Secretary, who gave evidence on 28th April 1976 in his capacity as a Health Minister. His evidence was very frank and fair, and he was very well prepared to go along with many of the major recommendations of the Committee and with the attitude the Committee was taking. I think that this is emphasised by the form of the Government's White Paper. They have gone further than merely giving a formal reply to the Committee and have covered a wider range of matters. One example of this concerns preventive medicine for the elderly, with which the Expenditure Committee did not have time to deal.

In my judgment, it is the best reply from Ministers for a very long time. From time to time we in the Expenditure Committee have criticisms to make—and I have made them here—of slowness and of rather superficial treatment of our reports. It is true that this report is not exactly a Concorde. It has taken its time. But, having arrived, it is thorough and constructive and it reflects very well the careful constructiveness of my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) and her colleagues on the Sub-Committee and, as I say, for a long time the Government's response has matched the considerations of the Committee. Indeed, many of the points made by the Government in the White Paper invite a continuing dialogue from the Committee. I hope very much that this will occur.

Some right hon. and hon. Members will know that in the last two years the Expenditure Committee has tended to move in the direction of a more continuous survey of public expenditure. Some of the criticisms which have been made of lack of control of public expenditure are a bit superficial. In the Expenditure Committee, there is now an annual review which all the the sub-committees do of their areas of expenditure, and there is much more a continuing review of those matters which have been raised, normally with the Government though not invariably, and which need further comment and further pressure for development.

This White Paper offers many opportunities, and I am sure my right hon. Friend the Minister of State, whom I congratulate on being made a Privy Councillor, will be in the van in co-operating with the Committee in furthering this very helpful dialogue.

Perhaps I may turn to the very last pages of the Government's observations which set out the way that they have handled the Committee's recommendations. At the end of the day, what action has resulted in really the test of the effectiveness of the Committee's work.

Of 65 recommendations—58 main ones, plus some double-barrelled ones—the Government have accepted 24 without reservation and 17 with some reserva- tions. By and large those reservations are very helpful and constructive. They are not the sort of reservations which damn the original proposition but those which carry the main recommendation forward. Therefore, two-thirds of the Committee's recommendations have been substantially accepted.

Of the remainder, 16 are still under consideration. These are the ones that the Sub-Committee will have to get its teeth into in the future, but again, very few of the Government's comments on these recommendations are negative. Even of the eight recommendations which are rejected there are some in which the rejection is more or less sympathetically in line with what the Committee had been striving for.

For example, if hon. Members look at Recommendations Nos. 26, 27 and 28 on smoking, they will find that the Minister's comments on these are designed to further the objective which was in the mind of the Committee. Hon. Members should read paragraph 71, on page 22, of the Government's report on sponsorship of sport by the tobacco manufacturers. Here the Government are in the process of negotiating with the sponsors in order to eliminate some of the worst effects of what is implied by sponsorship. That might not go quite as far as we had hoped, but at least it is a move in the right direction.

As a second example, let us take coupons, which are referred to in paragraph 72. The Minister comments that coupons have almost disappeared, and the Government is watching this development closely. That is a very convenient phrase, but I give the Minister the benefit of the doubt. I can imagine hon. Members having something to say about that, but I must point out that there have been Government reports on Expenditure Committee reports in which the Government have not even been watching developments.

The same applies to fluoridation. The Committee asked for more research. Ministers, rather surprisingly, were very positive about this. Normally, research is a wonderful let out for Government and for inaction generally. But here the Government says that fluoridation research is not necessary because they know the answer. Good for them. I think that I am going to be stabbed in the back over that, and perhaps in the front as well, but that is no uncommon experience for an ex-Defence Minister—

Mr. Ivan Lawrence (Burton)

Will the hon. Member not agree that this is a perfect example of the utter complacency of this Government? Having had a recommendation that there should be further research, the Government sweep it to one side and say that there is no need for it.

Mr. Boyden

I would have thought that the hon. Member would appreciate the smack of firm government.

I have a feeling that the actual recommendation of the Committee—and here I speak personally—was motivated by the need for a certain amount of consensus. Of course this is a weakness of the Expenditure Committee. We seldom have any great party controversy. Throughout this investigation the conflicts were not great. There were some, as hon. Members will see if they look at the proceedings of the full Expenditure Committee and the voting on some issues. Generally speaking, consensus is the way in which we can get reports out and get movement in certain fields. I praise this Committee and this report for a large area of consensus which is in the public good.

Expressing another personal view, I am not sure about Recommendation No. 40 on fluoride research. However, I think that the Government handled it with a smack of firmness, and they are to be commended for it.

A similar situation arises on Recommendation No. 57. Here the Committee asks the health authorities to give their percentage of expenditure on preventive medicine. Again, the hand of firm Government has been shown with the Minister saying that this is not practicable. Of course, that is a standard reply from Ministers and I shall be interested to hear my colleagues' views on this.

Of the eight rejected recommendations, five were rejected in a constructive way which does not in any way derogate from what the Committee had in mind. Members of the Committee may argue one way or the other about this, but I am sure that it will not upset them very much.

In several fields where the Committee has pressed for more resources—I pick out two, more dental hygienists and more health centres—it is perfectly right that it should concern itself with these matters. A few years ago I campaigned hard for more dental hygienists. The matter has dropped out of my sights lately, and I was rather disappointed to find how few hygienists there are. Therefore, the Committee was right to say that we want more. Obviously, if there were enough there would be a great improvement in the dental health of the population, particularly children.

At the end of the day the Government must decide the priorities and provide the cash. This again is partly a weakness of controlling public expenditure, or attempting to, through Committees which have no responsibility. In the end it comes back to Ministers who have to take that responsibility.

I have always campaigned for health centres. When I was on the Durham County Council we made excellent progress with health centres—although it was a long time ago. But once again, I have not applied my mind to that matter much lately and I was delighted to see the answer that the Minister gave to the Committee's request for more health centres, because it is pretty encouraging. Paragraph 198 says: At the end of 1976 there were 120 health centres under construction, most of which were likely to come into use in 1977 or 1978. A further 93 health centres were due to be started in 1977–78. Many others are being planned to come into the capital programme within the next few years. That is a substantial move forward and it has certainly taken us a long way from the days when we had to struggle to convince the public, the House and local authorities that health centres were a good thing. In these days of complaint about the National Health Service, there is considerable building of health centres. This is the kind of comment from the Government which shows nothing but good sense.

There is the typical, comparatively minor matter of the Committee wanting taxation placed on harmful cigarettes. This arises in paragraph 75. The Government say that they are very sympathetic towards this proposal but that they are prevented from doing anything by the EEC. No doubt that will provoke some rather interesting replies from unexpected sources. It demonstrates the difficulties that the Government face in carrying out these recommendations, and how much easier it is for us, without responsibility, to make recommendations.

The Committee was absolutely right to concentrate on readily identifiable aspects of prevention where early practical action was possible. The report is not an academic exercise on prevention. It is entirely practical and will produce a great many changes for the public good.

It is particularly important and interesting to note the concentration on what ordinary people can do to prevent themselves from getting ill. I do not know whether the parliamentary gymnasium arises out of this, but if hon. Members consider preventive medicine on themselves, that is a marked step forward.

The points made in the report are made not solely with an eye to saving money or freeing resources but to improve the quality of life. There is much talk of improving the quality of life, but I believe that there is no area of activity in preventive medicine which will not benefit from the recommendations of the Committee and the stimulus to discussion provided.

Health education is clearly a very important part of prevention, and the Committee's recommendation providing for increased financial support for the Health Education Council is sound and has been matched by a tangible effort of Government approval in the allocation of £1 million in the current year and in the next two years.

I am also pleased that the Government have accepted the Committee's views about radio and television publicity. The media, directly and indirectly, can have a large impact in this respect. They are taking more interest in these matters, which can do nothing but good for the public in general.

Great responsibility rests on parents and teachers and on those who are responsible for bringing up young people. The advice in the Committee's report is directed at parents and teachers as much as it is directed at anybody. In the same way, general practitioners have an extremely important part to play, and the Government entirely endorse the Committee's view about greater improvement in preventive medicine and the training and education of nurses, health visitors and doctors in this field.

In conclusion, I wish to emphasise two points. The education of children, preventive medicine as it applies to children and the general care of their health should be given top priority. Not only will this provide an investment for the future on economic grounds, but it will be an area in which the quality of life can be improved.

A great deal of the Committee's comments amount to common sense and to a plea for self-control. It is easy to enunciate that concept, but it is much more difficult to see that it is carried into action. I very much hope that a wider public than Parliament and those associated with it will take an interest in this subject and will be in which ways they can get the best out of these recommendations.

This report illustrates what is within the capacity of the Expenditure Committee, most of which is entirely laudable. The Sub-Committee has fixed on a sector of public expenditure which it can put into focus. That expenditure is of considerable concern to the public. The Sub-Committee subjected the matter to a thorough and searching review and took an all-party view. Such differences as existed were not based on party considerations, and the discussions in Committee will help to stimulate, debate, which can only be helpful to the Government and do nothing but good to the public.

I wish to congratulate my hon. Friend the Member for Wolverhampton, North-East on the way she drives her Committee and on the manner in which she leads its deliberations. She is a formidable Chairman and hon. Members respond to her lead.

Mr. Nicholas Winterton (Macclesfield)

Very formidable.

Mr. Boyden

I am glad to see that the hon. Gentleman, who is a member of the Committee, responds to that comment. My hon. Friend and her colleagues are most diligent—and I make that as a point of praise, not of criticism. The staff of the Committee is very small, and I can think of no better cost-effective exercise than the way in which this Committee operates. I congratulate my hon. Friend, the Committee members and its staff who joined in making the report effective. I hope that, as the debate develops, we shall have the same enthusiasm among those who have not been on the Committee for the excellent work which it has carried out.

3.55 p.m.

Mrs. Renée Short (Wolverhampton, North-East)

I wish to thank my hon. Friend the Member for Bishop Auckland (Mr. Boyden) for his kind words of support and I am grateful for his accolade to the Committee. I am pleased that he also commented on the high productivity rate of the Committee, particularly as we work with a very small staff. I believe that there is a good case for an improvement in its numbers.

Preventive medicine is not new. It is about 150 years since the first measures of preventive medicine were introduced, and those occurred during the upheaval of the Industrial Revolution. People came into the towns from the countryside and were living in appalling conditions, involving overcrowding in poor dwellings. There was widespread pollution of water supplies, no proper sewage disposal, problems of air pollution, and the use of women and children in sweated workshops and factories. All these matters provided a backcloth for change.

It was in 1848 that the first Public Health Act was passed, and that was the forerunner of many other mandatory Acts. Diseases such as smallpox, pneumonia, diphtheria and tuberculosis caused heavy loss of life among adults and children. Because of the existence of preventive medicine and the legislation that was introduced, many of those diseases have now disappeared. In those early days many women died in childbirth or as a result of horrific methods of illegal abortion. This led to a high death toll among women and girls. Gin was the solace of the poor and was given as a pacifier to babies and young children. The average life expectancy in those days was 40 years. Therefore, it can readily be seen that much progress has been made.

Public Health Acts were passed regulating work in factories, and that legislation had a profound effect on the nation's health. All these Acts affected the nation's health, environment and life expectancy. It can be argued that the greatest benefactors of our people were not doctors but civil engineers who were responsible for installing sewerage schemes, pure water supplies and so on. I hope that the doctors will not be offended by that comparison.

In these days, in the very much better conditions in which we all live, we are nevertheless cencerned, as my hon. Friend emphasised, about certain areas of disease where environmental factors, personal habits, susceptibility to accidents and other factors indicate a higher incidence of disease, a rising death rate from certain avoidable diseases in some sections of the community, and hazards arising from the individual's own life style appear to be deliberately ignored or not understood at all.

Better education is required to cope with preventable disease and we require a greater understanding of causes and effects. Such diseases not only cause premature death and unnecessary suffering to individuals and their families, but also place an unnecessary burden on those concerned in terms of cost and pressure on medical and nursing services within the National Health Service. This situation causes great anxiety. It must therefore be possible to relieve the National Health Service of some of this burden of self-induced disease and thus release resources urgently needed in other areas of the NHS by shifting resources from curative to preventive medicine.

This was the background to our study, and it provided a vast collection of expert papers and oral evidence from a great number of eminent witnessses We were encouraged and helped in our inquiry by the medical and supporting professions in many varied areas. We received many opinions and reactions as a result of our invitation to witnesses to give evidence to our Committee. Since the publication of our report, we have received many welcoming comments, and I wish to take this opportunity of expressing our thanks to our witnesses, to those who showed us their work in medical schools, dental schools, health centres and clinics and to others who unsparingly gave us their advice and time. It was a rewarding experience and I hope that it forged strong links between Parliament and those working in the NHS at every level.

I must also thank those who submitted written evidence. Our special thanks are due to our Clerk, Miss Milner-Barry, who had the considerable and exhausting task of organising the whole inquiry, assembling the witnesses in order from one week to the next, and collecting, indexing and presenting the mass of evidence in the three volumes that are before the House.

My thanks are also due to hon. Members on both sides of the Committee who make it a pleasure to be a driving Chairman, as my hon. Friend the Member for Bishop Auckland described me. They gave great support to the work of the Committee.

There were ways and means of hon. Members expressing their opposition to the report but the report was unanimous, even on the fluoride issue. I was entirely on the side of saying that enough research had been done. We know enough about the effect of fluoride. Experimental fluoridation schemes have been carried out. I should like to see the Minister taking a firm line about the addition of fluoride to water supplies. However, there were some hon. Members who were not so convinced. Unfortunately, one member of the Committee changed his view after hearing the evidence. It was, therefore, a compromise to say that more research should be carried out. I have been perfectly honest about that.

We had to be selective in our choice of areas of investigation. The whole range of preventive medicine is so vast and goes into so many medical specialties that clearly we had to choose. We chose areas where we believed that there was considerable concern among both the profession and the public, where we felt that progress had to be made as rapidly as possible in educating the groups most at risk, and where progress could be made fairly quickly. Our recommendations have now been responded to by my right hon. Friend and his advisers.

I hope that more consideration has been given to the recommendations where my right hon. Friend indicated that ongoing consideration was continuing. I hope that he might have had second thoughts about some of our recommendations that he felt unable to accept, or about those to which he felt unable to give further consideration.

I must stress that underlying the whole of the report and the recommendations is the need for more effective education in all matters affecting the nation's health and the individual's health. There is a special need to improve the health of women and children. We suggested that that need should be given priority, especially to promote good health among children.

We were concerned to learn that at the time of the inquiry the income of the Health Education Council from the Department was only about £1 million a year. It is in competition with some of the big spenders that are advertising ways and means of undermining health, and that was clearly an inadequate sum. We were glad to hear of the allocation of a further £1 million to the Council beyond that to which my right hon. Friend is already committed. I think that the House will wish to hear of the further help that the Department intends to give to the Council.

In pursuing our proposals for more education we recommend the reintroduction of the Radio Doctor programme, preferably at the high peak listening spot before the eight o'clock news in the morning. My right hon. Friend accepted that recommendation. I hope that he will tell us what progress he has made in consultation with the BBC.

We recommend the strengthening of the health education content of teacher training embracing the range of preventive medicine in the report as a first instalment. We cannot emphasise too much how important we believe it is that teachers should be properly and adequately trained to deal with young children at school and young adolescents who do not receive the guidance and help that they should get from their parents in matters pertaining to adult relationships, such as sexual relationships. It is essential that teachers should be trained. Teachers who are especially interested in undertaking that valuable work in school should have special training courses to fit them for it.

We recommend that preventive medicine should play a more important part in the training of medical students. It is amazing that it does not do so already when so many within the medical profession understand that it is an important part of medicine. I am sure that medical students learn much that is not completely relevant to most of them when they go out into the great wide world to practise and to start treating patients, which they do not do when they are training. Therefore, we recommend that the content of medical training should be reconsidered in that regard.

We recommend that community medicine as a career should be more attractive and should enjoy better status to attract more people into it. I understand that community physicians are now concerned about their salary increases vis-à-vis those given to clinicians. My right hon. Friend should also consider that matter.

One of the areas that causes us most concern is smoking. I think that it is generally accepted throughout the country that smoking is a major area where firm action is needed. It is accepted by the medical profession that the smoking of cigarettes, in particular, causes lung cancer, coronary heart disease, and chronic bronchitis. The medical profession does not distinguish between low and high tar cigarettes. It considers all cigarettes to be dangerous.

In 1976 the tobacco firms were spending no less than £15 million on cigarette advertising. That is apart from their increasing expenditure on sport sponsorship. Since our report has been available we understand that the British American Tobacco Company is intending to spend a considerable amount on sponsoring sport, thus propagating the entirely erroneous view that husky young sportsmen and tough young sportswomen may be equated somehow with cigarette smoking. That is unacceptable.

The fact that my right hon. Friend the Minister with responsibility for sport has given approval to new expenditure in that area is surely a contradiction of what my right hon. Friend the Secretary of State said only a month or so ago, when he stated that sponsorship of sport by the British American Tobacco Company and other cigarette firms was grotesque. Given the efforts of the Department to reduce cigarette smoking, it seems especially appropriate that my right hon. Friend should take action to reduce rather than increase the toll of premature death and disease caused by cigarette smoking. I hope that my right hon. Friend the Minister of State will comment on that.

It is most annoying that such an announcement should be made at the time when the report is before the House for discussion and when the tobacco firms are spending a great deal of money on straight advertising. When the Health Education Council had its campaign against smoking about two years ago it was able to spend only £400,000 to counter the fantastic expenditure of over £15 million by the tobacco firms.

It is worrying that more women are suffering from lung cancer. As more women in socio-economic groups 4 and 5 are smoking more, men and women in the higher groups are smoking less. There has been a worrying increase among men and women in groups 4 and 5.

It is vital to give young people proper information about the consequences of smoking so that they never start to smoke. That is why the training of teachers is so important. There is evidence that children are starting to smoke while at primary school, not even waiting until adolescence. Clearly that has to be taken on board by the Department of Education and Science. That places great responsibility on teachers to guide their pupils on such matters and to give them a good example when they are in school. What they do at home is their business, but teachers must decide not to smoke in school if they are to give a good example to pupils. That means not smoking in the staff room either, because when a youngster knocks on the door to speak to a teacher and is met with clouds of stale smoke billowing out, it does not reinforce the teacher's example or teaching. That is a counter-productive exercise. I hope that the teaching profession will take it on board.

Mr. Patrick Jenkin (Wanstead and Woodford)

Did the hon. Lady's Committee receive any evidence about the rise in smoking among nurses in hospitals? Does she think that is perhaps a matter for almost greater concern, because those who ought to know better are not necessarily setting the kind of example that we want to see?

Mrs. Short

I absolutely agree with the right hon. Gentleman. Nurses ought to follow the example of the medical profession. Many doctors have now given up smoking altogether. Nurses should follow suit. Smoking caused 25,000 unnecessary premature deaths in 1974–75. Yet it is in this area that I find the Department's and my right hon. Friend's response the least satisfactory.

We had the opportunity to talk to Dr. Kjell Bjartveit who was responsible for the preparation of the Norwegian legislation which now exercises strict control over cigarette advertising, the availability of cigarettes for young people and so on. His report was highly encouraging. He was able to report a steady reduction in cigarette smoking.

I had occasion to discuss this matter again at a medical seminar. I was glad to learn that the decline in smoking in Norway had been maintained. Yet our recommendation to follow Norway's example and to ban advertising except at the point of sale—that is, at the tobacconist's shop, not in the Press, on radio and television, in magizines and so on—was not accepted. Nor was our recommendation that cigarette machines should be available only in places where children do not have easy access to them.

I found it even more surprising when my right hon. Friend refused to consider the need for a much stronger health warning on cigarette packets specifically saying that cigarette smoking caused lung cancer, coronary heart disease and bronchitis. That would be stronger than the warning on the packet now. Perhaps the Minister of State will tell us why these strong recommendations were not accepted.

However, my right hon. Friend supported our recommendation that there should be more non-smoking areas in public places, including buses, trains, cinemas and so on. I hope that British Rail, London Transport and other bus companies will take this on board and eliminate smoking areas altogether. The smell of stale smoke and having to breathe in other people's smoke if there are not places available in non-smoking compartments is sickening to non-smokers. Smoke clings to hair and clothes, and the debris of cigarette ends and spent matches thrown on the floor is unattractive and dirty.

I have tried, unsuccessfully so far, to persuade my right hon. Friend the Prime Minister, who is a non-smoker, to raise the whole question of cigarette advertising and the specific matter of the Royal Warrant, which is given to certain cigarette manufacturers, with Her Majesty on one of his Tuesday visits. The consequences of cigarette smoking are now widely recognised, and it would be a great encouragement to all who are concerned about the serious diseases which arise from the habit if the Royal Warrant were withdrawn from those firms. I hope now that it will be possible for that to be done.

Mr. Clement Freud (Isle of Ely)

Does the hon. Lady agree that in certain cases the Royal Warrant is exceedingly useful—for example, the picture of George V on a cigarette packet with the motto By appointment to His late Majesty King George V".

Mrs. Short

I understand that he died from lung cancer. In fact, four of our kings have died from smoking-related diseases. That makes it even more extraordinary that the Royal Warrant should be given.

Mr. Freud

I thought that was a health warning.

Mrs. Short

People do not see it as such. They are perhaps not as well informed as we are about the causes of royal deaths recently.

Dr. M. S. Miller (East Kilbride)

Before my hon. Friend leaves the question of cigarette smoking, may I ask her to comment on the lack of success of the recent campaign to get people to smoke what was known as new smoking material?

Mrs. Short

I was going to come to that matter. The fact that so much money was spent on research into this smoking material and on its manufacture, packaging, promotion and so on indicates the steps which some tobacco firms will take to try to continue to make money out of this activity. All those millions of pounds could have been better used in some area of preventive medicine. It is sad that all that money, effort and resources were wasted in that way.

Mr. Nicholas Winterton

On that point, I hope that the hon. Lady—

Mrs. Short

I have not given way.

Mr. Winterton

Will the hon. Lady give way?

Mrs. Short

I am sure that my right hon. Friend, for whom I have great regard, will catch Mr. Speaker's eye a little later in the debate. Perhaps the hon. Gentleman would care to make this point then. I have given way several times. I say that in all friendship.

I should like to know my right hon. Friend's view on our recommendation for a significant increase in duty on cigarettes, which was being considered when the White Paper was published, bearing in mind that cigarette smoking has increased in certain sections of the population. I know that a small step was taken in the last Budget, but I do not regard that as a prohibitive increase. We want to see a considerable increase in tobacco duty so that people really will think two or three times before buying another packet of cigarettes.

The attitude of doctors to alcohol is different from their attitude to smoking. The doctors in their evidence told us that reasonable quantities of alcohol could be beneficial. It is the abuse and misuse of alcohol which is dangerous and the incidence of drinking among the young which is so worrying. Violence in the family, foetal damage, road accidents, cirrhosis of the liver, absenteeism from work and other problems arise from the misuse and abuse of alcohol. We raise over £2,000 million in duty and tax on alcohol. We should like to see some of that money devoted to the education of the young about the dangers of alcohol abuse.

The price of alcohol must have some effect on consumers, just as the price of cigarettes does. If it appears relatively cheap, consumption will go up. That applies particularly to the young who are able to go into supermarkets and buy alcoholic drinks, apparently with impunity in some cases.

Diet also plays an important part in the promotion of good health and the avoidance of certain diseases. If only we could persuade parents to give children less sugar, sweets and chocolate, that would certainly help children, particularly the state of their teeth. It would also help adults and children in the slimming process, which causes such a lot of people so much concern. Some people say that they cannot give up smoking because they are afraid that they will put on weight. If they would look at their diets as well as giving up smoking, they would find it easier to avoid putting on weight. People who are overweight put additional strain on the heart and joints, so it is to their advantage to try to lose weight.

If children could be offered things other than sweets and chocolate, their teeth would improve. The nation's teeth are nothing to brag about. We have very poor teeth. Too many children lose too many teeth much earlier than they should. We spend £150 million a year on dental treatment. Yet our children's teeth are in a poor state. This is partly because they eat too many sweets and partly because they have never been told how to brush their teeth properly. We recommend that more dental hygienists should be trained and employed, and this is an important part of the job they would do. It is also an important job that teachers could do, especially teachers in nursery schools where children have to learn to brush their teeth as soon as they have teeth to brush.

A high consumption of saturated fats can cause coronary heart disease. Housewives should be told much more about the food they buy, especially convenience foods. Then it is up to them to avoid what they understand to be dangerous.

In order to improve teeth, we recommend that dentists working within the NHS should be able to use sealants and fluorides. The White Paper accepts this with some reservations. I wonder whether my right hon. Friend could tell us what those reservations are. Perhaps he can say why the proposals were not accepted wholeheartedly and what he intends to do about it. We have strong dental evidence to support the use of sealants and fluorides as being of great help, especially for young children.

Of special importance to women is the provision of safe, efficient fertility control and an adequate number of day-care centres for the termination of pregnancies within the NHS. We have evidence to show that a day-care abortion costs £35 whereas an in-patient abortion costs about £112. My right hon. Friend has taken this matter on board and has agreed that some expansion of day-care facilities should be provided. Unwanted pregnancies, apart from the misery that they cause to the girls and women concerned, are a great financial burden on the NHS and local authorities.

In 1972, Mr. W. D. Laing estimated the cost of an illegitimate child, by the time it reached the age of 16, at £4,400 to the taxpayer and ratepayer in providing care and facilities. That figure must have more than doubled by now. One can see the cost of not having an efficient and effective family planning service and proper education.

Family planning advice is available now on the NHS for men and women. It is possible to get information locally about doctors and hospitals. We recommend that the same information should be available for women seeking abortions to save shopping around when their general practitioners refuse to help. Time is crucial if early, safe abortion is our aim. I hope that my right hon. Friend will be able to take this matter on board and will agree that it will be of good value to the NHS if it can be done.

Another of our proposals was that one of the tiers of administration in the NHS should be removed. I am interested to see that in a research paper produced for the Royal Commission which studied the National Health Service entitled "The Working of the National Health Service", there is a thorough examination of the cost and the effect of the present administrative system of the NHS. The report calls it "top-heavy and over-elaborate" and says that it leads to extra work and delayed decision making. The conclusion of the research team, which was led by Professor Maurice Kogan of Brunel University, was that there were: too many levels of administration and too much duplication of functions at the different levels. He went on to say: The multiplicity of levels, the over-elaboration of consultative machinery, the inability to get decision-making completed nearer the point of delivery of services, and what some describe as unacceptably wasteful use of manpower resources were recurrent themes in most of the areas where we worked. That bears out the evidence that we took about the present administration system of the NHS. This is a major cause of the frustration and anxiety among nurses and doctors working within the NHS. This should be considered as quickly as possible so that all the frustration and delay can be removed. It is not only staff who suffer. Patients have to wait for long periods before they see a doctor, before they get a consultation, before there is any follow-up and before they are referred to a hospital for whatever treatment or operations they need.

My right hon. Friend has in our report a good deal of ammunition for many of the things that the Department is considering and would like to do. I hope that he will recognise our concern about the incidence of disease caused by the lifestyle of people. By education and proper instruction of parents and children, much of this can be reduced so that resources, which are never sufficient in an expanding NHS, can be transferred to the areas of medicine in which there are still acute shortages and long lists of patients awaiting certain specialist attention in hospital. I hope that my right hon. Friend will be able to answer the points that I have raised and that he feels that the report supports him in the work that he and his Department are doing.

4.26 p.m.

Mr. Robin Hodgson (Walsall, North)

I was not a member of the select Committee, so I begin by congratulating the Committee on a stimulating and interesting report. I congratulate the Government on being able to reply quickly to what the Committee said.

I agree with the hon. Lady the Member for Wolverhampton, North-East (Mrs. Short) on what she said about education. If we are not careful and push this bandwagon too far too fast and do not carry public opinion with us, we shall be in danger of setting up a countervailing public reaction against what she and I are seeking to do.

I agree also with what the hon. Lady said about the need to transfer resources to make sure that we get the maximum good effect from the money that we are able to spend on the health services. The figures in the report that show the amount spent on prevention, as against that spent on cure, demonstrated the point better than any figures or remarks that I might make.

The definition of "health" in the preamble of the charter of the World Health Organisation reads: Health is a state of complete physical, mental and social wellbeing and not only the absence of disease or infirmity. If one accepts that as a desirable objective, one's approach to preventive medicine is considerably changed. If we support this reversing of traditional objectives, perhaps the Government's response to the Committee's report has been a little flabby in certain places.

For in reversing the traditional approach, we no longer exclusively consider sick people. We consider the population as a whole. We get away from the problem that we have now in that the NHS has become more of a national hospital service or a national medical service. If we could find ways of re-emphasising the health aspect at the expense of the curative side, perhaps we should be able to make greater strides toward the fulfilment of the World Health Organisation's definition of health. The aim must be to keep people out of the hands of the doctors—I mean that in no disparaging sense—because this would increase individual responsibility and cut costs.

Every person who goes to hospital must be regarded as a failure of our health services rather than a success. It is no good Secretaries of State for Health and Social Services from whatever party proudly saying that more people were admitted to hospital this year, as if that were evidence of good stewardship. That is the wrong way to look at it. We should prevent people from going to hospital by not allowing them to become sick in the first place. This may seem Utopian, but there is a considerable need for urgency.

Two groups in our population are particularly at risk to illness and particularly absorb resources from the NHS—the children and the elderly. Though there will not be a dramatic change in the number of children over the next few years, there will be a considerable increase in the number of elderly people. I was therefore slightly disappointed to see that the elderly rated only four paragraphs in the Government's response. While it is true that the number of males over 65 and females over 60 will rise only from 9.3 million to 9.7 million over the next 15 years—an increase of 400,000 or about 5 per cent.—the number of elderly and very elderly people will increase much more dramatically than that. The number of elderly, who are defined by the Department as being aged between 75 and 84, will increase from 2.2 million to 2.8 million. That is an increase of nearly 30 per cent. The number of very elderly, who are defined as those over the age of 85, will increase from 500,000 to 750,000—an increase of nearly 50 per cent.

I would hypothesise, though I have no figures to back it up, that the older a person becomes, the more he will be dependent on medical resources of one sort or another and the more value we shall get if we are able to find ways of preventing such elderly people from becoming ill in the first place.

This is only part of my overall contention that unless people are encouraged to take more care of themselves and to take more responsibility, above all, for minor illnesses and ailments, the NHS will continue under intolerable strain. How do we do this? The hon. Lady the Member for Wolverhampton, North-East spoke about the need for education. I agree with that and I also emphasise the need for fiscal incentives. The hon. Lady mentioned some of these, but there are others to which I should like to refer later. We also need to create the right social climate and end the "smart-to-smoke" idea which can be carried, by analogy, into other areas of preventive medicine. This three-pronged approach—education, fiscal incentives and the creation of the right social climate—is a process which must go on through the lives of every citizen.

It starts with every child being a wanted child. Much has been done in family planning, but there are still gaps in the service that need to be filled. There are still clinics where opening times are poor, the location is unattractive and where the doctors are of an age and generation which inhibits young girls from approaching them to discuss these delicate social questions. More needs to be done in that area.

I do not want to stray down this next avenue for more than about two sentences, but we are concerned in the West Midlands about inequalities in relation to abortions on the NHS. Figures have been produced time and again to show that because of the activities of a handful of gynaecologists in the region, it is extremely difficult for women in the West Midlands to obtain an abortion on the NHS. The national average is 50 per cent. of abortions carried out under the NHS, but in the West Midlands it is 20 per cent. and in my constituency, the figure is 10 per cent. That is not very satisfactory and the Government could take action here.

We need to have a great deal more advice provided on parenthood. For example, I have heard in my constituency of mothers wanting to look after their children by feeding them fruit juice at a relatively early age. Of course, the juice contains sugar, which gets stuck in the child's gums, rests against the teeth for a long time and, even though the mother has acted with the best of intentions, the result is severe dental decay for the child. It is in that simple example, repeated many times in other areas, where an ounce of prevention and education is worth several tons of cure.

In schools, the words "health education" have too often been nothing more than a euphemism for sex education. We need to expand this to cover diet and exercise—I was glad that the Committee referred to the need for exercise—and education about the future responsibilities of parenthood. For example, why is it not possible to have crèches or nurseries attached to some comprehensive schools so that in the last few years of their school life, pupils can see what parenthood involves by working with children? This would be a valuable way of ensuring that all sections of the community and all socio-economic groups have an opportunity to learn what parenthood and having children involve.

Turning from childhood to adult life, I should like to refer particularly to the question of diet. The Committee's recommendation on fats was accepted by the Government only with reservations—and that is a great disappointment. The Committee said: We recommend that information about fats should be placed before the public in order to show up clearly the risks from a high intake of saturated fats and to encourage people to moderate their fat intake or switch to polyunsaturated fats. The Royal College of Physicians' Report in 1976 and the McGovern Report in the United States seem clearly to have linked coronary heart disease with a high fat intake. The Registrar-General's figures show that out of about 600,000 deaths in this country in 1975, 300,000 were a result of coronary heart disease. The Government's own White Paper said that 3,500 beds a day were used by people under the age of 65 suffering from coronary heart disease. In that context, it is unsatisfactory that the Government have been able to accept the Committee's clear suggestion only with reservations.

We can also do a great deal more to improve the amount of information on food content. In a pamphlet entitled "Exemptions from Ingredient Listing and Generic Terms" the Ministry of Agriculture says: We have for some time believed that it is no longer a defsensible argument to propose to a consumer, who may be a busy housewife, that to discover the ingredients of, for example, bread or ice cream she should visit the public library or buy the appropriate food standards regulation from HM Stationery Office. I know that this does not fall within the Minister's departmental brief, but I should like to know what the Government are doing to implement the recommendation of that study group.

The Government have accepted the need for research into dietary needs, but what is going on in this area? I have read the annual report of the Medical Research Council for last year and it contains little about preventive medicine and virtually nothing about research into diet and dietary needs of different sections of the population.

The hon. Lady the Member for Wolverhampton, North-East comprehensively covered the question of smoking. I add only that our successors in this House in 25 or 30 years' time will be amazed that we have allowed public advertising of a product which clearly has a linkage with major causes of death, namely bronchial disease, coronary heart disease and emphysema generally. We shall look illogical and stupid to succeeding generations for having allowed this advertising to continue when we are clearly in possession of facts that indicate, without a shadow of doubt, that there is a link between smoking and chronic ill-health.

I wonder whether there would not be some benefit and value in considering the possibility of a reduction in national health insurance contributions if a person has annual screening against some of the more common diseases. This sort of fiscal incentive could encourage people to take advantage of such a screening process.

I turn finally to research into what I understand is called iatrogenic illnesses, that is, those that are side effects of being treated for other illnesses. We have, increasingly powerful drugs that set up countervailing reactions. A constituent of mine who was being treated for nerves—she lives in a multi-storey block of flats, a condition with which many hon. Members will be familiar—found that a side effect of the drug she was taking was that it gave her chronic vertigo, a condition which is not conducive to living on the twentieth floor of a block of flats.

We need to discover much more information about such illnesses and more research should be done into the effects of the treatment of one illness on the creation of another. This is particularly important as we are using increasingly powerful drugs which are changing the basic metabolism of the body.

The chronic problem of the elderly is loneliness. There have been many articles on this. Much loneliness shows itself in psychosomatic illness or nervous diseases, which are now believed to account for a third of the average doctor's caseload. Again, I was slightly disappointed in the Government's response. There was not much emphasis on the importance of building up the voluntary organisations which are so familiar with their localities and responsive to local needs and which can respond much more imaginatively to specific local interest groups than the rather more plodding although more thorough Government organisations. There is an increased need for home helps, health visitors and district nurses.

If we are to have an effective preventive policy, it will be achieved only if we can get at people in the community, which will mean having non- or only partially medically trained people. This places heavy responsibility on the medical profession to respond constructively to this development. I understand that the medical profession are jealous of their position. After all, they take the ultimate responsibility for the treatment of patients and have done extensive training and their professional livelihoods depend on it being kept at a high level. Their professional standards are of worldwide approbation.

But if prevention is to work and become effective, doctors will have to allow a broader range of people to become involved in the treatment of the public. They will have to allow less skilled people to have a primary role in preventive medicine. Has the Minister any thoughts about discussions with the medical profession to allow such auxiliaries an important role in developing comprehensive preventive care?

I have described the Government's response as a little flabby. There are two pieces of evidence for this. Paragraph 15 of the White Paper says: Preventive medicine permeates to a greater or lesser extent the work of virtually all Divisions within the DHSS and this has been reflected in an administrative reorganisation". I accept that it permeates, but on the other hand administrative reorganisation is hardly what we are looking for. We are looking for evidence that we shall be able to move forward and achieve concrete results affecting the health of the community.

The hon. Member for Bishop Auckland (Mr. Boyden) quoted from paragraph 247 of the White Paper as evidence of the smack of firm government. I hope that I do not misquote him. However, that paragraph says in part: This recommendation is, however, one which presents substantial problems and one which the Government is unable to accept. That is hardly the smack of firm government—

Mr. Boyden

The point is that the Government were not accepting the Committee's recommendation that there should be more research. There was enough known about it—that was the important point.

Mr. Hodgson

I take the point on fluoride, but this is a reference to diversion of resources from curative to preventive medicine.

Mr. Boyden

Perhaps I got the figures wrong. I was talking about fluoridation.

Mr. Hodgson

Perhaps I have misquoted the hon. Gentleman in carrying forward his reference to the smack of firm government to the contents of paragraph 247.

Hon. Members are perhaps over-used to tramping over familiar ground and this is a new field in which there is room for imagination, new projects, original thought, pioneering and flair. Flair is what is missing from the Government's response. Worthy it certainly is, but a little dull. I hope that the Minister will be able to bring some leaven to the subject when he replies.

4.44 p.m.

Mr. Clement Freud (Isle of Ely)

In common with other hon. Members, found the Select Committee's report interesting and at times fascinating and I am sure the chairmanship was exemplary. If one must criticise, the only obvious criticism is that its terms of reference were too wide; it was virtually impossible to touch on all the subjects. Despite all those who accuse us as a nation of being medically cossetted, it should be remembered that a lower percentage of our gross national product is spent on health than is the case in France and many European countries—and it is certainly less than is spent by almost any country on the other side of the Iron Curtain.

The point which comes out from the report is that medicine has infinite financial demands, especially if one considers some of the innovations, whereas finance in general, especially our finance, is finite. Obviously, there has to be a limit and we have other necessities than health—for instance, food, housing, education and transport, all of which are close and relevant to health.

Over the years, medical science and technical innovation have seen the end of some disease. Thanks to hygiene and improved housing, vaccination and industrial safety schemes, we have helped to eliminate once common ailments. But alongside that process, new medical problems have arisen, some of which are actually brought about by our new hygiene, by our new leisure-conscious and mechanised life, by the extra stress of sophisticated work and by early retirement.

In a ballad written in the 1920s, W. H. Auden made a point which was then believed to be only poetry but which later became virtually accepted by the medical profession. Writing of an old lady named Miss Gee, who had cancer, he wrote that the doctor came home to his wife and mused: Childless women get it and men when they retire; It's as if there had to be some outlet for their foiled creative fire. It is now found that when people give up work or are frustrated in their ambition, those are the circumstances in which cancer proliferates.

Greater wealth has led to more eating and drinking. Clearly, that has had its own problems. And the healthier lives we lead, even despite the new ailments, mean a greater number of older people; therefore greater geriatric expenditure. So the workload will grow and our resources for health expenditure are likely to remain more or less static.

I suppose that it is possible, although this can be no part of this debate, that one advocates the abolition of something else in order to find more money for health. The Diplomatic Corps or the Army could go. I have no great faith in those arguments either.

With static resources, we have to decide how we should get value within the NHS. This debate is useful because it gives the House a chance to examine our processes.

One of the difficulties about the new medical practices is that once it is decided that something is desirable in medicine—whether it be a new practice, a screening method or a diagnostic procedure—we decide to try to make it available to everyone because it is "a good thing". The present-day doctor's dilemma is not so much what to do as what not to do.

The efficiency of our NHS and probably of any health service depends on four things: the number and the quality of the people who do the work; the adequacy or otherwise of the premises in which they do it; the availability and the effectiveness of the tools with which they work; and the administration whereby those three are welded together.

I believe that in all four fields there are serious shortcomings. First, as a matter of urgency, we have to try to eliminate waste and duplication. My noble Friend Lord Winstanley gave a lecture not long ago at the Manchester Statistical Society, a print of which is available at a price of £1.50.

He said: Take for example the School Medical Service. (I am not making any criticism of school doctors who I am sure do their very best in difficult circumstances.) I have done sessions of School Medical Service work just for interest. I find that I am examining healthy child after healthy child after healthy child. Finally, when I come across one with a defect and the light of knowledge shines in my eyes as I say triumphantly to his mother, 'Oh, he needs his tonsils removing,' she says 'Yes, he's been on the waiting list at Crumpsall Hospital for four years'. Or I say, 'He's got flat feet'—'Yes, he goes regularly to such and such a place for exercises.' This is skilled medical manpower working in isolation that could be helping the general practitioner or the hospital services, but, because it is working in isolation, it is very often merely duplicating their work. The School Clinic does useful work, but is so often used by patients merely as a sort of buckshee second opinion. They bring the child along to me and say 'What do you think it is?' and I say 'Well I think it's so and so', and on the way out they say 'We'll go and see the school doctor and see what he says', and they go and see him and he says something different, as often as not, which helps neither the child nor the parents nor me nor the school doctor. Please do not take this as an attack on the School Medical Service; I just mention it by way of illustration. He went on to the nursing services, talking about the health visitor who will go and see a patient and talk about meals on wheels or invalidity allowances or whatever it might happen to be. If you say' And while you are there, will you give him an injection?'—oh no, that is the District Nurse, the working nurse. She does not do it.

He also said: Another example is industrial medicine where skilled, highly trained doctors are doing pre-employment medical examinations day after day, not at all sure what it is they are looking for or whether they will ever find anything, but often tying up highly technical and expensive resources in a field of activity the usefulness of which is questionable to say the least. Now do not suppose that I am dismissing industrial medicine; I am merely saying that some of the work done by the industrial medical services seems to me to be wasted work and that they could in fact spend much of the time better. Those medics in the House will appreciate that, for instance, a student would fail his medical examination if the psuedopatient whom he was examining said that he had a change in his bowel movement and the examinee omitted to answer that the patient needed a barium meal. Yet what chaos there would be in the medical service if every patient who had a change in his bowel movement went to the doctor and demanded a barium meal.

Health education must be partly education of the healthy as well as education of the sick and of the doctors. Patients should learn danger signals and, above all, non-danger signals. Far too often a patient rings up the doctor and says "I have what I think is a 48-hour cold", and it is utterly pointless if the doctor replies "I have no time for you today. I shall come and see you the day after tomorrow."

The doctor's criteria today are "Does it matter?" and then "Can I do anything about it?". The doctor's complaint is no longer "Why did you not come sooner?" but very frequently that the patient has come too early, that patients come with a non-symptom which they identify as something somebody else had before he or she got something different. That is immensely time wasting.

I would like to give a warning on statistics—which can be and usually are enormously misleading. Anyone who attended Question Time today and heard the Secretary of State for Prices and Consumer Protection answer Questions will have noticed just how misleading statistics can be. I read recently in a paper on the evils of consuming animal fats that in the United States in a 12-year period during which the consumption of liquid milk doubled, the average American woman's thigh increased in circumference by seven inches.

Mrs. Renée Short

I do not believe it.

Mr. Freud

This is a perfectly accurate statistic, but it is difficult to believe that the increase is connected solely with the increase in the sale of liquid milk.

Mr. Nicholas Winterton

It is all that jogging.

Mr. Freud

It is rather like the statistics on hanging. Those who are in favour of reintroducing the death penalty will tell us that since it was abolished crimes that were hanging crimes have increased by 450 per cent., without saying that muggings have gone up by 2,800 per cent, and that non-hanging crimes in general have gone up by 3,000 per cent., or whatever.

What is indisputable in the matter of preventive medicine is that there are things that we now do that we should not do. That is what the debate has been about. Smoking is perhaps the most signal example. I believe that our mistake is very much in the attitude that we adopt as a nation towards nonsmokers. We seem to believe that it is natural to smoke and that one is a freak if one does not smoke. If one walks down a railway carriage one sees seven compartments with nothing written on the door and five with "No Smoking" on the door. For good measure, there is also one marked "Lavatory".

Mrs. Renée Short

The hon. Gentleman means "Toilet".

Mr. Roger Sims (Chislehurst)

It shows that the hon. Gentleman has not been on a train for a long time.

Mr. Freud

Is it now called "Toilet"?

Mr. Sims


Mr. Freud

I thought that it was called "Toilet", but that is such an ugly word that I expected them to have changed it by now.

My point is that by the same token, if it were that unnatural, the extra compartment should have nothing on it and all the others should say "This is not a toilet" or even "This is not a lavatory". It would be much more sensible if a railway compartment that had nothing written on it meant that one did not smoke there. For good measure, there could be certain compartments with "Smoking" written on them and perhaps someone to see that people damned well smoked in them.

The attitude is what I object to. Smokers are notoriously thoughtless. They never realise how desperately unpleasant it is for non-smokers to go into the polluted atmosphere, especially in cars and lifts. I suppose that it is good for me, because I am overweight, that I cannot use the lifts in the House because there is not one that has a "No Smoking" sign on it. Those who find smoking obnoxious or difficult to take are in a bad way if they are in a lift and are unlucky enough to have someone come in puffing a pipe or a cigar.

Mr. Nicholas Winterton

The hon. Gentleman should change to "Hamlet".

Mr. Freud

I shall give way to the hon. Gentleman's lunatic remarks if he wishes.

Attention must clearly be given to smoking, drinking, diet and exercise. On the subject of exercise, it is very important to remember that if people could become breathless twice a day—no matter how—there would be much less cardio-vascular disease. If one prepared one's heart for shock by working it to its full extent, there would be fewer heart attacks, because the heart would be ready.

However, it is also important to remember that none of these matters works in isolation. Although it is another statistic, and therefore open to doubt, I believe it to be a fact that carrying an extra 10 lb in weight is equivalent to smoking 20 cigarettes a day, which means that none of us has a right to look down on the possibly suicidal mode of life of others, unless we abide by rules relating to smoking, drinking, diet and exercise.

Let me quote again from Lord Winstanley: It is time that we in the health services all look at what we are doing and asked ourselves whether what we are doing really is necessary and whether it is bringing any real help to anybody. It is time that we thought about standardising some of our procedures and requirements in the interests of economy of both time and resources. It is time too that we gave some thought to the business of cutting corners and taking risks on a calculated lather than a random basis. Finally it is time to persuade the public and ourselves to begin to put health back into perspective. We have got to do those things, all of them. The medical profession has to and I think the general public has to as well. The present road leads to chaos. Ever-increasing demands on resources which are fixed and an ever-increasing inability to cope, result in an ever-increasing requirement to cut corners, often in a very dangerous way. I will just give one final example of how we should start thinking about priorities again Look at the enormous waiting list for so-called "non-urgent" operations. Let me add that the degree of urgency in any particular operation rather depends on who is going to have it. If it happens to be your own operation, you tend to think perhaps it is not so non-urgent after all. Look at the social and economic consequences at the moment. Let me take a patient of mine, a worker in a heavy job, who has an irreducible inguinal hernia. He is the family breadwinner, with four children, and he has a wholly non-urgent complaint in the sense that it is not suddenly going to kill him. But he is unable to work and he may have to wait two years before it is operated on. During those two years the State may very well have to maintain him, his wife and his four children because he is unable to work, because he needs a non-urgent operation. I am not saying that economics should always take precedence over medical urgency, but I really do say that it is time we started thinking about these things and looking at the priorities that we give to certain things. Finally, I want to mention one matter which I did not see in the report and which has not so far been touched upon in the debate, except fleetingly by the hon. Member for Walsall, North (Mr. Hodgson). I refer to the infant, the very young child. It has to be remembered that what is done in the first two years of a baby's life determines much in its adult existence. The multiplication of the fat cells determines whether the baby will grow up to be in the image of my hon. Friend the Member for Rochdale (Mr. Smith) or in that of the hon. Member for Ealing, Acton (Sir G. Young). Perhaps that is a good point at which to sit down.

5.3 p.m.

Ms. Maureen Colquhoun (Northampton, North)

I believe that it is important, as a member of the Committee, to thank my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) for the efforts that she made as Chairman of our Committee and for the results which she achieved with a Committee made up of what I would described as parliamentary individuals with many conflicting political philosophies. As hon. Members can imagine, we had our political moments. It says much for my hon. Friend's chairmanship that they were overcome.

There was one area, concerning fluoridation of water, which cut across party barriers and upon which there was no choice but to agree to disagree. There was no consensus about that. There was merely total disagreement.

The thread that ran through the inquiry was that, although Britain's Health Service is under attack—is it not always, not least by those who run it and do not necessarily believe in it?—it is still Labour's greatest achievement and compares immeasurably favourably with any system of medicine in the world, particularly in the United States of America where ambulance men still fight for the privilege of picking up lucrative insurance cases.

Latterly consultants in this country have been pursuing private interests at the expense of public service. I have been a total critic of this practice, both in the House and in my constituency in Northampton, where a new private hospital is being built and where National Health Service facilities have been used for private, queue-jumping patients. It is common knowledge in my constituency, and in the constituencies of many of my hon. Friends, that a person can buy an operation privately rather than have to wait for the same operation on the National Health Service, which might not take place until next year or the year after.

I hope that in considering this report my right hon. Friend will study the other, more serious, abuses of the NHS because they are still an unthinkable cancer on a great and honourable service which has achieved honourable success. Despite all of its faults, and despite some of the consultants in Britain, we in the Labour Party still have reason to believe that Nye Bevan's introduction of the National Health Service amounted to a revolutionary and basically irreversible decision, which ensures that those in need receive medical attention and that those who are well pay for that attention. Such is the blend of Socialism and dignity, and long may it continue to survive.

What I still do not believe is widely realised in Britain, because we constantly hear so much about cuts, is that this Labour Government have given more and more resources to regional health boards and from them to area health authorities while they have received less and less patient care for the money. This is something which must be remedied. Too many health authorities have built administrative offices to too high a standard, overlooking the point that their first motivation ought to be the improvement of patient care. Priorities have been wrong. I hope that my right hon. Friend will have something to say about that.

There is no doubt that private practice in Britain has been a barrier to the NHS. It is up to those working in the Service to see that the barriers are done away with. NUPE and COHSE share this view and are showing the way ahead. Medicine has become highly scientific and centralised, with the general practitioners being the fundamental key to preventive medicine. More resources must be directed to them so that they in turn can give a more thorough service to those who really matter—the patients—particularly when it comes to the prevention of disease. This is the area where money should he spent. The Committee's report shows this up very clearly.

A great many of the Committee's recommendations tell ordinary people what to do to avoid illness and premature death. The Committee totally believes that people must take more direct responsibility for their own health. It makes sense for public money to be spent in educating them to do this, in helping them to achieve that responsibility towards themselves. We have made many recommendations about health education, cancer screening for women, self-help medicine—which is being practised in women's groups—abortion, dentistry, alcohol and tobacco. We have said that cigarette coupons should be abolished, and that cigarette machines should be available only on premises to which children do not have access.

One thing we have forgotten to comment upon is cigarette smoking in schools. We should have included a recommendation on this subject. We know of the dangers and the appalling health risks and the cost to the community arising from heart disease, bronchitis and lung cancer. In short, we know that cigarettes are killers.

It is extraordinary that so many of our young people in the fifth and sixth forms are allowed to smoke. I am a non-smoker, but I have three children who smoke, which I very much regret. They were never allowed to smoke at my table or in my sitting room, and it does not seem to me unreasonable that teachers should be able to resist allowing children to smoke in the lower sixth or sixth form common rooms. But the answer I have received is that there is nothing or very little that teachers can do about it. What an extraordinary example these schools are setting.

In the light of the evidence we took, a really strong Government would ban smoking altogether, and I hope that the Minister will tell us that the Government are prepared to introduce legislation at least to ban the advertising of tobacco and tobacco products except at point of sale, which is what the Committee recommended. That would be a significant advance towards preventive medicine if the Government had the will to do it. But unfortunately, if their response is anything to go by, they have no such will because, with respect to them—and here comes the nasty bit—I have never seen such a wet and weak-kneed response to a very strong Select Committee proposal as we have had from the Government on this subject. They simply say that they believe they should keep an open mind on the question of a total ban on cigarette advertising.

Mr. Boyden

And an empty head, by the sound of it.

Ms. Colquhoun

And, as my hon. Friend says, an empty head, by the sound of it.

What are the Government to do also about the question of the high-tar cigarettes being sold in the Third world? Is my right hon. Friend not prepared to ban them? Is the motto of the cigarette companies not rather reminiscent of the words of Goldsmith: And honour sinks where commerce long prevails"? I hope that my right hon. Friend will give very serious attention to what we are doing to our brothers and sisters in the Third world, and particularly also to the activities of the British American Tobacco Company, which is making a very strong attempt to get into the British market. We read in The Guardian today that State Express, despite the fact that cigarette sales are falling in Britain, is producing an advertising campaign implying that sales campaigns for cigarettes are something to do with world ideological battles.

The Government have a direct responsibility to do something about cigarette advertising rather than continue to sit on the fence and pretend that nothing very much harmful is happening. BAT is extending into what it calls the "free world". It is one of the main sellers of high-tar cigarettes to the Third world, and is trying to persuade Africans, South Americans and Asians to advertise, too. Perhaps there is not a great deal that the British Government could do about that, but they could put their own house in order and do something about the situation in this country, and, if they had the will, do something serious about carrying through, in the light of the evidence and of the Select Committee report, a complete ban on cigarette advertising.

We were told in the Committee that it was the policy of the Department of Health and Social Security to encourage the development of water fluoridation schemes, and that the Department had made available £500,000 for assisting with the annual capital cost. Although we were told also that at present there were no plans to legislate for compulsory fluoridation, the Secretary of State told us that he felt that the time might come.

As an opponent of the fluoridation of water, I must put on record that, after listening to the Committee's evidence of the Department's plans for preventive medicine, it seemed to me that its main plan, indeed the only plan that it had available for preventive medicine, was to put fluoride in our water. When it was asked who had taken this decision, since Parliament had not, it did not appear to know. So I must protest very strongly about these plans. It has even been put to me that contracts are about to be signed, or were to be signed, by the Government with Rio Tinto-Zinc for the supply of fluoride. If there is any truth in that report, perhaps we can hear about it from the Minister.

Mr. Robert Hughes (Aberdeen, North)

Could my hon. Friend tell us why she is opposed to fluoridation? Given her commitment to the importance of preventive medicine, that the matter has been debated over many years, and the examples that where fluoride is in being it has shown itself to be safe and effective, why is my hon. Friend opposed to this useful, worthwhile and urgent measure?

Ms. Colquhoun

We are not having a fluoridation debate, but my hon. Friend must have read all the arguments about fluoridation of water by its opponents. We have been a very active and intelligent pressure group, and I shall not delay the House at this stage by reading out reams of reasons why I am opposed to fluoridation.

Mr. Robert Hughes

Give us one.

Ms. Colquhoun

I am not going to play this public schoolboy game. My hon. Friend knows very well what the opponents of fluoridation say, and we are just as entitled to have a say about the fluoridation of water as anyone in the Department of Health and Social Security who has not been elected to have a say. Certainly the fluoridation of water is properly the concern of Parliament. Why should not Members of Parliament be the ones to take the decision as to where the money available for preventive medicine should go, and if there is a body of opinion in the House which is opposed to fluoridation why should there not be a debate on it so that we can hear both sides of the argument and then make a decision? A lot more research is needed before such a decision is taken, and I was shocked by the Department's evidence to the Committee, by its attitude that the decision had more or less been taken, and by the reply from the Department to the Committee's report.

Dr. M. S. Miller

My hon. Friend keeps threatening us about the anti-fluoride lobby. Will she tell us what more research is required? Fluoridation has been used for more than 30 years in many well-developed parts of the world, where it is to be expected that all kinds of precautions are taken and investigations made. In spite of that, there is no evidence of any value to indicate that fluoride in small amounts does anything but good. It causes no harm at all.

Ms. Colquhoun

That is the point of view of my hon. Friend but it is not the point of view of the anti-fluoride lobby, which has an entirely opposite view. It believes that the research does not show what my hon. Friend claims that it shows. People want pure water. They do not want additives. Why cannot those who wish to have fluoride additives take tablets for the purpose, and permit other people to have unadulterated water?

Dr. Miller

My hon. Friend knows the answer—

Ms. Colquhoun

My hon. Friend says that I know the answer. The difficulty is that he is getting up and down and saying either that I know or I do not know, or that he knows and I do not know.

Dr. Miller

Will my hon. Friend permit me—

Ms. Colquhoun

I will not give way. Why should I continue to give way to my hon. Friend when he is playing games about fluoridation? I am making the perfectly proper democratic point that I am totally opposed to it. I do not like the Government's attitude to it, and I did not like the evidence given to our Committee about it by the DHSS. As an opposer of the fluoridation of water, I suspect that this policy will be foisted upon the British people and foisted upon Parliament without adequate discussion and debate.

Mr. Corbett

I take the opposite view to my hon. Friend about fluoride. May I draw her attention to Recommendation No. 40 of the report, in which the Committee recommended that there should be more research into the long-term effects of certain levels of fluoride addition to water supplies? Concern was expressed in the Committee about the almost total absence, in any of the countries which have used fluoridation for a number of years, of adequate long-term research into the effects of fluoridation. That was the point that we were making.

Ms. Colquhoun

I thank my hon. Friend for that information. I suppose, in a way, that that was part of the agreement to disagree. It did not seem to be an unreasonable thing to do, with the Committee split very evenly up the middle.

Another aspect of the Government's reply which I find very unsatisfactory to women concerns screening for breast cancer. We recommend in our report that radiographers should be trained in and used for the interpretation of mammography, and that a national breast cancer screening service, for women most at risk, should be introduced This recommendation did not receive very much support from the Government, despite the figures showing that 13,000 women died in the United Kingdom in 1975 from breast cancer.

The Committee visited the British United Provident Assocation and saw—it comes hard to me to confess to this—its first-class facilities for breast cancer investigation.

Mrs. Renée Short

And the Royal Marsden Hospital.

Ms. Colquhoun

We also went to the Royal Marsden Hospital as my hon. Friend said. I was very impressed by the facilities set up by BUPA, and by the costings that it was able to make, as well as the efficiency with which people were dealt and the comfort that they received. We were given some very worthwhile figures of the cost of this sort of investigation. Here is an example where the National Health Service can learn a great deal about preventive medicine from private enterprise. It was a very interesting and informative visit, and I should very much like my right hon. Friend the Secretary of State to consider whether the kind of business costings done by a private medical group such as BUPA cannot be introduced into the National Health Service. Apart from this aspect of accountability, there is an agreeable environment in which women are able to undergo this kind of investigation. It could well be copied by the National Health Service.

The Government, in their reply to the Committee, should at least have admitted that facilities are not available for women. In fact, the Well Women Clinic at the Royal Marsden Hospital, which started life as the Well Women Clinic—the psychology of the name was very important—has now deteriorated, in that it applies to women who are thought to be at risk from cancer. There is not a great deal of preventive medicine in that kind of screening.

The inquiry was wide-ranging. The Committee dealt with important issues concerning smoking, diet and health screening, and considered all the things which are absolutely vital if the NHS is to be a preventive medicine service rather than a disease service. I hope that the report will be of immense value to the House and of immense value also to area health authorities and regional health authorities. I hope that those hon. Members who have contacts with members of area health authorities and community health councils will ensure that those people have an opportunity of reading the report.

It was a great pleasure to work on the Committee. I hope that the Government will be less wishy-washy than they have been in some of their attitudes to the report. I hope that they will have the will—they certainly have the ability—to act on some of the more difficult and controversial recommendations.

5.28 p.m.

Sir Bernard Braine (Essex, South-East)

May I begin by saying how much I welcome the debate? It is long overdue. The House knows that I have an interest in the matter, in that for some years I have been chairman of the National Council on Alcoholism. In that capacity I should like to pay my tribute to the hon. Member for Wolverhampton, North-East (Mrs. Short) and to those members of the Expenditure Committee who gave the problem of alcohol abuse so much consideration. I find the Committee's recommendations generally acceptable, although I shall have one or two reservations to make.

There is no doubt that alcohol abuse—here I entirely agree with the hon. Lady—is immensely costly in human, social, and economic terms. It is a major factor in the tragic story of battered wives, of child cruelty, of death and injury on the roads, and of accidents at work.

I acknowledge straight away that the Government have been generally helpful to those of us working in this area. Their publications "Prevention and Health: Everybody's Business", "Better Services for the Mentally Ill", "Priorities for Health and Personal Social Services in England", have constantly reminded us of the need for primary and secondary prevention, for a multi-disciplinary approach to the problem, and for the development of services involving local authorities, social services and local voluntary organisations.

In the last few years there have been some encouraging developments. But progress generally is still very slow, and in some parts of the country it is an uphill battle to get adequate services established on the ground. The National Council on Alcoholism and its affiliated regional councils are voluntary bodies but we now receive about £250,000 a year in public money from the DHSS, local authorities and area health authorities. This is perhaps an appropriate point for me to say that we are also very grateful to the officials of the Department of Health and Social Security for the advice and help which they so willingly give.

I must declare my belief that the best way of tackling the problem of alcohol abuse is by this type of partnership between the statutory authorities and voluntary bodies. Again I want to emphasise—it is necessary to go on saying it—that there are still areas in this country where partnership of this kind is poor. Yet there is no doubt about the gravity of the problem of alcohol abuse everywhere. I was disturbed that members of the Expenditure Committee held out very little hope for adults who are already alcohol dependent. That is, I fear, a view which is commonly held. The Committee says in paragraph 142 that: It may be that those who have already surrendered their freedom to choose whether, and how much, to drink, and are driven to alcoholic abuse are beyond any reasonable action by a well-intentioned legislature. It is a great pity that the Committee did not call for oral evidence from the National Council on Alcoholism. We would not have encouraged such a pessimistic view. I am, therefore, very pleased indeed that the Government came down on the Council's side when they expressed their own view that Adults who have already surrendered to alcoholic dependence or alcohol abuse are not beyond reach". That message must go out. The sufferers are not beyond reach. Indeed, the Advisory Committee on Alcoholism, which is a committee of specialists, in this field, maintains that a main ingredient of a prevention strategy is that people who may be developing a drinking problem should be encouraged to recognise the problem and to seek help.

There are two areas where a break into the circle of excessive drinking at an early stage is possible and would have beneficial results. The first is at work, in the context of the Health and Safety at Work etc. Act. It is surprising that very little attention has been paid to alcohol-related accidents at the work place. The important Robens Report never mentioned alcohol as a factor in industrial health and safety. But the fact is that people with drinking problems do not cease to have those problems on a Sunday night. They take them to work on Monday morning. The relationship between drinking and road accidents is well established and is recognised by the general public. But the fact that problem drinkers have three times more accidents at work than the generality of workers is totally ignored.

In research commissioned by the French Government it was found that alcohol was the main factor in 7.4 per cent. of all accidents. Where accidents involved a work stoppage the percentage increased to 15 per cent. Last year I was chairman of a working party which brought together a number of specialists. We went into this matter and found that people with drinking problems at work had five times the absence due to sickness as the generality of workers. The report of my working party recommended that industry should have a code of practice for people with drinking problems.

It is absolutely essential that employers should encourage early recognition of problem drinkers so that their employees will seek treatment and rehabilitation during which their jobs will be safeguarded. The time has come not to treat this as a crime but as a condition which cries out for help.

In the United States more than 300 companies have adopted policies to help their employees with drinking problems. I submit that cost-conscious American companies would certainly not have formulated and implemented such policies unless they were cost-effective. The interesting thing is—and this is the answer to the Expenditure Committee's pessimistic view—that the recovery rates for alcohol dependents are in the region of 70 per cent. to 80 per cent.—well above the recovery rates for this country. I am confident that money spent to initiate health education and counselling programmes for problem drinkers will reap substantial benefits. American experience in this regard has been very encouraging and we in the National Council believe that such positive programmes in this country would lower costs, reduce absenteeism, improve production, increase safety, assure better decision making at every level, retain the services of skilled and valued employees, and reduce the heavy toll on the hard-pressed NHS.

I note that the Government's reply to the Expenditure Committee's report accepts the view that research is needed to identify those drinkers most at risk and that a number of relevant research projects are being considered by the health departments, the Medical Research Council and the Health and Safety Executive. I hope, therefore, that the recommendation of my working party that the Health and Safety Executive should commission research to assess in terms of financial costs the loss in production earning due to accidents, absenteeism, sickness and substandard work performance as a result of alcohol impairment is being taken seriously. I am in no doubt that when the true costs of alcohol abuse are ascertained they will shock the nation. Only when industry has been shown the true costs will it find the means of tackling this seriously neglected problem.

The second area in which we could break into the circle of excessive drinking is with regard to drinking and driving. Here, I am sorry to say, I find that the Government have been dragging their feet for far too long. This is an area where, on the Government's own estimates, road accidents caused by alcohol costs the NHS £6 million a year and the material cost to the community is about £80 million a year. The figures leap upwards when one looks at the total human and economic costs of road accidents. There are grounds for believing that a high proportion of drinking drivers are alcohol dependent or problem drinkers and that at present the consequences of conviction are not sufficient to break their habit or motivate them to seek treatment.

The Expenditure Committee report rightly shows very great concern about abuse by young people but appears to shy away from, or ignore totally, abuse by the middle-aged. The figures support my contention. It is, of course, a dreadful thing that the major cause of death for young male adults is a road accident with a raised blood alcohol level at the time of the fatality. Yet we should not be surprised. A survey published only last week in the consumer magazine Which? shows that the drink-driving laws of this country are now being extensively abused. This is not solely by young people. Why should young people always be dragged out as an example of what is going wrong with this society? The middle-aged and older drivers are equally affected. I do not have the time to go into the details of the figures now, but I could prove it if I had to.

More than two-thirds of middle-aged drivers have a blood alcohol level of over 150 milligrammes at the time of their offence. Educational messages about the dangers of drink and driving will have very little impact on a driver who has developed a dependence on alcohol. In my view aiding and motivating the alcohol-dependent driver to seek treatment would make as valuable a contribution to reducing accidents as any educational campaign on drink and driving.

It is a scandal that this House has not had an opportunity to debate the findings of the Blennerhassett Report. It recommended that those motorists convicted with a blood alcohol level of above 200 milligrams and recidivists should not have their licences reinstated after statutory disqualification until they could prove to the magistrates that their drinking no longer presented a problem. Implementation of these proposals would mean the screening of 16,000 convicted drivers a year. But the costs should be offset against improved safety on the road and less misery in the home. Can anyone dispute that such screening would be a lifeline in society for countless numbers of problem drinkers and their families? We must always remember that it is the family who pay for the last round. It is the family who pay in embarrassment, fear, disruption and sometimes violence from alcohol abuse.

Money is required for both primary and secondary prevention services. We cannot do anything very effectively without it. Many of my regional councils are run on a shoestring. Their staffs do not know at the end of each month whether there will be sufficient to pay their salaries. Although we are very grateful to the Department of Health and Social Security, there is still too often a failure by local authorities and area health authorities to accept their responsibility for financing the voluntary component of a service which in many areas is the only community-based service offered, despite the recommendations in the White Paper on "Better Services for the Mentally Ill". Hon. Members will remember the phrase in that document: voluntary services have a part to play for many years to come. Area health authorities, separately or jointly, need to accept a degree of responsibility for their financial viability, and for the support their staff may sometimes need. I beg the Minister to indicate that he will use his best endeavours to persuade these authorities to face their responsibilities.

I support warmly the recommendation of the Expenditure Committee that a larger proportion of the £2,000 million raised annually in duty and taxation on alcoholic drink should be spent on prevention. But I would extend it to those who are alcohol dependent and to their families, who also require counselling and social work support. In another place the noble Lord, Lord Kimberley, has raised the matter repeatedly of the Licensing Compensation Fund, which was established in 1904 to compensate landlords whose licences were not renewed in an attempt to cut the number of drink outlets and to help alleviate the widespread alcohol abuse of the time. Surely it is appropriate that the money held in that fund should be used to help alleviate the problem today.

I congratulate the Health Education Council on its initiative in organising a mass media campaign on alcohol abuse in the North-East of England. The National Council and our regional council in Newcastle have collaborated closely with the Health Education Council and been the focal point of the campaign. This has been a very good example of the way in which national and local agencies, both statutory and voluntary, can operate.

The Advisory Committee on Alcohol, in its most interesting report, published recently, recommended using health education to alert people to the dangers of alcohol abuse and to encourage those with drinking problems to come forward for help. I am pleased to see that the Government accept that view. However, I think that they will have to be a bit more realistic in the amount of money that they grant the Health Education Council if future campaigns are to make sufficient impact, because the £175,000 which the Council was able to spend on alcohol campaigns from its increased budget of £1 million is paltry compared with at least £30 million spent on advertising alcohol by the drink industry. Let us, at least, get that matter into perspective.

The Expenditure Committee had suggestions put to it for raising additional revenue but rejected them. The Government find difficulty in accepting the Committee's revenue proposals. Let me speak plainly. If we mean to conquer the problems with which alcohol abuse confronts us and if society means to control alcohol rather than having alcohol control it, the Government must recognise that more public money will be required to equip those in the front line to win this vital battle. If we mean business, we must stop playing games.

I welcome also the Government's decision not to introduce any wild and reckless gamble with any further liberalisation of the licensing laws. Their answer to the report states: At the present time the Government has no plans for legislation to change the minimum drinking age or to make major amendments to the licensing laws. That is a very sensible approach. Before any tampering is done, we need to be certain that changes will not increase consumption and alcohol-related disabilities.

It is far too early to make claims about the changes in Scottish drinking patterns, since amendments to the licensing laws take at least five years before any judgment can be made. However, I know that the early euphoria and claims by those in favour of liberalisation need to be treated with the utmost caution. The recent record of the Chief Constable of Strathclyde said: The changes in licensing laws which came into operation towards the end of 1976 have now had a full year to prove themselves. I regret to say the decline in drunkenness noticed in early 1977 was not maintained and by the end of the year the level of drink-related offences had returned to their former level. Last week I asked the Secretary of State for Scotland how many road accidents where alcohol was considered to be a factor took place in Scotland between the hours of 8 p.m. and 2 a.m. in each of the years 1974 to 1977. I got the written reply on Tuesday 6th June. It showed that offences declined from 1974 to 1975 by 5.2 per cent. and by 6.1 per cent. from 1975 to 1976 but that they increased by 4.6 per cent. in 1977 from 1976. After the first six months of the operation of the licensing changes, claims were made about the success of the venture which now seem clearly to be, in the face of these figures, a little imprudent. The second six months showed a deterioration. Indeed, comparison of the last six months of 1977 with 1976 shows an increase in the number of drivers involved in accidents with a positive breath test of more than 14.1 per cent. during the period 8 p.m. to 8 a.m. Those figures show me, at any rate, that any tampering with the licensing laws at present, when we see the evidence of alcohol abuse all around us, would be a great mistake. Therefore, I support strongly the stand which the Government have taken.

Finally, I congratulate the Health Department on its initiative to publish a separate consultative document on the mis-use of alcohol. I hope that the document will have the effect of informing public opinion more clearly about what is happening and what needs to be done and that it will encourage a more concerted, complementary approach by Government Departments and local authorities to the prevention of alcohol abuse.

Dr. Griffith Edwards, a very distinguished witness was asked by the Expenditure Committee what he would do to reduce the cost of alcoholism and save money. He replied that there was a great need for statutory organisations and Government Departments to get together, adding: Alcohol problems touch labour problems, the Department of the Environment, problems with roads, then Home Office, the DHSS … but I say if you want more value for money first of all get better integration so that the left hand knows what the right hand is doing. That is simple advice, but it is quite crucial in this context.

Perhaps from this debate we shall recognise that alcohol control policies are a public health issue and act accordingly. The problem of alcohol abuse is so great and the implications are so far-reaching for our society that the time may well have come for us to set up a specialist Select Committee of the House to look into the matter in depth and to carry on where the Expenditure Committee, which has done such a splendid job, left off. I recommend that course to the House.

5.50 p.m.

Mr. Gwynfor Evans (Carmarthen)

I speak as one who believes that the National Health Service is the greatest accomplishment of the State in our generation. I have derived great personal benefit from it. I am one of millions who has had an enormous amount of benefit from the ministrations of doctors and nurses in the NHS.

Of course, there have been weaknesses and disappointments in the service, but these are inevitable. Some of the greatest disappointments spring from the aspect of medicine that we are debating today. It is probably unavoidable that the emphasis within the Health Service is on the consequences of the breakdown of health rather than on the maintenance of good health. It is no criticism of practitioners to say that the NHS has been disease-oriented rather than health-oriented. Members of the medical professional are educated in, the main, to deal with disease and ill health, and we are conditioned to expect that of the profession.

I have heard that in China members of the medical profession are paid so long as those for whom they are responsible have good health. When the patient becomes ill, the doctors are no longer paid. I do not know whether that is true.

Dr. M. S. Miller

This has been claimed for a long time. What I would like to know is, who makes the diagnosis whether a patient is ill?

Mr. Evans

I shall touch on this in commenting on the situation. The situation that I should like to see is one which may be thought to be Utopian—one in which people would visit their doctors once every year or two for a check-up, or for good advice on the best way of looking after their health.

Sir Bernard Braine

The hon. Member for Carmarthen (Mr. Evans) is advancing a very sound argument. In answer to the hon. Member for East Kilbride (Dr. Miller), is he aware that in China, which I have visited, the emphasis in the health service is on preventive medicine? There are a large number of "bare-foot" doctors or medical auxiliaries who deal with small ailments and show people the proper way to take care of themselves. Undoubtedly this reduces the burden on the hospitals.

Mr. Evans

I am grateful for that helpful intervention. I am sure it is underlined by the fact that matters of health are largely matters of education. The kind of education which our overworked doctors have been given hitherto trains them for dealing with ill-health and disease. Their education in anatomy and physiology does not train them so much to prevent ill health and disease—bodily or mental.

It is no surprise to see, in these circumstances, that medicines are so often used to suppress symptoms rather than effect a cure. Often these medicines cannot affect a cure; the cure should have been made beforehand and the ill health should not have happened. One looks forward to the day when members of the medical profession are trained as thoroughly in promoting health as they are in combating disease.

Dr. Gerard Vaughan (Reading, South)

I think that the hon. Member for Carmarthen has misunderstood the present-day education of members of the medical profession, and he does it an injustice. There is a good deal of training today in good health. A great deal of medical advice is given to people on how to lead a healthy life. I think that the hon. Member's comments are rather out of date.

Mr. Evans

I hope I am right in saying that there has been an emphasis on treating disease and ill health in the NHS up to now. I think that emphasis should change. I agree that there is a great deal of good work being done by doctors themselves in preventing ill health, but not enough is being done to keep healthy people healthy. That should be the main work of doctors. Many doctors have told me that they would much value refresher courses in health-promoting methods. However, more of that kind of instruction is being included now in courses at universities and colleges.

The prevention of ill health is not just a matter for the medical profession, it is one for the whole of society. It is good to see increasing public attention being given to the need for physical exercise and the evils of drugs such as marijuana and cocaine and here we must also remember the effects of nicotine and alcohol, because these, too, are drugs. Today it is harder for people who smoke to excess to plead ignorance of the unhappy consequences of that habit. But here there is plenty of room for increasing the education of young people. That is also true of alcoholism. Because nicotine and alcohol are so socially acceptable as drugs, there is less vigour than there should be in trying to prevent their abuse.

The fact is that the manufacturers of all popular drugs, whether they are legitimate or not, are immensely wealthy and powerful, and society must draw on all its resources to fight them.

This is also true of some of our most popular foods such as white bread and white sugar, which has been described as "sweet white poison". The human body has within it all the resources necessary to prevent and recover from most diseases, given proper rest, exercise, nutrition and thought. There was a time when malnutrition was a terrible scourge in this country, as it is now for the greater part of the world's population. In the affluent West today, over-nutrition is the greater evil. We must be taught to eat properly. We must have the right quantity and the right type of food. Overweight is the cause of a great deal of ill health and the basic cure is to eat less. Diseases of the heart are often caused by the food we eat and by the amount of cholesterol that clings to the arteries. From the health point of view the most important shop in the high street is the greengrocer. The value of fresh fruit and vegetables should be vigorously promoted. Great claims are made for some natural medicaments, such as lecethin which comes from the soya bean. These claims should be thoroughly investigated and, if confirmed, it would be a good thing of that kind of medicament, which is quite natural, were promoted by the NHS.

On the subject of the health of the mind, which is closely linked with bodily health, we should always bear in mind the contribution of Christianity. I believe that ministers of religion should be trained in psychiatric methods to help people think most effectively in a healthy way.

All these matters have claims to more time in our schools and colleges. I wish to say, in passing, that it is good that more children will soon be drinking more milk in schools. Although milk may add to the girth of those in middle age, we know that it is a fine food for children.

These matters deserve more time to be devoted to them on the media. One recalls the astonishing success of the Radio Doctor during the war, when our diet was far more simple than it is today. I think it is true to say that the health of the people of these countries was better during the war than it was before the war, or indeed than it has been since. There is a lesson there for us all.

It is on the subject of publicity for preventive medicine, in which nutrition—and therefore, food and drink—features largely that I wish to lay most emphasis. I believe that people are interested in health and are concerned not only for their own health but for the health of their children. Because people have a great interest and concern in this matter, I believe that television and radio programmes dealing with the subject would command a great deal of attention. I think that more attention should be paid on the broadcasting media to this huge and important subject.

It is good to see more use being made of the media to promote health-giving habits, but not nearly enough is being done. The firms that produce foods and other products which cause so much ill health have at their service incomparably more advertising space and time than do those organisations concerned in promoting good health. We cannot claim to be doing all that is possible to be done to keep people healthy until we ensure that as much time is given on the media to the promotion of good health as is given to the promotion of the products and foods that do so much damage. Far more space and time must be given to the promotion of good health through education in schools and through the media that applies and not only to children but to parents and adults in general.

My main purpose in intervening in this debate is to add my voice to the demand for far more time to be given by the media to educate people in a healthy way of living. I hope that the Government will take this suggestion very seriously. I believe that as a result the National Health Service will benefit, as will its institutions, servants and, most important of all, our citizens.

6.4 p.m.

Mr. Lewis Carter-Jones (Eccles)

I congratulate my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) and her Committee on producing such a useful report. There are one or two items which have been omitted from the debate so far, and I shall mention them in my speech. I hope that my hon. Friend will assure me that her Committee will examine these matters in greater depth.

On a family note, I wish to deal with paragraphs 53 and 54 and I then wish to deal with the subject of child care and perinatal care. I have my wife's permission to say that she has had her breast removed. She was extremely well treated in a National Health Service hospital, and we owe a tremendous debt to that service. My wife had her operation five and a half years ago and she has since done extremely well. Indeed, she works a longer day than I do, and it is a great tribute to the NHS.

My wife's good progress happened because she was caught early rather than late. I wish to go through the recommendations in the report with regard to breast cancer. Recommendation No. 53a, on page 81, reads: A national breast cancer screening service for the women most at risk should be introduced. The Department's reply to that was "Under consideration". That recommendation should have been accepted.

Recommendation No. 53b reads: The Secretary of State should expedite as a matter of urgency the production of reports by the working groups referred to in paragraph 274. The Department's reply to that was "Accepted with reservations." I would ask, what reservations?

Recommendation No. 54a reads: Women should receive guidance in the techniques of self-examination of the breasts from their general practitioners. The Department's comment on that was "Accepted with reservations." Again I ask, what reservations? The House is hearing my voice, but I am making my wife's speech on this matter. I suppose she has probably more practical experience of this killer disease than anyone present in the Chamber.

Recommendation No. 54b reads: It should become routine practice when a patient applies to a doctor for gynaecological advice for her to be examined for breast cancer. The Department's reply to that was "Not accepted." My question is, why not?

Recommendation No. 54c reads: Full use should be made of 'self-help leaflets'". That recommendation was accepted by the Department. It was that kind of leaflet which helped my wife. Perhaps we should take more action on that recommendation.

My right hon. Friend the Secretary of State for Social Services has given me a helpful reply on breast prosthesis, but as yet the NHS is not fully aware of it. The hon. Member for Carmarthen (Mr. Evans) spoke of advertising and of informing the public of these matters by way of radio and television. This could be one way of putting over the message.

I now wish to quote from an admirable summary by the Department on the definition of prevention. It reads: Prevention in relation to health is either an attempt to prevent disease or disability before it occurs (primary prevention), the early detection and treatment of conditions with a view to returning the patient to normal health (secondary prevention), or the continuing treatment of disease or disability to avoid needless progression or complications (tertiary prevention). My wife had the benefit of secondary prevention.

Let me deal with the matter of primary prevention, on which great difficulty may arise. My hon. Friend the Member for Wolverhampton, North-East has produced this report with the assistance of her colleagues. She and her colleagues worked hard at the task and have produced these recommendations. I would submit that the writing of the report was the most difficult part of it. No doubt the putting forward of recommendations was possibly the easier. The Department, on the other hand, has now accepted with reservations a substantial part of the report. However, the important aspect is not acceptance but implementation. When somebody clearly spells out what can be done for the good of the country and our society, surely we should implement that proposition straight away.

I now wish to deal with the topic of perinatal care. For about two years I have fought a campaign in this House to bring about better perinatal care facilities. My major interest in past years has been the care of the disabled, but one day somebody said "Why do you not do something about prevention?" I had to admit that many people were ignorant of the amount of prevention that could take place. Perinatal care is a good example. Perinatal care is the care of the pregnant woman from the twenty-eighth week of pregnancy to the first week of the baby's life. If we compare our figures with those of Sweden—these are the figures of some years ago—we find that 4,000 babies in Britain die unnecessarily and 10,000 are born with a handicap that they need not have.

Has the situation improved? In relative terms, the answer is "No". On the Order Paper today I had 28 Questions on perinatal care. As I was waiting to be called in the debate, I received a reply from the Department. The figure of 4,000, which has been disputed as being too high, has now increased, according to the Department, to 4,400. As there is a relationship between perinatal death and handicap of 2½ times, it means that the number of children born disabled unnecessarily has also increased. That is because the figures in Sweden have improved more than ours.

The difficulty is that we can be taught nothing further about perinatal care. The areas that have the best practice have rates that are better than those in Sweden. It is not the technology, it is not the medicine, it is a mixture of the way in which money is spent in some areas and the fact that we have social deprivation in urban areas. Those are factors that make a major contribution. However, area health authorities can do more by upgrading and retraining doctors and midwives. The hon. Member for Carmarthen was contradicted on that score, but I think that he was right.

One of the features of the system in Oxford is that GPs are called in quite regularly to be updated on new techniques and new methods of saving life. The use of oxygen at the time of birth has been subject to much criticism. There are large gaps in retraining in that area. I am saying that basically if we get good perinatal care we shall in the long run save substantial sums.

In 1966 the French decided that their priority of priorities in saving money to make more money available would be to spend more on perinatal care. They have proved their point overwhelmingly. It is intriguing that it was the French Treasury that made that decision. It is a decision that has paid off. If we get good primary protection and good secondary prevention, we shall be able to get larger sums allocated to tertiary prevention. It is in that area that the growth rate lies.

Technology has a role in reaching the severely handicapped or the aged who are tucked away in their homes and left sometimes to rot. Technology could keep them in touch with the world if items such as Possum equipment were made available. I declare an interest because I am an unpaid director of Possum.

The National Health Service has made provision and is making a growing provision for Possum and other forms of equipment. There is nothing worse for the elderly and severely handicapped than to be cut off from society and placed in isolation. If we can give them a means of controlling their environment, albeit their home environment, or a means of communicating by telephone, no matter how severely handicapped they may be, we prevent a further development of handicap, sustain them and give them a fillip.

We have had about 30 reports on perinatal care since 1945. I am sure that right hon. and hon. Members on both sides of the House will agree that when we get a report of any sort there is inevitably about one page of recommendations. On reading the reports on perinatal care, it could almost be said that the same man wrote them. There have been hardly any changes. They are almost the same to the dotting of the i's and the crossing of the t's. We have the evidence, we have the skills, and we have the knowhow, but we must have the will to produce better prevention. Reports are presented to the House for implementation either by Departments or by Parliament.

6.15 p.m.

Mr. Nicholas Winterton (Macclesfield)

I am pleased to follow the hon. Member for Eccles (Mr. Carter-Jones). The hon. Gentleman has delivered an emotive but extremely well-informed speech. I share his views about not only breast cancel screening but perinatal treatment. I share his views about breast cancer screening because my late mother lost both her breasts through the disease of cancer. The disease ultimately contributed to her death. However, after her death I hope that she made herself useful, because she bequeathed her body for medical research. I entirely endorse the views that the hon. Gentleman has expressed. I agree that it is disappointing that the Department has not been rather more forthcoming on these important matters.

I pay my tribute to the Chairman of the Social Services and Employment Sub-Committee of the Expenditure Committee. The hon. Member for Wolverhampton, North-East (Mrs. Short) is a highly controversial personality. She is a forthright personality. However, she is an extremely good Chairman. Even to members of the Committee who take different views from herself, she allows full debate on any controversial subject. It is a tribute to her that so many of the recommendations in the report ultimately were unanimous, and I pay my full tribute to the hon. Lady for the major contribution that she made to the report. It is a valuable report and I am delighted that it is being debated. The hon. Lady can always be relied upon to produce a stimulating debate. Although the numbers in the Chamber are not great, I believe that the content of the debate will be widely read.

It is appropriate also to pay a tribute, as has been done by hon. Members on both sides of the House, to the National Health Service, which celebrates its 30th birthday this year. Despite many difficulties and ups and downs, the contribution made by consultants, doctors, nurses and ancillary staff to the health and welfare of our nation cannot be adequately described.

I believe that there should also be a private sector of medicine. I was pleased that the hon. Member for Northampton, North (Ms Colquhoun) paid tribute to BUPA and its medical centre. The hon. Lady indicated that she hoped that the Department—I am delighted that the Secretary of State is now in his place—would take some lessons from BUPA and the way in which it runs the medical centre. BUPA, together with the NHS, has a major contribution to make to the health of the nation.

I shall discuss certain aspects of the report which are controversial. Many forthright statements have been made by hon. Members on both sides of the House about smoking. However, the message that has come from all quarters—there are many matters on which we disagree but I put forward the principal message—is, "Stop smoking" or "Do not start smoking". It may be that the subsidiary message is "If you must smoke, reduce the risk". I take a somewhat different view from that expressed by the hon. Member for Wolverhampton, North-East. I do not believe in the draconian methods that she has advanced.

Any strategy must take into account that the only way to succeed is through co-operation with the tobacco industry. Therefore, it is clear that the present approach to the problem by way of the voluntary agreement between the Government and the industry is the most fruitful. That view is shared by a wide body of opinion. I am not misquoting when I say that the Government described the three-year agreement announced in March 1977 as a significant and valuable advance. The Government acknowledges the industry's co-operation in achieving this agreement. It is important to get this statement on the record, because the industry goes a great way in co-operating with the Government over smoking and all that goes with it.

I think that I must inevitably refer to advertising which features in the recommendations of the report. It is instructive to note how the Government's view on the effects of advertising cigarette brands has changed over the past two years and how their position is much nearer the realistic attitude adopted and held by the tobacco industry. In 1975, the then Minister of State, Department of Health and Social Security, now the Secretary of State for Foreign and Commonwealth Affairs, said: There is good evidence that cigarette advertising increases cigarette smoking".[Official Report, 8th July 1975; Vol. 895, c. 317.] By contrast, the White Paper states: Before the Government could support a policy of outright banning of cigarette advertising, the merits of doing so would need to be confirmed beyond doubt. The industry suggests that advertising is predominantly concerned with promoting brands. I know that there is doubt whether it is holding to that view from a purely commercial standpoint, but that argument is worth putting forward. There is little direct evidence one way or the other about this and, if a ban had only a minimal effect on total consumption, it would doubtless be regarded as an unnecessary restriction on the liberty of the individual.

Mrs. Renée Short

The hon. Gentleman must make clear that he supports Recommendation 23 in the White Paper: Legislation should be introduced to ban the advertising of tobacco, and tobacco products, except at the point of sale. That recommendation was put forward by the Committee as a whole and there was no dissent from it. The basis of that recommendation was the Norwegian experience. I think that, unless I am mistaken, the hon. Gentleman met Dr Kjell Bjartveit when he talked to us about the Norwegian experience and its effects, which have been confirmed, as I said when my right hon. Friend was not present. I expressed my concern that that recommendation was rejected by him and I asked for the reason for it. However, I should make it clear that the hon. Member for Macclesfield (Mr. Winterton) supported that recommendation.

Mr. Winterton

I wish to make my position clear. I believe in democracy. I moved a number of amendments in the full meeting of the Expenditure Committee on matters relating to the tobacco industry. I declare that I have no interest whatsoever in that industry. Indeed, I am a non-smoker, except for the odd cigar after a particularly convivial dinner—and they are few and far between. I accept the majority view of the Committee. However, I did not support the majority view. I do not support that particular recommendation, althugh I accept it because it was the democratic wish of the Committee. I was a member of the Sub-Committee which produced the report, and I endeavoured during the discussions that took place to reflect another point of view. Sadly, although I had support from both sides of the Committee, my view did not prevail.

I was about to move on to further areas of advertising. Before doing so, it is important to point out that many thousands of people are involved in the tobacco industry and in industries allied to it. I believe that at least 30,000 people are employed directly in the industry, and many more people in the retail trade depend for their livelihoods upon tobacco sales in one form or another. Therefore, in putting forward proposals which feature in the report, we are talking about the livelihoods of many thousands of people.

It is worth while highlighting one particular area of advertising. Our national and regional papers are not in a particularly sound financial state. Some 8.1 per cent. of the total advertising revenue of the national Press in 1977 came from the tobacco industry. Inevitably whether we believe that is good or bad, any arbitrary decision on the banning of advertising through the media—particularly the Press—could have a substantial effect upon papers in this country. It is important that these points should be reflected in debating this report.

I turn now to new smoking material. I have a constituency interest. Imperial Tobacco co-operated with ICI, and ICI is situated in my constituency. ICI has carried out considerable research and development into new smoking material. As we know, research and development, which led to the introduction of cigarettes containing substitute materials in July last year, was pursued by the industry because it was advised that it was likely to make a significant contribution to the strategy both of reducing tar yield and of modifying tar to make it less hazardous to health which, it was believe, had the support of the Government. Indeed, the logic of the publication "tar" league tables by the Government surely rests on the premise in the White Paper that the Government welcomes the advent of substitutes". The industry, sadly, has good reason for doubting that. At the time of the introduction of these new kinds of cigarette both ASH and the Health Education Council, each being organisations funded by the Government, conducted campaigns directed against the new substitutes in a thoroughly sensational and misleading manner, which I regret.

I endeavoured to intervene earlier when the hon. Member for Wolverhampton, North-East was speaking to ask whether she supported a smoking substitute or the new smoking material or whether she was absolutely opposed to it and, if opposed to it, was she not, as it were, adopting a position which would increase, not reduce, the problems. If the tar level in cigarettes is reduced, that is a contribution to making cigarettes safer, although they may not be totally safe. I am happy to give way if the hon. Lady wishes to intervene.

Mrs. Renée Short

I made it clear that research and development and promotion of the alternative material in an effort to persuade people to switch from ordinary cigarettes was a waste of money. I said that money would have been better used in areas of preventive medicine. It was a waste of effort. The fact that the public decided that it was not a suitable alternative showed that the whole exercise was a pointless waste of time and money. As I said, the medical profession does not distinguish between high and low-tar cigarettes. Low tar cigarettes are dangerous, though perhaps not as dangerous as high-tar cigarettes.

Mr. Winterton

I am not sure that all the medical profession would agree with the hon. Lady.

The White Paper takes a more positive attitude towards substitutes. It suggests that the Government may have taken more notice of the opinions of certain senior members of the medical profession, one of whom I will quote. Professor Sir John Butterfield, Regius Professor of Physics at Cambridge, stated in a letter published in the Daily Telegraph: One earnestly hopes the successful brand(s) of new smoking materials contained in cigarettes will not be taken off our market. I personally—and I write personally—believe this important research and development programme should go on. There was no Health Education Council or ASH—Action on Smoking and Health—when the original filter tip was introduced. The fact that new smoking material seems to be capturing the market quicker than filter tips did is a credit to health educators, among others"—

Mrs. Renée Short

It is not.

Mr. Winterton

Yes, it is. There have been grave problems, but I should like to continue my speech. Other hon. Members can put their points of view. I am endeavouring to put mine. It is important that the other point of view should be put fully.

Just as no one would have perceived how acceptable filter tips would ultimately become, is there not now a case for those who do not agree with smoking and those who do to pull together and encourage the use of the new smoking materials in order to make smoking, whilst smoking lasts and is available to people, a much safer habit and pastime?

The reference to tobacco substitutes in the White Paper is inaccurate. Unfortunately, it fails to register the point that the tar created by burning NSM is far less carcinogenic than that from tobacco. I agree with the sentiments of the hon. Members who have spoken from the Labour Benches when they urged, as in the recommendations of our Committee, that there should be more non-smoking areas in public places. I share their view that no smoking should be the order of the day and that smoking areas should be the only places that are signed—I hope that such areas are few and far between—whether they be in halls, public places, cinemas, London Transport, on the Underground or on British Rail.

One of the first things that I did when I came into the House, having met while travelling by train a member of the Cadbury family who was strongly opposed to smoking in public places, was to table a series of Questions urging British Rail to increase the number of "no smoking" compartments in carriages on trains. After all this time British Rail has done this with a vengeance, albeit too late. I am delighted that it has taken such action.

On this matter the hon. Member for Wolverhampton, North-East and the hon. Member for Northampton, North and are in complete agreement. Much more could be said about smoking, but much has already been said and other Members may wish to contribute to this important debate. I shall therefore leave that subject.

On the subject of alcohol, I must declare an interest as the non-executive chairman of an organisation called CAMRA Real Ale Investments Ltd. That is a fine, flourishing and progressive small company whose objectives are the promotion of traditional British beer in the traditional English pub. In addition, it supports the smaller breweries and wishes to give the discerning drinking public a genuine choice of the brews which they care to sample.

Having declared such an interest, so that people know that I view the matter in an unbiased way, I direct one or two remarks to the subject of alcoholism. In many respects I share the views of my hon. Friend the Member for Essex, South-East (Sir B. Braine). His views on the subject are well known. To every Member of the House the subject of alcoholism is of great concern. Over the last two to four years a great deal has been written and said on the growing problem of this disease, particularly, as the hon. Member for Wolverhampton, North-East rightly and properly said" as it affects women and the younger age groups.

Attention has been drawn by the Helping Hands organisation to the increasing number of admissions to psychiatric and general hospitals in England and Wales with the diagnosis of alcoholic psychosis and alcoholism. The Christian Economic and Social Research Foundation of New Zealand has indicated an increasing number of offences of drunkenness committed by persons under the age of 18 and by women under the age of 30 and suggested that it was due to easier availability of liquor.

Dr. Griffiths Edwards, who came to our Committee—I did not agree with everything that he said in his memorandum—attempted forcefully to outline the problem in great detail. In a recent series of articles on the subject, the Manchester Evening News—a newspaper in the area that I represent—described alcoholism as A disease that can wreck your career, your marriage, your health, your entire life, and cause untold misery and suffering to those around you. Anyone who reads the newspapers will have read of many such cases of distinguished people whose lives have been destroyed because of an ultimate dependency upon alcohol.

We must get the matter in perspective. Alcohol in short measure can be of considerable benefit. Perhaps it is because of some of the rules and regulations that apply that many of the problems that we face today are being encountered. Dr. Griffiths Edwards recommended steps to ensure that the real price of alcohol does not fall and that a moratorium be placed on the relaxation of licensing control. Some of these recommendations on controls and regulations feature in the Committee's report.

Many people believe that this is a shortsighted view which could lead to gross inconvenience to the vast majority of the moderately consuming public and severe hardship to the small minority with a genuine drink problem who will continue to buy and drink alcohol privately whatever the price and restrictions placed upon the sale of alcohol. Many people do not believe that a relaxation in drinking controls will lead to an increase in alcoholism. Many people believe that such an argument is not proven, and there is strong evidence to suggest that those holding such a view may be right.

We must realise the extent to which the Government depend upon the revenue from the drinking industry, whether it is spirits, wines or beer. Many members of the public would be amazed to learn of the extent of the tax element within the price that we pay for any alcoholic drink which is levied by the Government in one form or another.

I turn now to the question of diet. Many stupid statements have been made about animal fats which have caused concern to the dairy and farming industry. The hon. Member for Carmarthen (Mr. Evans) commended the drinking of milk. Such foods, if taken in modera- tion, particularly for those leading healthy lives, make a major contribution to our health. If more people ate natural foods rather than foods concocted and put in a tin or a packet, the nation would be much healthier than it is.

Again, I declare a constituency interest. I represent a dairy area which is concerned about the matter. If I look unhealthy, the dairy industry is wrong. If I look healthy, the dairy industry is right. I drink at least one pint of milk a day and I eat plenty of bacon and meat. If I dropped dead, some people might be grateful, but I hope that that time is a long way off.

I am covering a number of subjects and I wish to go on to another that is highly controversial. Certain recommendations relating to abortion were made in the report and are before the Government. I agree that there should be more sex education in schools, with particular emphasis on the importance of responsible and loving relationships. I make that point forcefully because sex education taught in a stark and animal fashion will cause great problems for young people and so much of the future of our country depends on them.

I also emphasise the proviso in the recommendation provided that the views of the parents have been considered in this context". It is important that young people should appreciate that sex is not just about the physical act, but is about a loving and caring relationship of two people. If this can be carried through and if more teachers can be taught the subject and can pass on what they have learned with care and dignity, the Committee's recommendations could make a major contribution to the health of our young people.

I fully support the recommendation that contraceptive advice should be offered both to women having normal deliveries and to women having abortions. I have some difficulty with the other recommendations that we put to the full Expenditure Committee. I do not believe in free and easy abortions. I believe that they should be available only in cases of rape or when a woman's life would be in danger if a pregnancy went full term. I know that my views may not be shared by the House and that many people outside believe that abortion should be available to young people and others who are in difficulty for one reason or another. I do not share that view, and I must state that fact clearly in the House. However, if the recommendations are implemented with humanity and care, maybe the dangers that I foresee will not be as great as I anticipate.

I support what the hon. Member for Northampton, North said about fluoridation of the water supply. She was right to point out that people have other ways of protecting their teeth, whether by regular cleaning, diet or taking floride tablets. These methods are preferable to mass medication of the water supply, which can be against the interests of certain people. Some hon. Members may believe that the debate is over and that the case for fluoridation has been made without reservation, but I believe that that is not the case. There are countries in Europe and states in the United States of America that have withdrawn mass fluoridation for one reason or another.

Until I am clear in my mind that mass fluoridation is good for everybody, young or old, I shall oppose it because I believe that there are better ways of dealing with dental decay and the problems that some young people have with their teeth. I fully support the views that were bravely put forward by the hon. Member for Northampton, North. In addition, I oppose mass fluoridation because I believe in responsible freedom and freedom of the individual and because I believe that mass medication goes against that philosophy.

There are some first-rate recommendations concerning sport. In the House we have a "stamina room" which goes under the name of a gynasium. The word "gymnasium" conjures up an image of a lavish and large establishment. Our room is not lavish or large. It was opened by Mr. Speaker with some wise and well-chosen words and there were dozens of hon. Members buzzing around wanting to be interviewed by the media and to have their pictures taken. It is amazing and sad to see how few of those who came to the opening just a few weeks ago are now patronising the establishment. It may be that they cannot afford the subscription or cannot be bothered, but we do no ser- vice to the people we represent when we urge that they should take exercise, but do not take the opportunity that is presented to us in the provision of such an establishment.

The Services Committee has had to open the stamina room to almost all and sundry. The police, journalists, staff—almost everyone—are using it, but it is still not fully subscribed. Too few hon. Members take advantage of the excellent facilities which have been provided.

Ms. Colquhoun

Does not the hon. Gentleman accept that the workers in the House, including hon. Members, should be entitled to gymnasium facilities free of charge? His Committee recommends that private firms should provide these facilities. Is it not a total nonsense to suggest that we should turn our gymnasium into a small, elitist club with the sauna available to women Members only on Friday afternoons when they have done to their constituencies?

Mr. Winterton

That is not quite true because I almost had a pleasant experience last Wednesday. I went to the gymnasium, thinking that it was open for male hon. Members and other men, when in fact it was a period allocated for lady hon. Members and other ladies. If I had not gone to the young man in charge of the gymnasium first but had gone straight into the changing room I might have been called in front of Mr. Speaker for unbecoming behaviour or, shall we say, an indiscretion.

I sincerely commend to the House and the Secretary of State our recommendations on the subject of sport and exercise. In the first paragraph, we say: Parents should encourage their children to walk to school where it is possible and safe to do so". We often receive correspondence from constituents urging that children should be given free transport to school. If more young people indulged in positive exercise at least once or twice a day, the health of our nation would be very much better.

We have talked in the report about advertising, and perhaps the Secretary of State and the Minister of State, whom I congratulate on his elevation to the Privy Council, could spend some of the money that they have coming in to use in the media to educate the public on the value of exercise. The Committee recommends: The Department of the Environment and local authorities should be required to make more adequate provision for physical recreation in any future major developments or redevelopments both public and private, particularly in inner city areas". The catastrophic vandalism and hooliganism in our inner cities has increased dramatically in recent years. Adequate provision for exercise and leisure pursuits—leisure centres, running tracks, gymnasia and so on—is one area of public expenditure which I should not oppose.

Another aspect deeply concerns me, involved as I am in education. In both primary and secondary schools there should be a compulsory period of physical exercise, whether for team games or for individuals, at least once a week. In some schools, this practice seems to have died out.

If this House set a better example which got through to the public, we should become healthier in body and mind not just through jogging but through real physical exercise. That would surely be good for us all.

6.51 p.m.

Mr. Robin Corbett (Hemel Hempstead)

I was grateful to be able to serve on the Sub-Committee—

Mr. Robert Hughes

It seems that the only hon. Members who are being called are those who served on the Committee.

Mr. Corbett

As my hon. Friend will appreciate, I have no control over that matter.

In paragraph 304 of our conclusions and recommendations, we say that preventive medicine … is literally a matter of life and death. Judging from the attendance at this debate, we have clearly failed to get that message across to hon. Members, let alone further afield.

Increasing numbers of us are in danger of smoking ourselves to death, gorging ourselves into obesity, drinking too much or becoming so flatulent that some of us make extra and continuing demands on the NHS and many of us are unable or unfit to work. That is a sombre picture, but it is not overstated. I do not wish to be pious. I am a pipe smoker, I probably eat and drink too much and I certainly do not get enough regular exercise. In that sense, I am a fully paid-up member of our society.

In their response, the Government have put their finger on a central issue: Some of the Sub-Committee's recommendations would need legislation which would limit the rights of the individual by legal, fiscal or other means. The hon. Member for Macclesfield (Mr. Winterton) is against forcing people to have fluoride in their water, but he favours compulsory physical exercise for children and hon. Members. Those two views are not compatible.

These matters must be faced, as the Government have tried to face them. If we are to start making inroads in this familiar problem, there will come a point when we consider not only whether to use compulsory measures but how and when. The Government have concluded that, since it is often society which has to foot the Bill for people's so-called rights to act with folly over their own health and that of their families, The real question is not whether the Government should intervene but when and how. I agree, and I hope that the Government and the House will take these matters far more seriously.

The report says that millions of pounds a year of scarce and much-sought-after NHS cash is tipped down the drain. It points out that at current prices £85 million a year is spent on the treatment of smoking-related diseases. That is leaving out of account the fact that, according to the latest figures, 17 million working days a year are lost as a consequence. In my constituency, just a tenth of that £85 million would provide the money we need for the first phase of our desperately needed new hospital. I am talking not about big flashy district hospitals but of something smaller. Nationally, £85 million could make a start on the first phases of smaller nucleus hospitals in 12 or 15 towns. That is the kind of money that successive Governments have presumably been content to see wasted.

How we can tolerate—no one seriously disputes the facts given in evidence to us—the fact that about 50,000 people a year die needlessly through excessive smoking? The BMA disputes that figure and says that it should probably be nearer 75,000 or 80,000. That number of people will literally kill themselves year by year.

I come back to the question of individual rights and freedoms. If the consequence of that kind of regular, persistent and abusive use of nicotine were confined solely to the individual we might then be right to say that the Government and the House should do nothing. But the consequences are not personal. Apart from the personal tragedies, there is an immediate consequence for the NHS. How many more families do we have to see fatherless or motherless or, in the case of one-parent families, deprived of their only breadwinner, and how many more tragedies do we need through self-inflicted wounds before this House summons up the courage to grasp this nettle? We are pussy-footing with the problem of cigarette smoking.

The three-year agreement of which the Government give us notice in their observations is some kind of step, but I am cynical. Why should those who make vast profits from cigarette smoking voluntarily take steps to put themselves out of business? It is like the chief inspector saying to the local burglar, "Can we come to an agreement? Instead of burgling all the houses in that road you will only do every other one, or you will do only two rooms instead of four or five in each house."

The tobacco companies are in business to make money—at best to sustain the present level of cigarette smoking if they can and at worst to put obstacles in the way of any slow-down which would lead to the disappearance of their market.

As if that were not bad enough, 43 beagle dogs in Stockport are tethered and confined—

Mr. Winterton

indicated dissent

Mr. Corbett

It is no good the hon. Gentleman shaking his head. The last time that I received a parliamentary reply on the subject there were 43 of them. They have been put there by ICI as part of an experiment to find a safe cigarette. Those dogs are muzzled and tethered for no medical purposes, but solely in the pursuit of profit. That was all that was involved in that disgusting experiment. I am amazed that any Government could give a licence for such experiments to take place. When it became known, not with any help from ICI, that that was happening, the Government seemed to be powerless to stop it. It is not only human beings that are involved. We even go into the animal world to inflict—

Dr. Vaughan

Does the hon. Gentleman realise that the experiment he has chosen as an example was started at the direct request of the Hunter Committee? It was not started on the initiative of the tobacco industry.

Mr. Corbett

I am most grateful for that intervention, but I must say, because I feel very deeply about the matter, that I still believe it was mistaken and misguided to abuse animals in that way, wherever the suggestion came from.

There does not seem to be much disagreement in the House or outside that cigarettes kill—

Mr. Winterton

Can kill.

Mr. Corbett

—that regular and excessive use of cigarettes and tobacco is a killer—not "can kill", but is a killer. Even accepting that cigarettes can kill, we know that there is a big probability that the "can" will become "will". The Royal College of Physicians, the World Health Organisation and the International Union against Cancer all want the kind of tougher action that we propose in our report.

The priority target group should be the young. The aim should be to try to stop them from starting to smoke, but that does not absolve those of us who are older from trying to get out of this addictive habit.

A constituent of mine, a cigarette smoker, told me on Friday night that the House should be bold enough to take draconian steps. He proposed that we start this year with a ban on cigarette smoking by anyone under 15, moving on next year to the age of 16 and after that to 17, 18 and so on up the age scale, until we come to the point where there is a minority of us middle-aged and more elderly people who are using and depending upon this drug. He proposed that at that stage a licence should be issued, with tobacco products being available on prescription. That is indeed a draconian suggestion.

Mr. Winterton


Mr. Corbett

One could say that about any law.

I hope that the House, spurred on by the Government, will give a lead along those lines. Until it does, we shall see the continuation of the tragic and very expensive results of heavy dependence on nicotine. It will be said that this is a case where "they" know best. I think that here "they" do.

We asked one of the witnesses at our evidence-taking sessions on another topic "What is the view of the medical profession about this?" He replied "Never mind the view of those in the medical profession about it. Ask them what they do." That was very sound advice for the rest of that inquiry. Research has demonstrated that an overwhelming number of people in the medical profession, particularly general practitioners, have given up smoking, much to their credit.

I am sure that there is no argument about the points made about the Health Education Council. We were very impressed, not so much by what it had done, although that was impressive, but by what it wanted to do if it could obtain the necessary finance. We have heard about the totally inadequate amounts of money available to the council for its task, ranged as it is against those whose business is resulting in destroying good health. The council needs much more cash. I hope that it will be provided in our time.

At the same time, I hope that we shall make a much better and more direct attack on those who sell cigarettes, an attack on the kind of basis we advocate in our report. I am extremely unhappy with the Government over our Recommendation 23, for example. They have not accepted—which I assume means in plain English that they have rejected—our suggestion that Legislation should be introduced to ban the advertising of tobacco, and tobacco products, except at the point of sale. I hope that my right hon. Friend the Minister of State will be able to tell us that he has thought again about this matter during the debate.

Recommendation 26 was that Cigarette coupons should be abolished. In their reply to the report, the Government say that they have no need to abolish them because the coupons have nearly disappeared. What a beautiful opportunity it is for the Government to say "There are so few of them left that we should put our feet out and kick them into oblivion, and then take the credit for having achieved that wonderful state of affairs". There must be decisive action of that kind if we are to make a dent in this problem.

There are two other areas with which I wish to deal. The hon. Member for Essex, South-East (Sir B. Braine) mentioned the problem of alcohol abuse. I am aware of the great increase in the abuse of alcohol by younger and younger people in my area, and I am sure that many other hon. Members are aware of it happening in their areas. To my knowledge, at lunchtime in the main town in my constituency students are coming out of school and going to pubs for drinks and obtaining them. To be fair, I am sure that both teachers and publicans take all sensible steps open to them, but those steps are not enough if it is happening on the scale on which I am told it is happening in my constituency.

I am told that on the main road outside the gates of another school, where clearly there is a strict regime, groups of students can be seen smoking at any lunchtime. It is not allowed on the school premises. At least in my day it was done furtively behind the bicycle shed. Now apparently it is done in the open.

The hon. Gentleman was right to put great stress on the problem of alcohol abuse among the young, because it contains the seeds of great social menace for the whole of our society.

The second area is exercise. It is all too often envisaged as people lifting great dumb-bells and leaping about on antiquated, frightening-looking machinery. On the Committee we wanted to do our best to get away from that image and approach the matter in a much saner and less frightening way. It seems to me that some developers and planners of many of our towns and inner city areas believe that people have lost the use of their legs. If we go on in that way, perhaps we shall. In such areas, the car is king. I agree with the hon. Member for Macclesfield that we need to put much more thought into the design of new estates and redevelopments to encourage people to walk, or rather to ensure that they have to walk reasonable distances to get to some of the public facilities, such as shops and community centres. I am delighted to see that this is being done in one of the newer bits of the new town of Hemel Hempstead. At a new development at Grove Hill it is being done very sensibly, with nice underpasses. Perhaps I should not say this, but at present it has the bonus of providing illegal slopes for skateboarding.

The Hertfordshire Area Health Authority and the Dacorum District Council have just launched a "Look after yourself" campaign, which is probably about the right psychological approach. Good health is something that is very personal. It cannot come out of a bottle. One cannot get a tablet for it. It is not available on prescription. The House has agreed this afternoon that it is a matter of sensible personal responsibility and determination to put into practice a number of things which too many of us regularly say on 1st January each year we shall do.

I cannot leave this debate without commenting on that part of the report dealing with dentistry. It is appalling that 31p in every pound of the £200 million or so spent annually on NHS dentistry goes into the filling of permanent teeth. We are told that two-thirds of the school population has untreated dental decay while one-third of the adult population has no natural teeth. To describe the present position as an NHS dental service is, on the basis of my experience, a cruel hoax.

It is virtually impossible in my area for anyone to be taken on to a dentist's list to have work done under the NHS. We should celebrate the 30th anniversary of the founding of the Health Service by declaring this year that the Government will start a full-time dental service to parallel that provided by general practitioners. That is the only way in which we shall overcome this appalling problem affecting the state of the nation's teeth. In a sense, this goes back to the arguments about rights and freedom.

The existing rights in relation to dental health, whether it is the freedom to clean our teeth or not to clean them—the freedom to care for them is not as easy as that because of the non-availability of the NHS service—has led to the nation's teeth being in the state outlined in the report. That is evidence enough for the Government and the House to say that the situation is intolerable and that something should be done.

Finally, I choose what I suppose must be the most public place to make a pledge. I have been trying to give up pipe smoking and, as a result of reading this report and the Government's observations, I intend to have another try. I agree with those who have said that we are public people and should try to set an example. I did not smoke when I went around school. I noted the prints made by an hon. Member about knocking on the staff room door and being greeted by clouds of smoke. I will try, not for the first time—it is the third time—to give up pipe smoking. I hope that, having made this pledge in public, it will spur me on.

7.13 p.m.

Sir George Young (Ealing, Acton)

I am sure that the whole House will want to wish the hon. Member for Hemel Hempstead (Mr. Corbett) every success in his resolution to give up pipe smoking. The hon. Member touched on a number of points with which I hope to deal in the course of my remarks.

I take up first what the hon. Gentleman said about the smoking beagles. He reminded the House that three years ago a number of beagles were smoking cigarettes in an ICI laboratory. As happens in cases like this, an Early-Day Motion was tabled and was signed by no fewer than 204 hon. Members. Three months ago, to draw attention to the fact that 52,000 people—not dogs—are killed as a result of smoking cigarettes, I tabled Early-Day Motion No. 246. So far 55 hon. Members have signed it. I despair sometimes of the priorities of this House when we get such a disparity in concern about disease.

The hon. Member for Hemel Hempstead dealt with two points with which I particularly want to deal. The first was smoking, to which I shall return shortly, and the second was the important principles involved when we move into an area of preventive medicine. These are principles upon which the Government touched in their comments on the report in paragraph 17 entitled "Liberty of the Individual". The Government point out that Some of the … recommendations would require legislation which would limit the rights of the individual by legal, fiscal or other means … such proposals raise important ethical considerations". It is worth examining those considerations for a moment.

It is common ground between the parties that investment in curative medicine has now reached the point of diminishing returns and that the improvement we can secure in the nation's health is through the less traditional, or preventive, medicine. What is a matter for debate within and between the parties is the relative roles of the Government and the individual in preventive medicine. With curative medicine there is no problem. The NHS is funded by the Government and the Government decide what services are to be provided, to whom, when they are to be provided and where. The individual is the consumer and the State is the provider. The relationship is simple. With preventive medicine the relationship is not so simple.

On the face of it, responsibility rests exclusively with the individual. Decisions about what to eat or drink, whether to smoke or whether to take exercise, are decisions taken by the individual and not by the Government. There is, therefore, a temptation to adopt the argument we have heard this afternoon regarding preventive medicine and to say that the role here rests exclusively with the individual.

The argument we have heard many times is that we in this House represent adults who are accountable for their views and actions and who may wish, at risk to themselves and no one else, to do things which doctors think foolish. The argument is developed by saying that one of the problems facing the country is the erosion of the responsibility of the individual, the insidious expansion of the involvement of the State, and that soon Members of Parliament will be banning skateboarding, potholing, tightrope walking and the like. The argument usually ends with people saying that if Members of Parliament got on with getting the country out of the mess they have got it into and left the people to get on with their own lives everyone would be better off. That is an argument which, as it affects health, I reject.

In a Welfare State the avoidable ill health and death of an individual are not just a matter of concern to that individual. He may have a family and the taxpayer will have to support that family because he cannot do so. If he needs health services, they will have to be provided out of the finite resources of the NHS. If an avoidable illness is treated, it often means that an unavoidable illness cannot be treated. The hon. Member for Hemel Hempstead said that £85 million was spent on treating wholly avoidable smoking-related disease. That is £85 million which is not available for curing unavoidable illness such as kidney failure, rheumatism and arthritis. It is unrealistic to claim that the actions of one's neighbour in relation to his health are of no consequence to oneself.

Secondly, it is not the case that curative medicine, traditional NHS medicine, involves no loss of individual freedom while, by contrast, preventive medicine does. The NHS costs £6.1 billion each year to run and we extract from each individual roughly £100 a year. That diminishes the individual's freedom. He is not free to spend that money because the State is spending it on his behalf. With that as a background, is it outrageous to suggest that the activities which we know to be harmful, such as smoking and drinking, should be taxed more highly? If we are prepared to tax people's income to cure them, why are we not prepared to tax their expenditure to stop them becoming ill?

My third reason is more general. There is constant pressure from our constituents to improve the quality of the nation's health. They look at international comparisons and at waiting lists abroad, comparing them with waiting lists here. They look at mortality and morbidity statistics and find that we do not do so well. There is pressure on us to improve the effectiveness of the NHS. If we say to our constituents that the only way to do this is to switch resources into preventive medicine to try to stop people becoming ill I think that they would support us.

Such surveys as have been carried out show that even smokers would welcome higher taxation on cigarettes, a ban on cigarette advertising, and further restrictions on smoking on public transport and elsewhere. No one I have yet met wants his children to smoke. It is not the case that tougher action on preventive medicine would be resented as interference by our constituents. I understand that 68 per cent. of smokers wish to give up the habit.

My fourth reason for rejecting this traditional argument is based on what has happened overseas. Let us consider Norway, a European democracy, where, as far as I know, the freedom of the individual is valued as highly as it is here. Norway has recently taken firm action against cigarettes. In that country deaths from lung cancer are 110 per 100,000 people as against 410 in this country. Consumption of tobacco is 2,000 grammes per adult per year as against 3,200 grammes in this country. The Norwegians have just taken action against tobacco on a scale not yet contemplated in this country. Yet there has been no adverse effect on their democratic system or on the freedom of the individual. It is nonsense to say that putting fluoride in the water or banning tobacco advertisements is inconsistent with parliamentary democracy.

Finland banned tobacco advertisements with effect from 1st March this year. Before doing so, a Select Committee was set up to look at the constitutional issues involved, such as the threat to free speech, the threat to the freedom of the Press and to freedom of expression, to see whether a restriction on sales promotion or advertising would offend those liberties. It was concluded that the original purpose of these constitutional liberties was to guarantee free criticism of the Government and not to assist the sales promotion activities of life-endangering substances. The Bill went through the Finnish Parliament without a single vote against it and was widely welcomed as a step in the long process of moving from a tobacco policy serving commercial and fiscal interests to one which is explicitly health oriented. I understand that in Australia a similar recommendation has been made by one of the parliamentary subcommittees.

Therefore, experience overseas does not imply that it is a threat to democratic freedom if firm Government action is taken against smoking. Indeed, if one is to talk emotively about freedom, what about the freedom of children to grow up in a society where cigarette-associated disease is as unusual as tuberculosis, cholera and typhus?

Finally, on this general point, the House of Commons has already shown by its decisions on seat belts and crash helmets that it is prepared to intervene to protect the individual against the consequences of his own actions. Opinion in the House is changing. In 1956, when the Road Traffic Bill was going through, there was a proposal to make motor cyclists wear crash helmets. The Labour Opposition spokesman at the time condemned this as a gross infringement of personal liberty. I recently reread that debate and the consensus was that it would be an outrage. The proposal was therefore turned down.

By 1973 such a law was on the statute book, put there by a Conservative Government. In a free vote on 1st March 1976, the House voted by 249 to 139 in favour of making seat belts compulsory in cars. That was on exactly the same principle that we are discussing—whether the House should protect the citizen from the adverse consequences of his behaviour—and, of course, the seat belts issue and the crash helmets issue raised difficult questions of enforcement which do not arise in the case of tobacco.

Again, the number of lives saved is very different. The number of lives saved by the compulsory wearing of seat belts is 1,000 a year, but in the case of tobacco we are talking about a figure 52 times as great. So the House has already conceded one of the principles touched on in the Government's reply. I believe that our constituents will tolerate Government action to improve the country's health, and that if we are to make the best use of the resources of the NHS we have to be much tougher on preventive measures.

It is against that background that I turn to the section of the Committee's report dealing with tobacco. It makes 10 recommendations which taken together form a cumulative package, the one reinforcing the other, to tackle smoking. I agree with every one of them. It is a matter of regret that the Government apparently agree with only one of them. It is worth emphasising that this report was unanimous, as the hon. Member for Wolverhampton, North-East (Mrs. Short), the Chairman, has said. The members of the Committee represented all shades of opinion in the House, and for the Government to treat those unanimous recommendations as they have is to treat the Sub-Committee in a rather cavalier way.

Mr. Nicholas Winterton

As a member of the Committee, I want to re-emphasise that, in fact, while all members of the Committee ultimately accepted the recommendations, it was not a unanimous report in the sense that everyone agreed entirely with everything said. I for one did not agree with many of the recommendations on tobacco or abortion.

Sir G. Young

I accept what my lion. Friend says. I was quoting the hon. Member for Wolverhampton, North-Fast. I thought she said that the report was unanimous. If she was wrong to do so, I apologise.

By their own admission, the Government rejected four of the recommendations, the most important of which was that legislation should be introduced to ban the advertising of tobacco and tobacco products save at the point of sale—legislation which already exists in other countries, which the World Health Organisation wants, and which is supported by the British Medical Association, the Royal College of Physicians and the International Union against Cancer. The argument for restricting advertising to the point of sale is that it gives information about cigarettes to those who wish to buy them, and to no one else, and prevents the tobacco industry from seeking to persuade non-smokers, particularly children, that smoking is normal and socially acceptable.

The industry argues that advertising is simply a way of promoting one brand at the expense of another and that it does not enlarge the market as a whole. The Sub-Committee examined and rejected that argument. Indeed, if one thinks about it, the claim is nonsense. We can remember advertisements about summer holidays, about toothpaste or about oil for cars without remembering whose oil or toothpaste it might have been. Indeed, I recall the advertising industry a few years ago defending the amount of money spent on promoting rival brands of toothpaste by saying that advertising on that scale did not just promote rival brands of toothpaste but helped to promote dental hygiene. If that argument is true of toothpaste it is true of tobacco as well.

The response of the Government—and I think that it is the weakest response—comes in paragraph 70. There they say that the merits of an outright ban must be proved beyond doubt before they will support it, and that they propose to keep an open mind in the hope of fresh evidence turning up. If those are their conditions, nothing will ever happen. But that approach is consistent with what the Government did in 1965, when they banned cigarette advertising on television, presumably because they felt that its effects would be harmful.

Nor is it true to claim that a ban would hold up the switch to lower tar bans, because the Sub-Committee recommended that the information should be available at the point of sale. To argue that advertising should be encouraged because the health warnings on the advertisements are valuable is sheer nonsense. If there were no cigarettes, there would, of course, not need to be a health warning, and since the purpose of advertising is to ensure that more and not fewer cigarettes are sold it is hard to see why the health warning on the advertisement is justification for the advertisement. Indeed, those who advertise presumably think that the value of the advertisement is greater than the health warning, for otherwise they would not advertise in the first place.

It is worth emphasising that a ban on advertising is not just a step in itself but is part of a total package aimed at cutting down the consumption of cigarettes in the long term.

The second recommendation that was rejected was that the health warning should be beefed-up. The Government are quite frank about the reason for this. In paragraph 79 they say that the wording Cigarettes cause lung cancer, bronchitis, heart disease' … was not acceptable to the tobacco industry". If the Government policy on tobacco and preventive health measures is to be dictated by what is or is not acceptable to the tobacco industry, they might as well say so and we can immediately stop the debate on prevention as far as tobacco is concerned. But the Government should balance the distress and inconvenience caused to the tobacco industry and the 30,000 people who work in it against their responsibility for the health of the community as a whole.

On this theme, the Government go on to say: The Government take the view tthat, in the overall context of the existing agreement with the industry, the value of agreed measures outweighs that of a health warning referring to specific diseases. I believe that the industry will agree to measures only if it thinks that they are not too harmful to its interests. One will not make progress if one insists on co-operation and agreement with the industry. I contrast this situation with what is happening in Sweden, which already has 16 different very strong health warnings and will shortly be introducing another 16.

Two other recommendations rejected by the Government concern coupons and vending machines. Whilst these measures might have helped, I do not think that their rejection is as important as in the case of the other two recommendations I have just mentioned.

I turn now to the two recommendations that the Government say they have accepted. One is so innocuous that they could hardly not have accepted it. It is: That the present trend to provide nonsmoking areas in public places be encouraged to continue. Perhaps the Minister can tell the House what progress he has been able to make in that direction.

The other recommendation which the Government say that they have accepted concerns sponsorship, which, like advertising, is a form of promotion. On 6th May 1976, the present Foreign Secretary, then Minister of State at the Department of Health and Social Security, wrote to me as follows: I am under no illusion about sponsorship of sport by tobacco companies and I agree it is being used by them to advertise their products. The big increase in sports sponsorship by cigarette manufacturers has occurred since the ban on the advertising of cigarettes on television in 1965 and sponsorship has in many cases been used to circumvent that ban. Sponsorship has less to do with an altruistic wish to help sport in this country and more to do with finding a way around the restrictions on the advertising of tobacco.

That view by the Foreign Secretary is shared by his successor, the present Minister of State. In reply to the hon. Member for Glasgow, Maryhill (Mr. Craigen), the right hon. Gentleman said on 26th May: Our view is that on health grounds any association between cigarette smoking and active sport is undesirable and should be strictly limited."—[Official Report, 26th May 1978; Vol. 950, c. 806.] However, it is not he or his Department with responsibility for what shall happen with sponsorship, but the Department of the Environment Minister responsible for sport, who holds totally different views on the matter, and it is his view, unfortunately, that prevails.

The agreement between the tobacco industry and the Government, referred to in the DOE Press notice 691 on 15th December last year, makes it clear that it is the Minister responsible for sport and not the Minister of State at the DHSS who decides, for example, if a new sport not previously sponsored by the tobacco industry is to receive funds, and it is that Minister who can allow existing companies to promote their products more extensively by increasing their sponsorship. It is clear from what has happened since last December, with the State Express 555 campaign, that the Minister for Sport's rather relaxed interpretation of the scheme rather than the more restricted view held by the Minister of State at the DHSS is the one that has prevailed.

The Daily Mail described this new campaign on 12th May as The richest sports sponsorship to be devised in Britain The British American Tobacco Company had not previously sponsored any sport in this country. Its campaign attempts to associate cigarettes smoking with sport in a way that has not even been tried before. Up to £2 million of State Express money will be used to finance training and coaching of young sportsmen who will then be used to promote, either directly or indirectly, this brand of cigarettes.

The money passes through the Sports Aid Foundation, a semi-official organisation, thereby giving official blessing to the project, in direct contravention of Government policy as put forward by the Minister responsible for health matters. So annoyed was one of the vice-chairmen of the Sports Council at this involvement of the Sports Aid Foundation that he had the good sense to return his SAF tie to the organisation concerned.

The Minister responsible for health matters is against a link between sport and smoking. So is the Select Committee. The Government say that they have accepted this. But a few months after the Government statement, a tobacco company, which has not sponsored sport before, enters the market with the approval of the Minister for sport and commits £2 million on top of the existing E10 million to sponsor sports which have not previously been sponsored, such as athletics, football, racing and swimming. The Government speak with a forked tongue on this issue. It is time that the two gentlemen concerned were locked together in a room in order to find out whether they can agree on what Government policy is to be. They should be left there until they agree on a joint policy. The Government have let the tobacco industry off the hook, but this House should not let the Government off the hook.

The remaining recommendations were either under consideration or accepted with reservations, the most important one being the recommendation for an increase in duty each year to achieve a price increase sufficient to reduce cigarette consumption. Last year the Chancellor of the Exchequer found compelling health reasons for increasing the tax on tobacco. This year—perhaps because it may be General Election year—he has found the arguments less compelling.

Like some of the other measures proposed, this is not an instant solution but part of a total package aimed at removing tobacco smoking from this country. It is worth quoting, in conclusion, what the British Medical Journal in the issue of 18th March 1978, said about the Government's policy: Sadly, the Minister"— that is, the Secretary of State for Social Services— was vague about future Government plans, but there seems little prospect of early comprehensive legislation along the lines successfully pioneered in Scandinavia. Indeed, Britain has not implemented many of the recommendations of the World Health Organisation or even those included in the House of Commons Expenditure Committee Report on Preventive Medicine. The report goes on: Thus, while the British smoking problem has long been worse than most, Parliament has been slow to face its responsibilities. The current Government policy of negotiations and 'voluntary agreements' with the tobacco industry recalls Clausewitz's dictum, 'Statesmen and generals have at all times endeavoured to avoid the decisive battle, seeking either to attain their aim without it or dropping their aim unperceived.' I find the Government's response to this section of the report deeply disappointing. The Government have not accepted the recommended strategy. In addition, they have put nothing in its place. The doctors have put the ball firmly in our court, but the Government have not even a racquet in their hand with which to put the ball back. Future generations will condemn us for the very lax way in which we have tackled the problem. The Government, under the influence of the tobacco lobby, have abandoned their overall responsibility for the health of the community. I condemn without reservation what the Government have done about the tobacco recommendations.

7.33 p.m.

Dr. M. S. Miller (East Kilbride)

I believe that the media are very well aware of what they are doing when they regularly televise matters concerning health, because it is a subject in which most people are very interested. Although we are not large in number, our debate indicates clearly that those who have attended and spoken in it speak with a great deal of knowledge at least of the preventive measures that they would like put into effect. They have spoken with a considerable degree of passion and dedication to the subject.

It is a sobering thought that if we in this country banished every doctor, except those concerned with the control of epidemiological disease and those responsible for clean water and making sure that our food was not tainted, our mortality statistics would not indicate any noticeable increase. But morbidity is another story, and there is the rub.

The Sub-Committee deserves to be congratulated, and I join in the congratulations of my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) on the report which has been published. It is appropriate that on the eve of the thirtieth anniversary of the establishing of the National Health Service we should be discussing the element in the NHS which was never really there, except in ephemeral form, from the beginning, and that is the prevention of disease and not just its cure.

Many have described our National Health Service as a national ill-health service or a national disease service. That is a little unfair, because a good deal of work is done on prevention. A good part of the reason that we have not obtained the results we should have liked to obtain lies within people themselves. Seeing the remedies there, and able to seize them with their own hands, they do not seize those remedies, and carry on as they have in the past.

I want to concentrate on the prevention of certain diseases and certain conditions. And I start with epidemiological conditions. We have come a long way since the days when diphtheria, whooping cough, measles, poliomyelitis and a host of other conditions, including smallpox, ravaged the land. I am glad that my right hon. Friend the Minister of State—I congratulate him on his elevation to that lofty position—and his right hon. Friend, who is in a slightly loftier position, are still committed to the continuation of vaccination and inoculation of children, albeit with safeguards. There must be safeguards present, but I am happy to know that the control of epidemiological disease is still in our grasp, and that this is an element of prevention which is pursued and is producing results.

A second large area where disease has to be prevented and can be prevented is that of cancer. It is not because they are not important that I shall not discuss cancers such as skin cancer. More can be done to prevent skin cancer by preventing the attack on the skin that is made by certain carcinogenic agents, but I shall leave the other cancers and concentrate, because of lack of time, on lung cancer.

Lung cancer is a disease which, as we know, claims the lives of 30,000 people every year. Most of these 30,000 people, or a very high proportion of them, are certainly not in the very old age group. Indeed, with the increase in smoking in the last 50 to 60 years, the age group has become lower. Men even in their thirties, and certainly in the early forties, have been dying of lung cancer directly as a result of cigarette smoking.

I do not think there is much dispute nowadays about the relationship between cigarette smoking and cancer of the lung. The figure of 30,000 is a very large one, especially when we consider that this is something that could be prevented. But it is not just with lung cancer that cigarettes are so deeply involved. The figure of 30,000 deaths from bronchitis and emphysema is also a direct result of cigarette smoking. Again, many young people are involved here because of the fact that cigarette smoking increased tremendously for a long time. I am glad to say that in recent years it has not increased, but for many years it went on and on increasing.

If we want to consider what happens when a group of people slops smoking, it is interesting to consider the medical profession. Twenty-five years ago the proportion of cigarette smokers among male doctors was roughly the same as among the male population generally. It might have been a little lower but it was not much lower. The lung cancer rate was the same for each group. The first report implicating cigarette smoking in lung cancer came out exactly 22 years ago.

During that period there has been time to correlate statistics. It has been found that instead of roughly 70 per cent. of doctors smoking cigarettes, as they did 25 or 30 years ago, the figure is now down to 22 per cent., and the lung cancer rate among doctors has fallen in a proportionate fashion. As someone said "Do not ask the doctor what he thinks. Ask him what he does." It is sad to note that there are still 18 million cigarette smokers in this country and that in addition to the premature deaths which cigarette smoking causes it is estimated that about 50 million working days are lost as a result.

The hon. Member for Macclesfield (Mr. Winterton) mentioned the new smoking material. This was lauded by the tobacco companies. It was a dismal failure, but not because of any campaign against it. The amount of money spent by those who opposed it was infinitesimal. I personally am in favour of anything that helps. Therefore, I was not totally opposed to NSM. However, NSM was killed—in spite of the ballyhoo by the tobacco companies—because smokers did not like it. It did not satisfy them. I can assure the hon. Member for Macclesfield that the amount of money spent by those of us who, generally speaking, are opposed to the whole campaign was tiny. I shall not go on with a repetition of the hazards of cigarette smoking. They have been well covered. I agree with what has been said with regard to what the Government should be doing.

I turn to the prevention of heart disease, which is another big area about which we have to take note. This applies especially to hon. Members. The hon. Member for Reading, South (Dr. Vaughan) and myself are trying hard to get a medical surveillance scheme for Members of Parliament, because we here are perhaps subject to the conditions which many doctors believe make us liable to cardiac conditions. I should like to mention several areas in this regard. Much has been published and said about the relationship between the ingestion of saturated or animal fats and the incidence of cardiac disease, particularly fatty degeneration of the heart and coronary thrombosis.

There is a school of thought of which there is an eminent spokesman—Professor Morris of the London School of Tropical Medicine, which believes that animal fats are deeply implicated in the causation of coronary heart disease. There is another school of thought which says that the ingestion of animal fats is not the problem and that it is too much sugar. This school is perhaps typified in this country by Professor John Yudkin, who is the Professor of Nutrition at London University. There is a divergence of opinion because absolute proof is almost impossible to obtain.

I would say in passing that it is astonishing how little people know about their own bodies. Some people do not even know where some of their organs are. There are certain organs about which they know, but there are other organs about which they do not have a clue, for example, where they are placed in the body. A lot of nonsense is also talked about many of the so-called health foods or natural foods which are sold in health food shops. I believe that these are just confidence tricks on the public. There is really nothing wrong with most of the processed foods which we eat, although there may be some kind of psychological value in imagining that one has food which is fresh. But it is probably no fresher than the food which we eat in other forms.

As I was saying, there are differing schools of thought about food. A lot of common sense is needed in this regard. I am very much in favour of the message in the song "A Little of What You Fancy Does You Good". For example, if one really believes that the ingestion of too much fat is not good—there is a great deal of truth in that and, therefore, campaigns are waged against drinking milk or eating butter, eggs and cheese—then one has to think about sections of the population which seldom see large amounts of cheese, butter, eggs or milk. For example, old-age pensioners do not indulge themselves greatly in foods that the more affluent of us in society can afford to eat. One needs to have common sense in tackling problems such as this. It would be terrible to put the wind up people who are not liable to gorge themselves on huge amounts of cholesterol material just because some people are worried in case they take too much.

The same applies to sugar. A lot of nonsense is talked about the dangers of chocolates, but it is all a question of how much of these one eats, whether one eats them in huge quantities or, as with alcohol whether one treats them with respect. To those of my colleagues who are worried about the foods they eat I would say that if they are swayed by the erudite words of those who claim that saturated fats are dangerous, the questions they must ask themselves is "Do I really want this huge steak with its runny fat with a load of chips or can I do without it?" or "Do I have to eat it every day?" There is no difficulty if one indulges in meals of that sort from time to time. Common sense is what is needed.

There is also the question of stress with regard to heart disease. I need not emphasise this because I think that there is also a correlation between the incidence of certain heart conditions and the stresses to which people are subjected. Exercise is a matter which has been mentioned by several hon. Members. Again, one must be reasonable. There are plenty of people who do not take a great deal of exercise and who remain quite healthy. There are other people who take a fair amount of exercise and who suddenly collapse. We do not know the reason for this. One must not expect the medical and scientific professions to be able to solve every problem which arises in much the same way as we as politicians seem to be able to solve very few of the problems which we are supposed to be experts at solving.

I turn to dental caries. This is an area where better progress could have been made and still could be made. I am sorry that my hon. Friend the Member for Northampton, North (Ms. Colquhoun) is not here, because she mentioned fluoridation. The point is that fluoride tablets, as she suggested, or other methods of giving it, are not the answer. There are two reasons. First, it is extremely difficult to obtain the exact dosage with fluoride tablets. The mother or father, or whoever is giving it to the child, cannot be quite sure whether it is better to give two tablets instead of one just in case they forgot to give the child a tablet the day before. There is a great difference between giving one part in a million, two parts in a million or more. I do not believe that it is right to put something in the hands of people especially where mistakes could be made with regard to dosage.

But the more important argument against this is that fluoride is most effective while teeth are developing. It should not be left to parents, who may not be highly motivated, to give it to children. We all know that these are the very children most unlikely to be given it. They are the problem cases. It is the children who will suffer, and it is not right to permit future generations to suffer because their parents neglected to give them something that we could easily have given them.

I noticed that the hon. Member for Macclesfield (Mr. Winterton) is leaving the Chamber. Before he goes, it ought to be said that his opposition to fluoridisation is based on the claim that there are better methods, although he mentioned none. I wonder whether he thinks that he drinks untreated water, and I wonder whether he would swim in an unchlorinated swimming pool.

Mr. Nicholas Winterton

I drink treated water, but it is treated to make it fit for me to drink. It is not treated to give me medication.

Dr. Miller

I do not see any difference. The hon. Member is splitting hairs. It is not fit enough to drink if it produces dental caries in a child.

Mr. Winterton

It cannot produce dental caries.

Dr. Miller

I am saying that it if has not fluoride in it, caries can develop in a child. It is important to point out that fluoride has been added to water for many years without the slightest evidence that it causes any trouble, and there is no link between it and cancer in any part of the body.

I want now to switch to three areas which have not been touched upon in the debate so far. The first concerns the prevention of deafness. In the Western world we have a growing problem of noise pollution, with a growing number of people who are becoming deaf as a result. The estimate of the number of people in this country who have some hearing impairment is about one in five, yet we do not have the same kind of facilities available for helping people who are partly deaf as we have for helping people who are partially sighted. It is worthwhile looking into this problem, even in young people. I believe that we shall have a generation of people liable to deafness because of discos, if they continue to listen to the pounding of a very loud beat for long periods of time.

The second area concerns genetic disease. There are some diseases which can be prevented, and I should like my right hon. Friend to look into the possibility of preventing one specific disease—Huntingdons Chorea. I will not say any more about it, but I hope that my right hon. Friend will take that on board.

The final area which has not been mentioned is the prevention of mental illness. This is perhaps the biggest problem that we have today. Certainly it will be the biggest problem in the future unless we tackle it. We have only to look at the hundreds of millions of tranquilisers and sleeping tablets ingested by people in this country over a year to realise the problem that we have in the incipient development of mental illness or the possible prevention of it by the simple method being adopted at the moment of taking tablets. I think that a lot more investigation has to be done in this.

In trying to push the development of preventive services we need a switch of our resources to the area of primary health care—to the family doctor—to encourage general practitioners in teaching their patients how disease can be prevented. When one thinks that only 8 per cent. of total expenditure of the National Health Service goes to the family doctor service and 12 per cent., half as much again, goes to the drugs which are used in the NHS, there is an imbalance which could well pay my right hon. Friend studying very carefully. The family doctor knows his patients well. He knows their families, their backgrounds and where they work. I think that it would be a very cost-effective method of tackling the problem if we made such a switch of resources.

The National Health Service is an open-ended commitment. The expectations of people as a result of the technological advances which have been made, the new diseases which some people say have been invented and the new cures which can be used against these diseases, have made people expect a very much higher standard, which has led them to have greater expectations of what can be done than they had formerly. In that respect, we should be wary about talking about the finite resources of the National Health Service. In a matter as important as health, I do not think that we should easily use the word "finite". I think that we shall always find that, if we switch resources from one area to another and if we increase a little what we are spending on the NHS, we shall get results.

With the reservations which right hon. and hon. Members have mentioned about cigarette smoking and one or two other areas, with which I agree, by and large I commend the Sub-Committee for its diligence. I hope that we shall get the results which have been indicated in the answers that my right hon. Friend's Department has given in its White Paper.

7.57 p.m.

Mr. George Thompson (Galloway)

I, too, welcome the debate on the report and on the Government's response to it, and I take the point made by the hon. Member for East Kilbride (Dr. Miller) that one of the maxims we should adopt is moderation in our eating habits, and that we should follow our common sense.

Like the hon. Member for East Kilbride, I regret the absence from the report of a section on preventive mental health, but I understand why the Committee felt obliged deliberately to omit consideration of this sector. Perhaps it will have an opportunity to come back to it. However, in the Government's response to the report, I noticed some paragraphs devoted to the subject and the promise of a further paper on it. I look forward very much to that further paper and others which have been promised.

I noted that the report stressed the value of the media in educating people. It mentioned the need to bring back the Radio Doctor. The White Paper pointed out very properly that on BBC Radio Scotland we have a Radio Doctor in the morning magazine programme "Good Morning, Scotland". I always find what he has to say of interest. He has one of those comforting, comfortable Scots medical voices. It might be useful to adopt him on this side of the border.

I turn now, naturally, in the Scottish context to the subject of smoking because Scotland has a quite disgraceful record in the incidence of lung cancer, heart disease and chronic bronchitis compared with England and Wales, as the report points out. There is no doubt that excessive smoking lies at the back of this record, and I see no reason why the health warning on cigarette packets should not say so.

I remain eternally grateful to a single Woodbine which I attempted to smoke at about the age of eight. I had purloined it from someone's five small cigarette packet that we had in those days. I am glad to say that after one or two draws I felt obliged to pull the plug on it and on what had resulted in my inside following this casual encounter with a Woodbine. I have never touched the weed since, and I do not propose to do so.

I was disappointed to see that the Committee's Recommendation 23 was marked with a "D" in the Government's response, indicating that the recommendation had not been accepted. The Committee recommended that the advertising of tobacco and tobacco products should be banned except at the point of sale. It seems to me that this should be done. I am very glad that my own party's recent annual conference passed a resolution to this effect and committed itself to promoting legislation in the Scottish Assembly, when it is finally set up.

I am not trying to say that the SNP is taking a "less smokey than thou" attitude. I recall that when I was assistant national secretary one of the most unpleasant things that I had had to do was to put my clothes on the morning after a meeting of the national executive committee. They were absolutely full of smoke. I hope that the Minister will have another look at this matter, and come back with a more positive response to the Committee's wisdom.

The hon. Member for Wolverhampton, North-East (Mrs. Short) stressed the need to ban smoking in school staff rooms. As one who has suffered from that in my time, I absolutely agree with her. One of the worst sights I remember in the school in which I taught was when three nurses came to carry out medical inspections of the pupils. As soon as the bell went for the interval they hurried to the staff room, lit up and smoked like chimneys. No doubt after that they went out to exhale their smokiness on to the pupils, some of whom were quite willing to be led astray.

I agree that cigarette machines should not be allowed on premises to which children have access. I do not understand why the mere fact that provision to that effect would require legislation is thought to be a good reason for not accepting the recommendation. This Government do not have a renowned reputation for parsimony in legislation, as lawyers frequently point out to me.

The hon. Member for the Isle of Ely (Mr. Freud) made some good points about railway carriages. However, I think that he was speaking of the old-fashioned ones with compartments. Nowadays we have open-plan compartments, and despite the division in the carriages smoke often penetrates from the smoking section into the non-smoking section. Perhaps something should be done about that.

The point was made that often smokers make non-smokers feel as if they are oddities. I sometimes give people lifts in my car and they ask me whether I mind if they smoke. As I have a majority of only 30, I do not find it in my heart to tell them that I do not want them to smoke, but it is really revolting to have to empty the ashtrays afterwards.

Mrs. Renée Short

The hon. Member should be tougher on them.

Mr. Thompson

Perhaps after the next General Election I shall be tougher.

When I was teaching in France it was a pleasure to go to the cinema because no smoking was allowed. There was a big interval between films when people could go outside and smoke. That was a much better arrangement than having non-smokers subjected to streaming eyes in the cinema.

In my constituency we have seen what happens as a result of the habit of dropping cigarette ends. We had a large forest fire in Galloway and it is believed that it was caused by some less-than-careful visitor dropping a cigarette end.

On the abuse of alcohol, once again we Scots have a poor record. Certainly we need more detoxification centres to treat alcoholics but we must aim at educating people in the sensible use of alcohol.

I agree that prohibition is not a possibility as it would lead to just as many difficulties and ills as it would remove. However, I was a little disappointed to hear from the hon. Member for Essex, South-East (Sir B. Braine) that, according to the chief constable, the abuse of alcohol has risen again in Strathclyde. We had hoped that the change in the licensing laws in Scotland recently would have promoted a more sensible use of alcohol.

I turn to the problem of teenage drinking and drinking habits among schoolchildren. Inevitably those members of the school population who are over 18 are entitled to go into a public house, and there are others who are more than willing to go in with them. But a head master with reasonable control of his school should be able to cure this.

In providing education about the misuse of alcohol we must ensure that this is fitted to the age of the child. I remember when I was a small boy some people came around with a caravan and showed us some specimens of livers in various dreadful stages of decomposition. It all went over my head and I had no idea what they were talking about. All I knew was that the head master was inclined to light up a cigarette and walk up and down while we were all listening.

The connection between drinking and driving is well known and I am certain that the House will have to tighten up the laws on this subject. In Scotland we are well aware of the action of alcohol in the incidence of violent crime among teenagers and young adults.

I welcome the efforts of the Scottish Office, through its "Fit for Life" scheme, in promoting a minimum of physical exercise among the sedentary, the lazy and the community at large. As a student in Edinburgh I used to notice schoolboys carrying shoulder bags containing sports gear, taking a bus to school, two or three stops away. That seemed to be a complete contradiction in terms. Why did they take a bus when they could have walked?

I also regret that so few people cycle these days. However, I do not blame them. I would be terrified to cycle in London as some hon. Members do. I congratulate them on their bravery. I would not even drive a motor car around Parliament Square, let alone cycle.

One of the great changes that has taken place since I was at school is that individual sport is now encouraged just as much as team games. I did not have much liking for team sports; I did not fancy being kicked or even kicking other people. Pupils are now allowed to follow the sport of their own interest, and the one that best suits their physical make-up, rather than being dragooned into team sports.

Recommendation 15 says: We recommend that the career structure for doctors in community medicine should be improved, so that this increasingly important medical discipline may attract more, able candidates. I have recently had representations made to me about the need for such a structure for clinical medical officers in the community sector of the National Health Service. These medical officers used to be employed by the public health departments of the local authorities and they had a promotion ladder open to them into partly or wholly administrative posts. I understand that this is not so now. Clearly, if we are to have a contented community health sector justice must be done to these medical officers.

I note that the Government have accepted this recommendation with reser- vations. Perhaps the Minister will spell out what this means. Paragraph 236 of the White Paper is less than clear.

A correspondent wrote to me as follows: My own view and this is one with which I know some Chief Administrative Medical Officers and District Medical Officers concur, is that as a first step a new grade of Principal Medical Officer be instituted immediately. This would really be a restoration of a grading which existed in the Public Health set-up, and would carry some administrative responsibility. The salary scale would be that of the Medical Assistant grade. I shall be interested to know whether the Minister has anything to say on that matter. We must never forget that a sustained attack on social deprivation will produce major improvements in Scottish health in those parts of Scotland where a legacy of poor housing, overcrowding and poverty contributes to the high incidence of disease and infant deaths. Community health care depends on social conditions and on the way of life in each area.

I look to a great improvement in the social and community psychology of the Scottish people as a result of selfgovernment—first through the Assembly, and later through a full scale Parliament.

8.10 p.m.

Mr. Robert Hughes (Aberdeen, North)

I hope that I shall be forgiven for not taking up the remarks of the hon. Member for Galloway (Mr. Thompson), who believes that the psychological health—meaning presumably the mental and physical health—of the Scottish people is dependent on the Scottish Assembly or on the attainment of independence. Apart from those few remarks, the hon. Gentleman made a sensible speech and discussed the problems that we face. Those problems are not confined to any one part of the United Kingdom but are suffered by almost all people wherever they live.

The Expenditure Committee should be commended on producing this report and certainly on succeeding in having it debated. Far too often Select Committees and their Sub-Committees meet, put in a couple of years' hard work and produce sensible recommendations which never see the light of day. The Committee produced its findings in February 1977 and the Government, somewhat unusually in terms of speed, produced their response in December 1977. Here we are six months later discussing that report. That is a tribute to the Committee and to the importance of the subject of preventive medicine. It is worth noting that of the 58 recommendations made by the Committee, 25 have been accepted by the Government without reservation, 17 have been accepted with some reservation, and 14 are under consideration. In other words, only a small minority of the recommendations have been rejected.

Having said so many good things about the report, it may seem a little odd or carping if I begin my speech by pointing to one omission from the subjects dealt with by the Committee. The Committee did not discuss the important subject of occupational health. I know that the Committee faced a wide remit in terms of preventive medicine. In paragraph 16 it says: The scope of the enquiry was so wide that we have deliberately excluded from it certain areas which we nonetheless realise are of great importance. We have not considered occupational health nor, in detail, environmental pollution or preventive mental health. I hope that the Sub-Committee will continue its work and I will look seriously at the subject of occupational health. One of the biggest faults with the National Health Service, and one of the reasons that it has not lived up to its great expectations, is that we have only half a Health Service. In other words, we are concerned with the end result of disease. It is a curative service, and in that sense we have not a whole NHS.

It has long been the desire of the Labour Party—a desire shared by the Labour Government—that we should have an occupational health service. Until we begin to attain such a service, we shall not be treating preventive medicine in any real sense. Much of the disease that affects people is influenced by the way in which people are treated in their environment and at their work.

It is no use saying that we are concerned about the effects of smoking and various other aspects of life that affect health if we do not take into account the fact that people are subject to conditions of employment which are bad for their health. We hear a great deal from time to time about the number of days lost because of industrial strikes but hear very little about the many greater number of days lost due to ill health. If we could have even the rudiments of an occupational health service, with regular check-ups and medical advice available at the place of work, I believe that much disease could be stopped—and if not stopped immediately, it could certainly be picked up.

Part of preventive medicine also encompasses early diagnosis. Often by the time a person visits his general practitioner and is referred to a hospital specialist, and certainly by the time he comes to be treated for the disease in question, that disease, especially if it is of a cancerous variety, has gone so far that there is no cure. We have examples in recent times of illnesses caused in industry because of lack of knowledge and, I believe, lack of proper screening.

Let me quote three examples. The first—and this was mentioned by my hon. Friend the Member for East Kilbride (Dr. Miller)—is the condition of deafness. If hon. Members have not seen the programme made by my hon. Friend put on by the BBC in Scotland, which gave Back-Bench Members of Parliament the opportunity to produce a television programme, they should take the opportunity to go upstairs and play the video cassettes relating to the programme on deafness. We should examine all these matters because they are most important.

The second disease that I wish to mention is asbestosis. That disease came to light only because of the incidence of cases that were beginning to be reported. If a preventive medicine service had existed in industry, I believe that disease could have been picked up much earlier.

Thirdly, let us take the condition referred to as welders lung. This is caused as a result of the fumes from that process and the varying gases that are now used to produce a cleaner and more efficient weld. Many workers who are vital to industry are now suffering from this disease because of the growth of these methods of production. I often wonder why it is that eventually it is the NHS which is finally held responsible for the care and protection of workers in industry. I wish that the industry would put a lot more of the money it earns into the protection, care and health of workers. For too long industry, as in many aspects of life, has not been concerned about matters affecting the health of its workers so long as it has been able to produce its products.

I now wish to deal with the subject of health education. The amount of money available for this purpose is quite pitiful. I am glad to see that health education is now becoming fashionable. I remember a great pioneer in health education who introduced the idea of the health visitor in general practice. I refer to the one-time medical officer of health of Aberdeen, Dr. Ian McQueen. Fifty-five years ago he begged the local authorities to spend money on health education and health visiting. He was then dismissed by many people as a simple empire builder who was concerned only with building his own prestige. Yet it is due to the work of such pioneers, who were willing to speak out in favour of health education when such thinking was unfashionable, that we are at last beginning to find greater recognition of the importance of health education and the achievement of better health through proper living standards.

I wish now to deal with two somewhat more controversial matters. I refer first to the fluoridation of water supplies. I was astonished to hear my hon. Friend the Member for Northampton, North (Ms. Colquhoun) say that she was an opponent of fluoridation, but when asked to give one reason for saying that fluoridation was bad, she replied that it was all documented. She would not give the House one reason for saying that she was against that process. She seemed somewhat hurt by the fact that we were pressing her for an answer. We were not trying to stop her saying that she was against fluoridation but were asking why she was against that idea. All the documented evidence clearly shows that fluoridation is effective, safe and worthwhile.

Mr. Lawrence

The hon. Gentleman cannot possibly have read the minutes of evidence, Vol. II, of the Committee's proceedings, especially pages 216 and 217 where there is an assessment of a statistical analysis of cancer in areas which were highly fluoridated in the United States. That is one of a number of examples that are set out in the evidence that was heard by the Committee. That is the sort of thing upon which the hon. Member for Northampton, North (Ms Colquhoun) was basing her conclusions, and which she said was well documented. The fact is that it is well documented.

Mr. Hughes

The hon. Gentleman must not misunderstand me. I was saying that my hon. Friend the Member for Northampton, North was given the opportunity to put her views before the House on why she is opposed to fluoride. She declined to do so. She merely said that she was opposed to it. If we consider the evidence, it is clear that practically every paper that has been produced stating that fluoride is connected with cancer of the lung or of the bone, heart disease and other diseases has never been repeated by any of the authorities concerned. Nor have such papers ever been proved.

It is worth quoting in full the Government's reply in paragraph 130 in "Prevention and Health". It is stated: Improvements in dental health shown by studies in areas of the UK where fluoridation has been introduced provide ample support for the Government's policy. For example, the two published reports of the first five and eleven years of the official studies (Reports on Public Health and Medical Subjects Nos. 105 and 122, HMSO 1962 and 1969) showed considerable reductions in the amounts of dental decay among children in the study areas, compared with the unfluoridated control areas, where much smaller changes took place. One of the study areas, Kilmarnock, where similar improvements in children's dental condition had been observed, ceased to fluoridate its water supply in 1962; by 1968 caries in 5-year old children there had increased and reverted to substantially the same high level as in the unfluoridated control town of Ayr. It goes on to make various other statements and quotes the experience of Anglesey. It is said that fluoridation is an important and safe public health measure.

Why is it that the opponents of fluoride will never produce any information that will stand up to examination about the incidence of disease? I have seen evidence precisely to the contrary.

Dr. M. S. Miller

I draw my hon. Friend's attention to the report that has been mentioned by my hon. Friend the Member for Northampton, North (Ms Colquhoun). It indicates that from 1944 to 1969 average death rates increased in both unfluoridated and fluoridated cities. It is true that according to the table average death rates increased more in cities where there was fluoridation. However, it is interesting to note that death rates increased in both fluoridated and unfluoridated areas. That suggests that there must have been another factor involved.

Mr. Hughes

I am grateful to my hon. Friend for drawing my attention to that part of the appendix. That is so in every study that has been produced. Those who are opposed to fluoride in the water supply have conducted emotive campaigns. That is because basically they stand for what they say is pure water and echo the statements, for example, of the National Pure Water Association. They neglect the fact that there is no such thing as pure water or natural water. In many instances water has to be treated before it is fit for human consumption. I consider the addition of fluoride to be different in no way from the sort of thing that is occasionally done in other areas to provide good health.

There are some areas where it is necessary to introduce iodine into the water. That is done because for reasons that no one knows for certain there has hitherto been a high incidence of goitre. It has been found that the addition of iodine into the water supply reduces goitre. Are we to say that the addition of iodine should be stopped although no one has made a great deal of fuss about it?

In its original recommendations the Committee makes clear that political philosophy and political will are involved. It seems strange that it should be argued on the one hand that certain compulsory measures should be taken in various areas but not in others. It may be that those who take that view and who are opposed to fluoride have swallowed the propaganda of the National Pure Water Association.

I turn to compulsion and the advertising of smoking, which is related in a sense to the freedom of individuals, which is often expressed by the anti-fluoride brigade. It is argued that there should be no intervention by the State between the individual and his right to do what he wishes as regards his health. It is said that there should be no imposition and that people should be free. That argument is extended to some extent when we come to the advertising of smoking. It is said that there should be limits but that advertising should not cease altogether. Why is that said?

It has sometimes been argued that we should lift the ban on the use of heroine and opium. It has been argued that the use of cannabis resin should be legalised. If it became a commercial proposition to provide cannabis resin in cigarettes, there have been rumours—I put it no stronger than that—that the cigarettes companies would be able to produce cannabis cigarettes for mass consumption. Where do we draw the line in the limitation of individual freedom?

We all recognise that in the freest of societies there has to be some limitation. I am satisfied that where the line is drawn depends very much on the extent of the vested interest. I am sorry that the hon. Member for Macclesfield is not in the Chamber. I should have taken his speech in defence of tobacco advertising much more seriously if he had not qualified it with the caveat that he had a strong constituency interest, one of the tobacco companies having a factory in his constituency. It would have been much better if the hon. Gentleman had been speaking irrespective of that interest. There are times when we have to speak out even when our constituencies are involved.

In my view the Government's response to the £2 million campaign of sport sponsorship by State Express 555 is utterly abhorrent. It is time that my right hon. Friend the Minister with responsibility for sport is told bluntly that if our performance in the Olympic games, for example, depends on that type of sponsorship, we would rather do badly in the Olympic games. It is no great help to fitness if people have to smoke to provide the money. The significant feature about cigarette advertising is that it may be that the total number of people smoking is decreasing or that the number of young people taking up smoking is increasing, but there are sinister figures which suggest that consumption among those who smoke is increasing. That can only be because of the power of advertising and of sponsorship, particularly in sport.

I congratulate the Committee on its report and the Government on their response generally, but we shall not begin to tackle health and preventive medicine unless we do two things. One is to meet vested interests head on and the other is to have a proper Health Service. That means the urgent beginnings of an occupational Health Service on a national basis.

8.30 p.m.

Mr. Michael Shersby (Uxbridge)

As one who is not a member of the Expenditure Committee, but who nevertheless takes an interest in those aspects of preventive medicine which relate to health, I welcome the opportunity to contribute to the debate.

My interest, apart from the general one which we all share, is due to the fact that I have for a number of years worked in the food industry and have a close association with the sugar industry. Therefore, it is right that I should declare those interests at the outset. I believe that sometimes an interest in a particular industrial or food activity enables a Member to contribute a certain amount of knowledge which otherwise might not be available. I shall endeavour to make my contribution in that spirit.

The Expenditure Committee's report is an important landmark, because the recommendations which have been made for Government action in a number of areas will in due course impinge on the life of every citizen. Therefore, I want to concentrate my remarks on two aspects of the report: first, diet and, secondly, dental caries.

It is the generally accepted view, expressed in the Government's response to the Expenditure Committee's report, that ill-health in Britain today arises from over-indulgence and unwise behaviour. It is therefore said that the greatest problem for preventive medicine now lies in changing behaviour and attitudes to health.

The principal aim of the Government's publication "Prevention and Health, Everybody's Business", which was published last year, accepted that the individual can do much to help himself, his family and the community by accepting more direct personal responsibility for his own health and welfare. It reminded the public that that responsibility was everybody's business and that it was in everybody's interest to adopt a healthier lifestyle. The document pointed out that smoking and related diseases, obesity and its consequences, alcoholism and drug dependency are major preventable problems and that, in relation to all of them, positive action by the individual can lead to an improvement in health. The question then arises as to what action, if any, the Government should take to promote healthier living in the context of some of the major topics considered by the Expenditure Committee.

The Government have indicated, in their response to the Expenditure Committee's report, that they believe that their responsibilities should be directed to ensuring that food sold to the public is safe and to increasing public awareness of the significance for their health of the choices that they make.

The individual diet is made up of a number of different types of food and of many individual items of food. There are important differences between considerations concerning individual foods and foodstuffs and those relating to diet as a whole.

There is no doubt that the public have a right to expect that, with regard to individual foods, what they eat is safe and is sold under hygienic conditions. It has long been accepted by the public that the Government have a duty to ensure both safety and hygiene, and all our legislation reflects that.

With regard to diet, the Government point out that questions arise on the desirable balance of nutrients and show that most food is chosen having regard to taste, texture and price, not to its nutritional value.

The White Paper states: In connection with diet the role of Government is directed primarily towards assembling, assessing and disseminating information based on scientific evidence in the light of which individuals can form their own views and take their own decisions. That is in paragraph 135 of the White Paper. I find that one of the most interesting and encouraging paragraphs in that Command Paper.

The White Paper also points out: Issues in this field are complex. Individuals' metabolism and material circumstances vary and the present state of medical and scientific knowledge about the relationship between diet and health is incomplete. … It is sometimes more appropriate to bring facts to the attention of those professionally concerned with diet and health to enable them to give suitable advice to individual members of the public. That, again, is contained in paragraph 135 of Cmnd Paper 7047.

I should like to emphasise the importance of the statement in that paragraph in as much as it relates to the relationship between diet and health being incomplete. I entirely agree that it is far from easy for the Government to produce clear, straightforward advice applicable to the public in general. For this reason, I personally tend to become rather concerned when an agency of Government attempts to give such advice, as, for example, the Health Education Council is now doing.

I think that the efforts of Government should be directed much more to those who are professionally concerned—to general practitioners, for example, as the hon. Member for East Kilbride (Dr. Miller) said earlier. They are in a much better position to give advice which is tailored to the metabolism of individuals. That advice is better given to them than in a shotgun fashion to the public generally.

As a result of the report of the Expenditure Committee the Government have indicated that during the course of this year there will be a preventive follow-up paper on diet and health which will explain in detail ways in which diet can assist in promoting health and avoiding disease. I understand that this paper will consider results of recent research in relation to different components of the diet and will discuss controversial subjects such as the amount of fat in the diet. I assume that the publication of this paper on diet and health in the preventive series will place before the public information which is based on up-to-date medical and scientific knowledge. I think that that will be the right approach to take.

However, I hope that the Government will bear in mind that recommendations made in the light of medical and scientific knowledge need to be reviewed as new knowledge becomes available which sometimes contradicts the results of earlier research.

Before we have any recommendations by the Government they are urged by the Expenditure Committee in paragraph 139 of its report to do so only where a consensus exists. What is a consensus? What will be the criteria used? I wonder whether the Minister will be able to tell us that when he winds up the debate. I should like the Minister to assure the House that the Government will not regard as a consensus a small but persistent group of articulate critics of any particular drink or food whose views are unsupported by acceptable clinical or epidemiological evidence. It would be far better if the criteria for a consensus view included such bodies as the Medical Research Council, the Royal Colleges and, not least, the Expenditure Committee of the House of Commons and other appropriate bodies.

There is another danger which I hope the Government will avoid when publishing any paper on diet and health as a result of the report of the Expenditure Committee. That is the danger of seeking to recommend specific dietary goals for the British people on the lines adopted by the Select Committee on nutrition and human needs of the United States Senate. I am glad that these were not recommended by the Expenditure Committee.

Those who have studied the dietary goals recommended by the American committee and the furious reaction of the American medical profession will, I trust, avoid making the same mistake. I say this because the goals originally produced in the United States in 1977 met with so much controversy that revision had to be commenced almost immediately. In fact, United States senators, in their new foreword to the revised edition, went so far as to state this: The American public would be in a better position to exercise freedom of dietary choice if it was stated in bold print … that the value of dietary change remains controversial and that science cannot at this time ensure that an altered diet will provide improved protection from certain killer diseases such as heart disease and cancer. I was interested in a report that I saw in the Daily Mirror newspaper recently of a letter to The Lancet by a distinguished scientist, Sir John McMichael, who believes that trying to change our food habits may be harmful in itself. He said in his letter: It is better to trust to luck in respect of diet than to foster neurosis by the pretence that we can save lives by interfering with life habits. In a recent article in Food Technology, Dr. Robert E. Olson, chairman of the department of biochemistry at St. Louis University medical school, made the most important observation on the whole business of dietary goals. As a physician he was concerned about the likelihood of inadequate nutrition in many segments of the population if the goals were adopted as national policy. The American experience illustrates clearly the dangers of trying to lay down strict goals as to what the public should or should not eat.

We should remember that it is thanks to antibiotics and other magnificent drugs developed by our pharmaceutical industry that there are today only to remaining killer diseases, namely cancer and coronary heart disease, from which people normally die in middle age and thereafter. The fact that in 1978 people are living longer is one of the most important points that we have to take into account this evening. Compare that with the position in, for instance, the year 1920 when concern was being expressed about the problems of adequate nutrition—not over-nutrition as is the case today—and about the effect of killer diseases such as tuberculosis, pneumonia and diabetes.

Having agreed that a paper on diet and health, providing information to the public in the light of which individuals can form their own views and take their own decisions, is a legitimate action of the Government, I am becoming increasingly disturbed about the action now being taken by the Health Education Council in its "Look After Yourself" campaign, the high point of which I believe is coming this month when there will be an all-out attack on British eating habits and an attempt to change them. I understand that television commercials are to be the spearhead of this campaign to persuade the British people to eat less white bread, sugar, fat and butter. Part of the campaign, rightly, is to encourage people to take more exercise.

The HEC is coming close to the line between giving information and trying to persuade the British public to take a certain view in relation to their diet, namely to give up white bread, flour, sugar or fat. Bearing in mind that well over £1 million has been spent on the campaign, I hope that the HEC will take great care not to overstep the line.

I draw to the Minister's attention another aspect of the campaign, namely, the nature of the advertisements appear- ing in the national daily newspapers. I have one here which shows a large pair of plimsolls. The caption is: You'd enjoy sex more if you had a pair of plimsolls. That is a very arresting advertisement, but is it suitable to be read by young children or many women who would find such an advertisement embarrassing? I do not think that advertisement is in very good taste. I hope that the HEC will concentrate on providing information which is based on hard evidence and not merely on opinion. There is no conclusive proof that eating butter and other saturated fats contributes to heart disease, although the evidence so far can be interpreted as pointing in that direction.

Dr. M. S. Miller

I hope that the hon. Gentleman will agree that we need not wait until there is conclusive proof before warning people that there are indications of problems. If we were to wait, it would be too late and sometimes it is not possible to get conclusive proof.

Mr. Shersby

I take that point, but when there is not conclusive proof, it is important that the nature of the campaign run by the HEC, with the backing of the Government, should reflect that and that we should not seek to give the impression that all these matters are cut and dried when, as the hon. Gentleman knows, they are not.

One area of the report is of considerable interest because it refers to the controversy that has been before us for more than a decade—the fat or sugar controversy. This is concerned mainly with coronary heart disease. About 12 years ago, Professor John Yudkin, who was then professor of nutrition at Queen Elizabeth College, University of London, said that, in his opinion, sugar was the main cause of heart disease.

I should like to contribute some of my knowledge of this subject. I hope that the House will forgive me if I take a little longer than I might otherwise have done because this is a subject of which I have special knowledge. As a result of Professor Yudkin's comments, a number of independent medical institutions of impeccable repute have undertaken a series of research projects, designed mainly to establish whether there is anything in the allegation that sugar is involved in the causation of coronary heart disease. The hon. Member for East Kilbride referred to this in his admirable speech, which was a model of moderation and good sense.

The sugar or fat controversy was one of intense interest to the Committee and was considered carefully in its evidence and report. The outcome is that while Professor Yudkin's views, which have been expressed over many years, were considered, they were not accepted by the Committee. Indeed, they have not been accepted by many leading members of the medical profession, but they have been responsible for the sort of investigation that has taken place not only in the United Kingdom but overseas.

In order to assess the risk factors cited as increasing risk of heart disease, a joint party of the Royal College of Physicians of London and the British Cardiac Society examined the evidence and reported its findings as recently as April 1976. Commenting on the assertion that a high consumption of sugar was an important factor in the causation of coronary heart disease, the report stated: At present there is no firm evidence linking intake of dietary sugar and Coronary Heart Disease and most workers do not regard a high intake of sugar by itself as an important factor in the aetiology of Coronary Heart Disease. This view refutes the suggested causative association between sugar intake and coronary heart disease mortality noted in many countries.

In its report to the Medical Research Council, the working party said: Evidence in favour of high sugar intake as a major factor in the development of myocardial infarction is extremely slender". It is not only in Britain that sugar has been under examination for more than a decade. In 1976, the US Food and Drug Administration issued an "Evaluation of the Health Aspects of Sucrose as a Food Ingredient", which was prepared for the Bureau of Foods by the Life Sciences Research Office, which stated: It would appear that the primary dietary factors involved in cardio-vascular diseases are the nature and amount of fat in the diet. In view of the virtually universal clearance of sucrose as a dietary factor in the causation of coronary heart disease, it is hardly surprising that the Committee was more inclined to listen to the alternative view, first put to it by Professor Morris of the London School of Tropical Hygiene and Medicine, that the main cause of coronary heart disease is saturated fats, mainly animal fats. There seemed to the Committee sufficient evidence to suggest that saturated fat consumption should be reduced.

It is for this reason that in paragraph 247, the Committee recommended … that information about fats should be placed before the public in order to show up clearly the risks from the high intake of saturated fats and to encourage people to moderate their fat intake or switch to polyunsaturated fats. That recommendation has now been considered by the Government and in their response they make it clear that they accept it but with reservations.

That is right, because there is much further work to be done on the role of fats in relation to coronary heart disease. Presumably, however, the House will expect to see some comment on the role of fats in the diet appear in the follow-up paper on diet and health which is to be published this year. My case today is that any evidence of this kind should be brought to the attention of those professionally concerned with diet and health so that they can give suitable advice to the public who are their patients.

I hope that the Government will ensure that the Health Education Council does not go off on a public campaign against saturated fats, because the evidence is still far from complete. What is needed is not preaching but advice to general practitioners, hospital dieticians and others after the evidence of the case of each individual has been carefully weighed.

I was going to speak about dental health, but I wish to give my hon. Friend the Member for Burton (Mr. Lawrence) time to speak. I would only say that I hope the Minister will look carefully at the articles now being published in the dental magazine The Probe by Professor Douglas Jackson of the University of Leeds. He takes a different view from the orthodox acid attack theory which has been accepted by the medical establishment for many years as the main reason for the incidence of dental caries. Professor Jackson is concerned very much by the genetic factors in the causation of dental disease and his articles repay careful study. I hope that that will be borne in mind in any consideration of a paper on diet and health.

I am grateful for the opportunity to speak in this debate. I am only sorry that more time is not available.

8.53 p.m.

Mr. Ivan Lawrence (Burton)

I congratulate the hon. Member for Wolverhampton, North-East (Mrs. Short) on the excellent way in which she chaired the Sub-Committee, of which I had the honour to be a member. I wish that more of the public could see that much of Parliament's work is done in Committees of this kind, where the parties, although diametrically opposed in their political beliefs—it is hardly possible that two hon. Members should be more opposed than the hon. Lady and myself—manage to work together for the good of everyone. Although the work is not always exciting, it is constructive and, particularly in this case, very useful.

I congratulate the hon. Lady on a tour d' horizon of our report in a very short time. Since I have only five minutes, my speech must be even shorter and I must give up the idea of a tour d' horizon.

The achievement of the Sub-Committee was to focus attention on the need for more preventive measures. As my hon. Friend the Member for Walsall, North (Mr. Hodgson) said, we tend to think of the National Health Service as a curative institution, pure and simple, when it should stop people getting ill at all. Prevention is not only better than cure but it is also cheaper, which is why a Sub-Committee of the Expenditure Committee was considering preventive medicine.

I suspect that the Committee's failure will be that the Government, although our report will have interest for them and they are broadly in sympathy with our conclusions, will respond only to those recommendations that they were thinking of dealing with anyway. They will of course examine the others, but unfortunately there are entrenched positions, which those in power and with influence always seem to have in whatever activity, and they will not be altered by one millimetre as a result of anything we have said. If I am wrong, the Minister of State will happily tell me.

The hon. Member for Bishop Auckland (Mr. Boyden) was a little too compli- mentary to the Government. He said that whenever they rejected one of our proposals the Government were being constructive, and as an example of constructive rejection he gave the rejection of Recommendation 40, on fluoride. We recommended further research, and the Government said that it was not necessary. That is supposed to be taken as proof that they are being constructive. The hon. Gentleman ended by saying that it smacked of firm government. It may have done that, but it is hardly proof that they are taking our work seriously.

If the Government are to make a beneficial response to our deliberations, they must do two things above all else. First, they will have to transfer a massive amount of their present resources from cure to prevention. That is the gravamen of most of our recommendations. Secondly, they will have to do whatever can be done in the media and elsewhere to get the public to help themselves to be healthier. Publicity is everything. It is too much to expect the Government to show flair at the same time as they are showing a clean pair of heels. But we need at any rate something to stir the imagination. That is necessary because the greatest advances in this field will have to be made by ordinary members of the public themselves and not by Governments.

I should like to say something about fluoridation, because the regional health authority in the West Midlands is about to try to fluoridate the water supply of Burton and Staffordshire. It is staggering and alarming to see the degree of complacency of the Government's reaction to the Committee's recommendation and conclusions on fluoridation. Two questions arise from the issue whether the State should medicate the general water supply by fluoridation. First, there is the libertarian question: why should everyone in the country be forced to drink medicated water, whether it is good or bad for him or her, just because the Government—or, worse, bureaucrats—think that it would do them good? The Committee as such was not directly concerned with that issue. But we said: As Members of Parliament we are—naturally concerned that any interference with the liberty of the subject should only be entertained where substantial common good would result. The second issue is the scientific one: would fluoridating the general water supplies do good—that is, would the good that it might do far outweigh any harm that it might do? On that issue the Committee was directly concerned, and concluded: We are unable to make any recommendation on the use of fluoride in the genera] water supply. We recommended: That there should be more research on the long-term effects of fluoride. The Government's response, rejecting that Recommendation 40, says two things. The first is that the evidence is that there is a substantial improvement in children's teeth where the water is fluoridated—and about that there is dispute among scientists only over the degree of the improvement. It is not argued that no good comes from fluoridation at all.

Secondly, the Government say that: Extensive studies here and abroad have shown no harmful effect associated with the recommended proportion of fluoride of one part per million parts of water. That is not only patent rubbish but is patently dishonest. In that response is enshrined a disgraceful refusal to look at, let alone try to deal with, a growing amount of evidence of possible harm. In that response is enshrined a quite deliberate refusal to examine whether the conclusions arrived at on certain data are scientifically justifiable. In that response is enshrined a quite deliberate refusal to acknowledge important areas where there is no evidence one way or the other and where there ought to be evidence before the Government act. In that response is enshrined a determination not to listen to the increasing body of scientists who are declaring doubts about the scientific justification for fluoridating the water supply.

The sheer irresponsibility in the dental and medical profession about this problem is frankly frightening. I should have thought that any Government Department responsible for allowing the use of thalidomide, Eraldin, hormone pregnancy testings, to say nothing of Phenacetin—which required 75 years of use before it was discovered to be harmful—and tetracyclines—which took 10 years for the harmful effects to be discovered—would have had a stronger sense of responsibility before letting fluoridation loose on an unsuspecting public.

The public trust the Department of Health and the medical profession. They may think, reading the Government's response, that there is no opposition to fluoridation. Yet there is, if anything, a worldwide trend away from fluoridation. I draw the Minister's attention to paragraph 216 of the report which sets out the countries that are changing their minds on fluoridation. The public might imagine that the benefits from fluoridation are simply enormous, that as long as fluoride is taken it stops or greatly reduces tooth decay. Yet the Government's own publication "Fluoridation studies in the United Kingdom and the results achieved after 11 years", makes it clear that fluoride does not prevent tooth decay in children let alone adults but merely delays its onset by 18 months. Its effectiveness is essentially limited to children.

The public might think that there is sound scientific evidence that fluoride works where it is present in 1 part per million parts of water in areas of the country where the incidence of dental caries is lower. Scientist after scientist has dealt with this. Professor Scorer, the professor of theoretical mechanics in the department of mathematics at Imperial College London and a Fellow of the Royal Society of Health, says: I find that most of them"— that is medical and scientific colleagues— are in favour of fluoridation, and assume that the surveys have been subject to the same scientific discipline as they are accustomed to in their own work. Unfortunately this is not so, and they are surprised to hear it, having accepted the idea of fluoridation without actually looking at the papers.…Actually almost all of it"— that is the evidence— has been collected without applying scientific tests that would be normal in their fields, and so it has been accepted uncritically as long as it appears to confirm hopes. The public might think that there was no evidence or responsible opinion to the effect that harmful effects result. Yet the list of evidence concerning harmful effects is now quite long. Not only in the United States but all over the world there is evidence. There is evidence that the use of fluoridated water is discouraged for artificial kidney patients. There is evidence of awareness of the dangers of dental fluorosis and skeletal fluorosis arising from large intakes of fluoride.

Professor Carlsson, the head of the pharmacology department at Gothenburg University and an adviser to the Swedish Government, says that there has been far too little research into the action of fluoride on tissues in the body and that there are too many doubts. He was instrumental in getting the Swedes to stop fluoridating their water supply. At page 216 of Volume II of our report there is documented evidence concerning 10 of the largest unfluoridated cities in America compared with 10 large fluoridated cities in America. Two distinguished men, Dr. Dean Burk formerly with the United States National Cancer Institute for many years and Dr. Yiamouyiannis, the scientific director of the National Health Federation, have concluded that one-tenth of the 350,000 cancer deaths per annum in the United States is linked with the artificial fluoridation of public water supplies.

It cannot be said that there is no evidence. What can be said is that in a debate of this length, or in the sort of time that hon. Members take to sit down and look at the evidence that exists, it is difficult to review it all.

The truth is unhappily that the people's trust in the honesty of the reply that "Extensive studies here and abroad have shown no harmful effect associated with fluoride" is completely misplaced. There have not been extensive studies in Britain. We do not know, because no one has studied the question, how much fluoride one can safely ingest. We do not know, because no one has studied it, how much fluoride accumulates in the human body—and it is cumulative. We do not know how much of it accumulates in what we eat and one of the witnesses said that we come at the end of a poisonous chain. We do not know, because no one has studied it, what effect fluoride has on someone after 40, 50 or 60 years of drinking fluoridated water. We do not know why people have arthritis or some of the degenerative illnesses, so how can one say that it is not a result of fluoridated water?

I can use one example, that of cystic fibrosis. Until recently no one knew why children, who were in fact suffering from this disease, were dying in the early months of life. Only recently was this disease discovered.

Medical science does not know the answers to all sorts of questions, and it is no use telling the British people "We have made extensive studies" when we have done no such thing. I was the Member on the Select Committee referred to by the hon. and learned Member for Wolverhampton, North-East who started off pro-fluoride and ended up against. I ended up against because I asked myself at the end "Where is the proof that fluoridation over a long period is not harmful?" Everywhere I saw people assuming that there was proof. The dentists relied upon the accepted wisdom; the Royal College of Physicians merely reconsidered the established evidence. Everyone ignored the evidence in America and all over the world where scientists were saying that fluoridation is too dangerous.

I am not saying that all the evidence against fluoride is acceptable. What I do say is that it may be, and if it is a matter of "may be", is it not dangerous to take risks with people's lives, and to let undemocratic organisations force those risks upon us?

The people's will on the question of fluoride has been tested from time to time in public opinion polls, and the public seem to be about 80 per cent. against the forced medication of our water. But it has never been tested in this place, and until the will of Parliament decides the matter after a full and thorough analysis of the situation it would be quite wrong for this House, let alone the Government, ever to suggest, after our report, that the case for fluoridation's harmlessness has been made out. The position is quite the contrary. The case is not proven, and we should no go ahead with the fluoridation of our water supply.

9.9 p.m.

Mr. Paul Hawkins (Norfolk, South-West)

I entirely agree with all that has been said about preventive medicine, but I want to make one particular point.

Surely our health services must be in a fit state to treat those people who can be cured before we burden them with another branch, for the National Health Service is in a critical state. The surgeons, the doctors, and the nurses, with even a louder voice, have said so recently. I have taken up on behalf of doctors in my constituency their worries about the health services in my area, and I have corresponded with the Minister over a long period, and yet, I fear, he is still complacent.

I want to make one point that has come home to me from my own family experience recently. I have 300 or 400 people in my constituency awaiting hip operations. Some of them have been waiting for two or three years, in great agony, yet knowing that if they could have the operation they could be cured of their pain. My wife waited for 12 to 18 months. She has now had the operation. She is walking as she has not walked for 18 months, and is free of pain. I have seen this with my own eyes. I have also seen it with other people. This operation has a rate of success of over 90 per cent.

We ought to be able to put more money into this side of medicine, and into helping those who can be cured, so that we can give people freedom from pain.

9.10 p.m.

Dr. Gerard Vaughan (Reading, South)

Anticipating that he may catch your eye in a few minutes, Mr. Deputy Speaker, may I, too, congratulate the Minister of State on his elevation to the Privy Council?

We have had a long, very lively and very informative debate. We welcome these reports very much. I believe that the debate has shown the wide interest held among hon. Members in the House and has fully justified the excellence of the report which the hon. Member for Bishop Auckland (Mr. Boyden) and the hon. Member for Wolverhampton, North-East (Mrs. Short)—it is very nice to be able to congratulate the hon. Lady on something—have brought before us.

It makes great sense, of course, to prevent disease rather than always to be trying to cure it. My party is unequivocally behind the concept of preventive medicine and the need to extend its services. In 1901, a male child could expect to live to 48. Today, the same child could expect to live to 69. That is one of the measures of success of preventive medicine in recent years.

We have covered a wide range of subjects in the debate, and it would be impossible for me to deal with all of them in the short time available. I think that the Government have a great deal to answer for in the debate. Therefore I propose to keep may remarks rather short. We have had a passionate speech from the hon. Member for Essex, South-East (Sir B. Braine) on alcoholism. We have had an equally passionate speech from the hon. Member for Eccles (Mr. Carter-Jones) on the care of small children. I think that we all appreciated the remarks that he made.

Two themes have come out in particular from among the wide range of subjects dealt with in the debate. One was the concern about smoking and the tobacco industry. The other was the concern about fluoridation and preventive dentistry. I shall come back to these in a moment, if I may.

Although congratulating the Committee on its report, I would not go quite so far in congratulating the Government on their White Paper. One of my hon. Friends made a very pertinent remark about the Government's report being flabby and complacent. It is flabby, it is complacent, and it is very disappointing. In parts it reads rather like a script for a barn dance—one step forward, one step backward. I think that we were entitled to expect a good deal more from the Government. We were entitled to expect a better grasp of the opportunity which lies ahead of us today in this field, and a more constructive, vital, robust and enthusiastic contribution as to what should be done.

We believe that a great deal can be done. We think that there is a real opportunity today for an effective role to be played in the field of preventive medicine. Indeed, we have taken this so seriously that we have set up a special committee, under the chairmanship of my hon. Friend the Member for Ealing and Acton (Sir G. Young) to look into this subject alone.

From the great range of subjects I should like to pick out three aspects on which to comment. The first of these is the aspect of perinatal damage and the whole field of birth, pregnancy and the care of new-born children. This is not the first occasion on which the hon. Member for Eccles and I have agreed on this subject.

My party supports wholeheartedly the current campaign to reduce not only mortality among infants but the number of damaged children which occur today. We shall do everything we can to pursue this campaign with vigour, flair and enlightenment. Not only is there the tragedy of a child who dies, the tragedy of a child who is deformed—which is a tragedy for the child himself—but there is the terrible tragedy for the whole family which has to bring up a highly damaged child for the whole of that child's life. For a great many children this can be prevented. We certainly want to see more done in this regard.

Mr. Carter-Jones

The hon. Gentleman mentioned the damaged child, the hardship suffered by the child and the debt which we owe to the family. The difficulty is that very often damaged children outlive their parents and then become society's burden. Does he agree that an extremely good way of saving money is to improve perinatal care?

Dr. Vaughan

I agree entirely. The sad thing is that when the parents die society often cannot fill the gap. For the unfortunate person it is like walking off the end of a gang plank. There is nothing there to help him. That is one aspect which we wholeheartedly support and want to see advanced.

The second aspect relates to preventive dentistry. I agree wholeheartedly with the hon. Member for Bishop Auckland that the campaign for extending the number of dental hygienists and dental auxiliaries should be increased. We want to have more of these people. It is a tragedy that paragraph 125 of the report states that there will be two new schools. I would ask the Minister "When?". What is he doing about this? My belief is that he is doing nothing and that this is another one of those pious, wishful-thinking remarks that so often appear in this report.

With regard to fluoride, my personal view is that fluoride is probably a good answer and should be carried out. I should like to see more in this report about the other methods, other than through the water supply, for distributing fluoride. For example, what is the Government's view about putting fluoride into milk, which could be directed at the age group—the children—who actually need fluoride? What is their view about putting fluoride into salt? Perhaps that would be an alternative. The Government should have discussed this with us.

Most of all, it is totally irresponsible of the Government to have left a situation where there is conflict and uncertainty between area health authorities, the health services, the water authorities and the local authorities as to what is expected of them. At the same time as encouraging those authorities to fluoridate the water there is the question for some of them about whether it is legal to do so. That, I suggest, is an area in which the Government should give direction and guidance, because this is something to which those authorities must have a clear answer.

I turn finally to health education generally, to the Health Education Council and the extra £1 million. I think this is a good idea, but how worth while will it be? When one reads the second volume of the report from the Committee, one cannot help but be struck by the uncertainty in this area and by the number of people who gave evidence. In the present state of affairs there are not enough trained people to give proper health education. The Committee was not sure on which subjects they should be educating us. It was unclear whether this money was likely to produce a reasonable return. It would be a mistake, certainly for my party, to pour large sums of money into an area unless we are quite sure that it will produce a reasonable return. At a time of scarce resources we do not want to run the risk of taking money away from some other aspect of the Health Service in order to perhaps squander it in an area which is attractive but unrewarding. This is an area that we should want to look at.

Mrs. Renée Short

Is the hon. Gentleman saying that he does not accept the recommendation that teachers should be trained to give health education to young people?

Dr. Vaughan

I accept that. However, I could not help noticing the number of witnesses giving evidence who said that they were unsure about the value of some of the suggestions put to them and about some of the research on which decisions about health education might be based.

Reading reports from other countries, we see that right across the world where health education is being developed people are asking who is to decide what the subject should be, what the standard of some attitude in health care should be, how it is to be arranged, and how can it be certain that they are the right standards. I do not want to make too much of this, but it is a matter of which we should be aware and to which we should give consideration. Health education can be very worth while, and I know from my own experience that, for instance, children coming into hospital are very poorly informed about how to clean their teeth, how to wash themselves, how to dress themselves and how to avoid some of the more common hazards. These are all skills which should be taught in their schools.

I cannot see the logic, in the section on smoking, for saying that educating the young about the hazards of smoking is a high priority when, in the section concerned with education in schools, the Government say that they would not want to pick out smoking or alcoholism for special campaigns. I cannot see the logic of that.

I cannot see why proper medical screening cannot be instituted for all children during their school careers. What is more, I cannot see why it should not be routine, when a woman goes to a specialist gynaecologist for advice on women's diseases, for her to be screened at the same time for breast cancer. I hope that the Government will take a more common sense and practical approach to these questions.

The hon. Member for Northampton, North (Ms. Colquhoun) and the hon. Member for Wolverhampton, North-East both talked about the top-heavy, confusing committee-ridden administration in the National Health Service.

Mrs. Renée Short

Who did it?

Dr. Vaughan

This has been brought up before. It was four and a half years ago that the reorganisation took place. What have the present Government done about it?

The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)

This is taking matters rather too far. We have set up a Royal Commission to advise us. If only Opposition Members had done the same themselves before all the committees got going, we might not be in the mess that we are in now.

Dr. Vaughan

The Minister must address himself to his own White Paper a little more than that. In it he will find the Government saying that they do not intend to make any changes in the administration until the Royal Commission has reported. That is not our view, and it is not the view of the nurses, who made their view known to the Secretary of State the other day when, after that extraordinary speech, he had to apologise to them.

There is a widespread view among those concerned with health matters that something has to be done to free the people working in the National Health Service from the mass of committees which prevent their making day-to-day decisions. That cannot wait until a Royal Commission reports, and the Opposition have clear proposals for dealing with it.

I do not see how the Minister can brush on one side the report from Brunel University, for example. A great deal is wrong. But the Government say that they intend to do nothing. That is an absolute travesty of what government should be about, and I call upon them to take back that section, to admit that something has to be done, and for the first time, to show a littlte true leadership and positive action to put the National Health Service back on its feet.

9.24 p.m.

The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)

Perhaps at the outset I may be permitted on a personal note to thank all those right hon. and hon. Members who congratulated me on my recent appointment to the Privy Council.

I am delighted that the House has found time to debate the subject of prevention and health because it is an opportunity which occurs only too rarely in our proceedings and one which the Government welcome.

Apart from the contribution of the hon. Member for Reading, South (Dr. Vaughan), this has been a debate in which there has been a tremendous amount of unanimity on both sides of the House. If there is one subject upon which the Opposition should maintain a vow of silence it is the future organisation of the National Health Service. If there is one subject on which the Opposition totally lack credibility as a result of what they have done in the past, it is that. I pass this advice on to the hon. Member for Reading, South as a guide to his future conduct on such matters.

I do not want to deal with party politics unduly because the whole debate has been devoted to a large measure of unanimity across the Floor of the House, even though there have been criticisms expressed from time to time, either of the Government or of the different lines taken by hon. Members.

I am grateful to my hon. Friend the Member for Bishop Auckland (Mr. Boyden), speaking in his capacity as Chairman of the Expenditure Committee, for the constructive way he opened the debate. I thank him for saying that the White Paper was one of the best replies from the Ministry for a long time. I also listened with close attention to the speech of my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short), who so ably chaired the Employment and Social Services Sub-Committee in the course of its inquiry into preventive medicine.

There is a central and unifying theme which can fairly be said to have underlain much of what has been said by hon. Members on all sides of the House today. It is a theme which was admirably expressed by my hon. Friend the Member for Wolverhampton, North-East and her colleagues in their report of April last year. They said: We have tried to concentrate on areas where we felt that a small diversion of resources might have an impact in the foreseeable future. If the NHS is to continue to spend several thousand million pounds each year, it is vital that this money should be spent to promote the highest possible standard of general health. Nevertheless, prevention as a policy will always suffer from a handicap in competition for funds with other health policies—that is, that it seeks to prevent people from falling ill or suffering handicap or injury. In consequence it is rarely possible, for example, to point to a particular person and say that he or she is alive as a result of prevention policies successfully applied when if they had not been so applied he or she would be dead.

It will also always be dogged by a problem. To a large extent prevention seeks to alter life styles as a way of removing the possibility of falling ill, for example. Given that a not inconsiderable minority of our people demand the right to go to hell in their own way—to assert a God-given right to take a nose dive through their windscreens if they so wish—then it will be readily seen that practitioners of prevention will often be treading that narrow, obscure frontier between licence and liberty.

This matter was also raised in connection with fluoridation by my hon. Friend the Member for Northampton, North (Ms. Colquhoun) and the hon. Member for Burton (Mr. Lawrence), who claimed that fluoridation was a matter for Parliament and that it should be debated here. I do not intend to discuss fluoride tonight because it is worthy of a larger debate on a more important occasion. My hon. Friend the Member for East Kilbride (Dr. Miller) dealt with many of the points that have been raised and I do not wish to duplicate them.

I mention these snares not to daunt the devotees of prevention, but merely to make us fully aware of what we face as we set off down a road that broadly has many attractions. Because this road has these attractions, because of the message in the Expenditure Committee's report—a message which commended itself in every way to the Government—and because of what we said last year in our White Paper on prevention and health, we took the matter up and responded to it in a way which made clear our view of the central role of prevention and health. I must tell the hon. Member for Reading, South that it is not a matter of one step forward and of one step back, but of 50 steps forward and eight steps back. That is a slightly different analysis from that which he advanced.

The White Paper, as well as looking individually at the recommendations in the Expenditure Committee's report, went a little wider and took in such topics as mental health and, briefly, the occupational health problem, to which my hon. Friend the Member for Aberdeen, North (Mr. Hughes) referred.

In the White Paper we were able to accept, although with reservations, or to set aside for further consideration, the great majority of the recommendations in the Expenditure Committee's report. In fact, we rejected only eight outright, although it may turn out to be the case that in the event we shall need to reject one more.

I now turn to the subject of health education—a subject raised by a number of hon. Members, including my hon. Friends the Members for Bishop Auckland, Wolverhampton, North-East and Hemel Hempstead (Mr. Corbett), and the hon. Members for Burton and Carmarthen (Mr. Evans). They all mentioned the importance of education and publicity. I fully accept the need for growth in the work of the Health Education Council. We have taken action to make such growth possible. For the years 1977–78 and 1978–79 the Council has been allocated an extra £1 million and £1,281,000 respectively over and above its normal budget. I hope that it will be possible to maintain the current level of provision.

The Council's total budget for 1978–79 is £3,020,000. The comparable figure at current prices for 1975–76, the year in which the Expenditure Committee first started its inquiry was £2,300,000. This represents an increase in real terms of 28 per cent., and that is no mean achievement in a period of severe financial restraint.

As has been mentioned in the debate, the Council is devoting the bulk of the additional money we have provided to a national "Better Health" campaign, entitled "Look After Yourself". The main object of the campaign is to encourage members of the public to adopt healthier living habits. The first phase of the campaign was launched in mid-January. It is concerned with diet, exercise and smoking and health and is hinged on commercials and Press advertisements. That campaign has got off to an excellent start. A total of 670,000 members of the public wrote in for packs of pamphlets and other literature and health and local authorities and voluntary bodies have ordered a further 5 million items for distribution locally. Several large commercial undertakings are featuring the campaign. That campaign will remain a central feature in the Council's operational activities in the next year or so.

Dr. Vaughan

Why have the Government not put special emphasis in education in schools on the dangers of smoking and alcohol? That is surely a most important matter on which to instruct children.

Mr. Moyle

I shall come to that point later. I wish to deal with the Health Education Council's campaign. The second phase of that campaign, which has just begun, represents a slight shift of emphasis from exercise to diet, using the same basic pack materials and involving further advertising on television and the other media.

In addition, we have increased the resources to the National Health Service in the current financial year by £50 million. Health authorities have been told that health education is one of the areas to which health authorities must give priority in planning the expenditure of this additional money.

It should be borne in mind that the resources going into health education are in excess of the budget given to the Health Education Council as all health authorities have a special responsibility for promoting health education at local level. Joint financing arrangements are sufficiently flexible to allow local authorities and health authorities to propose health education measures for joint financing.

In addition, we are beginning to reap the benefit of the initiative that the Government have taken in regard to the growth of the health education service. At the beginning of 1977 it was agreed that health education staff should be exempted from staff recruitment restrictions resulting from the need to save on management costs. We began a management cost exercise in April 1976 that was aimed at reducing the management costs of the Health Service to 5 per cent. over two or three years. Health education staff were exempt from those restrictions and reductions.

In England and Wales the number of health education officers in post, including area health education officers, rose from 200 to 260 between 1976 and 1977. Since then we have taken on a further 44 officers and trainees. In the present economic climate that represents reasonably good progress. It means that in just over two years there has been an increase of 50 per cent. in an important sphere.

We are following up the publication of "Prevention and Health: Everybody's Business" with a number of papers to expand on the policies that were laid down in that document. In that consultative document, which was prepared jointly by the Health Departments, and in the White Paper of last December we promised that we would follow up with a series of booklets on particular aspects of prevention. The first two papers have been published—"Reducing the Risk—Safer Pregnancy and Childbirth"—in which my hon. Friend the Member for Eccles (Mr. Carter-Jones) will be taking a special interest and "Occupational Health Services—The Way Ahead", which we published last December and in which my hon. Friend the Member for Aberdeen, North will be interested.

The second booklet was published by the Health and Safety Executive. As part of the long-term strategy we shall be publishing later this year a paper entitled "Diet and Health", and this we hope will in due course be followed by one on the avoidance of heart disease and one on alcoholism. The other subjects which we have in mind for the future include mental health, environmental pollution, in collaboration with the Department of the Environment, vaccination and immunisation and health education itself.

Mr. Patrick Jenkin

In all the publications, some of which we have seen and some which we shall see, will the Government take note of the points made over and over again in the evidence to the Select Committee, and reinforced by my hon. Friends the Members for Reading, South (Dr. Vaughan) and Uxbridge (Mr. Shersby) in the course of debate, that there is still a great deal of uncertainty about these areas of policy and that it is not possible to give clear, categorical advice that one thing is right and another wrong? Will the right hon. Gentleman ensure that his documents carry the doubts forward so that the public may make up their own minds?

Mr. Moyle

The whole status of "Prevention and Health: Everybody's Business" was that it began as a consultative document. The main object of the papers that are being put forward following that document are to promote discussion along lines that can be recommended with reason. The last thing that we would do—this was a point made by the hon. Member for Uxbridge (Mr. Shersby) in drawing attention to the appropriate paragraph in the White Paper—would be to attempt to lay down hard and fast rules from the centre that people must follow. That was the purpose of drawing attention to the fact that in the whole area of health and preventive medicine we are treading a difficult path between liberty on the one hand and proper advice and guidance on the other. I hope that that will explain to the right hon. Gentleman the line that we intend to take.

Mr. Shersby

Will the right hon. Gentleman be kind enough to tell the House whether before the papers are published there will be any consultation in respect of "Diet and Health" with the British Nutrition Foundation, which as the Minister knows represents a wide spectrum of scientific opinion as well as the food and drink industries?

Mr. Moyle

I cannot tell the hon. Gentleman whether the British Nutrition Foundation is one of the bodies which will be consulted. The Department consults a wide range of people representing all kinds of expertise in a particular sphere before a document in this series is published. However, I shall check on the specific point that he has made.

I turn now to a matter of considerable importance which my hon. Friend the Member for Eccles has made his own, but which I hope he will be able to make a subject in which the House will be interested. I refer to perinatal mortality. The hon. Member for Reading, South drew attention to the fact that perinatal mortality was also associated with perinatal handicap. Perinatal handicap involves not only a tremendous amount of human misery, but a tremendous amount of cost. The National Health Service has to provide special facilities for each handicapped child for life in an attempt to offset the consequences of infant handicap.

Perhaps we should do better in terms of eliminating both mortality and handicap. My hon. Friend the Member for Eccles put forward one idea which I intend to follow vigorously. He proposed that area health authorities with infant perinatal mortality statistics below those of the national average should be approached and asked what specific policies and decisions they intend to take in subsequent years with a view to reducing those perinatal mortality figures.

Mr. Carter-Jones

Area health authorities with above the national average.

Mr. Moyle

Above. It all depends how one looks at it: worse than or better than; above or below. I shall ensure that when we get the next statistics for 1977, which should be in the not-too-distant future, those area health authorities whose statistics are worse than the national average will be approached and asked to explain what they intend to do in the coming year to try to combat the problem.

The problem, as my hon. Friend recognised, is as much a social as a medical one. Although something can be done by area health authorities to improve the perinatal mortality statistics and infant handicap by a process of adopting the right medical and health policies, the approach must be on a broad front. The analysis shows that babies are subjected to these unfortunate risks as a result of an overall total social picture. For example, in Newcastle only 13 per cent. of children were living in three inner city wards. Yet they provided 45 per cent. of infant mortality in Newcastle.

'We find more and more that perinatal mortality occurs in a family where the father is probably an unskilled manual worker, probably an immigrant, and living in the core of our large cities. My right hon. Friend the Secretary of State drew attention to this aspect in his Eleanor Rathbone lecture in Bristol some little time ago. There must be a broad approach to this problem.

One factor which emerges is that, in dealing with perinatal mortality, there has been no narrowing of the class differential barriers in these matters since the National Health Service began. In fact, the gap between the incidence of perinatal mortality among the social classes to which I have been referring and middle-class parents has, if anything, widened rather than narrowed during the 30 years since the foundation of the NHS.

We are taking action with a view to trying to solve this problem. For example, there was the launching of the rubella immunisation campaign. In 1976, 296,600 children were immunised in England and Wales. We are endeavouring to persuade young mothers to give up smoking during pregnancy. A campaign to persuade expectant mothers not to smoke has been a feature of health education for some time. We hope to introduce a routine screening service for neural tube defects as soon as this may be safely and effectively done.

My hon. Friend the Member for East Kilbride raised the question of genetic counselling. To this end, the Medical Research Council and the Department of Health and Social Security have set up a joint working group to look at genetic counselling and clinical genetic research. The Clinical Genetic Society, at the request of the Department, has set up a group to look into the service needs for pre-natal diagnosis.

We are looking, too, at how the role of the midwife might be developed. This is being undertaken by the health studies department at Chelsea College.

Members of ethnic minorities, and in particular Asian communities, pose special problems, in that there is often a cultural and linguistic barrier which prevents their being drawn fully into comprehensive ante-natal care. A great deal is done to try to contact groups such as these with leaflets in their own languages. Two initiatives are in hand which may help to overcome these problems. The Department has just agreed to join the King's Fund in financing the production of a training package for health workers in contact with members of the Asian communities. We are also exploring the possible application of an automated history-taking device which might be very useful in antenatal clinics. Those are some examples of the positive research and action that the Department is undertaking with a view to backing up the policies we are urging upon area health authorities.

The hon. Member for Reading, South said that the question of smoking had proved the most contentious question in this debate. I agree. I found it encouraging that every Member who spoke while I was present had nothing good to say about smoking. The sense of the debate was that smoking was a very unhealthy pastime and the sooner people could be persuaded to give it up the better it would be for the nation as a whole.

I agree with that view, because my advice is that the greatest damage to the health of the nation that can be conceived of is smoking and that, if people could be persuaded to give up smoking cigarettes, a substantial contribution would be made to the country's future. That is why the achievement of opposition to smoking is one of the major tasks of the Health Education Council, and of preventive health measures.

The Government encountered fairly severe criticism because of their refusal to impose a ban on the advertising of cigarettes apart from at the point of sale. The general view was expressed that our policy of moving towards a reduction in smoking in agreement with the industry was possibly founded on the wrong principle.

The criticism that we are wrong to be operating on the basis of working in agreement with the industry might have some validity if the policy were not leading to good results. In the period 1974–75, for example, the number of male smokers decreased by 4 per cent. What is even more encouraging, because up to now the number of women smokers has been increasing, is that over the same period the number of women smokers decreased by 2 per cent.

Hon. Members may have noticed that in The Financial Times this morning it was said that during the period from April 1977 to April 1978 the number of cigarettes sold was reduced by 5.8 per cent. That is a noticeable reduction for a 12 months' period. I do not claim that the entire reduction is due to the policies of the Government. Some of the reduction may be due to the switch from ordinary size cigarettes to king size cigarettes, during which time smokers tended to buy fewer king size cigarettes than small ones. However, that is only part of the story. The general trend is encouraging.

I am not prepared to accept that the whole basis of our strategy is necessarily wrong. The Government have an entirely open mind on whether there should be a complete ban on advertising cigarettes apart from advertising at the point of sale. We shall review our policies in these matters in the light of evidence. It cannot be argued that, because cigarette sales are falling in Norway, Norway is on the right lines. We are in exactly the same position in this country, although we have not yet imposed a ban. Our policy so far has been to enter into agreements with the industry which are aimed at removing the glamour from cigarette advertising.

The hon. Member for Macclesfield (Mr. Winterton) put in an urgent plea to support NSM. It is not a question of supporting it. On this matter I take technical advice. That technical advice is that NSM is no more dangerous than tobacco. As long as I receive such advice from Professor Robert Hunter's committee, I am constrained to take the line that I take. The advent of NSM provides a potential for moving towards a safer cigarette if it can be developed, but I shall not go further than that.

The hon. Member for Isle of Ely (Mr. Freud), who is not in his seat, made a good point. He said that the whole of society in this country was based on the idea that it was natural to smoke and not natural not to smoke. As a result of a reduction in cigarette smoking because of the Government's policy over a period of years, those who smoke are for the first time in a minority and those who do not smoke are in a majority. Therefore, we should ensure that from now on our social arrangements change to meet that changed social pattern.

More and more as time goes by it should be accepted that people who do not smoke have the right of the road on their side and that people who smoke have to defer to those who do not smoke, particularly in a public place. The hon. Member for Ealing, Acton (Sir G. Young) criticised the Government about sports sponsorship.

He accused the Government of speaking with a forked tongue and suggested that my right hon. Friend the Minister responsible for sport and myself should be locked in a room until we agreed. We were not actually locked up in a room, but we spent a considerable time together in a room. At the end of that time the Government's policy is the code on the sponsorship of sport by cigarette firms which emerged. That is the Government's policy in these matters.

Mrs. Renée Short

Why did the Minister turn down the proposal for a more realistic health warning on cigarette packets? Why did he turn down the proposal to make cigarette machines available only in places where there could be adult supervision? My right hon. Friend has just mentioned sports sponsorship. Will he comment on the recent proposal of the British American Tobacco Company to spend more money on increased sponsorship in the face of what his right hon. Friend described as a grotesque situation?

Mr. Moyle

I meant to mention the BAT advertising drive and I apologise for not having done so sooner. It is not a campaign that I like, but having carefully considered, before the campaign started, the advertising code that we have entered into with the tobacco industry, I could not find grounds for disallowing the campaign, and therefore it has to go ahead.

We carefully considered the question of vending machines in public places where children are likely to have unsupervised access to the machines, but the number of machines in such places has declined rapidly because they are subjected to vandalism. We felt that it was not necessary to take action.

The health warning that appears on cigarette packets was the one that we could agree with the industry. As it was stronger than the previous warning, we felt prepared to compromise on that point.

Sir Bernard Braine

I have been listening intently to the right hon. Gentleman and I hope that he will refer to the scourge of alcohol abuse and its heavy cost in social and economic terms.

Mr. Moyle

The hon. Gentleman was next on my list. He raised the subject of alcoholism, and there are a number of points that I wish to put to him. The Health and Safety Commission's medical advisory committee is setting up a subcommittee on mental health at work which intends to meet soon. The hon. Gentleman asked about alcoholism and industry and the sub-committee will consider, among other matters, the problem of alcoholism and work and the recommendations of the Braine Report on alcohol and work. The sub-committee will consist of representatives of the TUC, the CBI and specialists in mental health. I shall pass on the hon. Gentleman's comments to the Health and Safety at Work Commission, which has a major role in this area.

The hon. Gentleman suggested that part of the revenue from liquor tax should be set aside for health education. That would go against one of the major principles of revenue and expenditure in this country—that the product of a particular tax is never hypothecated for any particular policy purpose but goes into the general funds of the nation for dispersal in accordance with the decisions of the Government of the day. I cannot concede that point.

The hon. Gentleman also referred to drinking and driving and was discouraged by the lack of education. We feel that there should be more legislation on this matter, and the Department would certainly support proposals for making the wearing of seat belts compulsory, but this is one of the areas in our public life, as some hon. Members have mentioned, where some people feel that they have the right to take a nose dive through their windscreens if they wish to do so. The House of Commons seemed to agree with them when we last considered this matter. For that reason, we have not been able to make the progress that I would have liked.

There are a tremendous number of questions to which I have not been able to refer. The best that I can offer hon. Members is that I shall write in reply to all the points raised in the debate. I hope that the House will take note of the report and that we shall be able to go forward and take action on it.

Question put and agreed to.

Resolved, That this House takes note of the First Report from the Expenditure Committee in the last Session of Parliament (House of Commons Paper No. 169) on Preventive Medicine and of the relevant Government observations (Command Paper No. 7057).

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