Healthcare Services: Acute, Primary and Community
(1 week ago)
Lords ChamberRead Hansard Text Watch Debate Read Debate Ministerial Extracts
Baroness Janke
That this House takes note of the relationship between (1) acute, and (2) primary and community, healthcare services.
Baroness Janke (LD)
My Lords, it is a great privilege to open today’s debate on matters that are of such concern to so many people and which lie at the heart of our local communities. As we all know, health services are severely overstretched, whether in a local context or elsewhere. The systems are simply not coping.
Anxiety and fear are facts of life for many, particularly the elderly and vulnerable, who fear they will not have proper access to healthcare—so much so that A&E has become the default destination for desperate patients unable to find care or advice through their local doctor. Some 18% of patients attending A&E did so because there was no GP appointment available to them; this amounted to 4.5 million attendances. Nearly half a million people waited 24 hours or more in A&E last year, an increase of 150,000 patients in just three years. Over 1.1 million patients were stuck in A&E, specifically waiting for an in-patient bed to become available. Even more frightening, according to the Royal College of Emergency Medicine report published in June this year, in 2025 around 15,860 patients died in NHS A&E departments in England while waiting for care that could have saved them. That is roughly 1,300 people every month, nearly 10 times the figure recorded in 2015.
However, the Government’s 10-year primary healthcare plan promises us community-based health services with a focus on illness prevention and promotion of good health. The vision of a well-resourced community-based health service is attractive and powerful. It is what we all want, patients and professionals alike, but it could not be further from everyday experience.
With waiting times for GP appointments at record levels, people’s fears about access to healthcare are well justified, particularly among the vulnerable and elderly. Worse still, the system can be off-putting and daunting, and not everyone is able to navigate it. For example, there is the 8 am scramble: having to phone in by 8 am and then being told you are 20th in the queue; having to explain highly personal matters to the receptionist who answers your call; or having to deal with an online system, only to find that there are no appointments left and you must phone anyway and wait in the queue. There are many questions across the board as to how we get from where we are now to the reassuring and welcoming world of the 10-year vision.
The pillars of community healthcare that so often support the ailing service we have today are the community pharmacies, which offer a local service that is practical, easily available and embedded in local communities. I will use the rest of my time today to speak about the crisis in this essential service and its impact on community healthcare.
We often hear the community pharmacy described as the front door of the National Health Service, yet we are currently watching that door being systematically bolted shut in the communities that need it most. The scale of this crisis is staggering and, frankly, a damning indictment of a decade of financial neglect. Since 2015, England has seen a net loss of 720 pharmacies. Last year, closures reached their second-highest level on record, and current data suggests that the rate of closure this year is nearly 50% higher than at the same stage in 2023. Between January and April alone, 177 pharmacies closed their doors for good.
The root cause of this is a 30% real-terms funding cut since 2015. While the costs of medicines, energy and staffing have surged, core funding has remained stagnant, leading to an annual funding gap of at least £2 billion across the sector, as reported by the NHS. The human cost of this neglect is borne by pharmacy owners, 65% of whom are now operating at a loss. Nearly half—45%—have been forced to rely on personal savings or remortgaging their own homes just to keep their doors open to the public.
Every day, pharmacies facilitate 1.6 million daily visits, providing vital triage and advice that keeps pressure off overstretched GP surgeries. However, when a local pharmacy closes, these daily visits do not simply vanish. Instead, they are forced back into the primary care system, exacerbating the crowding of emergency departments with non-urgent issues that could have been managed in the community. Acute care is designed for rapid intervention in time-sensitive, high-stakes conditions such as heart attacks or severe injuries. By removing the pharmacy buffer, we are forcing patients with minor ailments into acute settings, wasting specialised resources and jeopardising the safety of those with life-threatening needs.
Pharmacies cater for many needs, such as dispensing medicines, vaccinations, medical advice and urgent medical care, as well as provide services to promote health, such as smoking cessation and weight management—and they could do more to ease pressure on other parts of the health service. According to a 2025 Department of Health and Social Care report, 70% of people surveyed would be happy to see a pharmacist for common conditions or prescription reviews if it meant being seen sooner. The same study found that 68% of respondents are comfortable speaking to a healthcare professional in a pharmacy setting rather than a traditional GP surgery.
Pharmacies offer a range of walk-in services and can work in tandem with GPs and other primary care settings to play a greater role in long-term condition management and point-of-care testing, but this has to be with the right investment and support. Pharmacies are small businesses, and like all small businesses, they have difficult issues affecting them, such as increased national insurance charges, increases in the minimum wage and rising business rates. Incidentally, GP practices and pubs are exempt from business rates, so many local pharmacists are asking why pharmacies cannot also be exempt as an essential service. I would like the Minister to consider that in her remarks. Some 95% of pharmacies also told the National Pharmacy Association that they were not in a financial position to be able to support the Government’s ambitions to move care into the community, as outlined in the 10-year plan.
Deprived areas with high health needs saw the highest rates of pharmacy closures between 2022 and 2025, with Liverpool being the nation’s capital for pharmacy closures per head of population, followed by Blackpool, Coventry and Hull. The pharmacy network in England now stands at its smallest since 2006. Some 63% of pharmacies could close this year, with 40% unable to pay the full cost of prescription medicines for patients. The current system of reimbursement for medicines is currently failing pharmacists and patients, and it needs reform.
We are also facing a workforce crisis, where locum costs have risen by 80% in a single year and overall staffing costs have grown by nearly 70% since 2015. Pharmacies simply cannot absorb this scale of increases without a fair and sustainable funding settlement. “Lights Out” is not just a campaign slogan; it is becoming a stark reality for high streets across the country. We cannot move healthcare out of hospitals and into the community if the community infrastructure has been allowed to crumble.
Can the Minister say when the Government will deliver the urgent investment needed to close the £2 billion funding gap and stabilise this sector? What specific protections will be put in place to prevent further closures in deprived areas where health needs are greatest? How do the Government plan to prevent the withdrawal of addiction and delivery services, which will inevitably overwhelm our GPs and A&E departments? The time for warm words has long passed. We need a sustainable road map that reflects the true cost of delivering NHS pharmaceutical care. If we do not act now, the front door of the NHS will be not just bolted but gone for ever.
Baroness Lane-Fox of Soho (CB)
My Lords, I thank the noble Baroness, Lady Janke, for her incredibly powerful opening and the chance to speak in this important debate. I stand here with two hats on: first, as the survivor of a major trauma who has spent a disproportionate amount of time in all parts of the healthcare system, and, secondly, and far more importantly, as patron of Day One Trauma, which I shall describe later.
I will make three points. First, we must start with the patient, not with the system. Too often, it seems that, as policymakers, we think about the policy and the organisational structure rather than the experience of the patient in the system. That is particularly true for trauma victims. I start with them because trauma is perhaps the sharpest end of our healthcare services. Trauma patients have to go through so many of the different services that are offered, from intensive care to rehab and community services and then to the long-term support they may need as they live at home.
When someone is hit by a car, has a fall or experiences a major trauma, they do not think about the system that they are in—they think about surviving. They do not think, “I’ve now left acute care and I’m in the long-term recovery ward”; they think, “I want to recover”. What matters to them is whether they receive physiotherapy, occupational therapy, psychological support, pain management, speech and language therapy, and practical help to return to work and life. I have met many trauma survivors through Day One, a charity that helps people when they have a severe physical trauma, with about 30,000 people entering the system every year. The charity works alongside healthcare professionals in the most intense settings to help people navigate what is happening to them. It could be help with how to get benefits while they are off work for a long period or how to work out whether or not to amputate a limb—very brutal decisions at the most difficult time of their lives, often involving working with their families alongside them. At Day One Trauma, too often we see patients bumping up against different bits of a system as opposed to being seen as a patient and one person.
That brings me to my second point, which, perhaps inevitably, is about technology. I welcome much of what is in the NHS modernisation Bill, particularly around single patient records, but this sometimes feels far removed from the reality of what is happening in the system. We must engage more deeply with people who are expert in this area and give them power within the huge networks that exist in the NHS to change the patient experience. It is not acceptable that families and individuals, at the most difficult time of their lives, have to navigate so many different systems. We have already heard from the noble Baroness, Lady Janke, about how people will be put into an online system only then to be chucked out to the telephone. Imagine if you cannot actually move or speak: how do you navigate the system then? Too often, at the time when we most profoundly need help and we have the opportunity to use technology, it is absent, both for the people caring for the patients and for the patients themselves.
I read just this morning on a blog from OpenAI—perhaps it was PR—that 230 million people a week are now using ChatGPT for health questions. Goodness knows what the quality of that information is. It is so important that we recognise what is happening in the outside world and try to build it into the system more effectively. We must start with the patient. We must join up policy, as opposed to organisational structures, that reflects the needs of how people are actually living with and experiencing the system. We must use technology to make sure that people have a more effective journey through their recovery, and that clinicians, doctors, physiotherapists and all the people who work so hard in the system are given the best shot at delivering the care they most urgently want to deliver.
Finally, we must support charities in the system. Again and again, both in my own journey and now as proud patron of a couple of them, I have seen how difficult it still is for charities to get access to some of the parts of the NHS where they want to help and where they are providing a vital ballast to the people working in the system more directly. Day One Trauma works across multiple trauma centres in the north of England. When its members are in the care units or acute care units, they are welcomed by the staff, because they are doing much of the work that the staff have no time to do. Similarly, Horatio’s Garden, a fantastic charity that builds gardens for spinal patients, gives access to the outdoors, doing valuable work for people at those acute moments.
We must be able to answer these three questions. Are we starting with the patient in these policies? Are we using technology to the best of our advantage? Are we enabling charities to help support the system where we do not have the resources ourselves?
Baroness Leaman (LD)
My Lords, I am grateful to my noble friend Lady Janke for securing this important debate. I will focus my remarks on the crisis in medicine supply, the collapse of our community pharmacy network, and the impact that these failures are having on patients, particularly children with ADHD, many of whom have just finished sitting their exams without access to the medication they need.
Since September 2023, we have witnessed a sustained and debilitating shortage of ADHD medications across the UK. Medicines on which hundreds of thousands of children and adults depend have been intermittently unavailable for nearly three years. At the height of the crisis, patients were reported to be travelling over 50 miles simply to find a pharmacy with stock. The House of Lords Public Services Committee, in its February report, Medicines Security: A National Priority, made the stark assessment that medicine supply shortages represent a potential national security issue. Some 73% of pharmacy workers stated that ongoing supply issues are putting patients at risk.
Consider what it means for a child with ADHD to face their GCSEs or A-levels without their medication. For many young people, that medication is the difference between demonstrating their knowledge, ability and hard work, and sitting in an exam hall unable to engage with the paper before them. Students have reported rationing tablets, taking half doses or going without entirely during the examination period. Parents have spoken of the distress of watching children who have worked diligently throughout the year face their papers in a state of disadvantage not of their making.
This is a vivid illustration of the Motion before us. When primary and community services fail to ensure consistent supply, the fallout is immediate. We do not only jeopardise a child’s health but derail their education and shatter their well-being. In the most severe cases, this pushes vulnerable young people into acute crisis, ultimately driving up demand on the very services already at breaking point.
The causes of these shortages are complex but not mysterious. The OECD identified, as far back as 2022, that medicines shortages were increasing globally, but here in the UK we have compounded these global pressures through our own policy choices. The first is our departure from the EU. A Nuffield Trust report in March confirmed what many had long warned: Brexit has been a key factor in the worst UK medicine shortages in four years. Between 2020 and 2023, drug shortages in this country more than doubled. Leaving the European Medicines Agency, losing our place in the EU bulk-buying scheme and creating additional regulatory complexity has significantly weakened our position.
The second is our overreliance on overseas suppliers. The Lords Select Committee noted that the majority of active pharmaceutical ingredients required by the NHS are controlled by China, India or other single sources. We have allowed our domestic manufacturing capacity to wither. The Government’s commitment of up to £520 million to manufacture more medicines domestically is welcome, but it comes late and it must be accelerated.
Even when medicines are available, patients must be able to access them. As my noble friend Lady Janke highlighted, some 700 pharmacies have closed permanently since 2022, leaving England with its lowest number of pharmacies in nearly 20 years, with the National Pharmacy Association warning that 63% of pharmacies could close within the next year.
The Government have taken some steps: the Community Pharmacy Contractual Framework for 2025-26 provides £3 billion in funding, and the expansion of Pharmacy First is welcome. We need to treat medicine supply chain resilience as the national security issue it is and place it on the national risk register, as the Lords committee recommended.
We need a critical medicines list and an active pharmaceutical ingredients list to identify vulnerable supply chains, inform stockpiling and guide domestic production. We need better communication of shortages to front-line staff, so that GPs, pharmacists and hospital clinicians can take timely action. We need proper investment in community pharmacy, enough not merely to survive but to thrive and expand services as the NHS 10-year plan envisages. As a matter of urgency, we need specific measures to protect children with ADHD during examination periods: emergency supplies, priority allocation and whatever it takes to ensure that young people are not disadvantaged by failures in our supply chain.
The relationship between acute, primary and community healthcare services depends fundamentally on patients being able to access the medicines they need, when they need them and where they need them. At present, we are failing that test: children are sitting exams without medication, pharmacies are closing at an alarming rate and supply chains remain fragile and reactive. The Government have acknowledged the problem, but acknowledgement is not enough. Urgent, sustained and adequately funded action is needed. I look forward to hearing the Minister’s response and I hope we will hear commitments that match the scale of the crisis.
Baroness Brinton (LD) [V]
My Lords, I thank my noble friend Lady Janke for calling for this important debate, and it is a pleasure to follow my noble friend Lady Leaman, who spoke movingly of services for children with ADHD. I support everything that the noble Baroness, Lady Lane-Fox, said earlier. The 10-year NHS Fit for the Future plan aspires to change the NHS to make it work better in the mid-21st century. Science, medicine, demography and lifestyles have changed so much since the NHS was founded that radical change must happen. But it must be patient-centred, not organisation-convenient.
My chronic illness means that I have more interaction with the NHS than the average patient, and recently that has escalated with new auto-immune problems, so I have seen at first hand what is happening in too many different hospitals in recent months. Good A&Es, including at my local Watford General Hospital, have in place not just an effective triage system but a 72-hour emergency admissions unit to which GPs can refer patients who do not need A&E but need very short-term hospital care—perhaps to get an infection under control. This latter system has worked well for a decade.
I have experienced two emergency eye clinics in the last three months. The first, in London, was a complete nightmare to navigate. The staff were wonderful, from the receptionist to the nurses and doctors, but the building was completely inadequate and hampered an effective service for people who may not be able to see where they are going. A&E was on the first floor, with a narrow waiting room with about 60 seats and at least another 20 people standing. It was barely wheelchair accessible, noisy and chaotic.
I contrast that with Addenbrooke’s Hospital’s emergency eye clinic in Cambridge, where I still saw at least three different professionals on each of my visits. It had four different smaller and quieter waiting areas, so a patient progressed through the system, being informed at each stage about the likely wait time. That was a calming and effective process.
The pressure on GP and community services with the move to reducing pressure on acute services has considerable unintended consequences. The time many GPs have with each patient can be as short as five minutes, so a GP who does not know the patient well just cannot read the longer history. I am at high risk of serious infection, but a locum GP told me that they did not just hand out antibiotics for minor infections. I was in A&E 24 hours later on an antibiotic drip. This is not about the locum; this is about the pressure that our GP services are under. This needs to be remedied.
The Government want to divert patients in surgeries to non-GPs, so, recently, my surgery system automatically got the pharmacist to call me to discuss my medication. I asked him how my hospital medication would interact with what he was proposing. He had not read my notes, either, and he realised that I must see a doctor instead of him. It was a waste of his time and a waste of mine.
Do not get me started on the barriers to accessing community physiotherapy if you have a chronic illness. Five years ago, my local physio community trust sacked all its specialist physios to save money. If you need help, you have to navigate two 20-minute automated triage assessments, but they only triage patients on one injury. When I finally got to talk to a human on the phone, I was then given interim exercises, which caused serious pain to my other joints. I cannot get past the gatekeepers to look at me as a whole person—and there is a national shortage of physios, without whom Fit for the Future will not work.
But there is excellence happening. Last October, my sister was diagnosed at William Harvey A&E in Ashford with terminal and untreatable cancer. The one thing she wanted was to be back in her own flat with her cat. Madeleine was put on the end-of-life discharge to assess pathway, run by the Kent Community Health Foundation Trust. My other sister and I were with her for those last two months, and we saw at first hand how an excellent and complex system can work well. They helped us with the expert end-of-life care at home company, the GP and nurses at her surgery, the Pilgrims Hospice and the community nursing team. We were told by the brilliant GP surgery nurse who visited often that, if we had to call 999, we should tell them her wishes from the start, on the phone, so that, when the paramedics arrived, it was all about getting her back into bed after a fall, not into hospital.
Managing all of this were exceptionally well-trained administrators, who understood their role and how to make things happen. She was able to be at home until the last 24 hours, but there was also a reduction in need for A&E space, acute bed space, and advice on tap when needed. This service should be universal, but it is not.
To conclude, as with many of the other wonderful parts of the NHS and care sector, there is real excellence, value for money and social care. The difficulty remains that it is not consistent. As long as acute, primary and community healthcare are not focused on the patient, services will be inconsistent and probably more expensive, to the detriment of patients in the community. A plan alone will not change things, but putting the patient journey truly at the heart of these changes can and does work.
Baroness Cass (CB)
My Lords, I declare an interest as a veteran of many health service reorganisations, through which I have consistently advocated for children and young people not to be forgotten, so it will not be a surprise that I am doing the same today. I have also spent many years making the case for better integration across primary, community and acute services, particularly increasing delivery of paediatric care in primary and community settings. The Government’s commitment to shift care from hospital to community settings is welcome, but we have heard similar aspirations before. How do we ensure that this time it becomes a reality?
I have four asks of the Government. First, I echo the comments of the noble Baroness, Lady Lane-Fox, about thinking about the patient journey. Please map child and family journeys clearly, so that people can understand where and how they access support. The 10-year health plan mentions children frequently, but, after reading it and its supporting documents, I was still unclear how neighbourhood health services will fit alongside family hubs, Young Futures hubs, community paediatric services and other existing models. Neighbourhood health services could provide the glue that joins these services together, but there is a risk of duplication and confusion.
My second ask is: build on existing good practice, rather than embarking on another cycle of pilots that are never adopted at scale. For example, the Well Centre in Lambeth—well known to my noble friend Lady Gerada—which is run by Dr Steph Lamb, a superb GP, provides integrated support for 11 to 20 year-olds, bringing together mental, sexual and physical healthcare, alongside social prescribing and community support. It already demonstrates much of what is envisaged for Young Futures hubs, yet remains partly dependent on charitable funding. We should invest in and replicate successful models such as this.
Similarly, the Children’s and Young People’s Health Partnership in south London has demonstrated that local child health clinics delivered by paediatricians and GPs and a nurse-led early intervention service can address unmet needs, reduce inequalities and reduce hospital attendance. This model has already been adopted elsewhere and provides an evidence-based example of community-based care in action.
We have another valuable community resource in the form of children’s hospices, which support children with life-limiting conditions not just at end of life but over a very extended period, as well as supporting their families. In 2025-26, their average caseload rose by 11%—a growing cohort that would otherwise fall to the NHS. Meanwhile, statutory funding has failed to keep pace, accounting for just 25% of hospice expenditure, with the rest dependent on charitable donations. If we do not fund these services properly, care will move from community to hospital rather than vice versa.
My third ask reflects concerns raised by the Royal College of Paediatrics and Child Health. As these reforms progress, how will the Government ensure that integrated care boards consistently prioritise and adequately fund children’s health? Will executive children’s leads within ICBs be protected? More broadly, how will changes to ICB membership ensure strong clinical leadership for children’s services and an appropriately planned and funded workforce? We are desperately short of community children’s nurses and school nurses. If the community workforce is not valued, incentivised and supported, there will be no meaningful shift of care into the community.
Finally, please listen directly to young people. Alex Parton, a youth intern at the Well Centre, said,
“healthy children become healthy adults, but”
young people are too often treated
“as bystanders rather than future citizens”.
He said that if, as the Secretary of State has said,
“the 10 Year Health Plan will ‘put a megaphone to the mouth of every patient’, it must make sure young people get a turn on the mic too”.
I look forward to the Minister’s response and am very happy to share my little black book—or little black iPhone—of very useful contacts of good practice.
Baroness Walmsley (LD)
My Lords, community and primary care services are at the heart of the Government’s objective in the 10-year plan to shift from sickness to prevention and from hospital to community. But the funding does not always support that.
Over the past nine years, the average increase in spend across health services has been 31% but primary care had only 24%. The patient population has grown by over 7 million since 2015, yet the number of GP practices has fallen by about 20%, leaving some rural areas without accessible cover. I heard a case only this morning of a rural GP who retired from a single-doctor practice; patients had to travel 12 miles to get to the nearest GP and there were no buses. The average list size is now 40% higher than a decade ago. Primary care, including dentists, optometrists and community pharmacists, is part of the prevention agenda yet there are major funding gaps and important aspects of the service suffer.
GPs control the patient’s health records, and their patients have in the past benefited from continuity of care, but this no longer always happens and the benefits have been lost despite evidence that continuity is beneficial and can save money. GPs are the first port of call for patients, the point of first triage or suspected diagnosis and the gateway to more specialised services. If people cannot get to see their GP, as my noble friend Lady Janke said, they eventually turn up at A&E, usually with a much more serious condition and at greater cost to the NHS.
Diet and vaccinations are key aspects of prevention. Some GPs employ dieticians, but nowadays it seems that the main response to obesity is through treatment rather than prevention. These injectable medicines are quite effective but their long-term cost-effectiveness is not yet proven. We need more dietician services in the community. Access to a healthy diet is dependent on many factors beyond the scope of primary care. The Minister will therefore not be surprised that my first question to her, again, is: what progress is being made with publishing the consultation on the healthy food standards? Has the department even established the parameters of the consultation?
GP practices also deliver the core childhood vaccination programme, mostly given by the practice nurses, and they are the most trusted people to answer patients’ questions. But some communities are hard to reach, leading to inequality of coverage. Reaching them costs a lot more time and money, but the benefit of doing so is felt not just by those patients but by the whole community when herd immunity levels can be reached. Dangerously, this is not being achieved, partly through lack of consistent funding. In transferring vaccination commissioning to ICBs, will the Government ensure consistent funding for outreach according to the need in the area?
Midwives, health visitors and school nurses have a role in advising patients about diet and vaccination, but all those services have experienced cuts. Many schools no longer have a school nurse, and newly qualified midwives are not able to find posts. The number of health visitors has reduced by 43% since 2015. This makes it difficult to ask them to do catch-up vaccinations in the home. Does the Minister have any results from the recent pilot on this? All these health professionals have a contribution to the preventive agenda and saving money.
We have all heard of dental deserts and community optometrist deserts. Both could save the NHS money given appropriate levels of funding. The main reason children go into hospital is to have rotten teeth removed. This is because they eat too much sugar and are unable to see a dentist. What is being done to avoid dental deserts?
In eye care, we have the workforce and infrastructure in the community, yet access depends on where you live, which pushes avoidable demand into hospitals. One in four people cannot access a local optometrist and there are 600,000 people on hospital waiting lists, many of whom could have been managed in the community. What steps are the Government taking to ensure equitable access to optometrists across England?
We have a wonderful range of community and primary care services and yet their full potential is not being used to prevent ill health because of underfunding or inconsistent funding. That is very unwise, to say the least.
Lord Scriven (LD)
My Lords, it is always a pleasure to follow my noble friend Lady Walmsley; I will pick up on her final theme. I thank my noble friend Lady Janke for initiating this important debate. As the vice-chair of the APPG on Pharmacy, I think the case for extra investment has been made by both her and my noble friend Lady Leaman.
When the Government took office nearly two years ago, they came with a narrative of transformation. They promised people a fundamental shift away from the expensive, reactive walls of acute hospitals and toward a proactive, preventative “neighbourhood health service”. But looking at the NHS ledger of the 2026-27 financial year, they are forced to confront a recurring theme: the Government’s policy is built on hope while the NHS is living a different reality.
The Government stated their hope that primary and community care would finally receive the financial engine required to keep people well for as long as possible at home. The reality under their watch is that the gravitational pull of the acute sector is still as strong as ever, accounting for between 75% to 80% of total NHS spend.
The data from integrated care boards for the year ahead show this. Out of a combined £139 billion allocation, the total identified for neighbourhood health transformation activity is a measly 0.25%—and this is to fund the flagship policy of the Government’s health strategy. The reality is that local efforts to invest in community, primary and preventive services have been actively crushed by top-down directives prioritising acute hospital performance.
The Derbyshire, Lincolnshire, and Nottinghamshire ICB cluster tried to deliver the Government’s vision, with a £33 million fund dedicated to community transformation. Yet, within days of launching it, national performance directives forced it to withdraw the whole funding and redirect it to acute services.
The Government’s financial priorities are also written clearly in their capital budgets. They have earmarked £2 billion this year for acute emergency care, yet allocated only £200 million for their flagship neighbourhood health centres. When you contrast £2 billion for the emergency machine against the £200 million for new community infrastructure, their true priority is laid bare.
Nowhere is the gap between the Government’s rhetoric and reality more damning than in community support for learning disabilities. Over the past 24 months, we have witnessed the continuation of the systematic hollowing out of the infrastructure that keeps these people safe and alive. Evidence published only last week by the Royal College of Nursing exposes what is happening right now under this Government’s watch. In its report, Safety, Equity and Expertise, the RCN warned that the specialist learning disability nursing workforce is in absolute crisis. In autumn 2025—the first academic intake under this Government—we see a catastrophic collapse in the pipeline. Fewer than 500 student learning disability nurses enrolled across the entire UK. In the south-east, the intake was exactly zero.
The workforce is evaporating because community budgets are being raided. What is the human cost? For someone with a learning disability, there remains a shocking 20-year life expectancy gap compared with the general public. When the Government force ICBs to pull transformation funds and look the other way as the specialist nursing pipeline dries up, they engage in a false economy of the highest order. When a vulnerable young person loses their community safety net, they land, eventually, in an acute crisis bed. The taxpayer pays a premium for this systematic failure. This is not just a policy failure but a profound human failure which is all too real for my family.
Why have the Government spent the last two years forcing local health systems to continue to feed the acute vacuum? When will they finally align the reality of NHS budgets with the hope of their rhetoric?
Baroness Gerada (CB)
My Lords, I am grateful to the noble Baroness, Lady Janke, for securing this debate and to the noble Baroness, Lady Walmsley, for saying many of the things around primary care and general practice that I want to say. I always feel that I am here defending my own profession.
The NHS was founded on a vision of care delivered close to home—in communities, general practices and by district nurses. Yet, over recent decades, a profound imbalance has appeared in resource allocation. Hospital-based care has grown in workforce, infrastructure and funding, while services that form most of the patient’s first point of contact have been left to wither, as we have heard. When I started general practice, on 17 February 1991, I had time with my patients and time to do what my patients—many noble Lords in this room—wanted.
The mantra of moving care into the community has not been associated with a simultaneous move of resources, people, infrastructure support or estate. I now do more than any other GP in any other comparable health services. General practice in this country does more and to a greater degree of complexity than in any other. I do everything except open heart surgery in my consulting room—I confirm, for Hansard, that I do not do that.
The consequences of this non-shift are evidenced across the full breadth of primary care. Millions of patients cannot register with an NHS dentist. Many resort to emergency departments for toothache—or, worse, leave decay untreated until it becomes a serious health problem. Optometrists, who are often the first to detect conditions such as glaucoma, diabetes and hypertension, are increasingly unable to sustain NHS-funded services. Continuity of care with a GP, which I will say a little bit about later, is becoming a rarity, while community nursing is stretched to breaking point.
These crises, which include physiotherapists and all the other community specialists that we have heard about, are not separate. They are symptoms of the same structural neglect: a system that has consistently prioritised acute, visible hospital care over the quieter but equally essential work happening in surgeries 360 million times per year, in consulting rooms and in communities. General practice alone receives less than 8% of the NHS budget—the lowest proportion for decades. This risks replacing continuity of care—the bedrock of my profession—with brief transactional encounters, despite clear evidence that continuity delivers better, safer and more effective care. Without continuity, the NHS becomes a maze where patients get lost.
On workforce, no system succeeds without the people to staff it: practice nurses, health visitors and district nurses. The quiet architecture of community health has been hollowed out over decades. Over the same period, the consultant workforce has increased by 120%, while the number of GP partners has fallen. Even with that fallen number, around one in five GPs cannot find full employment because we do not have the funding to employ these doctors.
When community care buckles, the consequences flow downstream. The result is a system paying premium prices for intensive care to manage problems that should never have reached that threshold. This is not simply an administrative question but a moral one. What kind of health service do we want: one that catches people only when they fall, or one that walks alongside them and, where possible, prevents the fall altogether?
What does “fair distribution” mean? It means teams without walls. It means multidisciplinary teams built around the patient rather than the disease or body part. It means shared records that follow the person rather than sitting in silos. It means social prescribing that connects people to their communities before loneliness becomes a clinical problem. We need step-down facilities that bridge the acute ward with a patient’s home.
I had all those resources 20 years ago. Noble Lords will remember the Tomlinson review in the early 1990s: integrated, step-down, community-based, multidisciplinary hospitals. Please let us stop reinventing the wheel. When community care buckles, the consequences flow directly downstream. As I said, redistribution is not simply an administrative question but a moral one. What is required is not another review or reorganisation but sustained political will, clear frailty pathways, a realistic workforce plan, training that ensures that all doctors—I mean all—spend meaningful time in community settings, and a rightful place for community practitioners on integrated care boards. When will we finally redress the balance and stop the imbalance of more and more resources going into hospitals rather than where patients receive most of their care?
Baroness Pidgeon (LD)
My Lords, I am delighted to follow the noble Baroness, Lady Gerada, with her first-hand expertise and experience as a GP, and her description of the service that we all would like to see. I am grateful to my noble friend Lady Janke for introducing this vital debate. The relationship between acute services and primary care goes to the heart of how the health service that we value can survive and function. The noble Baroness, Lady Lane-Fox, rightly highlighted the need for the patient to be the focus, not the organisation, and she described the needs of serious trauma patients and the opportunities for technology. My noble friend Lady Brinton highlighted the need for patient-centred services and the whole person being at the heart of this.
The consequences of the deep imbalance between acute, primary and community health services are starkly visible in the data. NHS England discharge data from 2025 shows that patients who were medically fit to leave hospital spent the equivalent of 4.34 million days stuck in beds. They were there not because they needed acute care but because the community and social care that was needed to support them simply did not exist. My noble friend Lord Scriven provided the clear financial reality of acute services being prioritised, community services being reduced and the hollowing out of services for people with learning disabilities.
Let us look at dentistry. NHS England statistics published in 2025 show that four in 10 children—over 5 million in total—had not seen an NHS dentist in over a year. The Darzi review in 2024 found that only around 30% to 40% of NHS dental practices were accepting new child or adult registrations respectively. As my noble friend Lady Walmsley mentioned, official data from NHS England and the Royal College of Surgeons confirms that tooth decay remains one of the most common reasons for hospital admissions among young children in this country. The reality is that preventable dental disease generates acute demand. A child admitted to hospital with rotting teeth is a child whose primary care failed, not their acute care.
The noble Baroness, Lady Cass, brought her expertise in children and young people and questioned how the Government’s plans will really serve families better and bring the change that is needed.
We should look at some other trends in primary care. As we have heard, general practice is under extraordinary and unsustainable strain. Our GPs are the front line of defence, positioned precisely where they need to be to detect health issues early. They are the front door through which the public interact with our health service, and they need investment. If accessing a GP feels impossible, then public faith in the wider health service collapses entirely. My noble friend Lady Walmsley highlighted that the funding of primary care is not keeping up with demand, population and key areas of prevention work. The noble Baroness, Lady Gerada, talked passionately and rightly about how GP services have been left to wither and now have less than 8% of the budget.
As we have heard, according to the Association of Optometrists, access to community eye care services varies significantly across England. As a result, one in four people cannot access these services locally. Patients with common eye conditions are frequently directed to GPs, A&E or hospital eye services, even though they could be safely managed by community optometrists. At the same time, more than 600,000 people are waiting for hospital ophthalmology appointments, adding extra pressure to acute services. This just makes no sense, and it is patients who suffer.
In mental health, the picture is equally distressing. Thousands of children and adults are waiting months, sometimes years, to receive the support that they need. The previous Government left mental health services in a state, but the consequences of mental health being underresourced, and only triaged at the point of crisis, flow directly into acute services. Psychiatric presentations in A&Es, lengthy detentions under the Mental Health Act and ambulance callouts could have been avoided with earlier community intervention. They are the heavy downstream costs of failing to invest upstream.
Emergency departments are already bearing that cost. Department of Health and Social Care figures show that the Government have announced an average of £376 million in emergency winter funding annually, over the past seven years. This is patching up the system, year after year. That is not a sustainable health policy; it has become a bad habit.
The Royal College of Emergency Medicine has long called for staffed hospital beds, social care capacity and community step-down services. The Liberal Democrats have proposed a £1.5 billion plan to deliver 6,000 more beds daily, boost step-down care and enshrine in law the right to be seen in A&E within 12 hours. But let me be clear: beds alone will not solve this. Beds will fill up again, unless what lies beyond the hospital in home care, community services and general practice is also fit for purpose.
Social care sits at the very heart of this problem. Local Government Association figures for 2025 show that total local authority spending on social care reached a record £29.3 billion in 2024-25, up by £12.4 billion since 2015-16. Social care now accounts for up to 80% of many council budgets, putting immense strain on other services, yet the commission tasked with recommending long-term reform is not scheduled to complete its work for a further two years, with implementation potentially delayed until 2036. Those waiting for care, and those stranded in hospital beds for want of it, simply cannot wait that long.
My noble friend Lady Janke described powerfully the role of community pharmacies, which are a key part of primary care, and my noble friend Lady Leaman described the real impact of medicine shortages on children and young people, continuing into acute services. She also referenced the excellent report on medicines security from the Public Services Committee, which I recommend to the House.
This debate has not even touched on ambulance services, the key role that paramedics can play and the potential that they have, with a shift in resources, to help ensure that people are treated in the right place and at the right time, rather than at the critical point we have today. I recommend that noble Lords also read the latest publication from the Public Services Committee on this very topic.
The noble Lord, Lord Darzi, commented in his review of the NHS:
“Since at least 2006, and arguably for much longer, successive governments have promised to shift care away from hospitals and into the community. In practice, the reverse has happened. Both hospital expenditure and hospital staffing numbers have grown faster than the other parts of the NHS, while numbers in some of the key out-of-hospital components have declined”.
The King’s Fund also commented:
“When trying to envision the future of the health and care system in England, the difficult question to answer is not ‘What do we do?’—the vision for care has been outlined by multiple governments in countless policy documents—but ‘How do we actually make it happen?’”
I welcomed the commitment in the Government’s 10-year health plan to shift from hospital to community. It is the pace of change and the resources needed to support the rhetoric that will actually make it happen. Rebalancing an entire national health service requires rewiring funding, stabilising the workforce and completely integrating local services. If we all agree on the diagnosis, we need to work together to implement the long-term, radical changes needed to fix this. I look forward to the Minister’s response to this timely debate.
Lord Evans of Rainow (Con)
My Lords, I thank the noble Baroness, Lady Janke, for securing this important debate. There is broad agreement across the House on one central point: if we are to build an NHS that is sustainable for the future, we cannot rely solely on treating people once they arrive at hospital. We need strong primary care and early intervention that prevents illness escalating in the first instance.
That principle is not new. Successive Governments, including the Conservatives, have spoken about shifting care closer to home. The current Government have made it one of the central pillars of their health strategy through the proposed neighbourhood health service and the commitment to move from hospital- to community-based care. The question, however, is not whether we support that ambition, but whether the Government are delivering it.
The figures set out in the House of Commons Library briefing are striking. Between 2015-16 and 2023-24, spending on acute services increased by £14.3 billion, while primary medical care increased by only £1.7 billion and community services by £3.1 billion. Those figures illustrate the scale of the challenge in rebalancing the system; they also demonstrate why simply announcing a shift is not enough. Resources must genuinely follow patients into community settings if the policy is to succeed.
These Benches welcome the Government’s stated commitment to shift care out of hospitals into communities. We also recognise the potential benefits of neighbourhood health centres in bringing diagnostics, rehabilitation, mental health services and primary care together and closer to where people live.
However, there are legitimate questions to be asked about pace and delivery. Before the election, Ministers spoke about increasing the proportion of NHS funding allocated to primary and community care by 2029. That objective has now been pushed further back to 2035. For many patients and practitioners, that will feel like a significant delay.
These Benches also have concerns about whether primary care is being given the tools it needs to succeed. The Opposition have consistently raised concerns regarding changes to the GP funding formula and the expectations placed on GPs through the advice and guidance system. Community care cannot become simply a mechanism for managing demand that would previously have gone elsewhere in the system. If primary care is expected to do more, it must be properly resourced to do so.
I turn briefly to mental health, where the relationship between acute and community services is particularly important. Community support and accessible treatment can prevent deterioration early and reduce hospital admissions. It is therefore concerning that the share of NHS spending devoted to mental health has fallen in each of the last three years—from 9% in 2023-24 to a projected 8.4% in 2026-27. At the same time, local systems are no longer required to increase mental health spending in line with overall NHS spending. These developments appear difficult to reconcile with the principle of parity between mental and physical health.
In closing, I therefore have four questions for the Minister. What specific milestones will the Government use to demonstrate that the promised shift from hospital to community care is taking place? What assessment has been made of the impact that recent GP contract changes will have on primary care capacity? How do the Government intend to ensure that mental health services do not lose out as NHS resources are distributed across the system? In the case of eye care, there is already a workforce and infrastructure in the community to treat patients effectively, yet access depends on where you live, which pushes avoidable demand into hospitals. What steps are the Government taking to ensure equitable access across England?
Strong hospitals will always be essential, but an NHS fit for the future also requires strong community services and effective early intervention. The challenge for the Government is not setting out that vision but delivering on it. I look forward to the Minister’s response.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I congratulate the noble Baroness, Lady Janke, on securing a very important debate. I am also grateful to all noble Lords for their contributions. I recognise many of the challenges raised, which is exactly why we are taking the action that we are. I am glad that the noble Lord, Lord Evans, in particular welcomed the direction of movement, as have so many noble Lords, including the noble Baroness, Lady Pidgeon.
It is important that we look at where we started, because I think it reminds us of the scale of the challenge. It was the noble Lord, Lord Darzi, who made the point that we inherited an NHS facing the worst crisis in its history. We all know of people stuck on waiting lists for many years, staff who have felt let down by bureaucracy and little support, and patients who have had to navigate a system that all too often felt complex, disjointed and fragmented—the noble Baroness, Lady Brinton, spoke about literal navigation, which I thought was a key point. Not only was that the situation but we recognise that, while we are making improvements, there is some way to go, and I want to set that out at the outset.
I am grateful to the noble Baroness, Lady Lane-Fox, for talking of her own personal experience, and I can say to her that, yes, the patient is at the centre of all the reforms that we are making.
The noble Lord, Lord Darzi, found that society is getting sicker. People are living longer but in poorer health and with more complex needs. I should emphasise that that burden is not shared equally. The gap in healthy life expectancy has grown between the richest and poorest areas, and the model of care that was in place, which we are still seeking to change, while making progress, is working least well for those with greatest disadvantage, who are most likely to have complex needs. I agree that the system we inherited and are changing has been too hospital-centric, too detached from communities and too organised into silos. To the noble Baroness, Lady Lane-Fox, I say, yes, modern technology has transformed everyday life, and the scale of change certainly had not reached the National Health Service. We had a stark choice, as noble Lords know, and our response is reform
We also heard from staff and patients that they do not want the status quo. To agree with the noble Lord, Lord Scriven, people said that they wanted radical reform, and we have embraced that. I believe that the 10-year health plan responds to that, setting out the three fundamental shifts—hospital to community, analogue to digital, and sickness to prevention—with neighbourhood health at its very core. Our neighbourhood health framework, which was published in March, gives partners the clarity to develop locally led plans.
What is at the core of this debate is how to make that shift real. For the first time, the medium-term planning framework sets a target to reduce long waits in community health services, with at least 80% of activity to take place within 18 weeks by 2028-29. We are restoring GP access; to some of the points made about the important role, which we acknowledge, of the GP, more than 76% of people are now saying that it is easy to contact their GP, which is up from 61% when we came into office.
The noble Baronesses, Lady Brinton and Lady Gerada, and the noble Lord, Lord Scriven, all spoke of the importance of GPs. We are training thousands more GPs, and we are boosting capacity. From July 2024 to April 2026, we had more than 2,000 additional GPs; in total, we now have over 30,000, which is the highest number since 2015. This has meant that we have delivered 12.7 million additional GP appointments this year compared with last year, and I am grateful to GPs.
We are investing directly in the services that will make neighbourhood health possible, which was raised, quite rightly, by the noble Baroness, Lady Cass. I totally agree with her about young people having that voice, and we ensure that that is the case, but I know where to come should we need further assistance.
We have invested an additional £601 million in general practice, taking total GP contract investment to nearly £14 billion in 2026-27. A number of noble Lords, including the noble Baronesses, Lady Janke and Lady Leaman, spoke about the importance of community pharmacy, which I totally align myself with. That is why, to recognise that key role, we have given a 10% uplift, which translates to £340 million. Further on funding, as a number of noble Lords have raised, including the noble Lord, Lord Scriven, over £9 billion is being invested through the better care fund, and there is a commitment to deliver 250 neighbourhood health centres, for which the first 27 sites have already been selected.
This is not just a vision, but vision is important: one of continuous, accessible and integrated care, centred around the patient, which prevents ill health, intervenes earlier and gives people more control, by 2035. I understand the wish for pace, and I share it, but we also have to be realistic. There is a reason it is a 10-year health plan: it is not so we wait but so we have a plan that will transform the model of elective care.
Many interactions will no longer take place in a hospital building, but they will be able to take place. The noble Baroness, Lady Lane-Fox, asked whether we are using technology to the best advantage; the NHS was certainly way behind where it should have been, but we are moving towards that, because interactions will be able to take place virtually or through neighbourhood services closer to home. We will see the first NHS online hospital, the development of the NHS app—which has already greatly improved, as many of us know, as patients access care, information and appointments more responsively through their phones—and, by 2035, two-thirds of out-patient care will take place digitally or in the community. Central to that will be the single patient record, which I look forward to coming to when we receive the Health Bill.
General practice will remain at the heart of neighbourhood health. I heard what the noble Baroness, Lady Gerada, said. We are introducing two new at-scale contracts—the single neighbourhood provider and the multi-neighbourhood provider—to support GPs and partners to work against larger geographies. I recognise the pressure on GPs. We are working with GPs to assist them in their effectiveness and in the way in which they serve patients. Integrated health organisations will take responsibility for local population budgets. They will support integration and move resources to where they have the greatest impact.
Key within this debate, and raised in particular by the noble Baronesses, Lady Pidgeon and Lady Gerada, the noble Lord, Lord Scriven, and other noble Lords, is funding. We know the importance of ensuring that investment supports the shift from hospitals to communities—and I say to the noble Lord, Lord Evans, that that will include mental health as well as primary care and neighbourhood care. The 10-year health plan sets out an operating model that shifts power from the centre to local commissioners and providers. As I mentioned, ICBs and providers are developing medium-term and multiyear plans through the medium-term planning framework to show how they will use funding in line with the priorities.
I assure noble Lords that ICB allocations give greater growth to community rather than acute services to support the community transformation that noble Lords and I seek and to support neighbourhood health. We will continue to set those national expectations, and we will support that by changes to system incentives, such as financial flows. I hear the call for ring-fences, which is often made. It is a legitimate challenge, but they do not by themselves guarantee better outcomes. Our approach is to set national priorities and accountability, as well as enabling ICBs to use funding flexibly, because they are best placed, as we know, to meet local need and secure best value.
Lord Scriven (LD)
My point was that flexibility is taken away when national directives come down, forcing ICBs to spend money on acute and emergency care.
Baroness Merron (Lab)
I always appreciate the expertise of the noble Lord, but I have set out our approach. We are focusing on outcomes and the best way to achieve them. We keep them constantly under review and discussion, so it is not top-down but how we are going to get to the place that all noble Lords want us to get to.
I know that I will be able to refer to only a limited number of questions, and I hope noble Lords will forgive me. The noble Baroness, Lady Walmsley, raised dental deserts. We are offering incentives to attract dentists under the golden hello scheme, which is what it says on the tin. Importantly, we are also increasing the supply of dentists. We have just announced the first sustained expansion of dental school places since 2007. The noble Baroness, Lady Walmsley, also asked about progress being made on publishing health food standards and the consultation. I acknowledge her particular interest and expertise. We will soon be consulting on the proposals for healthier foods targets and reporting. Importantly, we remain on track for delivering on this 10-year health plan commitment in this Parliament. If the noble Baroness would like further information, I would be very happy to obtain it for her.
The noble Lord, Lord Evans, asked about milestones that will be used to ensure that the shift from hospital to community is taking place, which is important. That is why we have published the Neighbourhood Health Framework, which will ensure that accountability. I am very alive to the points he made about mental health services, and I am sure that he welcomes the mental health strategy that will bring together all the points. I am very enthusiastic about the fact that we are piloting community-based mental health centres. I was glad to visit the one in Birmingham, which totally persuaded me of their value, but we must of course wait for the evidence.
I know that noble Lords know that the NHS that we inherited was under intolerable pressure. We have chosen reform, we have invested, we are rebuilding access, we are enhancing digital tools and we will deliver an NHS closer to home that is more preventive, joined-up and equal. That is the way we will take the NHS into the future.
Baroness Janke (LD)
I thank the Minister for her remarks and her explanation. She is obviously very committed to her plan. I think it is fair to say from what we heard during the debate, which had strong contributions from both professional and patient experience, that people in this Chamber are not convinced and that there is a lot of work to be done to convince people that the plan is going to succeed—not least the people who are working in it.
I draw the attention of the Minister to the morale and the sense of crisis that there is in many communities. On my point about local pharmacies, there is a crisis, and if we are not careful there will be none left to help to deliver the plan, and I am sure the situation is similar in other parts of primary care. So, while I recognise that the Minister has tried to be helpful, I think there is still a lot of work to be done and I—and, I know, others in this Chamber—will be pursuing the plan, in the hope that we will see it succeed in the future. It will need a lot of commitment and, as we have said, a lot of resource focused on primary care in communities and making sure that that focus is kept and that we remain committed to it.
Motion agreed.