House of Lords
World Trade Organization
(1 day, 8 hours ago)
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Lord Lamont of Lerwick
To ask His Majesty’s Government what proposals they have for increasing the effectiveness of the World Trade Organization.
The Parliamentary Under-Secretary of State, Department for Business, Innovation, Science and Trade (Lord Leong) (Lab)
My Lords, the WTO has failed to keep pace with trading realities and must reform. The UK has communicated our vision for a WTO that is more relevant, flexible and accessible. We are actively shaping the reform debate. Our proposals include ideas to stimulate discussion on how to level the playing field in trade, such as improved transparency and discipline on harmful trading practices, and to advance more flexible arrangements among subsets of members to make the WTO more responsive.
Lord Lamont of Lerwick (Con)
My Lords, I thank the Minister for that full and interesting reply. The WTO has been partially paralysed by disputes between China and the United States and by the United States withdrawing from part of its workings. Can the Minister tell the House whether the interim workaround measures, which were led by Canada and Australia and in which we participated, have helped to offset the effect of America’s withdrawal from the institution? Despite what the Minister said about transparency, will he confirm that, if we want to have growth in this country, in a world in which supply chains are politicised and there are tariff wars, it is extremely important that we do everything in our power to support a rules-based trading system?
Lord Leong (Lab)
I agree with the noble Lord that we have to abide by the rules-based trading system. As he knows, Canada, Australia and the United Kingdom are among the members using the WTO’s interim appeals arrangement, which currently has 61 members. It allows participating countries to resolve disputes without an appeal disappearing into the void while the appellate body remains paralysed. We continue to press for a functioning dispute settlement system that is accessible to every WTO member country, whether big or small, advanced or developing.
Lord Fox (LD)
My Lords, the noble Lord is right to emphasise the importance of a rules-based trading system and multilateralism. Although the WTO is stalled at the moment, there has been progress with the Comprehensive and Progressive Agreement for Trans-Pacific Partnership. As of Tuesday 1 September, UK businesses had full access to the CPTPP bloc. Can the Minister tell us what his department is doing to help British business, particularly SMEs, take advantage of this opportunity?
Lord Leong (Lab)
My Lords, the noble Lord makes a good point about trade agreements that we have signed with various countries, such as the CPTPP and the India free trade deal. Through our current dialogue, whether with the EU or the CPTPP, we are building support among members to reform the WTO. As Minister for Small Business and Enterprise, I speak to trade organisations and small businesses up and down the country and encourage them to take advantage of all the free trade agreements that we have. Governments can sign trade agreements with every other country, but it is meaningless if businesses do not take advantage of them. My ministerial colleagues and I are constantly reminding businesses to take advantage of the opportunities that we have created with these free trade agreements.
Lord Hannay of Chiswick (CB)
My Lords, last week the US electorate spoke negatively about President Trump’s erratic, chaotic and damaging tariff policy. Does this not now provide a real opportunity for the United Kingdom to help, with other nations, to put the WTO back at the centre of a rules-based trade order, where it should be?
Lord Leong (Lab)
My Lords, the United States’ actions have exposed serious structural weaknesses, particularly in dispute settlement, but abandoning the WTO would leave British businesses more vulnerable to arbitrary tariffs and economic pressure. For example, UK trade with non-FTA partners based on most favoured nation terms was something like £605 billion in 2025. So the WTO’s rules still underpin most global trade, and 72% of global trade operated under MFN terms at the end of February. We must engage with the United States in pressing it for reform and work with partners on practical agreements and interim arbitration.
Lord Spellar (Lab)
My Lords, is not the fundamental point that China was allowed into the WTO and then was allowed to relentlessly break its rules, trading unfairly with huge damage to our industrial manufacturing right the way across the West, with great social and political consequences? What assurances can the Minister give me that, in maintaining and improving the WTO, we will toughen up our approach so that we can properly trade with China on a level playing field to the mutual benefit of international trade?
Lord Leong (Lab)
My Lords, I totally agree with my noble friend. British businesses must be able to compete fairly, and our trade strategy calls for stronger action on subsidies that distort markets and create excess capacity. As major economies, we share the same responsibility as China to support the global trading system. Our bilateral discussions on WTO reform are focused on making the WTO more relevant, flexible and accessible. At senior official level between the UK and China, the WTO working group took place earlier this year in Beijing, covering a level playing field, development and reform issues. Together we have a common agenda to make sure that the WTO functions and works for everybody.
Lord Redwood (Con)
Will the noble Lord rule out imposing tariffs on new products and higher tariffs on them, other than anti-dumping tariffs, which are legal under WTO rules?
Lord Leong (Lab)
The noble Lord knows that we have to reform the WTO. As it currently stands, the dispute settlement is not functioning. It has been more or less paralysed since 2019, when the US refused to appoint any judges to its panel. Until such time that we get the dispute settlement resolved, we have the MPIA, which is the system that the noble Lord, Lord Lamont, mentioned. We are still coming together to try to get some resolution to where there is excess subsidy or dumping of cheap goods in this country. We need to resolve this through the system that we currently have.
Lord Anderson of Swansea (Lab)
My Lords, the consensus rule acts as a brake on positive developments. Do countries have to circumvent that to make progress? Is there any prospect of modifying it?
Lord Leong (Lab)
The noble Lord probably knows better than I do that it is quite difficult to get one consensus from 166 members. That is why consensus has broken down.
The Earl of Effingham (Con)
My Lords, seven leading members of the WTO have challenged the Government’s steel curbs, which cut tariff-free quotas and imposed 50% tariffs. Separately, the House of Lords International Agreements Committee, chaired by the noble and learned Lord, Lord Goldsmith, from the Government Benches, wrote that the UK-US economic prosperity deal was
“not consistent with WTO rules”.
How can this Government credibly claim to champion rules-based trade when the evidence suggests the opposite?
Lord Leong (Lab)
Our US economic prosperity deal is a landmark deal with the US that supports our key British businesses that employ thousands, if not millions, of people. If the noble Earl does not welcome that, perhaps he can tell us what deal he wants with the US.
Baroness Bennett of Manor Castle (GP)
My Lords, the current WTO framework is seen by many as grossly preferential to the largest and richest nations. Least developed countries account for only about 1.1% of global exports, far below the 2.2% target set for 2030 under the Doha programme. Will the Government work with the global South to support its interest, which is, of course, in the interest of the security of us all?
Lord Leong (Lab)
Yes, of course the Government will work with the global South, and any other countries for that matter, to resolve the current stalemate in the WTO. The dispute settlement appellate court is dysfunctional and not working, but meanwhile we have plurilateral, multilateral and bilateral arrangements with various members. There are 61 members in the MPIA, and we are working with them to resolve whatever disputes we currently have among members. We have to find a way to resolve the dispute settlement. Until and unless we find that, we have to carry on with these plurilateral arrangements.
Health: Women and Pain
(1 day, 8 hours ago)
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Baroness Nargund
To ask His Majesty’s Government what assessment they have made of the implications of research published in the journal Nature Medicine on 5 October which found that women report suffering more pain than men at every body site studied.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, it is unacceptable that women spend more years in poor health than men, while pain is too often dismissed and normalised. Our renewed women’s health strategy treats this as a systemic failure, and this research reinforces that. Patient-reported measures will be introduced in gynaecology services to assess whether women’s pain is heard and effectively treated, alongside testing patient power payments, which will be linked to women’s feedback, including their experience of pain.
Baroness Nargund (Lab)
My Lords, I thank my noble friend the Minister for her reply. This large international study has found that more women report pain across 11 body sites compared to men, and over half of them report that their pain has been either ignored or dismissed by healthcare professionals. Given that pain is a leading cause of disability and reduced economic participation, can my noble friend tell us what concrete steps the Government are taking to tackle the gender pain gap and the gender pain management gap, and what actions will be taken if healthcare professionals continue to ignore or dismiss women’s pain?
Baroness Merron (Lab)
My noble friend’s observations are quite right. We have already updated NICE guidance and introduced courses in order to strengthen professional education across a range of conditions. We have introduced targeted initiatives, including the Getting It Right First Time chronic pain workstream. Our introduction of Jess’s rule and Martha’s rule will mean that women can challenge when symptoms persist or they feel that they are not being listened to. We are developing a new multiprofessional capability framework for women’s healthcare in community settings, and that will address a pattern of women’s symptoms being dismissed or normalised.
Baroness Pidgeon (LD)
My Lords, the Government’s women’s health strategy pledges to eliminate the diagnostic issues for women with endometriosis. In the light of Emma Barnett’s recent BBC documentary and Endometriosis UK’s finding that women wait an average of nine years and four months for a diagnosis, will the Minister support the charity’s call for diagnosis times to be reduced to one year or less by 2030, and commit to publishing national data to track progress?
Baroness Merron (Lab)
Women are waiting far too long, which is the reason for the renewal of the women’s health strategy. We have, through the National Institute for Health and Care Research, commissioned a number of studies which are very much focused on the points that the noble Baroness is raising, which are endometriosis diagnosis, treatment and, importantly, experience. We have committed over £4.3 million for new research projects, including a trial to evaluate the effectiveness of pain management programmes, and the noble Baroness will be aware of our commitment for waiting times to be reduced in order that patients, including those with endometriosis, can know exactly what to expect.
Lord Kamall (Con)
My Lords, the Minister said that women’s pain and pain management will be addressed by the forthcoming women’s health strategy. What specific goals and objectives have been set and what accountability will there be if those goals and objectives are not met?
Baroness Merron (Lab)
Action 4 commits to testing patient power payments, and we are prioritising gynaecology services as a test. That will mean that if a woman’s feedback, which will be actively sought, is not what it should be based on their experience—and that includes pain—then payments can be withheld and invested to improve the situation. I am sure the House appreciates that often it is finance which drives change, and this is just one of our new ways of doing that.
Lord Watts (Lab)
My Lords, does the Minister agree that the country needs to target the poorest members of our community, male and female, whose health is worse than the average and who need the resources that we require?
Baroness Merron (Lab)
I agree with that. That is why, in the 10-year health plan and in our manifesto commitments, we are working towards the commitment to halve the gap in healthy life expectancy between the richest and the poorest regions, and setting a minimum standard of healthy life expectancy of 61 years in all areas. That is consistent with halving the gap, and means that we will give attention to all regions of the country, particularly those that need it most.
Baroness Hayter of Kentish Town (Lab)
My noble friend will not be surprised that I ask about osteoporosis. Not only are the fractures themselves painful but so too is the recuperation, and it is particularly women who are affected. As my noble friend knows, I am still awaiting a little more reassurance from the Government. Maybe she could tell us the moves that they will make on this.
Baroness Merron (Lab)
As I have previously committed to and confirmed, as my noble friend will be aware of, the 10-year health plan reaffirms the commitment to rolling out fracture liaison services by 2030 as part of more devolved health services. We continue to work with integrated care boards to make that happen, while investing, for example, £2.6 million in 20 new state-of-the-art DEXA scanners, building on the first wave of investment of £1.9 million in 13 of the scanners last year.
Baroness Hussein-Ece (LD)
My Lords, recent reports have shown a clear lack of awareness and understanding of women’s reproductive health conditions among primary health care practitioners. Other reports have cited that what is needed is to remove the stigma and for there to be more training and awareness, so that women across the country, wherever they live and whoever their GP might be, can expect the same level of support and pain relief should they need it.
Baroness Merron (Lab)
I certainly agree. Looking back at the 2022 women’s health strategy, 84% of women experienced not being listened to by a healthcare professional. As I have already stated, that is totally unacceptable. A third of those women said that this had harmed their mental well-being. This is a very serious matter and that is why we are strengthening professional education across a range of conditions, testing out the patient power payments and introducing patient reported-experience measures. All those should drive improvements of care over the next five years, some more immediately than others.
Lord Patel (CB)
My Lords, one of the commendable objectives defined in the 10-year health plan is the development of women’s health centres. Can the Minister confirm that these will be not just advisory centres but diagnostic and, if possible, treatment centres, and that they will be appropriately staffed and funded?
Baroness Merron (Lab)
The centres will very much take a multidisciplinary approach, not least because they are about seeing women as a whole rather than as a condition. That is the big change we will see. It will inspire change across neighbourhood health services, not just in respect of women.
Baroness McIntosh of Hudnall (Lab)
My Lords, does my noble friend agree that even where chronic pain has been identified in women, or in men, there is often considerable reluctance to accept the available treatment, because long-term pain is very often treated with drugs which have quite significant side effects? Can my noble friend say what work is being done, possibly supported by the health service, to develop pain relief strategies which do not create those side effects?
Baroness Merron (Lab)
Women are certainly more likely to experience multiple long-term and limiting conditions, and with that comes pain. In addition, we are absolutely committed to ensuring that there is a standard of care for, for example, gynaecological procedures such as hysteroscopy. We have consulted with the Campaign Against Painful Hysteroscopy for women with lived experiences around painful procedures, and we have gathered their insights. That is an approach we will continue to take as we develop pain management pathways across a whole range of conditions.
Reservoirs and Water Supplies
(1 day, 8 hours ago)
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Baroness McIntosh of Pickering
To ask His Majesty’s Government what assessment they have made of the latest figures regarding the state of reservoirs and the resilience of water supplies.
Lord in Waiting/Government Whip (Lord Katz) (Lab)
My Lords, the Government are closely monitoring resilience and water refill, but there is no immediate risk to public water supplies. As of 3 November, reservoir storage across England stood at 60.1%, 17% below average for the time of year, with eight reservoirs classed as exceptionally low. However, this is an improvement on the position a month ago. The National Drought Group, which is convened by my honourable friend Minister Hardy, is meeting weekly to ensure water companies take every action available to minimise the impacts of this drought, while the Environment Agency is prioritising protection of public water supplies in areas facing severe drought.
Baroness McIntosh of Pickering (Con)
My Lords, parts of the country are in severe drought. Yorkshire went into drought for the first time in October this year. We are told that we need 450 new farm reservoirs to be built each year by 2050, yet just 34 have been completed in the last five years. Will the department see fit to help growers and farmers by easing the drought permitting system, permitted development rights and abstraction licensing to facilitate building on-farm reservoirs?
Lord Katz (Lab)
Defra and the Environment Agency are working rapidly to improve and accelerate determination times for abstraction permits. We have reduced the average wait and processing times in significant performance outliers, with permitting performance now at its highest level since 2018. The Environment Agency is also improving digital systems to reduce administrative burden and complexity. We are reviewing approaches to high-flow abstraction, trialling dynamic abstraction and making up to £15 million available for on-farm reservoirs, which help farmers capture and store water during wetter periods, alongside taking steps to remove planning barriers to reservoir construction.
The Lord Speaker (Lord Forsyth of Drumlean)
The noble Lord, Lord Campbell-Savours, is taking part remotely. I invite the noble Lord to speak.
Lord Campbell-Savours (Lab) [R]
Looking worldwide at water supply resilience, Ismail Serageldin, a former president of the World Bank, has predicted that wars of the 21st century will be fought over water. With estimates of potentially millions of people migrating to more temperate climates due to climate change and water scarcity, are we thinking through the consequences of that for political turmoil and social cohesion at a time when we are cutting overseas aid and exacerbating the problem?
Lord Katz (Lab)
Unfortunately, I cannot quite find my tab on overseas aid on this Question about reservoir supply in England, but my noble friend is of course completely correct that, across the globe, supply of water and the somewhat combative approach to maintaining it are a real problem. That is only exacerbated by climate change and it is why this Government are taking on the challenge of meeting our net-zero targets, working with the rest of the world to ensure that we have proper climate change amelioration in place not just in this country but across the world. We want to ensure that people across the world, including in England, can access adequate supplies of water.
Baroness Grender (LD)
My Lords, of course we need new reservoirs, but does the Minister agree that, with failing water companies losing nearly 3 billion litres a day to leakage, they risk becoming like giant colanders emptying faster than they fill? Will the Government commit to binding leakage targets now alongside building reservoirs—given that Havant Thicket is not due until 2031—rather than waiting, as we are all waiting, for the water Bill, the timing of which keeps slipping?
Lord Katz (Lab)
I agree with the noble Baroness that it is important not just to invest in long-term infrastructure—reservoirs—but to make sure that we do the day-to-day work, whatever the conditions of drought or otherwise, to improve water infrastructure. She will be aware that the Government have set an interim target of a 30% reduction in leakage by 2032 from the 2017-18 baseline. We expect Ofwat to challenge water companies across the industry to halve leakage by 2050 compared to 2017-18 levels. That is one of the Government’s targets for Ofwat. Yes, there will be more of this in the forthcoming water Bill; I could say to the noble Baroness “when parliamentary time allows”, but I think she will be aware that this is right at the top of the Government’s priority list. Water legislation was announced in the King’s Speech, so we expect it in due course.
The Duke of Wellington (CB)
My Lords, it is the policy of the current Government, as it was of the previous Government, to reduce water leakage by 50% by 2050. Would the Minister agree to ask his departmental colleagues to review this target, which does not seem ambitious enough given the drought and other water supply problems that we all know about?
Lord Katz (Lab)
I am not sure I will ask my ministerial colleagues to review the target. We need to be ambitious on behalf of the water companies and put their feet to the fire a little more than they have been in the past. We are very clear: the water companies should have an ambitious target to halve leakage by 2050, because, as the noble Baroness, Lady Grender, asked, what is the point of building new reservoirs, which takes a very long time, if we cannot make sure that we are reducing leakage to conserve the supply that we are collecting from them?
Lord Roborough (Con)
My Lords, the concerning levels of water in storage—17% beneath seasonal norms, as the Minister mentioned—reflects not just a dry year but systematic underinvestment by the water industry against long-standing forecasts for demand growth and climate change. What assessment have the Government made of the speed, cost and volume of improvement that is possible from nature-based solutions and on-farm reservoirs, versus the expense, controversy and long timelines of new reservoirs? I declare my interest as a farmer and landowner.
Lord Katz (Lab)
I thank the noble Lord for his question. His point about the potential for nature-based solutions to water conservation is part of a wider picture. Yes, we have to make long-term investment in reservoirs and ensure that farmers find it easier and quicker to create their own abstraction on on-farm reservoirs, but there are nature-based solutions too. That is one of the reasons why we expect water companies to plan for one-in-500-year drought. We have to make sure that they prepare for all eventualities, and some of the smaller fixes that we find in nature-based solutions are quick wins that all water companies should promote.
The Lord Bishop of Manchester
My Lords, one of the fastest-growing areas of water usage is in data centres. How do the Government plan to assess how much water is used by data centres in future, where it is sourced from and whether we ought to insist that new data centres recycle the same water rather than constantly using fresh water?
Lord Katz (Lab)
The right reverend Prelate may be aware that the Minister for Water and Flooding issued a Statement on data centres last month, on 28 October, which set out a clear approach to managing water demand as the sector grows. Current evidence suggests that data centres account for quite a small proportion of water demand, estimated at less than 0.2% of the non-household sector in England, and that many facilities already use highly water-efficient cooling technology. Future growth could place extra pressure on local water resources, however, so we expect data centres to minimise water demand where they can and consider alternative sources before using additional public water supply.
Baroness Andrews (Lab)
My Lords, west Sussex is one of the areas that are very badly stressed, as the Minister will know. Ardingly reservoir has 20% of its normal infill. We have not built a new reservoir since 1992—interestingly, coinciding closely with the privatisation of water—and reservoirs take 10 years to build. What realistically can be done in the next 10 years, particularly in areas where we predict persistent drought?
Lord Katz (Lab)
We have to reform the sector, as the Government set out in response to the Cunliffe report. We need more streamlined, efficient regulation to ensure that water companies do the job that we have been talking about this afternoon—reducing leakage—as well as longer-term investment and promotion of better and wiser water usage by everybody, be they businesses, such as data centres, or households. That is why we are committed to setting up new, innovative responses, such as regional water councils, to ensure that water companies perform for the public and for businesses and not just for themselves.
Lord Teverson (LD)
My Lords, to come back to my noble friend’s question about leakage, the fact is that we lose 20% of the volume of water—some 2.6 billion litres a day—but that has not gone down. That percentage has stayed the same, so we are not going in the right direction. Will the Government get tough with the water companies to make sure they take the targets that we set seriously? At the moment, there is no action.
Lord Katz (Lab)
In 2024-25, the Government saw a 12% reduction in the total leakage reported by water companies. To sustain and build on this trajectory, we are investing £720 million through the current Ofwat price review period in smart technology, including meters, which will help to identify and reduce leakage. We are enabling increased rollout of smart meters via the smart water meter delivery group. We continue to hold water companies to account to ensure that they are delivering on their leakage reduction targets, rolling out more things such as smart metering and levying financial penalties if companies fail to meet these targets.
Interpol: Russia
(1 day, 8 hours ago)
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Lord Garnier
To ask His Majesty’s Government what steps they are taking (1) unilaterally, and (2) in co-operation with other member states of Interpol, to prevent the abuse of Interpol red notices and diffusions by Russia.
The Minister of State, Home Office (Lord Hanson of Flint) (Lab)
The Government take any misuse of Interpol systems extremely seriously. We will work with the National Crime Agency and Interpol to monitor safeguards, including the Notices and Diffusions Task Force, which scrutinises red notices and diffusions. We will also work with like-minded countries through Interpol’s governance structure to strengthen safeguards and take action against abuse, including by Russia.
Lord Garnier (Con)
My Lords, nobody who practises in this area of the law—I declare that interest—will be surprised by Russia’s abuse of the system to target its political opponents abroad. Ben Keith, a barrister well known for his expertise in this area of law, has recently written in the Times:
“Russia has been the worst offender for years”,
despite Interpol claiming, since the invasion of Ukraine in 2022, that it has the matter under control. Will the Minister ensure that, on our own and with our democratic allies, we take robust and effective measures to prevent Russia abusing the system, most obviously by not allowing Interpol to publish any red notices or diffusions unless they have been previously examined in detail?
Lord Hanson of Flint (Lab)
I am grateful to the noble and learned Lord for his question. He will know that Interpol is responsible for its own governance and structure; we are simply a part of that. We are keen to ensure that standards are maintained. That is why we play a role in the various committees to uphold scrutiny of these issues. Indeed, there is currently a UK candidate in the election for members of the body that examines red notices. It is important that those standards are maintained. If there are breaches then Interpol will take action, not the UK Government independently.
Lord Carlile of Berriew (CB)
My Lords, given that Russia has applied for 46% of the 6,370 Interpol red notices out at the moment, do the Government not think that this country should press against the slow, inefficient and not very effective appellate process, place the burden for proving such applications on the arresting state, and press for appeals founded on the merits of each individual case?
Lord Hanson of Flint (Lab)
Any misuse of Interpol tools, including red notices, is taken seriously by this Government and, I would suggest, by Interpol itself. There are robust safeguards in place: 100% of red notice requests are reviewed before publication by the Interpol Notices and Diffusions Task Force and the UK is an active participant in the governance committee for data processing, which discusses all aspects of Interpol’s constitution. There are sensitive matters for discussion. The noble Lord has made suggestions. Ultimately, it is for Interpol to determine its procedures.
Baroness Doocey (LD)
My Lords, earlier this year, the BBC’s extensive investigation revealed that Russia had used Interpol’s messaging system to find the whereabouts of a person, even though Interpol had already turned down a request for a red notice. Are safeguards in place to ensure that UK officials do not pass information through this system? Will those messages be given the same level of scrutiny as red notices?
Lord Hanson of Flint (Lab)
There are strict rules by which Interpol deals with these matters. Obviously, we will participate in helping Interpol to scrutinise those rules but, ultimately, it is for Interpol itself to determine how it deals with requests and how they are scrutinised. There is an important mechanism in place. The UK is very keen to ensure that scrutiny takes place, and we have measures whereby all requests are scrutinised and considered. Any abuse of those requests will be considered as very serious action by both Interpol and the UK Government.
Lord Alton of Liverpool (CB)
My Lords, what progress, if any, has been made in implementing any or all of the recommendations of the Joint Committee on Human Rights report on transnational repression, published in July 2025, which drew on the submissions of more than 180 experts? In particular, is the Minister revisiting the JCHR’s calls for a review to consider mechanisms for alerting individuals about politically motivated red notices, along with a mechanism to protect British nationals abroad, and the committee’s calls for enhanced police and immigration staff training? Has that report led to any changes in the handling of red notices or to greater cross-departmental and international co-operation?
Lord Hanson of Flint (Lab)
The noble Lord will remember that we had a debate on the report in this House in February. The Government will look at all the recommendations; we keep all the matters under review. I will certainly give him an update in writing, if I may, on progress on implementation of the recommendations that we have accepted. He will know that we did not accept all the recommendations—that is the nature of Governments and Select Committee reports—but I will give him a full response on where we are to date with their implementation.
Lord Davies of Gower (Con)
My Lords, the United States has addressed misuse of Interpol red notices by passing two related pieces of legislation—the so-called TRAP Acts. Given the deluge of threats from Russia and its ongoing campaign of transnational repression, will the Government show leadership and pass similar legislation in the United Kingdom?
Lord Hanson of Flint (Lab)
We are trying to play a constructive role in scrutinising red notices and other methods by Interpol as a whole. Ultimately, the governance of Interpol, which comprises 196 countries, is a matter for Interpol. We will help support Interpol in that scrutiny but, ultimately, it is for Interpol to determine its governance and operations.
Lord Garnier (Con)
My Lords, I am grateful to the Minister for his several answers but they give the impression that the Government are being a little passive. I agree that there are a huge number of members of Interpol, but it requires leadership from a major country such as the UK to engender some sense of enthusiasm for the proper scrutiny of red notices issued by countries such as Russia, which we all know—and he, his department and the Government as a whole know—is fiddling the system and causing abuse. Could the Minister, perhaps later this afternoon, have a word with some of his colleagues in government and ask them to move this up a gear?
Lord Hanson of Flint (Lab)
I never wish to give the noble and learned Lord the impression that I am not taking things as seriously as he would wish. The UK believes there are robust safeguards in place: 100% of red notice requests are reviewed before publication by the Interpol Notices and Diffusions Task Force, and the UK is an active participant in the Interpol governance committee for data processing, which discusses all aspects of Interpol’s constitution, including safeguards against misuse. We strongly support Interpol’s efforts to ensure that systems are in place and, where necessary, we will continue to press for reform on those matters. I return to the point that, ultimately, we are one part of a 196-member organisation; it is for Interpol as a whole to determine its governance and its responsibilities in those areas.
Lord Purvis of Tweed (LD)
My Lords, further to the question from the noble Lord, Lord Alton—I should declare that I am sanctioned by Russia—in September the UN rapporteur at the human rights office said that the industrial-scale transnational repression by Russia, including the abuse of Interpol procedures, warranted much further UN action, including the concept of a binding UN convention on transnational repression. Transnational repression is not codified in our legislation in those specific terms, but will we support UN efforts to ensure that Russia does not get away with abusing Interpol, and support other methods to ensure that transnational repression is cut out from the UK entirely?
Lord Hanson of Flint (Lab)
I share something in common with the noble Lord: I am also sanctioned by Russia, which is an interest that I declare. It is a matter for the Russians; they decided to sanction me for the Russia report that I wrote with the Intelligence and Security Committee back in 2019 when I was a Member of the other House. We will always hold Russia to account, particularly since the invasion of Ukraine, for its international transgressions. We will work with Interpol in this context to ensure that there is proper and effective scrutiny of red notices, and that they are not used for persecution or for political purposes.
Lord Hogan-Howe (CB)
My Lords, the Minister has concentrated, quite properly, on the governance of Interpol and its responsibilities. However, when a red notice is received in the UK a responsibility is placed on our Government and our police forces. It might help people to be reassured about how that process is managed to ensure that an improper red notice is not acted on to locate, arrest or attempt to extradite to another country.
Lord Hanson of Flint (Lab)
As the noble Lord will know, a red notice is not an extradition agreement; it is a request for information surrounding an individual. There are lots of safeguards in the UK with regard to that information, but in the context of the Question—and this is a perfectly legitimate point that all noble Lords have made in this case—the governance and work on this issue ultimately remains a matter internationally for Interpol.
Rape and Serious Sexual Offences: Jury Directions
(1 day, 8 hours ago)
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Baroness Levitt
To ask His Majesty’s Government what assessment they have made of introducing mandatory jury directions on harmful myths and stereotypes in trials for rape and serious sexual offences; and the potential implications of this for confidence in the criminal justice system among victims and the public.
The Lord Speaker (Lord Forsyth of Drumlean)
My Lords, I remind the House to exercise our customary caution in refraining from references to ongoing investigations or court processes.
The Parliamentary Under-Secretary of State, Ministry of Justice (Lord Lemos) (Lab)
My Lords, independent judges already can and do give directions concerning rape myths, based on the specifics of each case. In the Courts and Tribunals Bill, we are taking action to stop rape myths being weaponised in court, ensuring that previous allegations of rape or compensation claim information cannot be used unfairly as evidence. We will consider my noble friend Lady Levitt’s amendments to the Bill on this issue, which will be debated next week.
Baroness Levitt (Lab)
My Lords, Russell Brand has just been sentenced to 10 and a half years’ imprisonment. Irrespective of the accuracy of every detail reported from the trial, the reports themselves have caused considerable distress to victims and grave concern among those who support them. I welcome the Prime Minister’s recognition of that harm. Does my noble friend agree that, while most judges follow best practice by directing juries about harmful myths and stereotypes, the fact that some do not means that it is now time for Parliament to require that such a direction be given—before any evidence is heard, not just at the end of the trial, when the damage may have already been done?
Lord Lemos (Lab)
My Lords, your Lordships would not expect me to comment on the Russell Brand case but I will say this: I pay tribute to the courage of the victims in seeing this case brought to justice. On the wider question, judges give a tailored direction to assist the jury where they deem it necessary, based on the specifics of each case. The primary source of guidance, as my noble friend knows, is the Judicial College’s Crown Court Compendium, which gives examples where guidance may be necessary. All judges who hear sexual offences in the court receive specific training through RASSO ticketing. The specific issue my noble friend raises is exactly what we will be debating in relation to her amendment.
Lord Keen of Elie (Con)
Does the Minister consider that Parliament’s imposition of mandatory jury directions would ever be an appropriate intrusion into the exercise of independent judicial discretion?
Lord Lemos (Lab)
The Government support the exercise of independent judicial discretion. We are, as the noble and learned Lord knows, taking measures in the Courts and Tribunals Bill to ensure that evidence in relation to previous sexual behaviour that should be inadmissible is inadmissible. There is also our approach to the relevance of previous domestic abuse convictions. Of course, judicial independence is absolutely essential to the rule of law.
Baroness Stowell of Beeston (Con)
My Lords, I echo the Minister’s tribute to the women, and I would extend it to the journalists and media who have been quite dogged in this case. Does the Minister agree that any new anti-SLAPP law must contain an accessible early dismissal mechanism, such as that in my Private Member’s Bill, which is based on objective tests, to ensure that everyone subject to a SLAPP can access that mechanism? This includes litigants in person, such as Sylvie Berki, who has been subject to the most draconian injunction by Russell Brand—for life—preventing her even speaking to the police after accusing him of assault in 2014.
Lord Lemos (Lab)
I thank the noble Baroness. As I have said, I will not comment on the Russell Brand case—
Lord Lemos (Lab)
We will have an opportunity to debate SLAPPs again, not least in relation to the noble Baroness’s Private Member’s Bill.
Baroness Chakrabarti (Lab)
My Lords, does my noble friend agree that, while this House perhaps more than anywhere else will always be concerned to protect judicial independence and discretion, Parliament none the less legislates all the time? It is getting the balance right between discretion and rules that makes good law. Given the universality of rape myths in society and that in the past Parliament has intervened—for example, to prevent rape defendants cross-examining in person—this is a worthwhile debate that our noble friend Lady Levitt has raised.
Lord Lemos (Lab)
Yes, I absolutely agree that my noble friend has raised a worthwhile and important debate. At the heart of this is the fact that rape myths are pervasive, widespread and widely damaging in our society. That is what we need to do something about. The Government want to ensure—I am sure my noble friend agrees—that they are not used to distort criminal trials and retraumatise victims. Victims should never feel that they are on trial. We know we need to do better on ensuring that victims of rape and sexual abuse feel safe to seek justice. I pay tribute to my noble friend Lady Levitt’s work at the Crown Prosecution Service to achieve that. But this is ongoing work, and of course the Government will continue to think about it.
Lord Marks of Henley-on-Thames (LD)
My Lords, worryingly and counterintuitively, young people seem unduly susceptible to rape myths. End Violence Against Women found, for example, that only half of 18 to 24 year-olds recognise that rape is still rape even if the victim does not physically fight back, and that only 42% of that age group realise that a relationship or marriage does not mean assumed consent to sex, as against 87% of over-65s. Does this not underline the need not only for clear directions to jurors, with which I fully agree, but for more and better sex and relationship education in school?
Lord Lemos (Lab)
Yes, it does. The noble Lord’s points about the attitudes of young people are well known and deeply concerning, and they certainly need to be addressed through relationship and sex education. But it is not just young people: I make the fairly obvious point that we are particularly concerned about how some of these myths are perpetrated online and the access that young people have to that. That is why our work in the Online Safety Act, which is ongoing, will continue. This is an extremely important area of work, and the noble Lord draws our attention to how it is a matter not simply of the law but of wider attitudes in society among young people, and we need to address that on a very broad front.
Captain of the Honourable Corps of Gentlemen-at-Arms and Chief Whip (Lord Kennedy of Southwark) (Lab Co-op)
It is the turn of the Cross Benches.
Lord Burnett of Maldon (CB)
I am very grateful to the noble Viscount for giving way. Will the Minister agree with me, at least in respect of the following short propositions? First, the Court of Appeal has now, for almost two decades, been giving judgments about rape myths and encouraging judges to give directions in appropriate cases. Secondly, it would be a very good idea, before this matter is debated later in Committee, were everybody to read the Crown Court Compendium dealing with this topic. It is comprehensive, detailed and instructive. Thirdly, picking up the point made by the noble and learned Lord, Lord Keen, will the Minister agree that it is unprecedented for Parliament to seek to instruct judges on how they should direct juries, as opposed to laying down the substantive law, and that to do so would be an unacceptable intrusion upon judicial independence?
Lord Lemos (Lab)
I thank the noble and learned Lord for that question. As he says, we will debate it next week. But the principles he sets out are of course the right ones, and I agree with him. I have actually read the Judicial College’s Crown Court Compendium on this subject, and I commend it to people where the guidance may be necessary. I do not want to jump the gun on this—we will debate it in relation to my noble friend Lady Levitt’s amendment next week—but the principles he lays out seem entirely responsible and sensible.
Viscount Hailsham (Con)
My Lords, I support my noble and learned friend on our Front Bench by saying that, subject to appropriate guidance from the Court of Appeal, directions are best left to the discretion of the trial judge, who has presided over the trial and is familiar with the issues.
Lord Lemos (Lab)
I think I have made it clear, but I am happy to make it clear again, that the principle of judicial independence in these cases—in all cases, indeed—is a fundamental building block of the rule of law. We are not seeking to undermine that in any way. As I have said, independent judges already can and do give direction concerning rape myths; we do not want these myths to be weaponised, but we also do not want that to compromise the independence of judges.
The Lord Bishop of Manchester
My Lords, we have rightly been reflecting on the trauma that victims and survivors face in court and trying to see how we can reduce that. One of the things that make trauma worse is the sheer length of the delay between when offences are committed and initially detected and when trials happen. What work are the Government doing with the Crown Prosecution Service to try to see that serious sexual offenders are brought to justice more quickly, so that survivors and victims do not have to wait so long to give their evidence?
Lord Lemos (Lab)
I entirely agree with the right reverend Prelate on the damage that delays, particularly in the Crown Court but also in the magistrates’ courts, do to victims in those circumstances. That is why the Government are legislating in the Courts and Tribunals Bill. It is not a question simply of working with the Crown Prosecution Service, which of course we will, and already, do; it is with the specific intention of reducing waiting times and the damage those do to victims that we are legislating.
Baroness Armstrong of Hill Top (Lab)
My Lords, the evidence is that judges sometimes look as though they have not actually read the guidance, which leads to very different interpretations and control of trials. In the north-east, in Northumberland, a previous PCC recruited a group of women as volunteers who were given in-depth training around what the law actually meant and said, and they would turn up at rape trials. The judge would know that they were there—it was all agreed beforehand—but it meant that the judges were much more attentive to how they conducted the trials. When that happened, you did not get what I saw, with one group of perpetrators behaving so badly that the victims—or the alleged victims, as the alleged perpetrators would have said—actually left the courtroom and left the case because they were being so intimidated during the trial. We need to improve how we do it. Can we make sure that we improve these things by widening the number of people who say something?
Lord Lemos (Lab)
My noble friend is clearly right that if the experience of being a victim and giving evidence in these cases is so traumatising or retraumatising, one can understand—particularly, as the right reverend Prelate said, in the context of long delays—why victims would find that a really serious problem. As I have said, that leads to us not having the track record that we would wish for in prosecuting these cases. The specific initiative that my noble friend refers to is a civil society initiative, and I welcome civil society initiatives such as that as part of an ongoing social campaign to change this question of rape.
Baroness Sugg (Con)
My Lords, the Prime Minister’s comments on Friday:
“We need to do more to support victims of sexual assault and rape, and we will do that”
have been broadly welcomed by survivors but have also raised expectations of swift action. What concrete steps are the Government going to take to provide that support?
Lord Lemos (Lab)
I thank the noble Baroness and pay tribute to her for her own work in this area. On what we are doing to support rape victims, we are introducing independent legal advisers for victims of adult rape this year, with £6 million of initial funding over the next two years. We are introducing a package of crucial legislative reform to protect victims, which I have already talked about, and we are delivering on our commitment to introduce a specialist rape and serious sexual offences court, backed by £23 million of funding. That is an extremely important initiative—and I see the noble Baroness nodding in agreement. The way in which those courts are rolled out—and, as she knows, we are rolling them out— will, we hope, make a big difference.
Finally, we are establishing a new rape justice taskforce, chaired by the Lord Chancellor and bringing together leaders from across the criminal justice system, directly to tackle the rising rate of postponed rape trials and confront the rape myths that cause victims to withdraw from their own cases. I hope that that full answer gives the noble Baroness the reassurance that she seeks.
Business of the House
(1 day, 8 hours ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Smith of Basildon
That Standing Order 44 (No two stages of a Bill to be taken on one day) be dispensed with on Monday 23 November to enable the Church Appointments (Repeal of Discriminatory Provision) Bill to be taken through its remaining stages that day and that, in accordance with Standing Order 47 (Amendments on Third Reading), amendments shall not be moved on Third Reading.
The Lord Privy Seal (Baroness Smith of Basildon) (Lab)
My Lords, as this Motion refers to a fast-tracked Bill, I thought it would be useful to set out the arrangements for the scrutiny of this legislation, as agreed by the usual channels. Second Reading will take place tomorrow during the dinner break, at a convenient point after or around 7.30 pm. Subject to agreement of this Motion, all remaining stages will then take place on Monday 23 November. The Chief Whip will set out further details for arrangements from 23 November in due course, if they are needed.
Health Bill
(1 day, 8 hours ago)
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Lord Scriven
Member’s explanatory statement
This amendment, consequential on the amendment in the name of Lord Scriven to replace clause 11, limits delegation directions to ICBs to public health functions.
Lord Scriven (LD)
My Lords, in speaking to this group, which has many amendments in my name, I will speak in particular to Amendment 40. Amendment 30 is consequential and is a probing amendment. Most of my amendments in this group ask the question why the Secretary of State requires such huge powers of direction. I know that, in the next group, we will come to what happens if the Secretary of State uses those powers of direction. This is a probing amendment, and I will be very clear at the end about exactly why I am probing.
When you abolish a body the size of NHS England, its powers have to land somewhere. In this Bill, they land overwhelmingly on the desk of the Secretary of State. Clause 11 is the heart of that. It gives the Secretary of State a general power to direct integrated care boards on how they exercise their functions. I want to take the Committee through what that power actually does, because I do not think its breadth has been fully grasped. New Section 14Z61 lets the Secretary of State direct a board—one board, several boards, indeed all ICBs—on whether to use a power at all; on when and how a function is exercised; on the conditions to be met first; and on what the board must take into account.
Where an integrated care board’s decision depends on it forming an opinion, the Secretary of State can inform that opinion themselves and direct the ICB to act without forming an opinion at all. The board’s judgment becomes optional. There are three exceptions: there should be no directing the appointment of an aimed individual, the care of an individual patient or treatment contrary to NICE guidance. They are all sensible and my amendment keeps each one, applying them to its commissioners, which I will talk about later. But outside those three exceptions, there is little that the Secretary of State could not direct an integrated care board to do.
Look at what the department told the Delegated Powers and Regulatory Reform Committee: the department’s memorandum is remarkably candid. It concedes that NHS England has no general power to direct boards at all; it can direct only on primary care or where a board is failing or at risk of failing. It concedes that the Secretary of State’s existing
“power to direct NHSE … has only been used on highly technical functions”.
That is not a transfer; it is a brand new power far wider than anything NHS England has ever held dressed up as housekeeping.
How will this be scrutinised? It will not. The memorandum says plainly that there will be “no parliamentary procedure”—neither affirmative nor negative; nothing. Instead, there will just be publication
“as soon as reasonably practicable”
after the event. On the companion power in Clause 8, which will let the Secretary of State order a board to take on any of the Secretary of State’s health functions, the department says that directions are preferred because they act
“without taking up valuable parliamentary time”.
Scrutiny is not a waste of parliamentary time: it is the job of this House and this Parliament.
The memorandum goes further. Directions are chosen, it says, because changes can be made
“more quickly than they would through regulations”
and
“in a level of detail that would not ordinarily be included on the face of primary or secondary legislation”.
Translated, this route is chosen precisely because it avoids Parliament. It tells us that the two powers may be used together to direct a board to take on a function under Clause 8 and then direct how to carry it out under Clause 11. That is not strategic commissioning; it makes the ICBs a branch office of the Secretary of State.
There is an inconsistency, too. The department says that waiting times and patient choice requirements in Clause 16 belong in regulations because they
“need to be consistently applied across the NHS”.
Yet it justifies directions on service specifications and clinical pathways on exactly the same grounds of national consistency. If consistency demands regulations for one, why does it demand no parliamentary procedure at all for others? I note that Clause 16 will omit Section 6E, the existing regulation-making power, and put narrower powers on waiting times, patient choice and appeals in its place. Beyond those, rules that Parliament could see can be replaced by instruction it reads about afterwards.
Even the failure regime in new Section 14Z62A, which will let the Secretary strip an ICB of its functions, sack the chief executive and direct who replaces them, at least requires published reasons. The general power used on an ICB that is doing perfectly well does not even require that. The pattern continues. The Government’s October supplementary memorandum adds yet more direction powers over new maternity and neonatal commissioners and describes no procedure for how to do so. I also note that it describes these as “subordinate legislation”; subordinate legislation that Parliament never sees is a curious creature.
Add the removal of the mandate and the removal of the prescribed content of performance assessments, and the direction of travel is obvious. The things that give ICBs a framework and gave Parliament sight of it are taken out, and the things that allow ministerial instruction are put in. The Health Foundation is right that this hands too much of the day-to-day running of the NHS to Ministers, and a Secretary of State who can direct any ICB on anything will rightly or wrongly be blamed for everything.
My amendment is deliberate in its broadness, as I want to understand the Government’s thinking. I, for one, do not think that it will be accepted by the Government; that is why it is a probing amendment. It does not deny that the Secretary of State must be accountable for the NHS, but it offers a different way of doing it. First, the Secretary of State would set national outcomes for the health service in England, laid before Parliament, with an annual report on progress. That would replace the mandate that the Bill abolishes. Secondly, the Secretary of State would set outcomes for each board, after consulting it and having regard to local needs assessments and neighbourhood health plans. Those outcomes are results for patients, not instructions on means. That is the line between holding to account the NHS and the Secretary of State, and the Secretary of State operationally running it.
Baroness Bennett of Manor Castle (GP)
My Lords, it is a pleasure to follow the noble Lord, Lord Scriven, who finished where I am going to start, with the huge powers of direction that the Bill provides to the Secretary of State. His amendments are directed primarily towards parliamentary accountability; my Amendment 39 is about keeping decision-making power local.
This amendment would
“prevent the Secretary of State from using the general power of direction to determine individual local commissioning decisions, while limiting directions on specialised services to defined national purposes”.
The noble Lord, Lord Scriven, said that his amendments are probing. I am afraid that mine aims to suggest a way forward for the Government, because I suspect that we will find in many amendments in this area that the House wants to see something happen with the overweening power that the Bill currently provides. As the noble Lord said, this appears to be going in the opposite direction of what the Government say their intentions are for the devolving of power and resources down to local areas.
What we have here is a fundamental question about where decisions on the NHS should be made and who should make them. Of course there should be national standards and accountability, but that is very different from giving the Secretary of State the power to intervene in the day-to-day commissioning decisions of local health bodies. My amendment talks about things such as
“the opening, closure or relocation of a particular NHS service or facility … the location at which a … service is provided”
and who should provide services.
As the Nuffield Trust has pointed out, the English NHS is already unusually centralised, compared to other similarly sized health systems. The Bill takes us even further in that direction by giving the Secretary of State powers to intervene in integrated care boards well beyond those currently available to NHS England. The powers over NHS foundation trusts exceed the powers that the department held even before NHS England was created. The concern is that these powers might be used not simply when an ICB is failing but when it is not following the political interests, personal prejudices or even whims of the Secretary of State.
Integrated care boards exist to make commissioning decisions that reflect the needs of their local populations. Those needs vary across the country and Westminster does not necessarily—or even very often—understand such individual regional differences. The health challenges facing a rural community are not necessarily the same as those of an inner-city population, but a large inner-city population may have more political clout than a dispersed rural one. The availability of services, transport links and local demographics all matter. Decisions about where a service is provided, whether a facility should open or close or which provider should deliver care require an understanding of those local circumstances. They should not be a matter of political direction from Whitehall.
I think we can all imagine the real risk that these powers will encourage Ministers to announce some great input into an individual hospital facility or services without properly understanding the consequences for the community concerned, or indeed from political motivations. We are talking about the potential for political favouritism, with decisions influenced by that rather than the needs of patients.
The amendment would prevent the Secretary of State using the general direction power to make individual local decisions, but the separate intervention powers under Section 14Z62A remain available. It recognises that specialised services are different; they are often complex, expensive and relatively rare and there is a strong case for national consistency and collaboration between integrated care boards there. In relation to specialised services for clearly defined national purposes, the amendment therefore allows directions for
“determining which services should be commissioned as specialised services”,
ensuring compliance with national standards and commissioning policies, and requiring collaboration between ICBs. We would be allowing national co-ordination where it is needed without providing an open-ended power to micromanage local healthcare.
It is difficult to see how meaningful devolution can take place if local health bodies know that the decisions they make can be overridden by the Secretary of State. Local bodies must have the freedom to make decisions and the accountability that goes with that freedom. We should be building an NHS where local leaders are supported to make decisions based on evidence, professional expertise and the needs of their population, not a system where they are looking over their shoulders and anticipating the next political intervention from Westminster.
We know that that kind of central control can encourage defensive decision-making, discourage openness and make it much harder to have honest conversations about the challenges facing local services. This amendment seriously aims to offer a practical way forward: it would preserve the Secretary of State’s ability to intervene when an ICB is genuinely failing and ensure national co-ordination of specialised services, while protecting the integrity of local commissioning decisions.
Baroness Manzoor (Con)
My Lords, the noble Lord, Lord Scriven, has tabled the probing Amendment 40, which includes the proposed new Section 14Z61A. It is important because it seeks to improve health outcomes, rather than simply restructuring the NHS, which appears to be the central purpose of the Health Bill. As the noble Lord stated, it would require the Secretary of State to publish clear national health outcomes covering patient safety, quality of care, waiting times, health inequalities and the effective use of resources. Progress would be reported to Parliament, strengthening transparency and democratic accountability.
Crucially, proposed new Section 14Z61 would require the Secretary of State to set specific outcomes for each integrated care board, reflecting local health needs and involving consultation with local authorities and mayors. This would give ICBs clear responsibilities while preserving flexibility over how they deliver improvements, which would be key. Together, such provisions would strengthen the Bill by creating measurable accountability, protecting local decision-making and ensuring that NHS reform delivers tangible improvements in patient care, illness prevention and public health.
I strongly support this important amendment from the noble Lord, Lord Scriven, and I urge the Minister to adopt it, particularly if the Government’s 10-year health plan strategy is to succeed in the long term.
Baroness Coffey (Con)
My Lords, I am interested in the amendments tabled by the noble Lord, Lord Scriven, particularly Amendment 40, but I will speak to them in a slightly different way. What I am trying to understand is how his amendment differs from the current NHS constitution—it is reviewed every 10 years on a statutory basis; it happened only fairly recently—and the targets associated with patients’ constitutional rights. How would this work with the outcomes for the health service and integrated care boards?
I am actually very supportive of the change the Government are seeking to introduce. That partly comes from experience of trying to pull a few levers: sometimes the levers work, but other times you need to get on with things. A good example of how this could be deployed is if a Prime Minister decides that, instead of how IVF treatment happens now, there will be a postcode lottery around the country. At the moment, I think you are guaranteed just one. If they decided that everybody should have three, by issuing a direction and—importantly, given the clause—putting in the money to go with it, they could straightforwardly make a transformational change across the NHS. That would be instead of the Lansley Act approach, which is to work from the bottom up and evolve over time. This brings us back full circle: understandably, the public think that politicians are generally in charge and if they stand on a manifesto commitment, they should be able to deliver it. This measure is welcome in that regard.
I do not think that this will be used to stop the closure of a particular hospital, but—dare I say it—if it is, so what? That would be acceptable so long as the Government come up with the cash to keep that hospital or maternity care unit open. Very soon, there will be only one maternity unit in the whole of the county of Norfolk, and that is a big area to cover. Perhaps that is because there are fewer births, but it is nevertheless worrying, given that it is necessary to travel for well over an hour to get to a hospital to give birth. If the Government decide that this is not appropriate, instead of going through this rather complex ICB consultation, it would be much easier if the Secretary of State could say that they are not prepared for that to happen and are prepared to achieve something else—whatever the situation is. I am just giving examples because I think we were asked what kinds of examples this could be used for.
Lord Patel (CB)
My Lords, I have Amendment 47 in this group. I have others that were related—Amendments 241 and 83—but I am not speaking to them today as the Bill team did not like them being grouped together, so I have been kind and let them go. However, they all concern one thing: a total absence in the Bill of any public health and prevention safeguards, despite that being the key theme of the Government’s 10-year health plan.
I will speak briefly to Amendment 47, which is neither a probing amendment nor a way forward, but concerns a no doubt unintentional omission on the part of the Government regarding the Secretary of State’s statutory duty to consult public health professionals. Of significant concern is the repeal of the existing statutory duty on NHS England to consult public health professionals in the discharge of these functions. The duty removed by the Bill is not explicitly transferred to the Secretary of State. The BMA says that although the Bill’s Explanatory Notes state that
“the Secretary of State should continue to seek public health advice, relying on ministerial discretion”
—we should note the phrase “ministerial discretion”—
“rather than a statutory requirement weakens an important safeguard and risks further politicising”
public health decision-making. I hope that the Minister will agree that that duty needs to be reinstated.
Lord Hunt of Kings Heath (Lab)
My Lords, I find myself in sympathy with the noble Baroness, Lady Coffey, in her approach to Ministers’ ability to determine what happens in the National Health Service. Many of the amendments tabled, particularly when it comes to specific services, call for the intervention of the Secretary of State. That is very simple, because integrated care boards do not have any mechanisms for being locally elected, so their accountability is to the Secretary of State, and we cannot run away from that.
We have had power of direction in the health service since 1948. The Lansley Act modified it, and, although the wording has changed, we are essentially moving back to the original position. The fact is that the power of direction has been used very sparingly over the decades the health service has been in existence. It has rarely been required because in general, when Ministers or their officials are on the phone to the chair or CEO of those bodies, they understand that they need to do something—although I accept, as the noble Baroness, Lady Coffey, says, that there are some occasions when the additional powers in the Bill are probably required.
We really cannot have it both ways. If we want the NHS to be a national service, we know that the public do not accept that there should be variation. The very idea of a postcode lottery in this country is simply not accepted. It must follow that Ministers are accountable to Parliament, and therefore they must have the tools by which to determine the general way the health service is being run. There is a counterbalance. The reason why I am so pleased about the Healthwatch decision is that we need mechanisms at local level to secure some form of local input. But, ultimately, if we want a national health service, we have to accept that, in the unique way the NHS is funded and organised, Ministers need the tools to ensure that their accountability to the public is discharged effectively.
Lord Stevens of Birmingham (CB)
My Lords, I find myself in sympathy with the thrust of Amendments 39 and 40, but I want to draw your Lordships’ attention to some specific changes to the exceptions to the legal powers that the Secretary of State will have that are contained in the Bill. In 2022, Parliament decided that the Secretary of State should have a general power of direction over NHS England, which in turn would cascade through the system. In coming to that decision, the Government of the day rightly inserted three exceptions to the use of that power: a politician could not direct the individual treatment that a patient would get, who individually would be employed or not by the National Health Service or individual treatment availability.
For those who perhaps have not studied the text of the Bill in as much detail as I am going to now bore you with, I have to tell you that a very significant change is lurking in Clause 11, at proposed new Section 14Z62, specifying the exceptions. That is that, whereas the 2022 exception said that the Secretary of State could issue a direction about a specific medicine, treatment or diagnosis if NICE had said it should be available on the NHS, this Bill flips that and says that the Secretary of State can now direct what should or should not be available—particular treatments, particular medicines—in any situation where NICE has not opined on the topic. Given that the vast majority of treatments available on the NHS are not subject to a NICE appraisal or recommendation, that means we are giving a politician the ability to say, ex cathedra, “This treatment will not be available on the NHS; this type of diagnosis will not be available on the NHS.” This is a massive infringement on the medical autonomy and clinical judgment that we expect clinicians to be exercising across the NHS.
When one looks in the Explanatory Notes to see why the provision to amend the 2022 version has been proposed, answer comes there none. So this requires very considerable scrutiny, potentially on Report. I am not in any way detracting from the wisdom of the Secretaries of State that the health service has had in its history to date, but, as we have previously discussed, one has only to look across the Atlantic to the current US Health Secretary, RFK Jr, who has some pretty interesting personal views on vaccines. I will not list them: you can google them yourself. Were we to find ourselves with a future Secretary of State with a similar opinion set, does Parliament really want to grant that person the ability to strike out whole treatments or tests from the National Health Service? I would suggest not.
So that exception needs looking at. The other exception through which a coach and horses has been driven by this Bill is the exception that limited the Secretary of State’s power to the appointment or employment of a particular individual. Clause 37 allows the Secretary of State to fire named individual nursing directors and medical directors of foundation trusts. Again, we must ask ourselves, looking forward, whether that is something that we want or whether it is political overreach: in my opinion, it is.
Baroness Coffey (Con)
Can the noble Lord, Lord Stevens of Birmingham, explain to me again his interpretation of new Section 14Z62(3) and (4), to which he referred?
Lord Stevens of Birmingham (CB)
Certainly. The 2022 Act says that a direction
“may not be given”
by the Secretary of State
“in relation to the provision of any drug, medicine or other treatment, or the use of any diagnostic technique, unless NICE has made a recommendation or issued guidance as to its clinical and cost effectiveness and the direction is not inconsistent with that recommendation or guidance”.
NICE has to have set out its stall and, if it has, the Secretary of State can direct on the back of it. What the Bill says is that, in any case where NICE has not set out its stall, the Secretary of State has complete freedom to form a personal view about what should or should not be available on the NHS.
Earl Howe (Con)
My Lords, I am most grateful to the noble Lord, Lord Scriven, and other noble Lords who have tabled these amendments. They all raise important questions about the balance of powers and accountability within our health service. I listened carefully to the remarks of my noble friend Lady Coffey and will of course reflect on them appropriately. In general terms, I share the concerns that underpin these amendments, particularly around the danger of overcentralising power and what could become a distorted balance of responsibility between the Secretary of State, the Department of Health and Social Care, integrated care boards and local healthcare providers. The noble Lord, Lord Stevens of Birmingham, put his finger on some worrying features of these powers.
We have tabled amendments of our own that seek to address some of these concerns from a slightly different perspective, which we will debate in the next group. I will not therefore detain the Committee for too long, but I would like to make a few broad observations.
First, the relationship between national and local healthcare governance following the abolition of NHS England will be an enormously important one to get right. As my noble friend Lord Kamall and I emphasised at Second Reading, there is a question mark around accountability—not just the balance of accountability but the need for clarity on where accountability lies and where responsibility will ultimately lie when things go wrong. We cannot have a situation in which services are failing to meet their objectives or patients are not receiving the care they need and integrated care boards and the Secretary of State are pointing fingers at each other. If an integrated care board is expected to deliver particular services with well-defined outcomes but Ministers then exercise their powers to direct how the board exercises its functions, it is very difficult to see how anyone can be clear about where responsibility lies for the quality, accessibility or cost-effectiveness of those services.
There is also a wider tension at the heart of the Bill and a certain incoherence in how Ministers have presented the Bill as a whole. The Minister may enlighten me on this, but the Government have spoken at some length on the importance of localism and the benefits of allowing decisions about healthcare to be taken closer to the communities which those services exist to serve. I do not think anybody would argue against that as a sound principle.
Local healthcare leaders will usually be better placed to understand the needs of their populations, the pressures facing their services and the most effective ways of using the resources available to them. But if we believe that, we surely cannot simultaneously favour legislating for the kind of open-ended and all-encompassing power of direction such as that set out in Clause 11 of the Bill. Powers of direction are necessary on a limited basis as reserve powers. For example, I entirely see the case for them in a situation where an ICB may be failing to perform its legal functions or is at severe risk of doing so. I can also see the argument for a power of direction in relation to locally commissioned specialised services where unacceptable variation in provision occurs between different ICBs.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, in responding to this group, I will endeavour to set out how we expect the Secretary of State to act and our overall approach to this topic. I am doing that because I hope it will be helpful not just in this group but in the next one, which relates also to the power of direction. I appreciate the understanding of my noble friend Lord Hunt and the noble Baroness, Lady Coffey, in seeing the practical way that the Bill is seeking to work—in the round, I might add. That is what has struck me about this valid debate to unpick what the Bill will do.
With permission, I will address all the amendments in relation to Clauses 8, 11 and 21 together in this group. On Amendment 47, tabled in the name of the noble Lord, Lord Patel, I can confirm that the Secretary of State will continue to routinely obtain appropriate advice to inform all decision-making, and they will have access to a wide range of clinical, scientific and public health expertise. That will ensure that decisions are informed by professional and clinical insight—for example, from the Chief Medical Officer, the Chief Nursing Officer, standing expert committees and ad hoc advice. To further strengthen clinical leadership across the system and advice given to Ministers on the NHS’s major clinical priorities in the health and care system, which is a matter that has come up a number of times, we will establish the first clinical council. This will bring together a small group of senior clinicians to strengthen leadership, and their experience of treating patients and improving services will directly inform our decision-making in those areas.
Before moving on, I want to briefly mention Amendments 30 and 31, tabled by the noble Lord, Lord Scriven, which reference Clause 8 of this Bill. The power in this clause is distinct from the general power of direction in Clause 11, and allows the Secretary of State to direct integrated care boards to exercise functions on their behalf. While the ICB will be legally responsible for discharging a function, the Secretary of State remains accountable for it, may place restrictions on onwards delegation and must publish any directions. This measure empowers appropriate, flexible local service planning by the Secretary of State to assign functions to ICBs, in the way we see them developing.
On Clause 11, I will address as a group Amendment 39, tabled by the noble Baroness, Lady Bennett, and Amendments 40, 55, 56, 69, 76, 77, 114 and 117, tabled by the noble Lord, Lord Scriven. This clause establishes a general power for the Secretary of State to direct integrated care boards in the exercise of their functions, including directing a single ICB, a group of ICBs or all ICBs. If we reflect on the 2012 Act, as I think we should, the fact is that it was overcomplicated. When it comes to practice, it has been harder to respond to challenges, not easier—which is where we want to get to. It is important that Ministers have the humility to recognise what they cannot foresee, and that it is just not possible to legislate for every situation. I believe that it is crucial to have flexibility to meet these challenges when they emerge. The Bill returns us closer to the pre-2012 situation, when—as a number of noble Lords have observed throughout the passage of this Bill—the public expected Ministers to be able to intervene, but expected them to do so sparingly, and Ministers had the necessary powers required.
Over the years, Ministers have had to respond to emerging circumstances, and the noble Lord, Lord Scriven, asked for examples. I reflect back to the fact that Ministers in 2012, for example, did not anticipate having to respond to the situation in the Mid Staffs NHS Foundation Trust, nor could they have predicted challenges to existing contracts in the NHS coming about following the invasion of Ukraine. I am sure that there are many other examples that we could look to. The noble Lord also made reference to subordinate legislation. My reading of that is that it is very much a technical term, including orders, rules, schemes and regulations authorised by this legislation. It is usual for those not to be subject to parliamentary procedure. I confirm to the noble Lord that we can commit to sharing examples of developing drafts of directions as soon as possible.
Looking forward, the power that we are looking at here will be particularly important as ICBs take on a wider set of commissioning responsibilities from NHS England. We intend to use directions more routinely to support the system; for example, in setting standards for specialised services and establishing reporting standards to measure progress—all things that noble Lords, regularly and rightly, press me to ensure are in place. The noble Baroness, Lady Coffey, gave some examples of where powers of direction could be used in addition to the point that I have already made. They are indeed ones that could be addressed by the use of the power of direction.
This clause also includes important limits on the scope of the power. I emphasise that, as a number of noble Lords have expressed concern about it. The reality is that the Secretary of State will not be able to direct ICBs to appoint specific individuals nor to direct the use of a drug, treatment or diagnostic technique that conflicts with NICE guidance or recommendations.
The noble Lord, Lord Stevens, asked about the NICE exception. The Bill reflects that NICE has not made recommendations in relation to a number of treatments and services. It is important to allow the Secretary of State to issue directions in that absence of recommendations in relation to more specialised services commissioned by ICBs.
The noble Earl, Lord Howe, asked where responsibility ultimately lies when things go wrong. As I think all sides of the House know, the ultimate responsibility is with the Secretary of State, and there is no movement on that. Ministers have to act reasonably with directions. Directions will be challengeable in courts and Ministers will ultimately be accountable to Parliament for their use. Directions will be required to be made in writing and to be published as soon as reasonably practicable.
The noble Lord, Lord Scriven, raised a question about scrutiny of some regulations. There may be a need to act quickly. In that situation, as I have said, directions will be published, and Parliament can scrutinise. The Delegated Powers and Regulatory Reform Committee, which the noble Lord referred to, has reported on the Bill and did not challenge this.
Moving to Amendment 39, I can assure the noble Baroness, Lady Bennett, that existing legislative checks and balances on local commissioning decisions will continue, such as having regard to the need to reduce health inequalities and to ensure patient choice. Directions cannot be used to undermine those duties. The intention with this power is not to micromanage the system but to be flexible and reasonable, and for it to be used for the benefit of patients and the public as new commissioning approaches develop. Despite the intention of the amendment, I fear that it works against such flexibility, which I suspect is not the intention of the noble Baroness, Lady Bennett. We do not expect to use this power to constrain ICBs when selecting providers. However, the public expect Ministers to be able to intervene if they need to protect patients and the public.
Baroness Bennett of Manor Castle (GP)
The Minister said that the public expect Ministers to use this power sparingly. That reflects what the noble Lord, Lord Hunt, said about the power being used sparingly in the past. However, to pick up something that the noble Lord, Lord Stevens, said about what has happened across the Atlantic, health is a great deal more political in its provision than perhaps it has been in the past, and these have become controversial, much played out issues. We also have a much more febrile political situation. As a direct example for the Minister, drawing on experience, if we have two hospitals that have children’s emergency services and the suggestion is that only one of them can continue and there is a political contest in this area, is the decision going to be left locally or is the Secretary of State going to intervene?
Baroness Merron (Lab)
I think the bigger question that the noble Baroness is asking is about politicisation; I heard what she and the noble Lord, Lord Stevens, said about the situation elsewhere. I have to remind myself that, if there were, for example, a different Government with whom I did not agree—goodness me—it would be their right to make decisions and bring forward legislation. So, with the best will in the world, whatever we do here, we have to be realistic about what we can achieve. It is also important to note that checks and balances, which I have referred to, are already in the system. We are doing the opposite of tearing them up: we are continuing to apply them.
Lord Hunt of Kings Heath (Lab)
In the case that the noble Baroness raised, the issue is that of course we have an Independent Reconfiguration Panel but, ultimately, it should be the Secretary of State’s decision. Otherwise, we would have a situation where a decision to close a service in a locality would be made not by those elected by local people but by an appointed board. Surely, in the interests of democracy and accountability, the Secretary of State must in the end have that intervention power.
Baroness Merron (Lab)
My noble friend has put it very clearly and I most grateful. I think the public believe that the Secretary of State has that power already, but in fact she does not, which is a point my noble friend has made on many occasions.
Turning to Amendment 40, I should also draw attention to the distinction we have made between the more routinely used power of direction and the powers specifically reserved for use in cases of significant failure or risk of significant failure. Retaining the distinction between types of direction is important, as is the recognition of when an intervention is undertaken to protect patients, the public or taxpayers. I note the alternative proposal to appoint commissioners from the noble Lord, Lord Scriven, in Amendment 40. My concern is that this approach would likely be more cumbersome and would slow Ministers’ ability to intervene where significant failure was occurring—something that I know noble Lords would not want. Amendment 40 also touches on outcomes frameworks. I assure the noble Lord that I share the sentiment about the importance of outcomes frameworks, and, if necessary, we can complement existing frameworks by using directions.
I will now briefly touch on Amendments 76 and 77, which relate to Clause 21. The clause transfers the requirement to conduct annual assessments of ICBs from NHS England to the Secretary of State and focuses the assessment on the statutory functions of these organisations rather than a narrow list of duties. Currently, the position is that NHS England assesses ICBs annually, using data and local insight to review their performance against their functions, including a list of duties prescribed by the current legislation. The results are published online and they inform the oversight relationship between NHS England and each ICB. However, this list of duties forms a static list of requirements which are already part of the ICBs’ statutory functions. Performance assessments need to adapt to the evolving role of ICBs as strategic commissioners, and evening out the focus across all ICB duties supports that, making assessment more flexible and meaningful as ICBs adapt.
These clauses enable the Secretary of State to support the system, respond to unforeseen challenges and uphold the standards that patients expect and deserve, while ensuring that we have fairness and impartiality at the heart of the National Health Service.
Lord Scriven (LD)
My Lords, I thank all noble Lords who have taken part in this revealing debate on the powers of direction of the Secretary of State. What the debate has drawn out is that it is not as clear-cut as the Minister suggests, and accountability is not the same as having the right to make unfettered decisions about the health service based on nearly every clinical decision or every finance decision in a locality.
Throughout the health service, day by day, many decisions are made for which the Secretary of State is accountable. I do not think any noble Lord is asking that the Secretary of State should not be accountable; it is right that they are, and it is within the accountability framework of the NHS. The issue that noble Lords have raised is what powers the Secretary of State should have over the day-to-day running of health services at a local level. It appears from what some noble Lords have said—the noble Lord, Lord Stevens, the noble Baronesses, Lady Manzoor and Lady Bennett, and the noble Earl, Lord Howe—that in the Bill those powers of direction may be too concentrated in the Secretary of State’s hands. I think we will come back to this on Report. The point raised by the noble Lord, Lord Patel, about clinical expertise being drawn on to make the Secretary of State come up with clinically sound decisions, is really important.
I note that, once they are a Secretary of State or a Minister in the Department of Health, nearly everybody who has been in the department—apart from the noble Earl, Lord Howe—wants the powers. I believe that the power to make the strategic direction of the health service, and to be accountable for that, is the Secretary of State’s, and the power to intervene in an emergency or in unusual circumstances should remain with the Secretary of State. To use the Minister’s point, the intention is not to micromanage but to use the powers sparingly. It is very good to hear that that is the role of the present Government. But, as the noble Lord, Lord Stevens, pointed out, a different Government with a different political stance will be making important decisions that could potentially have an effect on clinical access to services, as well as on where certain services are. I do not think the Minister has answered on that balance to many noble Lords’ satisfaction. We will therefore potentially come back to this on Report, but at this moment I beg leave to withdraw my amendment.
Earl Howe
“(5) Where the Secretary of State has given a direction under subsection (1) the Secretary of State must publish a statement before the end of the period of seven working days beginning with the day on which the direction is given.(6) A statement published under subsection (5) must set out—(a) the statutory function in respect of which the direction is given,(b) the reasons for giving the direction,(c) the period for which the direction is to have effect,(d) the date by which the operation of the direction is to be reviewed,(e) any payment which the Secretary of State has made, or intends to make, to an integrated care board under subsection (4) in connection with the direction,(f) the Secretary of State’s assessment of the financial and operational effects of the direction on each integrated care board to which it applies,(g) the Secretary of State’s assessment of the effect of the direction on the ability of each integrated care board to meet the needs and priorities of its local population, and(h) the respective responsibilities of the Secretary of State and each integrated care board to which the direction applies for the exercise of the function and for any outcomes arising from its exercise.(7) If the Secretary of State varies or revokes a direction under this section, the Secretary of State must publish—(a) the variation or revocation before the end of the period of seven days beginning with the day on which a direction is made, and(b) a statement setting out the reasons for the variation or revocation and its expected financial and operational effects.”Member’s explanatory statement
This amendment would require a direction to an integrated care board to exercise a function of the Secretary of State to be set out in a statement published within seven working days.
Earl Howe (Con)
My Lords, in moving Amendment 32 in my name and that of my noble friend Lord Kamall, I will also speak to Amendments 37, 38 and 86.
These amendments, like those in the preceding group, concern the relationship between the Secretary of State and integrated care boards and, in particular, the powers of direction that the Government propose to introduce through the Bill. I hope the Committee will forgive me for having separated these four amendments out from those of the noble Lord, Lord Scriven, but I have done so because I felt it would be useful to debate these provisions from a slightly different angle from the one that he adopted, albeit persuasively, in some of his earlier amendments.
I have already set out my concerns about the mixed messages that the Bill sends out regarding where accountability for decision-making in the health service should lie, and the inherent contradiction of legislating for open-ended ministerial powers of direction over ICBs against the background of an explicit government policy that recognises the benefits of devolving decision-making to a local level. I will not repeat the points that I have already made on that theme.
I was reassured by the Minister’s statement in response to the last group that there is no intention to micromanage the NHS. Nevertheless, I underline the point that the powers as drafted would not protect decisions that ICBs may choose to make in some very important areas: which services to provide, how to allocate budgets across a population, and whether and how services should be reconfigured. I took the point made by the noble Lord, Lord Hunt, about service reconfiguration, and I will say more about that in a second. But, armed with the powers in the Bill, the Secretary of State would be able to interfere with all those things. That is the backdrop. Let me instead focus on the specific provisions of these amendments, which have one guiding purpose: to propose a set of basic, overarching principles that should govern the exercise of the powers of direction in any given set of circumstances.
Amendment 37 is perhaps the most substantive. It would require the Secretary of State to be satisfied that a direction is necessary and proportionate, and that its objectives would not reasonably be achieved through guidance, agreement with the integrated care board, existing oversight arrangements or some other less restrictive means. In other words, I am suggesting that the power of ministerial direction should essentially be a power of last resort, and not, as it could be read as being, a ready option available to Ministers whenever they happen to disagree with a local decision or the direction of travel taken by local decision-makers. The amendment would also require the Secretary of State to consult the relevant integrated care board and consider the potential consequences of a direction for the ICB’s finances, its operations and its ability to take decisions in the best interests of patients.
There are two important principles at play here. First, if we believe that local healthcare leaders are best placed to understand the needs of their communities and to commission in their best interests, their views ought to carry considerable weight before Ministers decide to override their judgment by insisting on something else. The other principle is that of local autonomy and the value we should attach to it. The moment that local leaders in the health service believe there is no point trying to do things in an innovative way to improve the delivery of services, for fear that they will be told by the powers that be to direct their energies elsewhere, we will breed a set of leaders who are leaders only in name. The best leaders are those who are motivated to take new ideas forward and to excel.
I am proposing this amendment as a basic constraint on the unfettered use of the ministerial power. As the Minister said in response to the previous group, there may be urgent and unexpected circumstances in which consultation cannot reasonably take place beforehand, and the amendment makes provision for that. Outside those circumstances, it is entirely reasonable to expect Ministers to explain why intervention is necessary and why other options would not be sufficient.
Amendments 32 and 38 are about another principle, that of transparency. They each seek to ensure that, where directions are issued, there is a clear and publicly available record of what has been decided and why. They would require the Secretary of State to publish a statement within seven working days of a direction, setting out the reasons for the direction, its intended duration, its expected financial and operational consequences and the resources available to the integrated care board to comply with it.
Crucially, they would also require an explanation of how the direction might affect the board’s ability to meet the needs and priorities of its local population. That is particularly important. A ministerial direction is no small step to take. Take service reconfiguration as an example. If a Minister directs an integrated care board to pursue a particular course, and doing so requires the board to divert resources away from another area of activity previously deemed a local priority, then everybody—Parliament, patients and the public—should be able to understand that. They should know who made the decision, why it was made, what alternatives were considered and what the consequences are expected to be. If the direction results in poorer performance elsewhere, there should be a clear record of whether that was the consequence of a local decision or of a requirement imposed by the Secretary of State.
Lord Stevens of Birmingham (CB)
I wonder whether this might be an opportunity for the Minister to set out how the new accountability arrangements would work in practice, because the amendment from the noble Earl, Lord Howe, would rightly require that, in the event that a power of direction is used, a rationale is set forth so that it is clear why a decision was taken and where responsibility for it sits.
One illustration of this might be the situation facing maternity services in Norfolk, which the noble Baroness, Lady Coffey, mentioned. I quickly had a look at the situation there. Of the three hospitals, two had under 2,000 births a year, and the prediction is that, within a decade, two of those three hospitals will be delivering four or fewer births a day. So there is a question about the sustainability and safety of that service. If, in the interests of a political direction, these new powers are used to insist that those small maternity units with a potential safety concern remain open, even though it might be hard to staff them and to provide the level of back-up said to be required, where will accountability for the safety questions sit? Will the Care Quality Commission, when it arrives at those hospitals, do an inspection to determine whether women may be put at risk, if that is the case? Will the Care Quality Commission then issue findings against the Secretary of State—potentially with criminal proceedings in certain circumstances—or against the local provider or the ICB?
To the extent that this group is about the integrated care boards, let us not forget that, as I understand it, the proposed route for direct influence from the Secretary of State to those hospitals in Norfolk would be only partly through the ICB strategic commissioning decision. The performance management function of those hospitals, including the way in which they manage their safety, will now be routed through this new offshore special health authority, which will then route back, on some sort of new vector, directly into the hospitals concerned. Can the Minister explain, in the interests of transparency and political accountability, how will it work in a situation like that? Where will the decision-making sit? When safety concerns are front and centre, will the Secretary of State override the individual provider, and will they do so via the new special health authority or just rely on the commissioning role of the ICB?
Lord Scriven (LD)
My Lords, it is quite a pleasure to follow the noble Lord, Lord Stevens, who asks some important questions about the transparency of the accountability mechanism—particularly since the whole reason for abolishing NHS England was to stop it being a stand-alone body in the department. As he has pointed out, we are abolishing a quango to set up a brand new quango. I look forward to the Minister’s answers on what the accountability mechanism will be if the CQC makes findings into maternity services in Norfolk.
I thank the noble Earl, Lord Howe, for these amendments. We made our position clear in the last group. We do not think that the general power in Clause 11 should exist in its present form, and in the last group we tabled a probing amendment with an alternative based on outcomes. However, if the Government insist on this, Parliament and the public should expect at least what these three amendments offer: a reason, a test and a record of those decisions.
Under the Bill, when the Secretary of State gives a direction under Clauses 8 or 11, they must publish it as soon as “reasonably practicable”. That is all. There is no reason, no duty to consult and nothing on how long it lasts or what it costs. The department’s memorandum to the Delegated Powers and Regulatory Reform Committee confirmed that there is no parliamentary procedure. On Clause 8, the memorandum says that directions avoid taking up “valuable parliamentary time” and that, unlike with voluntary delegation, a directed ICB would be “legally obliged” to carry out that function. It also says that publication means that the power is “used transparently”. Publishing an instruction is not transparency; explaining it would be the transparency that is required.
The Bill already accepts this. Under new Section 14Z62A, the Secretary of State must publish their reasons when they intervene in a board that is failing. A board in significant failure is told why; a board doing perfectly well which is directed under the general power—we should remember that this is a new power to direct an ICB that is not in any way underperforming—is not given a reason why the Secretary of State has decided to intervene. The Government cannot say that giving reasons is impractical when they require it a few lines further on in the Bill.
First, on the reason, the amendments to Clauses 8 and 11 would require a statement within seven working days on the function concerned, the reasons, how long the direction lasts, when it will be reviewed, its financial and operational effects, its effect on the ICB’s local population and who is responsible for what, which is absolutely vital for accountability. The Clause 11 amendment goes further. When subsection (3) is used and a board is made to act without forming its own opinion, the Secretary of State would have to say what opinion they formed and why, and why the board should not be able to form its own. This also matters for money. Clause 8 says that the Secretary of State may make payments, whereas Clause 11 says nothing about funding at all. A direction with no funding moves a cost from Whitehall to local services, and those affected deserve to see that reason.
Secondly, on the test, the memorandum says that directions are needed
“to respond to emerging situations”,
which is absolutely fine, and to secure nationally consistent standards. This amendment would stop neither: proposed new subsection (3D) would let the Secretary of State act first and consult afterwards where there is an urgent risk, with a decision on the direction within 28 days.
Proposed new subsection (3A)(c) expressly counts the benefits of consistency. It simply asks whether guidance, agreement or existing oversight would do the job and whether the direction is necessary and proportionate. It would also require the ICB to be consulted. If the Minister says, as I expect she may, that Ministers intend to act in this way, there is nothing to lose by saying so in the Bill. The Health Foundation has asked Ministers to set out safeguards for how the powers will be used, but we are still waiting for those safeguards and a full explanation.
Thirdly, in relation to the record, the proposed new clause after Clause 22 would put each direction in the board’s annual report: what has changed, what it cost, what risk the ICB warned about, and where responsibility lay. Under Clause 11, an ICB can be directed and, under Clause 21, is assessed on how well it has discharged its functions. Under new Section 14Z62A, failure includes failing to act
“consistently with what the Secretary of State considers to be the interests of the health service”,
and the chief executive can be removed. A board could follow an instruction, see its performance suffer and then be held to account for the subsequent result. Clear responsibility protects the ICB and protects patients.
I will be honest about the limits. None of these amendments gives Parliament a vote. Statements would be published, not laid. The test rests on the Secretary of State being satisfied, and Clause 8 has no such test. There is also a burden: consulting every ICB on a national direction takes time. Some of the drafting needs tidying before Report, but the general principle is one to be welcomed. The Minister may well call this bureaucracy, but if the Secretary of State cannot say within seven working days why they have given a direction, how long it lasts, what it costs and who is responsible, the Secretary of State really needs to think about why that direction has been given in the first place.
I have two very quick questions for the Minister. If reasons are required for a failing board, why not for every board, including boards that are performing well? Most importantly, what happens when an ICB follows an intervention and a direction from a Secretary of State and clinical outcomes or finance get worse? What happens in those circumstances and who, ultimately, will be held responsible? A reason, a test and a record—that is not much to ask of the Secretary of State who is taking so much power. I look forward to the Minister’s replies.
Baroness Merron (Lab)
My Lords, I am most grateful for this debate, particularly following on from the last group. I hope that noble Lords found that the previous group laid some helpful groundwork ahead of addressing Amendments 32, 37, 38 and 86 in relation to Clauses 8, 11 and 25. I am grateful to the noble Lord, Lord Kamall, for tabling Amendment 32, which was spoken to by the noble Earl, Lord Howe.
As I noted in the previous group, I share noble Lords’ commitment to transparency and to the appropriate use of directions. However—this applies to a number of the points that were raised—this needs to be balanced with some caution about overspecifying requirements in the Bill, given that that could well come at the cost of flexibility and speed, which I know noble Lords understand the need for. In some cases, the information required may not be relevant in terms of the amendment. I assure the noble Earl, Lord Howe, that it is currently standard practice for much of the information that is being asked for in the amendment to be included in directions issued by NHS England and the Secretary of State, where it is operationally relevant. I have no expectation that this will change in the future.
The duties of ICBs were raised by the noble Earl, Lord Howe. ICBs will continue to have a duty to commission a comprehensive health service except for those services that are commissioned by the Secretary of State as specialist, and the Secretary of State retains the duty to promote that service.
Baroness Manzoor (Con)
I would like just a bit more clarification, and for anyone listening to this debate, on this real issue of patient services and how we are going to improve them. So, are there the positive directions? I understand there will be special directions by the Secretary of State, which is totally understandable—it has always been the case, certainly in the last 30-odd years that I have been involved with the NHS in one form or another. If we are going to improve our NHS, we need duties regarding the outcomes. Is there any thinking on that? Sorry to push a bit further, but that is critical if we are looking to improve the NHS for patients.
Baroness Merron (Lab)
There is no need for the noble Baroness to apologise; that is what we are seeking to do. The point here is that we are, by definition, confining our discussions to when things are going wrong or there are concerns. It is important to state that all the changes we are making and all the frameworks that are in place—the whole suite of measures—are there to ensure patient safety, the right outcomes and the right service to patients. In this discussion there is inevitably a greater focus on when things go wrong, but we are trying to ensure that things do not go wrong.
Lord Scriven (LD)
My Lords, many of us are struggling and asking quite basic questions because we still have not seen the operational model or the framework for how the new system will work. Can the Minister give a commitment that, before Report, the operational model will be made available to noble Lords? If not, this is becoming a bit like trying to find your way through a maze while blindfolded. It really is difficult, and that operational model is vital for us to make legislation and help the Government improve it, which is in the interests of patients and the system as a whole.
Baroness Merron (Lab)
I will always make available as much information as possible. Some of the core of our discussion is around what is appropriate to be in the Bill and what is not. It would be unusual to have the detail of an operational model in the Bill—which the noble Lord is not quite suggesting. However, I can certainly undertake to give as much information as possible.
Earl Howe (Con)
My Lords, I am grateful to all noble Lords who have taken part in the debate on this group of amendments and for their insightful contributions. I am particularly grateful to the noble Lord, Lord Scriven, for his very helpful comments. As I mentioned in my opening speech, these amendments are intended to press the Government to address the key distinction between ministerial direction and local direction that the Bill has yet clearly to define, and to tease out more on the operational model, as we have just heard.
I thank the Minister for her reply, but I shall need to reflect carefully on her assertion that no explicit threshold on the use of the powers is appropriate or necessary. The noble Lord, Lord Stevens, set out a good hypothetical example of what could happen if amendments along the lines of those I have proposed are not adopted, especially Amendments 32 and 38 on transparency. The key questions are the ones so well expressed by the noble Lord, Lord Scriven, and, like him, I think that these are issues we shall wish to return to on Report. I am grateful for the briefing later this week to which the Minister has just referred, but I hope she will be open to working with us on these issues as we go forward. For now, I beg leave to withdraw the amendment.
“12E Presumption in favour of public provision of health services(1) In exercising functions in relation to the health service, the Secretary of State must secure, so far as reasonably practicable, that health services are provided by public bodies.(2) A health service may be provided by a private-sector body only where the Secretary of State or other relevant public authority is satisfied that—(a) no reasonable alternative is available for the provision of that service by a public body within a clinically appropriate timeframe, and(b) the use of a private-sector body is necessary to ensure the provision of the service or to meet the healthcare needs of patients.(3) A decision to arrange for a health service to be provided by a private-sector body under subsection (2) must— (a) be supported by a published assessment of the available alternatives,(b) explain why provision by a public body is not reasonably practicable, and(c) be limited to the extent and duration necessary to meet the need identified.”Member's explanatory statement
This amendment establishes a presumption that NHS services should be provided by public bodies and restricts private-sector provision to cases where no reasonable public-sector alternative is available within a clinically appropriate timeframe and private provision is necessary to meet patients’ needs.
Baroness Bennett of Manor Castle (GP)
My Lords, we come now to Clause 10 and what will be a discussion of great interest for many people who have an interest in the Bill, but who are not following the fine detail of organisational structures. It is worth starting by noting, particularly as we have a clause stand part notice, what Clause 10 actually does. It appears to say that the Secretary of State may not vary the proportion of health services provided by the public or private sectors, or by different sorts of legal entity, unless the Secretary of State considers it in the interests of the health service. We will hear later about an amendment from the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, which seeks to change that to the interests of patients.
My starting point to the Minister is that this clause appears to aim to fix in place the current arrangements, with their mix of public and private. I think that will surprise many people, given that the mix we have now is in many cases essentially a result of accidents and the outcomes of tenders, not of any sort of plan or systematic thinking. It is also, of course, the result of failures. I am thinking here of an example many noble Lords will remember: the rather infamous Hinchingbrooke hospital case. The private company Circle was running that hospital, but it was such a disaster that it simply handed it back to the state. That kind of historical accident reflects what has happened in our mix of private and public services. I also point the Minister to the article in the Lancet from 2024, entitled The Effect of Health-Care Privatisation on the Quality of Care by Goodair and Reeves. It found
“that aggregate increases in privatisation frequently”
are accompanied by
“worse health outcomes for patients”
—indeed, all too often, deadly outcomes—so it is curious that the Government seem to be seeking to fix it at what we have now. That is where we are at and where this discussion is starting.
I have three amendments in this group. I am moving Amendment 33 and speaking to Amendments 36 and 51. I will go through them in order, but all three address the same fundamental concern: that we have seen this growing role of private companies in the delivery of our NHS. The Green Party and many members of the public see the need to restore public provision as the organising principle of our health service.
Taken together, these three amendments seek to establish a presumption—different to the Government’s current position—in favour of public provision, which I argue is based on the evidence we have before us. They would require a proper review of the existing private sector arrangements and set a clear statutory duty on the Secretary of State to ensure that NHS services are publicly provided. The NHS was founded on a radical idea that healthcare should be available to everyone according to need, not to the ability to pay. But successive Governments have apparently been increasingly comfortable with the idea that it makes little difference who provides a service, as long as the patient does not receive a bill. I would argue that it makes a great deal of difference.
Amendment 33 seeks to introduce a presumption in favour of public provision. We have seen a growth in private sector involvement in the provision of NHS services. The House of Commons Library reports:
“In 2024/25 the NHS in England spent around £20.4 billion on non-NHS providers. This amounted to 10.3% of its resource budget for that year”.
Public money is increasingly being used to purchase healthcare from commercial organisations, rather than building and maintaining the NHS’s own capacity to deliver. The result has been a gradual erosion in the distinction between a publicly provided health service and a publicly funded market in healthcare.
Baroness Murphy (CB)
My Lords, this is the first time I speak in Committee, and I apologise that I have not intervened very often so far. On this amendment, I feel quite cross with the noble Baroness, Lady Bennett, who wants to take us back to the Soviet model of healthcare, which I thought we were moving away from.
Essentially, there are many services in which you find independent sector providers, and they are not all private. Many of them are not for profit or voluntary run, and many of them are absolutely excellent services, just as good as the NHS, and they keep the NHS on its toes—I speak, remember, as an NHS manager. The fact is that, for example, if you look at simple cataract surgery, people used to wait for years for the NHS to get round to doing their simple cataract extractions and replacement lenses. Now, it is a few weeks in most places, and these services are almost always provided by the independent sector—and very good they are too.
I agree there is an issue about the training of staff, because it is all done by the NHS or recruited from overseas. We need to know where people come from and what we are paying for. However, as an NHS doctor and manager, I can say that I have witnessed the transformation of services by the competition that is provided by some of these independent sector services where commissioners are able to choose the very best for their local patients. I therefore refute and wish to deny the proposals from the noble Baroness, Lady Bennett.
Lord Patel of Bradford (Non-Afl)
My Lords, I have added my name to the notice opposing the Question that Clause 10 stands part, alongside those of the noble Lord, Lord Hunt of Kings Heath, the noble Lord, Lord Kamall, and the noble Earl, Lord Howe. I share their concerns about the purpose of this clause and the safeguards governing its use. The Secretary of State should of course be able to improve services and respond to failure. However, patients also need confidence that changes in who provides their care will be justified by the benefits for them and for the communities that those services support.
Clause 10 sets out a duty that applies across health service functions, but it also gives the Secretary of State an exception. They can deliberately change the balance between different types of provider if they believe that this is in the interests of the health service. The scope and safeguards of that exception deserve careful examination. Will the Minister give us some practical examples of when this exception would be used? What specific problem is it intended to solve? Of course, improving services may mean changing who provides care, but the purpose should be to improve care for patients. Why is an exception needed that allows the Secretary of State deliberately to change the balance between public and private providers? Could this exception be used alongside the powers of direction in Clause 11to promote a preferred category of provider, even where a different provider could offer patients a better service?
It is important that we assess the whole effect of a commissioning decision. Quality and safety matter, as do timely access, value for public money and the sustainability of local NHS services. An apparent saving in one contract may create costs elsewhere. Equally, a change that looks attractive nationally may leave patients facing longer journeys, disrupted treatments or fewer services to choose from. That matters, particularly in places with poor transport links and few alternatives, whether they are in rural or coastal communities, towns or cities.
PSR, the provider selection regime introduced in January 2024, already provides a framework for selecting providers of healthcare services in England. Its criteria include quality, value, collaboration, service sustainability, access inequalities, patient choice and social value. Can the Minister explain how the discretion in Clause 10 will interact with the PSR framework and with existing patients’ choice rights?
I support the emphasis on patients in Amendment 34, tabled by the noble Baroness, Lady Coffey. It would require the Secretary of State to consider whether a change is in the interests of patients, rather than the health service more generally. I also support Amendment 35, tabled by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, which would require a change in the balance of provision to be necessary to improve patient outcomes. Both amendments bring us back to the essential question: how will the proposed change benefit patients?
I turn briefly to Amendments 33, 36 and 51, tabled by the noble Baroness, Lady Bennett of Manor Castle. I respect her commitment to the NHS. We share the objective of excellent care, available according to need and free at the point of use. However, I cannot support these amendments, because of their potential consequences for patients, staff and the services on which they depend. Amendment 33 would establish a presumption in favour of public provision, permitting private provision only where specified conditions were met. The existence of a public alternative does not by itself establish that it offers the best quality, the shortest wait or the most accessible service. We should be asking which arrangement best meets patients’ needs, alongside its effects on the wider NHS. There are also questions about scope. How would charities, hospices, social enterprises and GP partnerships be treated? Providers need to plan ahead to invest in staff, facilities and equipment. Would these restrictions make them less willing to invest because of uncertainty about how much care they would provide, and for how long?
Amendment 36 would require a review of existing private sector arrangements, followed by a plan to return services to public provision where private provision is considered unnecessary. The amendment recognises the need to assess financial, clinical and workforce implications. However, an assessment does not itself provide the staff, premises, equipment or funding that are needed to replace a service, nor does it resolve any contractual costs arising from early termination. Patients who are already receiving care would need continuity, while those waiting for treatment would need confidence that capacity would remain available.
Lord Hunt of Kings Heath (Lab)
My Lords, I have given notice of my opposition to Clause 10 standing part of the Bill to probe exactly how the Government intend to use the clause. Reflecting on the three amendments tabled in group 1 by the noble Baroness, Lady Bennett, she was arguing for greater discretion at local level for NHS bodies; here, though, she wants to constrain them quite extensively. We are all guilty to an extent of ambiguity in this central-local relationship, which shows how hard it is to get the balance right.
I do not take an ideological approach to the use of the private sector in the health service, because we have seen some of the benefits. I think of how waiting times were virtually eradicated in the 2000s—we used the private sector quite extensively. The noble Baroness, Lady Murphy, illustrated the impact on cataract surgery as one example. However, I bitterly oppose the proposals of the noble Lord, Lord Lansley, which were enacted, for compulsory contracting out and competitive tendering. I believe that it is horses for courses. Where we think the private sector can add value to what the NHS can provide, we should use it, but there should not be an edict that you have to contract out everything or go through the mechanisms of competitive tendering and all the rest of it, which have proven to be so expensive and, in many cases, destructive.
Clause 10 is a bit of a puzzle—you can read it any way that you want. It could be used to increase the amount of private sector provision or, equally, to reduce it. In what circumstances will it be used? Will there be any guardrails around its use in the future, by which I mean in the years ahead, when we may have Governments with a different approach? The Explanatory Notes do not make clear how it would be used.
Lord Stevens of Birmingham (CB)
My Lords, the noble Lord, Lord Hunt of Kings Heath, has nailed it. Essentially, Clause 10 says that the Secretary of State must not do something unless the Secretary of State thinks that it is a good idea—it does not matter whether a good idea is construed as being in the interests of the health service or patients. Any Secretary of State thinks that all their ideas are good, so that is an unrestricted new power.
If the Government do not like Section 12E of the NHS Act 2006 then they would be better zapping that section rather than introducing this clause amending it, which, for the reasons that the noble Lord, Lord Hunt, has given, would be an ideologue’s charter. Under these powers, a Secretary of State could determine that all elective surgery should be done only by private hospitals, and that would be consistent. Another Secretary of State could decide the exact opposite, or they could decide that no NHS-funded terminations of pregnancy will be done by the independent sector. Since that is 81% of terminations in this country, the NHS would not be able to cope, and that would then constitute a massive restriction on terminations of pregnancy.
You can have your own ideological view on whether these are good or bad things, but that is what this clause permits. Therefore, contrary to what the noble Baroness, Lady Bennett, says, it does not lock in the status quo but produces the possibility of quite extreme swings on the part of future Governments. This Government should remember that what is sauce for the goose will be sauce for the gander.
Baroness Coffey (Con)
My Lords, I tabled Amendment 34 to put the focus on patients. In my short time in health, working with brilliant civil servants and great Ministers, I created Our Plan for Patients. It tried to have a very specific focus that would address some of the concerns that have been raised about what a Secretary of State could do around provision.
The noble Baroness, Lady Bennett of Manor Castle, will be on her own in thinking that the only organisations that can provide this are state-run actors. This is not how the NHS was created. Most GPs are not state-run organisations; they take on a contract. The same is true of most primary care—opticians, pharmacists, the list goes on. In my time as an MP, I used to get infuriated with the local chief executive, because they resented using private provision, despite it potentially having been better to get more patients off the waiting list, because they were frustrated at paying the same consultants who were working in one hospital in the morning and then for a different provider elsewhere in the afternoon. The patients do not care. They just want to get their hip done or whatever it is.
We have to keep reminding ourselves why the NHS exists: it is to ensure that patients get access to the healthcare that they need regardless of their means. As for provision, there are things such as BUPA, which is the largest single provider of NHS dental care in the country; it is a non-profit organisation in that regard.
There is one thing worth exploring with the Minister. Having looked at the original clause, I think this already applies, with a few exceptions. I assume that two of the exceptions are due to the fact that, in the rest of the Bill, the Secretary of State is already taking the powers from NHS England. I want to be clear why procurement regulations in particular are effectively being rolled into this new power, whereas I think they are excluded in the original Act.
More broadly, I understand where the noble Lord, Lord Stevens, is coming from, but it comes down to this: if we can keep the focus on patients, it would reduce the opportunity for the Secretary of State to be arbitrary in how they go about their view and their running of aspects of the NHS, recognising the number of constituents right around the country. Otherwise, I am concerned that there could be some ideology that starts to squeeze out private providers. Sometimes that will be for good reason. A few years ago, Circle was saying, “Put up the tariff, or we won’t do NHS work any more”. I would say, “Circle, get lost—if you can’t do it for what the NHS is doing it for, then don’t worry”. There may be a broader challenge about what is going in—I will discuss the balance of primary care and so on later—but, in terms of NHS funding overall, if we keep the focus on patients as our guiding star, then, frankly, we will have done a good job in this Bill.
Baroness Thornton (Lab)
My Lords, the problem I have with this clause is that it is not nuanced enough. I say that as somebody who helped to found Social Enterprise UK and works with leaders of social enterprises, charities and mutual organisations that deliver public services, particularly in health and social care, and do a very good job indeed. My problem with this clause is that it is not nuanced enough, and that is also the problem I have with the amendments that the noble Baroness has put down.
The issue, pointed to by my noble friend Lord Hunt, is procurement. You should not be using the same rules of procurement to buy widgets, computers and office furniture that you use to procure human-facing services. That really seems to be the issue here, so anything that allows the commissioning of these services as people-facing services is to be welcomed. That is why the light-touch regime is so important, and it is underused in the NHS, to procure the services that we need for our patients.
Given the lack of nuance between public and private, where does the innovation that charities and social enterprises bring to the National Health Service sit in this amendment? That is not satisfactorily answered. My question to my noble friend the Minister is this: how can we make the commissioning of services more effective, more efficient and less bureaucratic, to end profit gouging where it exists but also allow the innovation that these organisations might bring?
Baroness Nargund (Lab)
My Lords, I agree with my noble friend Lady Thornton that the clause is not nuanced enough. I declare an interest as a former provider of care across three sectors—the public, charity and independent sectors. We talk about “public” and “private”, but it is not the case. I echo the comments from the noble Baroness, Lady Murphy. I am a former vice-chair and trustee of the British Red Cross; we were the largest partner to the National Health Service and provided health and social care across the country, compassionately, cost effectively and with good outcomes. The noble Lord, Lord Stevens, gave the example of pregnancy terminations. These are time-sensitive treatments, cares and surgeries for which you cannot wait. Women cannot wait; they need to have the care locally, swiftly, safely and to high standards.
Baroness Manzoor (Con)
My Lords, I do not want to repeat anything that has been said, and I agree with most of the comments that have been made, except, with apologies, those of the noble Baroness, for the reasons that have been articulated. We have an independent, private and state sector NHS. I was around in the 2000s, and we did an awful lot of commissioning in the independent and charitable sectors and it worked well.
To make this clause much stronger, the real emphasis should be on procurement. There is a real issue when the NHS procures—not thinking of the impact it has on other services being provided by that hospital, and it is usually hospitals. That funding, when things go wrong and that care has been provided by the private sector, reverts back into the NHS. There needs to be some mechanism and recognition of where those costs sit.
When she looks at this clause, the Minister should perhaps also look at what happens to the spare estate facility and capability of those organisations, because they still have rents, rates, electrics, et cetera. That does not get shut down because, irrespective of what we say, there are still block contracts. I know that we have clauses on block contracts, but procurement is very important and we should look at where choice is in the way that the contracts are let out. It is not cherry-picking; for the very simple operations—I think the noble Baroness, Lady Murphy, mentioned cataracts—that is very important. It is not just about the timeliness of things, which is important, but the quality and the outcome of that service that has been provided to that particular patient. I totally support the comments made by my noble friend Lady Coffey. We must put the patient at the heart of this.
Lord Scriven (LD)
My Lord, when we started this group, I did not expect the phrase “the Soviet model of healthcare” to be mentioned, but the noble Baroness, Lady Murphy, used it. It is always surprising what one hears and learns in Committee. From these Benches, our starting point is simple: the principle that defines the NHS is that care is free at the point of use and based on need, not ability, to pay. That is a line that I think most noble Lords would never wish us to cross.
Who owns the building matters less to a patient than whether they get good care in good time, and a good outcome without paying for it. As Liberals, we start from individual patients. We ask what power the patient has, who can take it away and why. I respect what the noble Baroness, Lady Bennett, is trying to do. She is right to raise concerns about profit and public money, but her amendments are the wrong answer. They would take choice from patients, and those with the least would lose most.
Let us take Herefordshire. It is a large, rural county with one NHS acute hospital: the county hospital in Hereford. The next-nearest NHS acute hospitals are in other counties, or even across the border in Wales. Many villages have few buses. The county’s own draft transport plan is still working towards better links between Hereford and market towns. Nuffield Health also has a hospital in Hereford, which provides some NHS services free at the point of use to patients. Under the noble Baroness’s presumption, that option exists only if there is no reasonable public alternative within a clinically appropriate timeframe. The test asks, “how soon?”, but not “how far?”, nor how a pensioner with no car gets to an operation in another country or county, and home again. Care is free at the point of use; the journey is not. For someone on a low income, a free operation that they cannot reach is not much use, nor is it right. A patient on a long waiting list at the only public hospital in their county should be able to choose another provider nearby, free at the point of use—whether that be private or NHS provided. Someone with money can already pay to leave the queue. Taking away that free option would not abolish the two-tier system; I believe it would deepen it.
This also goes well beyond hospitals, as other noble Lords said. The new clause in the amendment after Clause 11 says a service is not publicly provided if it is contracted to a private body, and only public bodies may provide it. As noble Lords said, most GP practices are private contractors, as are many community pharmacists, high street dentists and opticians. They are the front door of the NHS. What about hospices? There are 135 independent adult hospice charities in England. The National Audit Office says the sector cared for about 251,000 people in 2023-24, with the Government funding around 29% of its income. Are those to be taken out or shut down under this amendment? As has already been pointed out, in 2023-24, over half of NHS cataract operations were done by independent providers. Bringing them back at speed into NHS public bodies would lengthen waits for older people to have their cataracts done. The term “private sector body” is not defined in the amendments, so we cannot tell which of these would fall under the presumption.
The review in Amendment 36 is the most useful idea in this group from the noble Baroness, Lady Bennett, but it is framed around returning services to public provision. It should ask a neutral question: which providers—public or independent—give quality, value and fair access, with provision free at the point of use? None of this is a blank cheque for the private sector. Independent providers delivering NHS care must meet the same standards and publish the same data. They should train staff and not pick off the simple cases while the NHS keeps the complex ones. That is part of what ICB strategic commissioning needs to pick up. Independent providers delivered only around 7.5% of NHS planned care in February this year, based on their own trade body’s figures. They are a useful supplement, but they are no substitute for NHS care that is properly and publicly funded.
This brings me to Clause 10. What is the point of it? What problem is it solving? Can the noble Baroness give the Committee an example of what a Secretary of State cannot do now that they could do with this clause? We need to be clear that this clause changes a provision in the 2006 Act which stops the Secretary of State from swinging between private and public. The new clause would allow to happen the very thing that the 2006 Act stopped, depending on how the Secretary of State felt when they got up that morning and decided whether they were in the mood for public or private healthcare. The Committee needs to understand what problem this is solving, because, I think like most noble Lords, I have no idea why this provision is in the Bill and what it is trying to solve.
The noble Baroness, Lady Coffey, rightly asks in her amendment for us to think of patients rather than the organisation. The noble Lord, Lord Kamall, goes further, and I find his approach the most persuasive in the group. It is that, basically, a change would have to be necessary to improve patient outcomes. Surely that is the test against ideology from either a public or a private direction. The Secretary of State would also publish the reasons and lay them before Parliament.
The amendments from the noble Baroness, Lady Bennett, raise serious concerns in terms of completely undermining what a public health service—the NHS—should be about. It should be about quality, about outcomes and about patients having choice. The Secretary of State should not dictate which type of hospital a patient should go to, as long as the basis is free at point of use, the quality of care is monitored, and outcomes are the same as in a publicly funded body. I really look forward to the Minister explaining the reason for Clause 10, because I believe that most noble Lords would like to understand exactly what problem it is trying to solve.
Lord Kamall (Con)
My Lords, I am grateful to all noble Lords who have spoken on this group of amendments. Let me begin by speaking to the amendment in my name and that of my noble friend Lord Howe and to the clause stand part notice in our names as well as those of the noble Lords, Lord Hunt of Kings Heath and Lord Patel of Bradford.
This group of amendments seeks to query the future provision of NHS services and, in particular, the principles that should govern decisions about the balance between state or taxpayer-funded and independent providers. There is a straightforward principle here: decisions about healthcare and the provision of healthcare should be guided, as the noble Lord, Lord Scriven, said, by what is best for patients rather than by some predetermined preference for one type of provider over another. This should not be about ideology; it should be about the interests of individual patients.
We know that the NHS seeks to serve patients. Its success should therefore be measured not by organisational arrangements or ownership but by the quality, accessibility and timeliness of care, and how it improves the health and well-being of patients. As such, Amendment 35 seeks to give effect to that principle by ensuring that any variation in the balance between publicly and independently provided health services is undertaken only where the Secretary of State is satisfied that it is necessary to improve patient outcomes.
That is important because, as it stands, Clause 10 permits the Secretary of State to dictate that balance in what they consider to be
“the interests of the health service”.
Sadly, as we know, the interests of the health service are not always the same as the interests of patients. The focus must remain on the best possible patient outcomes, but the interests of the health service might be interpreted in terms of organisational priorities or administrative convenience. Can the Minister explain why the Government have not created a specific duty for the Secretary of State to justify decisions in terms of patient outcomes? Does she accept that
“the interests of the health service”
may be seen as too broad?
Baroness Merron (Lab)
My Lords, I am grateful for the debate that we have just had. With permission, I will address whether Clause 10 should stand part of the Bill, look at the amendments to it and refer to those things together.
As a number of noble Lords have rightly emphasised, we are indeed committed to a National Health Service that is free at the point of use. Noble Lords will be very familiar with the changes that we are making to ensure that patients are at its core, and that they find that the system works around them, rather than them having to work around the system. We see that throughout the 10-year plan. For many years, this has included the provision of NHS-commissioned services by charities and the not-for-profit and independent sectors, as referred to by the noble Baroness, Lady Murphy, the noble Lord, Lord Kamall, and my noble friends Lady Nargund and Lord Hunt, to mention a few. The fact is that all these sectors make a valuable contribution to the health of the people whom we serve. We should acknowledge that, but I think we should also celebrate it.
Clause 10 prohibits the Secretary of State using their functions deliberately to shift the balance between types of providers. It strengthens and extends Section 12E of the National Health Service Act 2006 to any health service function of the Secretary of State and applies to all providers, regardless of legal form—to answer the point raised by the noble Lord, Lord Kamall. The clause does not enable privatisation or nationalisation by the front door, the back door, the side door or indeed any door that we can think about. It is a general prohibition, with one exception: where the Secretary of State considers that to act differently is in the interests of the health service.
As to why we need that, currently under Section 12E, a Minister who sees a service failing and concludes that bringing it into the NHS is in the interests of the health service could not act. Equally, Ministers could not deliberately bring in charitable or independent providers to end a risky overreliance on a single NHS trust; nor could they see an entire sector dependent on a few external providers and choose to build more public capacity for the long term—something that noble Lords rightly would encourage—because such purposes are always prohibited, even though the outcomes can be beneficial.
Clause 10 enables Ministers to act when the interests of the health service require it. We expect Parliament to hold Ministers to account in doing so. I say to the noble Lord, Lord Stevens, and my noble friend Lord Hunt that Ministers, in their duty to promote a comprehensive health service, have a duty to act reasonably and rationally and, as I say, to be held to account for doing so.
The noble Lord, Lord Patel of Bradford—
Baroness Barker (LD)
I am trying to follow very closely what the Minister is saying. Am I right to take it from what she said that under Clause 10, an acute hospital trust could be moved to the private sector if the Secretary of State decided that that was in the best interests of the health service? Is that possible?
Baroness Merron (Lab)
At the risk of repeating myself, as I have said, the judgment is about acting reasonably and rationally and about whether it was fulfilling its duty. It would also be—I know that I am repeating myself, but it bears doing so—accountable to Parliament for its decision.
The noble Lord, Lord Patel of Bradford, raised a question—
Lord Scriven (LD)
If the Secretary of State was acting under Clause 11 powers, Parliament would not have knowledge of that or any say on it. Does the Minister agree that that would be a correct interpretation of Clause 11 being used to bring about a change in public/private provision in Clause 10?
Baroness Merron (Lab)
I am not sure that I can answer that right now, but I will certainly review the various clauses and come back on that point.
The noble Lord, Lord Patel of Bradford, raised a point about publishing reasons where an exception is made. I will look at that because, as he knows, we are very much committed to transparency.
I turn to the amendments from the noble Baroness, Lady Coffey, the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, which I will discuss together. The phrase
“the interests of the health service”
reflects the Section 1 duty to the health of all people in England—both those currently using the NHS and those who might want to use it in the future. That said, I understand the points noble Lords are making and, as with all things, I will certainly look at them. But we believe that substituting the phrase so that the test may be used in the interests only of patients, as spoken to by the noble Lord, Lord Kamall, is a narrower approach that risks excluding the potential benefits to the service over time, and it excludes the interests of people who are not currently patients—which I know is not the noble Lord’s intention.
I would also caution against using an additional requirement that exceptional action must be
“necessary to improve patient outcomes”.
This might prevent the rescue of a failing service, given that it relates to improving, and not stabilising, services. For example, if a dialysis provider serving a large area failed, stepping in would clearly be necessary to keep treatment going, before any action to improve it. It therefore risks failing the proposed test at a time when decisive action is needed.
Lord Kamall (Con)
Surely stepping in to continue that dialysis service is in the interests of patients.
Baroness Merron (Lab)
It is, and that is why I said I understand the point that noble Lords are making. We are not talking about the interests of the health service for the interests of the health service; it is there to promote the right outcomes for patients and their interests, too. That is why I acknowledged the points that the noble Lord and others made.
Baroness Nargund (Lab)
I would like some reassurance about making sure that the private sector does not offer any additional treatment at additional cost to NHS patients—it tends to happen in the IVF sector. When there is a block contract for NHS patients in the private sector, they may advise patients to have add-ons to get them to pay extra. Can the Government make sure that add-ons are not offered to patients with additional costs when they are NHS referrals?
Baroness Nargund (Lab)
Sorry, I must declare an interest: I am an authority member of the Human Fertilisation and Embryology Authority.
Baroness Merron (Lab)
I would not wish to stop any noble Lord from declaring their interest, so I am sorry that I stood up too quickly.
My noble friend speaks to the point of the importance of proper commissioning by ICBs, drawing lines around what is provided and how they performance-manage all their providers. I will certainly be aware of the point that she makes.
The amendment of which we were speaking would mean that a service that served patients well but could in principle be provided publicly would have to go, while one that served them poorly but could not be replaced by public provision would remain, and I do not think any of us would want to see that.
I recognise that there are a range of opinions and disagreements about provision in the health service and how it should be organised, but, as I mentioned earlier, we are focused on being pragmatic, providing fairness and improving access and quality for patients. We are not in favour of favouring one form of provider over another for ideological reasons, and I am glad that a number of noble Lords share that feeling.
Lord Scriven (LD)
Just to be helpful, will the Minister write to the Committee before Report explaining the reason for Clause 10? I am not sure whether other noble Lords were in the same position as I was, but I did not understand and was not convinced as to why it was required, even after the Minister explained. Could she give real, practical examples of why the clause is required, based on the 2006 Act not allowing the Secretary of State the powers to make the provision between private and public that is required to improve patient care in a particular area? That would be helpful, I feel.
Baroness Merron (Lab)
I will be pleased to write further on the comments that I made.
Baroness Bennett of Manor Castle (GP)
My Lords, I thank all noble Lords who have taken part in this fascinating and important debate, and I thank the Minister for her response.
The noble Baroness, Lady Coffey, said she thought I would be alone in my views, but we have heard from different quarters around your Lordships’ House expressions of concern about the destructive impact of markets and tendering on the NHS; the noble Lord, Lord Hunt, said so in his speech, and indeed he is nodding now. There is good evidence that the views of your Lordships’ House do not reflect the views of the public. I point noble Lords particularly to a study in Social Theory & Health in 2022, which I believe is the only time there has been an open-ended, representative survey of UK citizens about their view of privatisation. Lots of basic questions have been asked, such as “Do you think privatisation is a bad thing?”, but I think that is the only time the question has been asked: why do people think that? The largest single reason was the extraction of profits from NHS services. There is strong public resistance to that, and noble Lords should bear that in mind. The public see clearly that money that should be going to services is going to profits instead, and that is what my group of amendments seeks to address.
We have Committee stage for a reason, to probe amendments, and many noble Lords have probed at mine. To reassure the noble Baroness, Lady Thornton, and others, I certainly need to look at the wording of this. When I was talking about public and private, by “private” I was referring to for-profit providers. I reassure the noble Lord, Lord Scriven, and others that there is no intention here to do away with hospice provision, charity provision and not-for-profit provision. These amendments are all aimed at the for-profit sector.
Lord Scriven (LD)
So if the partners at a GP practice made a surplus or a profit at the end of the year, would they fall under the definition that the noble Baroness has just given?
Baroness Bennett of Manor Castle (GP)
There is a particular issue with GP practices. My position is that I do not think there should be for-profit in healthcare. That is my long-term position.
Lord Stevens of Birmingham (CB)
Nuffield Health, which provides private hospital services to NHS patients, is a registered charity. To clarify, according to what the noble Baroness has just said, she would accept that it would continue to be able to be funded by the NHS but, let us say, HCA hospitals would not.
Baroness Bennett of Manor Castle (GP)
I am aware that there are charities and there are charities, but yes, as long as something is operating for a genuinely charitable purpose, I would exclude that from a for-profit definition.
Lord Kamall (Con)
I am sorry to intervene, but we are probing the noble Baroness’s amendments. I made a point about some for-profit providers, such as Specsavers, which are often able to provide services much more cost-efficiently, particularly audiology and optometry services, in local communities, often closer to the patient than some distant hospital, which frees up money to be spent on other services in the NHS. Would the noble Baroness oppose that sort of for-profit service, which is clearly in the interest of patients?
Baroness Bennett of Manor Castle (GP)
Here, I would cross-reference the noble Lord to what the noble Baroness, Lady Nargund, raised in her intervention on the Minister, which was really important. I should perhaps declare an interest: I confess that my glasses are from Specsavers, where I went for practicality. However, in that kind of context, we also see significant upselling and pressure on patients that would not apply in an NHS not-for-profit context. That is something that we need to think about carefully. Is there alternative provision where that pressure is not applied?
I am at risk of turning into a Minister here, so I am going to try not to do that; I will later on, but not right at this moment. I want to pick up a point made by the noble Lord, Lord Kamall. I think it is fair to say that the noble Lord embraces the fact that more people are taking out private health insurance and paying for private provision. For me, it is a cause for concern if people are forced into that situation because they feel there is not the NHS provision there. If there is no provision of, say, a hip replacement within a reasonable time, so people put possibly a large chunk of their savings into that, that is a cause for concern, not celebration. From my native Australia, I know what happens when you have, in essence, a two-tier health system where many people feel the need to have private insurance. Then it is the leftovers, and the quality of public provision falls away significantly.
The noble Baroness, Lady Nargund, spoke about the importance of provision in disadvantaged areas. One problem that we have with private sector providers is they may see less opportunity to make profits from more disadvantaged areas and be interested in operating in areas that are more for profit.
I am not going to run through every contribution, because that would take too long, but one thing that has come out of this debate in a broad sense is that the Government—any Government—have to make a decision. I come to the challenge to me from the noble Lord, Lord Hunt, about the balance between local and national decision-making. Are the Government going to solve short-term problems by destroying a structure so that it is not there for the future? I would argue that they have a responsibility not just to the patients of today but to maintain an entire functioning health system that will be there with appropriately trained people, appropriate resources and the ability to deal with acute circumstances.
Baroness Pidgeon
“Cancer outcomesIn the National Health Service Act 2006, after section 1GA insert—“1GB Cancer outcomesIn exercising functions relating to the health service, the Secretary of State must treat objectives relating to cancer outcomes as having priority over any other objectives relating specifically to cancer.””Member's explanatory statement
The Secretary of State is currently required to set cancer outcome objectives for NHS England, with those objectives taking priority over other cancer goals. The Health Bill removes this provision. This new clause would place a new duty on the Secretary of State to prioritise cancer outcomes such as survival.
Baroness Pidgeon (LD)
My Lords, the number of people diagnosed with cancer in the UK continues to grow. For the first time, the number of new cancer diagnoses each year has passed 400,000. Almost one in two of us in our lifetime will have cancer, and I am sure it has affected all of us in this Chamber.
The commitments made in the national cancer plan to improve cancer outcomes are welcome. Driving up survival rates and increasing earlier diagnosis will transform the experience of people affected by cancer. Amendment 41 in my name, to which the noble Baroness, Lady Morgan of Drefelin, and the noble Lord, Lord Patel, have added their names, focuses on outcomes. Over the past five decades, cancer survival has more than doubled due to life-saving research, earlier detection and cutting-edge treatments. But over time the rate of improvement has slowed, with the 10-year cancer survival index for all cancers rising nearly three times faster in the early 2000s compared with the early 2010s. There is, of course, a substantial variation between different cancers.
The Health and Care Act 2022 included a requirement for the Secretary of State to include cancer outcome objectives in the annual mandate set by the Secretary of State for NHS England, and that those outcome objectives explicitly took priority. The current Health Bill abolishes the mandate, including the prioritisation of cancer outcomes, and a similar duty has not been replicated elsewhere in the Bill. In publishing the national cancer plan, the Government have shown that they are committed to transforming patient outcomes. However, with the removal of the current requirement, there is a very real concern that progress on cancer outcomes risks being deprioritised amid competing priorities. I am sure that this is not the Government’s intention, and I hope the Minister will be able to reassure us today and will consider tabling a government amendment on Report to ensure cancer outcomes are on the face of the Bill.
On the other amendments in my name in this group, Amendment 217 would require the Secretary of State to introduce regulations requiring the Government to co-ordinate research into cancers with the lowest survival rates. This is a long-standing failing in our approach to some of the deadliest forms of cancer. While welcome progress has been made in treatment and outcomes for many cancers, those with the lowest survival rate, which can include cancers such as pancreatic, brain, liver and lung, continue to receive disproportionately less research focus. Greater co-ordination would help identify gaps in knowledge, avoid duplication, encourage collaboration and ensure that our scarce research resources are directed where they can have the greatest impact. If we are serious about improving outcomes and reducing cancer mortality, we must focus on where survival rates remain stubbornly low.
Amendment 228 would give patients a right under the NHS constitution to start cancer treatment within 62 days of referral. There is an inconsistency in the NHS constitution between the rights to treatment and actual waiting times. There is a right to elective care within 18 weeks, but there are other pledges for other waiting times. Cancer does not simply stop while a patient waits for their treatment. Research shows that every four weeks of delay reduces patient survival by an average of 10%. That is why I have tabled this important amendment—so that there is a focus on starting treatment and that it is reported to Parliament.
Finally, Amendment 250 from the noble Baroness, Lady Finlay, addresses the important issue of radiotherapy. This is an area which can often be overlooked in terms of cancer care, facing the longest waiting times and significant problems with access, particularly in rural areas. I understand that England has fewer radiotherapy machines than comparable European countries, and thousands of people are having to travel over 45 minutes for their treatment. With around half of all cancer patients needing radiotherapy, it is important that access to this service is improved. This is a really important group of amendments, and I look forward to the debate. I beg to move Amendment 41.
Baroness Finlay of Llandaff (CB)
My Lords, I have two amendments in this group, and I am grateful to the noble Baroness, Lady Pidgeon, for having referred to one of them.
My Amendments 247 and 250 would address genomics and radiotherapy, because there are fundamental weaknesses in how diagnostic genomic services and radiotherapy treatment services are planned and improved across England. In both areas, rapid advances are altering survival and avoiding toxicity from poorly planned treatments. Current international comparisons by the OECD place the UK 31st out of 43 countries for five-year lung cancer survival and 26th for colon cancer survival. Overall cancer mortality data place the UK 26th out of 36 countries. Following on from the questions from the noble Baroness, Lady Pidgeon, I ask the Minister two specific questions. First, why is the UK no longer submitting information to the OECD on cancers? Secondly, will we be renegotiating for our cancer research to become part of the EU4Health programme again?
Diagnostic delays and inadequate radiotherapy services are largely responsible for our poorer outcomes. In cancer genomics, only 3% of pathologists are always meeting the 14-day national target for lung cancer genomic testing. Pathology personnel shortages are particularly severe in genomics and genetics, causing delays, which are compounded by high sample volume workload, administrative inefficiencies, delays in sample processing, and outsourcing, as well as inadequate equipment.
Recently, almost half of healthcare professionals had to start urgent treatment before biomarkers were available. Around 1,000 cancers are diagnosed a day, but delays compromise timely treatment decisions, patient safety, access to targeted therapies and eligibility for time-sensitive clinical trials, while precious time is wasted by fragmented reporting pathways, poor IT interoperability and outdated laboratory information management systems, or LIMS.
Yet genomics is one of the major strategic transformational priorities for the NHS to improve cancer outcomes. Innovation in genomics is advancing very rapidly, and AI advances in analysing and interpreting large-scale sequencing data need digital infrastructure. Although many local pathology laboratories can deliver results within clinically useful timeframes, whole-genome sequencing at genomic laboratory hubs becomes essential for complex cases and inherited cancer syndromes. In addition, it supports research and new biomarker assay development when integrated with tissue pathology and imaging.
The NHS workforce plan, which we have already discussed, must consider training and workforce development in genomics and genetics, cellular pathology, clinical biochemistry, and molecular pathology; otherwise, a bottleneck in cancer and precision medicine pathways will continue to compromise cancer diagnosis and will eventually leave us with even worse outcomes.
Radiotherapy is crucial for cancer treatment. It is the second most widely used cancer treatment. It is needed by half of cancer patients and is key to 40% of cancer cures, and there is also palliative radiotherapy. Yet radiotherapy has the worst waiting times of the main cancer treatments, with significant inequalities in access. The latest NHS figures show that wait times for radiotherapy are far worse than for surgery or cancer drug treatments. Only 42% of patients receive their first radiotherapy treatment within 62 days. In some ICBs, this is as low as 10%, so only one in 10 patients receives their treatment on time—far away from the target of 85%.
Delays to radiotherapy are worse in the east of England, the Midlands and the north-east. Delays jeopardise survival. For some cancers, every four-week delay in treatment, as we have heard, brings a 10% increase in the risk of death. That is very serious. Government data shows that access to radiotherapy among lung cancer patients was as low as 11% in some areas. As the noble Baroness, Lady Pidgeon, said, the UK has only five radiotherapy linear accelerators per million people, compared with more than seven in France, Italy, and the Netherlands. International estimates suggest that 53% of cancer patients could benefit from radiotherapy, yet in England only 35% received it as part of their primary treatment.
Improving this requires a new approach. I, like everyone, welcome the national cancer plan, but a previous error in it highlights the need for this amendment. The cancer plan claimed that 28 replacement radiotherapy machines would enable an additional 27,500 patients to be treated annually, but the now corrected figure is for 27,500 treatments, not patients. Patients can receive dozens of treatments, so this could be a tenfold overestimate in capacity increase. It shows why radiotherapy expertise must be involved in policy, particularly horizon scanning advanced technology.
Radiotherapy services do not map neatly within ICB boundaries and operate within in the wider operational delivery networks. Most ICBs have no named lead, having only one or two radiotherapy centres in their area. So the ICBs lack the necessary specialist knowledge. Secretary of State support to ICBs would improve access to modern techniques, including stereotactic radiotherapy and proton beam therapy. The financial case is compelling.
Radiotherapy is our most cost-effective curative cancer treatment. A curative course costs around £3,000 to £7,000, and palliative treatment is a few hundred pounds. It accounts for just 7% of cancer expenditure in England, despite being second to surgery for cure rates. Radiotherapy investment makes clinical and economic sense for the treatment of cancer patients. We must improve. I suggest that these amendments are practical, complementary to the Government’s cancer plan, and essential.
Baroness Royall of Blaisdon (Lab)
My Lords, I fully support all the amendments in this group. Anecdotally, on radiotherapy, a friend of mine was a very senior consultant in radiography, and he was so frustrated by the system that he retired earlier than he might. He just gave up the battle; it was so very hard. Obviously, that was to the detriment of his patients, but he could not continue any longer.
I have one question on Amendment 228, about the number of days that people should wait for treatment post diagnosis—62 days seems far too long to me, so I urge noble Lords to make it much sooner than that, because that would save lives.
Amendment 233 is in my name. I am grateful to the noble Lord, Lord Mott, and the right reverend Prelate the Bishop of Manchester for adding their names, and to Prostate Cancer UK for its support. It is a fantastic charity. Prostate cancer, as I have said so many times, is the most common cancer in men in this country. More than 64,000 men are diagnosed every year, and around 12,000 die. It remains the most common cancer without a national screening programme, but, like all cancers, early diagnosis is key.
Baroness Nargund (Lab)
My Lords, I understand the importance of the amendments in this group and I support them. I want particularly to speak to Amendments 41 and 217, from the noble Baroness, Lady Pidgeon; Amendment 250 from the noble Baroness, Lady Finlay; and Amendment 233 from my noble friend Lady Royall.
Cancer, as we all know, is one of the leading causes of death worldwide, and it has touched many, if not most, of our lives. As the noble Baroness, Lady Pidgeon, said, one in two of us will be affected by cancer in our lifetime. We know that the Government take cancer seriously. Their national cancer plan for England, and increased investment in earlier diagnosis and clinical trials, are truly to be applauded. But the core issue is about cancer research, which I have raised before in the House, and the impact—which I have not yet addressed in the House but have in a written form—of Brexit on our ability to conduct research, to attract research fellows from across the EU and to access funding.
Before Brexit, the UK was the second-largest beneficiary of scientific research funding after Germany, and we have lost that. We have lost access to our research fellows: I used to have access to so many research fellows from the EU who came across and helped, and we did that similarly. I must declare an interest that I was a visiting professor in Belgium for nearly two decades. We exchanged research fellows, which helped enormously for original research, in particular with drugs and medicines research. We have now lost that. That is particularly relevant when it comes to rare cancers, and cancers that affect, in particular, ethnic-minority populations, because the patient population size is small, so it is not possible for NICE to conduct its cost-effectiveness and clinical effectiveness studies and come up with meaningful data to publish in high-powered scientific publications without international and EU collaboration. We desperately need that for cancer research, particularly for trials.
Cancer Research UK is an absolute star in cancer research and one of the world’s largest independent cancer research organisations, but even it has had to establish trials in other countries—partnering, for example, with the Nordic Cancer Union—because it can be cheaper, easier, faster and more accessible to do so. This means that researchers can, potentially, understand how to treat cancer more quickly and effectively elsewhere than here on our own soil, particularly when it comes to addressing prostate cancer. The noble Baroness, Lady Finlay, mentioned the importance of collaborating with the EU. We know that the EU has moved on in some ways, particularly with targeted cancer screening in high-risk patients, which is something on which we seem to be lagging behind.
I echo the call of the noble Baroness, Lady Pidgeon, in Amendment 217 for the establishment of a research and fellowship programme for international academics in cancer research, alongside appropriate visa support to enable them to come to the UK. I personally know how brilliant minds have decided to go elsewhere for their studies and research since Brexit. We are losing talent, expertise, collaboration, research staff and, potentially, treatments that could save the lives of cancer patients.
I therefore ask my noble friend the Minister, who I know takes this issue really seriously, whether the Government have given consideration to the impact of what we have lost after Brexit. How can we get more EU collaboration for cancer research and cancer research funding? What steps are the Government taking to strengthen EU and international collaboration, in particular on setting up big research trials for rare cancers and cancers affecting minority populations, and on data sharing and access to academic clinical research trials and universities across the EU? What steps are being taken to expedite the pathway from research trials to MHRA, NICE and NHS funding pathways? That is urgent, particularly for certain cancers. What more can be done to make the UK an attractive and accessible place for international researchers, research trials, and academics?
Baroness Morgan of Drefelin (Lab)
My Lords, this is a very important group of amendments, which touches on all the key areas in cancer concern, including: the focus on the mandate that we are losing; the question of how to promote research; waiting times, and how incredibly stressful long waiting times are for patients; the importance of early detection and the need for screening; the importance of integrating modern approaches, such as genomic testing and personalised medicine, into daily care; and, of course, radiotherapy and the challenges facing the radiotherapy community. I support the amendments and I have added my name to Amendments 41, 217 and 228, proposed by the noble Baroness, Lady Pidgeon.
I will focus very quickly on Amendment 217 and talk a little bit about clinical trials. For me, clinical trials play an absolutely pivotal role in ensuring that outcomes for cancer patients have an upward trajectory in our new NHS. That remains central to me, and I would dearly love to hear from the Minister the reassurance that I think we need: that in following the transition, restructuring and so on, there will be an appropriate and dynamic focus on improving participation in clinical trials. Participation in clinical trials for cancer patients is falling. Although, following the O’Shaughnessy review, which was a huge wake-up call, the Government have taken important steps to tackle the amount of time it takes for clinical trials to be set up, and they have made great progress on commercial trials, we still need to do much more for academic clinical trials and those focusing on rarer cancers. That is my area of concern, and I would be grateful to hear something from the Minister on that.
As the noble Lord, Lord Hunt, has said a few times, structure needs to follow purpose. The cancer plan, the mandate from 2022 and the NHS 10-year plan are all phenomenally important commitments to improving outcomes for patients. However, if we have a hiatus because of a vacuum caused by restructuring the establishment of specialist commissioning in ICBs then are they really ready for this? Can we really be sure that all the amazing commitments in the cancer plan will be progressed further? That is really what I am looking for.
I do not think there is a lack of commitment at all on the part of the Government—the recent women’s health strategy is a great step forward—but we need to be realistic about the challenges that change creates in the system. It has taken years to develop the informal and formal ecosystem that promotes the research that we need to keep improving outcomes for patients up there on the agenda. Can the Minister please explain how we will ensure that there is a culture that really embeds the bench-to-bedside ethos that we know is so important to save lives from cancer, for rarer cancers, and for those patients experiencing cancer now but also in the future?
Baroness Ritchie of Downpatrick (Lab)
My Lords, I come to this debate as someone who is a breast cancer survivor of some eight years and who has been involved in a cancer trial—a double-blind aspirin trial. I do not know whether I was taking aspirin, but I will find out next year when the results of that trial will be revealed.
I am somebody who, from practice, firmly believes in cancer outcomes. I believe there needs to be concentration on cancer outcomes, on survival and on an expeditious way to ensure that patients have ready access, especially for rare cancers. Genomics is telling us so much about the type and the content of cancer tumours that we need to work at pace to ensure that those treatments and new treatments are available to deal with them. I have every confidence that the Government will be able to facilitate that, but the challenging issues are around radiotherapy times, and the intensification of radiotherapy and those treatments.
I remember, from my first diagnosis, being told that everybody’s tumour is different, even though you may have breast cancer, because that is the collective term. Therefore, the idea and the objective is to focus that treatment on the content of the tumour that you have, which is particular to you. Treatments are dedicated to the needs of patients; I would like to think that was continued as part of our Health Bill and of treating cancer patients generally.
Lord Patel (CB)
My Lords, I have put my name to several of these amendments. Much has been said already, so I will try to be brief. I will focus on two or three main things. One is where the developments are likely to lead us, which will complicate the issues even more than what we are talking about today.
Let me come to cancer outcomes first. It has rightly been pointed out where England stands internationally in terms of cancer outcomes. Cancer outcomes are the ultimate truth: the truth in terms of one-year and five-year survival rates of any cancer. They are often what we use for international comparisons, but there is a system-wide reflection to be had. Poor survival outcomes are, often, a failure of several other processes, including when the diagnosis was made, the aggressive nature of the tumour—the later it is identified, the more aggressive it is likely to be—and whether the treatment was given at the right time. As was mentioned, delayed treatment increases the risk of mortality.
Although the outcome, survival-wise, is an important parameter, there are other issues that need to be considered when assessing cancer outcomes, and they often relate to the processes. The balance metrics of measuring cancer outcomes may well include process indicators; operational timelines, in terms of how many days’ treatment the patient has; patient-centred outcomes, which are not often mentioned; and risk-adjusted clinical outcomes, based on the nature of the cancer. The core outcomes that are reported should include not only survival rates, but mortality rates, stage of diagnosis and operational and access metrics. The purpose of reporting—that is the important part for commissioning issues—is that accountability be taken into consideration. It should hold regional health services and Governments responsible for funding allocations and clinical performance, highlighting the gaps, and guiding policies and clinical improvements. Unless we have these measurements of outcomes, measuring survival rates only will not be enough.
I will briefly mention genomics and radiotherapy. On radiotherapy, I get a daily, or sometimes weekly, bulletin from a medical oncology consultant whom I know extremely well; I will not name her. The important point has already been mentioned: it is not that we do not have the expertise in clinical capabilities, as Cancer Research UK has mentioned in its report; it is that bottlenecks occur in the processes afterwards. The surgery might be good, but there are bottlenecks in other forms of treatment. On radiotherapy, we have already mentioned the unmet needs, waiting times, regional disparities and workforce and equipment pressures. They will multiply with the advances that are coming in radiotherapy, which not all centres in England have implemented. It is good that NHS England announced a major rollout of stereotactic ablative radiotherapy, which reduced treatments for prostate cancers, for instance, from 20 to five. However, only a few centres now use advanced technology and AI together to further assist the planning of radiotherapy treatments, which can sometimes take days.
There are developments occurring in radiotherapy that will put further pressures on patient access. With FLASH radiotherapy, for instance, radiotherapy is given in a concentrated way in a millisecond—not minutes, not hours, not days, but in a millisecond. Through biologically guided radiotherapy, integrated PET scanners, mentioned by the noble Baroness, Lady Finlay, are combined with linear accelerator scanners. They can immediately diagnose the nature of the cancer and deliver the appropriate therapy on the spot. Through generative AI adoption, AI is used while the patient is on the treatment table to identify the nature of the tumour and whether it can take higher-dose radiotherapy. There is also radiogenomics, whereby personalised genomics are associated with the behaviour of the tissue and the machine can decide whether it can give a higher dosage at a concentrated level. All these developments will put further pressure on our capacity to deliver to cancer patients, which needs to be addressed.
There are lots of issues to be addressed but, finally and briefly, the Science and Technology Committee is about to produce a report on AI, genomics and personalised medicine, which identifies the role of genomics not only in cancer but in other areas too. Cancer, in particular, will require the rapid genomic analysis that the noble Baroness, Lady Finlay, mentioned. It is good that NHS England established seven genetic hubs that now do mutation screening and genomic screening, looking at the mutations in each and every cancer to see whether it will react to a particular treatment or not. They are building up a library, and it is important to continue building that library.
Importantly, the only way to develop personalised medicine vaccines for delivery to individual patients is to do the genomics mutation study as rapidly as we can. The cancer genomics 10-year plan has identified all the issues, but it has not identified a way forward for implementation. This debate has emphasised that we need to know how we are going to deal with all the developments, deliver the cancer treatments and improve outcomes globally.
Lord Stevens of Birmingham (CB)
My Lords, I declare my interest as chair of Cancer Research UK and wholeheartedly endorse all the previous contributions on this group, which have been outstanding. The purpose of these probing amendments is simply to make sure that cancer remains very firmly on the Government’s agenda. The cancer plan, published in February, has a range of really welcome proposals, but the key thing will be putting them in place. In the cancer plan, there was a commitment to delivering the cancer waiting time standards by 2029. It would be fantastic if the Minister could confirm at the Dispatch Box that that remains the game plan the Government and the NHS have embarked on.
In doing so, can the Minister briefly comment, in the context of the three headline cancer waiting times targets, on the faster diagnosis standard for urgent referral of 28 days? We are seeing a bit of a bifurcation opening up between the faster experience that patients who do not have cancer are having—with cancer being ruled out for 79% of people, against an 80% target, which is great—and maybe only 55% of people who actually have cancer getting their diagnosis within that 28-day period. If we are interested in the outcomes improvement that will come from early diagnosis, it will be crucial to keep a beady eye on the waiting times for diagnosis for people who actually have cancer.
Lord Tarassenko (CB)
My Lords, I will speak very briefly in support of Amendment 250 in the name of the noble Baroness, Lady Finlay, to which I have added my name. I come to this debate as the husband of a cancer survivor. My wife was diagnosed with Hodgkin’s lymphoma 30 years ago, and I am very glad to say that she was successfully treated with radiotherapy.
I realise that, for lymphoma, the role of radiotherapy has decreased as chemotherapy has improved. But for some cancers, as we have heard, radiotherapy remains the treatment of choice. Chemoradiotherapy for cancer of the larynx cures patients while, very importantly, preserving their voice. For anal cancer, it has replaced an operation that once meant a permanent colostomy for every patient. For locally advanced cervical cancer and early lung cancer in patients too frail for surgery, it is the curative option.
Radiotherapy, of course, also works in partnership with other treatments. A study of more than half a million cancer survivors in England found that three-quarters of five-year breast cancer survivors and two-thirds of head and neck survivors had received radiotherapy. In the ProtecT trial, led by my Oxford colleague Professor Freddie Hamdy, which followed more than 1,600 men with localised prostate cancer for 15 years, radiotherapy matched surgery on survival but fewer men were left with long-term incontinence.
So, the problem is not the evidence but delivery. As the noble Baroness, Lady Finlay, has said, only four in 10 patients start radiotherapy within the 62-day standard against a target of 85%—far behind surgery and chemotherapy. More than half of cancer patients would benefit from radiotherapy, yet in England only around a third receive it. Some 60,000 patients a year miss out, and that is often because of where they live.
That is why a national delivery programme is important. First, we should think about equipment: the linear accelerators which generate the high-energy radiation of radiotherapy last around 10 years. A national programme can plan a replacement as a rolling cycle and buy at scale instead of trusts bidding for capital one machine at a time. In May 2025, the Government invested in 28 new machines, which is very welcome, but a plan is needed to go beyond one-off funding. Secondly, satellite centres such as Oxford’s, at Swindon’s Great Western Hospital, bring treatment closer to the patient’s home, but they need to be planned nationally once the gaps have been identified. Thirdly, a national programme can collect national data, including performance data, and have a co-ordinator responsible for delivery.
Radiotherapy is curative, cost effective and preserves organs. Patients deserve timely access to it wherever they live.
Lord Evans of Rainow (Con)
My Lords, I apologise for interrupting the noble Lord; the House always enjoys hearing from him. I am speaking in an incredibly important and delicate debate. I thank all the noble Baronesses for tabling such amendments which address some of the most pressing challenges facing cancer patients and their families. Cancer is a disease for which time is so often the difference between life and death. Too many patients face delays in diagnosis, uncertainty over treatment and unacceptable inequalities in access to care. These amendments speak to a fundamental principle: improving cancer outcomes must remain a clear and measurable national priority.
I welcome the amendments tabled by the noble Baroness, Lady Pidgeon, particularly Amendment 41, which seeks to ensure that cancer outcomes, including survival, remain a priority for the Secretary of State. Removing the existing statutory requirement risks weakening accountability at precisely the moment we need greater ambition.
That ambition must extend to cancers with the poorest survival rates. I was encouraged to hear last week from the noble Baroness, Lady Merron, that the Government have commissioned an expert review into brain cancer research and that findings will be expected within just three months. This is welcome, but patients and families have heard promises before. What will be different this time? Can the Minister explain how the review will translate into tangible improvements in research funding, clinical trials and, ultimately, survival?
The Government have also released a national cancer plan to support new clinical trials and increase research participation, coupled with an ambition to reduce clinical trial set-up times to 150 days by March 2026. These are positive steps, but they must be matched by the capacity to deliver them. Does the NHS have the workforce, infrastructure and resource necessary to turn this ambition into concrete results for patients? Research is essential, but so is timely treatment. What targeted funding do the Government further envisage for clinical trials?
I will now address the amendment from the noble Baroness, Lady Pidgeon, which would strengthen patients’ rights to begin cancer treatment within 62 days of referral. This should be a reliable standard. Can the Minister explain why this target is not being met and what steps they are taking to do so?
The urgency is particularly apparent in radiotherapy. As the noble Baroness, Lady Finlay, powerfully highlighted, radiotherapy is one of the worst performing cancer treatments. Only 62% of radiotherapy patients begin treatment in 62 days in comparison to 71% for surgery and 67% for chemotherapy—all fall short of the target of 85%. These figures should concern us all. Delays and geographical inequalities continue to undermine access to treatment. Can the Minister tell us whether the Government have begun to design a nationally co-ordinated programme addressing workforce shortages, equipment capacity and access to modern techniques?
Baroness Merron (Lab)
My Lords, I am most grateful for the constructive amendments that have been tabled on cancer services. Noble Lords will know that we take this issue very seriously, as evidenced by our national cancer plan, which sets out very clear priorities to transform cancer care and outcomes over the next 10 years. In addition to that, I say to the noble Lord, Lord Evans, that what is being spoken about now strikes at the very core of the Health Bill and the reasons we are taking the actions that we are to be able to improve the situation still further. I recognise the impact of cancer on many noble Lords, either directly or indirectly, and I thank them for bringing their personal experience to the debate. It is important not just within this Chamber but to so many people outside, where one in two will be affected by cancer.
I will address some of the amendments before us. On Amendment 41, I can assure the noble Baroness, Lady Pidgeon, of our commitment to improving cancer outcomes. The noble Lord, Lord Stevens, welcomed our national cancer plan, which sets out an ambition to increase five-year survival to 75% by 2035, which will save an estimated 320,000 more lives over the next decade. The current law requires the NHS mandate to include cancer outcome objectives, which NHS England must prioritise over other cancer-specific objectives. With the abolition of NHS England that mechanism will no longer be needed, but that is because our focus on prioritising cancer outcomes remains. I hope that that is the start of a reassurance to my noble friend Lady Morgan, who raised this point, and rightly so, at Second Reading.
The plan provides a clear programme for delivery, supported by annual reporting on progress against key measures and targets. Last month, we confirmed a new independent National Cancer Board that will help scrutinise our progress—progress that the noble Lord, Lord Patel, rightly seeks—and, importantly, will ensure that the voice of cancer patients is heard. I know my noble friend Lady Ritchie will particularly welcome that. We therefore consider an additional statutory duty to prioritise cancer outcome objectives unnecessary, in terms of legislation. Our priority, as the noble Lord, Lord Patel, spoke to, is to deliver the commitments of the plan.
Amendment 217 addresses research into cancers with the lowest survival rate. We invest around £1.8 billion each year on research through the National Institute for Health and Care Research. Cancer is a major area of expenditure, standing at £141.6 million in 2024-25, which reflects its high priority.
We recognise that research into all cancers—a point that a number of noble Lords have raised—including those with the lowest survival rate, is a key priority. Research is funded through open competition and peer review to ensure that the highest-quality proposals—the ones that are most likely to deliver real impact for patients—are funded without imposing financial targets or limits. Our cancer plan includes a commitment to make progress on rare cancers one of the six key research priorities, to tackle stubbornly low survival rates. Our aim is to be in the top quartile across 28 countries for survival of 14 rare and less common cancers.
To the point made by my noble friend Lady Nargund, we are strengthening international research collaboration. For example, a joint call with the Japan Agency for Medical Research and Development opened just last month, to which the NIHR is committing a total of £2 million to support UK-based components. In respect of my noble friend’s question about pathways from MHRA and NICE trials to making treatments available, this is absolutely key. A new cancer trials accelerator will make the NHS the first-choice partner for cancer clinical trials.
I can confirm to the noble Baroness, Lady Finlay, that the DHSC still participates in and influences the EU cancer mission. I hope that noble Lords will appreciate that we very much see the importance of international work, both with our EU partners and beyond the EU.
My noble friend Lady Morgan seeks reassurance that there will be an appropriate and dynamic focus on improving participation in clinical trials. The answer to that is yes. We are also looking into options to contact patients with rare cancers to offer them the opportunity to be part of clinical trials, through a tailored version of the Be Part of Research service. My noble friend will also know the demanding targets we have set ourselves in terms of setting up clinical trials.
Turning to Amendment 228, improving performance against cancer waiting standards is absolutely key. There has been year on year progress with waiting times, but I would be the first to admit that there is some way to go. To my noble friend Lady Royall, as well as the noble Lord, Lord Evans, I can say that cancer waiting time targets, including the 62-day referral to treatment target, are not set at 100% for several reasons. They include patient choice, clinical guidelines and the reality and complexity of diagnosis and treatment planning, which mean that not every patient can or should be treated within the waiting time standard.
Change, including improvements to parts of the cancer pathway and tackling variation in performance across trusts, which is something I know is of concern to noble Lords, will not be delivered overnight, but the national cancer plan sets out the concrete and measurable actions in how we are going to get there. I assure the Committee that the plan makes a clear commitment to meet all the cancer waiting time standards. We will go further, reviewing them once they have been met, to consider whether they should be strengthened. In other words, it will not be case of job done and move on; we will review what more we can do.
I am grateful to my noble friend, Lady Royall, for bringing Amendment 233 before the Committee today. The Government are determined to improve outcomes for men with prostate cancer, and we have partnered with Prostate Cancer UK on the £60 million TRANSFORM trial to find the best way to screen men for prostate cancer. That was something the noble Lord, Lord Evans, raised.
However, as noble Lords will be aware, the case for an early detection programme has recently been considered through the UK National Screening Committee’s established evidence review process. For men without symptoms, early detection would, in practice, amount to screening. The committee therefore recommended screening only where the evidence shows that the benefits outweigh the harms. With prostate cancer, earlier detection is not always better. Many prostate cancers are slow growing and may never cause harm, while PSA testing cannot reliably distinguish these from aggressive cancers. Screening can therefore sometimes lead to overdiagnosis and unnecessary treatment, with potentially life-changing consequences, so we continue to be guided by the evidence.
My noble friend Lady Royall also asked about further inclusion. Prostate Cancer UK is using local government engagement grants to ensure that local organisations that work in Black communities can support recruitment to the trial, which was the point she was concerned about, and can also spread awareness of the trial.
Turning to Amendments 247 and 250, tabled by the noble Baroness, Lady Finlay, the Government agree that genomic testing should be timely, equitable and fully integrated into cancer care. The cancer plan commits to providing genomic testing to every cancer patient who would benefit from one within a clinically relevant timeframe, so that the results can inform treatment decisions.
Our focus is on ensuring that the NHS Genomic Medicine Service works consistently for patients and ensures that results inform treatment. To the point about workforce, we will create 5,000 learning and training opportunities each year, including opportunities to develop knowledge of emerging technologies, such as genomics.
At the same time, NHS England is improving the links between pathology and genomics, expanding molecular profiling and developing national digital arrangements for requesting and tracking tests. These improvements are best taken forward through NHS commissioning and service arrangements, in our view, rather than through a broad statutory duty, so there can be adaption as clinical evidence and technology develops. I was glad to hear the noble Lord, Lord Patel, welcome the establishment of the genomic hubs and the work they do.
Finally, I turn to Amendment 250. We share the ambition in terms of radiotherapy, and patients should have timely access to modern, effective treatment wherever they live. The noble Lord, Lord Tarassenko, spoke to the points on radiotherapy. However, it is our view that a specific duty for the Secretary of State for one treatment in particular would set a precedent and cut across the devolved models in which local systems and cancer alliances are expected to deliver.
Baroness Finlay of Llandaff (CB)
My Lords, I am most grateful to the Minister for her comprehensive response to the amendments, including mine. Can she assure us that the data that she spoke about will now be supplied directly to OECD as well, so that we will be able to resume international comparisons, and that it will include quality of life data as well as simply survival data, because survival data itself may be misleading? In among the quality of life, of course, there is the impact of the family reported outcome measures as well, which can go along with that and be very informative. Unless all the data, including genomics data, is linked to demographic data, we will not get much further in untangling some of the underlying causes, which may be environmental, of the increase in malignancies that we see in the younger population. There has been an upward creep, but it is definitely there.
Baroness Merron (Lab)
I will need to check on the first point that the noble Baroness asked me about—the supply of information—but I will gladly write to her once I have looked at it. I absolutely agree with the point that she makes about data being one thing, but it is only as good as the use you can put it to. We seek to collect the right data for the right purpose; in other words, to improve outcomes.
Baroness Pidgeon (LD)
I thank noble Lords for the quality of the debate on this group. I particularly thank the noble Baroness, Lady Ritchie, for sharing such a personal story earlier.
I am glad to hear that the Government are committed to improving cancer outcomes, but I still have questions. Given that it was in the 2022 Act, and part of that Bill, where is the annual mandate that was set out for NHS England going to sit now? Perhaps the Minister can write to noble Lords setting out how that will not be lost, just to assure us. It is not just noble Lords here who are concerned; the sector and charities are very concerned that it will be lost. It was in a Bill before, so let us try to understand why the Government do not think it is needed now. But given the response we have had and the debate, I beg leave to withdraw my amendment.
Baroness Pidgeon
“Ministerial responsibility for social careIn section 1(3) of the National Health Service Act 2006 (ministerial responsibility to Parliament), after “service” insert “, and the promotion of social care,”.”Member's explanatory statement
This amendment would extend the Secretary of State’s ministerial responsibility to Parliament under section 1(3) of the National Health Service Act 2006 to the promotion of social care, alongside the provision of the health service.
Baroness Pidgeon (LD)
My Lords, I am moving Amendment 42 and speaking also to Amendment 44, in the name of my noble friend Lady Tyler, who is not in her place today. These amendments are both designed to make explicit in the legislation that the Secretary of State’s duty, in line with the ministerial title, embraces social care as well as health—the two being inextricably linked, as we have said so many times during the passage of this Bill.
Amendment 44 would extend the Secretary of State’s core duty in Section 1 of the National Health Service Act 2006 to cover social care, so that the duty matches the ministerial title. It also reflects Section 2 of the Health and Social Care (Reform) (Northern Ireland) Act 2009. Amendment 42 would extend the Secretary of State’s ministerial responsibility to Parliament under Section 1(3) of the National Health Service Act 2006 to the promotion of social care alongside the provision of the health service.
Let me just explain why we think that this is necessary and would send a really important signal. The amendments recognise the importance of ministerial responsibility at a time when power is being transferred back to the Secretary of State, with the abolition of NHS England.
These relatively small changes would signal acknowledgement of and respect for the growing number of people in England who need and will continue to need a well-supported social care system alongside a properly functioning NHS. The amendments would give legislative effect to the so-called
“new way of doing politics where we come together, face the challenge head on and build an integrated system that gives people security and dignity”,
announced by the Prime Minister when outlining his commitment to social care in July 2026. He also said explicitly that
“broken social care will in the end break the NHS”.
Correcting the mismatch and seeming imbalance between the ministerial title and duty would also help to ensure that the current momentum is sustained into future Parliaments and would not fall down the agenda again.
The background here, as I am sure many noble Lords will remember, is that the ministerial title was changed back in January 2018 as part of Theresa May’s Cabinet reshuffle. Jeremy Hunt went into Downing Street, amid all sorts of expectations that he might be moved on, and emerged an hour later with the enhanced title of Secretary of State for Health and Social Care—such is politics. However, let us make sure that the title and responsibilities fully match up and social care is given the important standing it needs alongside health. I beg to move the amendment.
Baroness Watkins of Tavistock (CB)
I have added my name to Amendments 42 and 44. I agree with the need for them, as outlined by the noble Baroness, Lady Pidgeon, on behalf of the noble Baroness, Lady Tyler, and will add only a few points. The health service is designed to prevent ill health, as well as providing services. Provision of high-quality social care reduces hospital care and provides respite to carers, as previously described on the first day in Committee on this Bill.
The Secretary of State for Health and Social Care has proposed a new special health authority to replace NHS England which, it is argued, will be a temporary measure. Earlier in Committee, I asked the Minister whether the Bill should be delayed to make adequate provision for the proposed revision of social care, which is to be initially detailed in the report of the noble Baroness, Lady Casey. If these amendments are supported in principle, this would prepare a path for further integration, where appropriate, of health and social care provision, and enable consideration of the metamorphosis of the special health authority to a new body—or possibly two bodies, depending on how we move forward on social care—to oversee areas in both health and social care services, particularly where they need to overlap.
Throughout our debate today, I have listened to various discussions about patients, but essentially the health service and social care are for the public. If we are to take health promotion and social care seriously, it should be feasible for service users to have real choice, not only in acute care but in mental health and physical health promotion, screening, prevention, deterioration prevention and, of course, where necessary, evidence-based health treatment, which is a vital end-process but should not in most cases be the beginning of the support that people have.
Baroness Ritchie of Downpatrick (Lab)
My Lords, I will speak to the amendment in my name, which has been co-signed by the noble Lords, Lord Weir and Lord Blunkett. The new clause it proposes seeks to improve the collection and publication of dementia data through an annual report from the Secretary of State for Health and Social Care, bringing together data from across the dementia pathway and outlining progress towards targets and standards set out in any national plans. This is particularly timely, as the modern service framework for dementia and frailty is due for publication before the House rises for the next recess.
I welcome the development of a national framework for dementia and look forward to seeing the details when it is published. However, a framework alone will not create the much-needed change unless it is delivered on. This amendment would ensure that there is sufficient transparency so that this House and the other place can see where progress is being made and hold government to account in implementing the new modern service framework.
However, the amendment is much wider than simply measuring the progress of a national framework. For too long, dementia has been sidelined. In his investigation into NHS performance, the noble Lord, Lord Darzi, highlighted that there is an important challenge to improve the quality and quantity of care for people with dementia. I do not need to tell the House what a challenge this is. Dementia is the UK’s leading cause of death, according to experts, and the condition which the public fear most. Sadly, too many people still fall through the cracks. The impact extends far beyond individuals and families. Dementia touches every corner of our health and care system and probably the majority of our families.
The condition has significant impacts on our hospitals, GPs, A&E services, the workforce and our economy. Data is the key to unlocking progress in these areas and improving the quality and quantity of dementia care, as called for by the noble Lord, Lord Darzi. Data would provide Parliament, the people living with dementia and the public with a clear picture of how dementia services are performing, allowing us to understand where variations lie and where more attention is needed.
As several Governments have neglected to face this issue head-on, the scale of the challenge is immense. I welcome the action that our Government have taken on dementia to date but believe that data is the foundation to ensuring that these measures make a difference. Efforts to improve dementia research, develop a national care service or bring in new leadership through a dementia tsar are important steps forward in improving dementia care. I look forward to that national care service.
Without joined-up, comprehensive and transparent data, we cannot know where or how these measures have improved the lives of people living with the condition now and in the future. If we want to make a difference in tackling one of the greatest health and care challenges of our time, we must have the data to strengthen our approach. I thank the Alzheimer’s Society, Alzheimer’s Research UK and Dementia UK for their efforts to strengthen the Bill’s focus on dementia. I hope that my noble friend the Minister will recognise the opportunity that this amendment creates to make meaningful progress for the 1 million people living with the condition across the UK. She may regard this as a scoping amendment but, notwithstanding that, I look forward to hearing what she has to say and, on Report, she might table a government amendment to that effect.
Lord Weir of Ballyholme (DUP)
My Lords, as the noble Baroness, Lady Ritchie, has said, I and the noble Lord, Lord Blunkett, have co-signed her amendment, I think rightly. It would provide a proper prioritised focus on dementia, as it is very significant within our society. Mention has been made of the estimated 1 million people suffering from it. That is very much an estimate, because roughly one in three people who have dementia is not diagnosed at present.
I suspect that there is nobody in this Chamber who does not have a family member who has suffered from dementia or, at the very least, a friend of the family who suffered from dementia. It is something that touches all our lives. For those families and individuals who have dementia, we know this can be an incredibly painful experience and a very difficult time for them.
As the noble Baroness, Lady Ritchie, indicated, this condition has much wider implications for the NHS as a whole. The statistics suggest that, at present, one in six hospital beds are occupied by someone with dementia. We know that this is a condition which is going to simply expand over time. Part of that is largely because of our ageing population, which itself is a testament to the success of our health service. We are seeing, with many terrible conditions, much greater levels of survival rates and much greater levels of increased lineage because of that, but it also means that we have an increasingly aged population. Even Northern Ireland, from where the noble Baroness, Lady Ritchie, and I hail, which has traditionally always had a very young population, will reach the tipping point next year, when the number of pensioners in Northern Ireland will outweigh the number of children. We can see that this is going to be an expanding problem.
Secondly, the amendment is important, because there is a lack of consistency around the country in tackling dementia in terms of care, although this is not unique to dementia. There are inconsistencies over the speed of diagnosis, over the advice given on pathways for those with dementia and over the level of provision of social care. I know the Government are very much right, when they look at inconsistencies, to tackle health inequalities. I do not think any of us would disagree with that, but this goes even beyond health inequalities. It is a certain level of postcode lottery where what you get can be very different according to the luck of geography. With a national report, on an annual basis, based very firmly on data, shining the light on the data could itself act as an incentive towards improving performance. Where we can see geographical areas lagging behind each other, it will be an incentive for them to improve. Where we perhaps see improvements on one side of things with dementia but not on another, having that data could act as a driver for that.
There is a race against time, given the increase in the number of people who are likely to suffer from dementia. Much more positively, we know that it appears that we are on the cusp of great breakthroughs in the treatment of dementia, perhaps through drugs that can slow it down and ultimately put us in a position, we hope, to provide a cure for various forms of dementia. However, a key barrier to that breakthrough has been the lack of consistent data, both in terms of quantity—we know that approximately only 1% of those with dementia are involved in any form of trials to push for solutions—and in terms of quality, because we do not necessarily have it on a consistent basis. Again, an annual report could help do that.
The amendment is well-timed, and it is very compatible with the proposed publication of the dementia side of the modern service framework. The amendment goes to a lot of the Government’s rightful aspirations to integrate social care within the system and to move beyond the idea of rhetoric and good intentions towards delivery.
Finally, the amendment, importantly, tries to provide a solution to one thing that sometimes, as legislators, we are not as focused on as we should be—I do not mean this as a criticism of this Government or, to be honest, of this Parliament, because it could happen in any legislative forum. As legislators, our tendency is to see a problem, find a solution through legislation, get that legislation passed and then we feel the problem is solved. The reality is that legislation should be simply the start of a process rather than the end. It is the implementation of that legislation and the follow-through into people’s lives that are critical. To put it another way, we often fall into the trap of seeing legislation as the full stop; we should see it as the comma and simply part of a continuum of a process.
Whether it is through this amendment or something similar, we need a clearer focus on dementia. We need something that is much more nationally based and data-driven. That could be a very useful tool in combating something which we are all on the same page on and in trying to provide better care for those with dementia and better support for their families.
Baroness Thornton (Lab)
My Lords, I will make one or two remarks and probably ask some questions of the supporters of Amendment 180. I regard these amendments as what one might call the “moving parts” amendments. We are all trying to work out how on earth we are going to get reform in the NHS and get social care and all those things, which is why the questions from the noble Baroness, Lady Watkins, were particularly pertinent. It is reasonable that, during the course of the Bill, we should be asking how social care is going to be pushed forward and whether we need to put measures in the Bill which will help that process, even though we know we are in the middle of the Casey review and we have the determination of our Prime Minister to deliver long-term change to our social care system.
There are two questions I want to ask the noble Lord, Lord Kamall. Why does Amendment 180 exist without any reference to what is happening at the moment, which is that we are in the middle of a social care review that will bring forward some proposals about what a national care service should look like? Also, perhaps the noble Lord would like to talk a little bit about the commitment that his party will make to that social care reform and the need for there to be consensus and cross-party review to take it forward. In that way, I kind of welcome what the amendment says, but I am slightly puzzled as to why it sits there in the Bill and does not really relate to what is actually taking place.
Lord Scriven (LD)
My Lords, these amendments seem small but they are slightly the elephant in the room in terms of dealing with real people who have complex needs, and who do not fall into administrative boxes called “health” and “social care”. They have needs that sometimes cross both care and the NHS.
At Second Reading, a noble Lord—I cannot remember who—said that the problem with this Bill is that it is not really a Health Bill; it is an NHS Bill. It is about the structures and how the NHS works. It is a bit more complex than saying there are two potential things—a Bill and a review—going on. There is the social care review, from which we expect the national care service, and possibly legislation will be required for that. There is this Bill going through Parliament. Yet there is also the context of rewiring the state, which will have a significant impact on health and social care, and therefore how services are commissioned and provided.
I ask the Minister a simple question: how do all three fit together? Do she and the Government foresee any changes to provisions in the Bill once those two other pieces—the review and the legislation—go through about how funding, commissioning and services will be provided to people who require health and social care?
Baroness Pitkeathley (Lab)
My Lords, I support Amendments 42 and 44, because—as others said—they are the nub of a lot of the stuff we are having to think about in the Bill. They are an attempt to change the status of social care, from being the Cinderella, the tail-end Charlie, always the bridesmaid, or the poor relation. How many times have we referred to social care in those terms? We know that the system is not fit for purpose. We know that local authorities in a very few years will not have any money even for waste collection because social care will take such a huge percentage of their budgets. Even now, local authorities provide services only for those with needs classed as severe or critical.
When people cannot get social care services, what do they do? Of course, they turn to the NHS, resulting in pressure on services, delayed discharges and shortages—in a service that is already under severe pressure. Cost-cutting is then put ahead of patient welfare, and hospitals themselves are not meeting the required standards and do not have enough staff on duty to care properly for patients. Time and again, we find that social care, properly delivered, of good, reliable quality and with an emphasis on prevention, is a better way of caring for frail, elderly or disabled people than healthcare—and much better than an expensive hospital bed could ever provide that kind of care.
What is needed is integration. Now, I have never heard anybody say anything other than that health and social care should be integrated. I have been working on this for 40 years and everybody always says, “Oh yes, we must integrate”. Yet as far as getting under way with that is concerned, we have not done very well, because we have not really done anything about readmission rates when people are discharged. As soon as a person comes into hospital, it should be a priority to ensure that they do not stay in hospital longer than they have to, by having discharge procedures which provide a seamless transition and making sure that the all too frequent readmission because of inadequate integration between health and social care is guarded against. In this sense, the Government’s plans for a national care service are very much to be welcomed—this will be discussed in a later group of amendments—particularly their emphasis on raising the status of those who work in social care so that they are not seen as inadequate partners of those working in healthcare.
Lord Patel of Bradford (Non-Afl)
My Lords, I support Amendments 42 and 44, tabled by the noble Baronesses, Lady Tyler and Lady Watkins, and introduced very clearly by the noble Baroness, Lady Pidgeon, which make the Secretary of State’s responsibility for social care more explicit.
I approach these amendments from my experience in social work and as a former chair of the Mental Health Act Commission. I hope that with that example I might illustrate the point of view of the noble Lord, Lord Scriven, about things not fitting neatly. The noble Earl, Lord Howe, will remember, perhaps fondly, that during the passage of the Health and Social Care Bill in 2011-12, I argued strongly for preserving the protections of Section 117 of the Mental Health Act. We returned to that and those issues during the Care Bill debates in 2013. The principle at stake was straightforward: a person leaving psychiatric hospital after detention may need treatment, somewhere suitable to live, help with everyday life and support to build relationships. Those needs do not fall neatly into separate health and social care boxes. Section 117 recognises that through a joint duty on the NHS and the local authority to provide or arrange aftercare for eligible patients free of charge. Its importance lies in requiring organisations to take responsibility together for the support a person needs.
That clarity remains important because those difficulties are not new. During the 2012 debate, findings from the Local Government Ombudsman showed that some local authorities had unlawfully charged for Section 117 aftercare or ended arrangements without proper consultation. More broadly, responsibility and funding could be disputed between the NHS and local government, leaving patients and their families caught between them. These concerns underlie the need to preserve a clear and enforceable joint duty. The House returned to those issues during the passage of the Mental Health Bill in 2025, which the Minister took through this House. I welcome the provisions clarifying responsibility for aftercare, requiring joint written notice when it ends and strengthening human rights protections for people receiving Section 117 aftercare from registered private providers. I pay tribute to the noble Baroness, Lady Barker, for pressing those human rights issues.
Those were important advances. The question now is how those protections will translate into dependable support in people’s lives. Section 117 illustrates why the amendments before us matter. Parliament has recognised that some people’s needs require health and social care to act together. Making the Secretary of State explicitly responsible for social care would help Parliament hold Ministers to account for how those services work together in practice. As the recent mental health reforms are implemented, how will Ministers know whether joint aftercare arrangements are working? Will oversight examine whether people receive the full package of support they need, whether disputes about responsibility or funding delay care and whether gaps in community provision prevent a safe discharge? Where those arrangements fail, how will the Government ensure that the responsible organisation puts matters right? A patient may have a carefully prepared plan, but that plan must lead to services being available and delivered. Families should not have to negotiate repeatedly between the NHS and local government social care to make that happen.
Section 117 concerns a particular group of patients, but the lesson is wider. Social care is essential to people’s independence, dignity and recovery. It deserves clear responsibility at national level and effective joint working locally. I support these amendments because they would make that national responsibility explicit.
Baroness Barker (LD)
My Lords, as I said at Second Reading, I have spent a lot of time over the last five years with people who are caring for people with severe neurological conditions. I want to tell one story, because I think it is the apposite, right moment to do it.
I know a carer who cares for her elderly mother, who has a very rare neurological condition. Her mother also has dementia—I do not know whether that is part of her condition or whether it is unrelated. With the assistance of their very supportive GP, she managed to get her mother an appointment at an acute hospital for a physical procedure. The carer got her mother to the hospital, which is no mean feat when somebody cannot move or stand, has to be taken in a wheelchair to get there and would have had to be hoisted on to a bed had things gone as they should have. When they got there and started to talk to the doctor, the doctor queried the fact that the mother could not consent to the procedure. She could not consent to the procedure because she had dementia. Because the carer could not at that moment produce evidence of an LPA, which she did in fact have, the procedure did not happen.
I was thinking about that this morning when I was sitting in an NHS waiting room and I looked at a sign that said, “If you don’t turn up for an appointment, that costs money”. Well, having systems that are so disconnected and acute hospitals that believe they are the be-all and end-all and do not understand that the majority of caring happens before somebody gets to their door and when they leave, is one of the most expensive ways of treating individuals. We will go on to talk about corridor care and all of that.
I listened with great care to what the noble Baroness, Lady Ritchie of Downpatrick, said. She talked all the way through about dementia services. The majority of health treatment for people with dementia will not be dementia services at all. It will be all the rest of the services they need: everything from dentistry onwards. So we cannot focus just on data in dementia services. We need all sorts of things. We need changes to the forms that people have to fill in before they go for assessment, so they can put down the fact that they have access needs and so on. That was the result that came out of that, because the carer just about lost it and was articulate enough to go and see somebody and say, “This is wrong”. They have actually changed the admission forms for that.
We need a wholesale cultural change throughout acute care if we are to cope with dementia, or else we are all going to break.
Lord Kamall (Con)
My Lords, I am grateful to noble Lords for bringing forward this group of amendments. They raise a number of important questions about the future of social care, ministerial accountability and the support available to those who depend on care services. Of course, although the previous Government proposed an integrated health and social care service, the British people decided not to give us a chance to deliver it. Therefore, when a new Government came in, they decided they were going to have a separate national care service. That deserves a number of questions to be asked. I fully respect the fact that there is a commission at the moment, but we do not seem to be getting much detail. We also know that you cannot fix healthcare until you fix social care, which is one of the many reasons why I tabled Amendment 180, and I will focus some of my comments on that.
We on these Benches recognise the importance of reforming the social care system. We understand all the reasons behind the proposal for a national care service: to raise the profile of social care, and to do many of the things that the other amendments in this group suggested to do so. To answer one of the questions from the noble Baroness, Lady Thornton—I feel like a Minister again, just as the noble Baroness, Lady Bennett of Manor Castle, did, but on the other side; I am happy to rehearse that if we are ever back in government—we will support the Government where they demonstrate that their proposals are affordable, sustainable and deliverable. We are not going to oppose for the sake of opposition. I hope the Minister will recognise that, as an Opposition, we have always tried to be constructive, particularly when it comes to health and social care.
While we welcome the Government’s ambition to improve social care, as I said, we remain concerned by the lack of detail. We have been told that the groundwork for this service will be laid during this Parliament and its establishment will take place in the next one, yet we know remarkably little about how it will operate in practice, what it will cost, whether the end of the triple lock will provide enough money to fund it and what it will mean for those delivering care.
All that Amendment 180 would do is require the Government, within six months of the Bill passing, to set out some intended functions and the scope of the national care service. We are not asking for a detailed funding plan for the next 15 years or anything like that—we just want a little more detail. This is a probing amendment to tease out a bit more detail from the Government and, hopefully, help them to clarify some of their thinking around social care and what the national care service means. What will the functions and scope of the national care service be? We are not yet clear about that. What about its relationship with the NHS? We are going to have not an integrated national health and care service but a separate national care service, so what does that mean for the interface between the National Health Service and the national care service? What about its proposed commissioning arrangements, its estimated costs and its sources of funding? As the noble Lord, Lord Scriven, said, what we are really asking is how it will all fit together. It is as simple as that.
My concern is affordability. The Government have indicated that the money will come from changes to the state pension triple lock, but that is not the same as providing an implementation plan. Has any assessment been made of what this new service would actually cost, what proportion of that cost will be met by central government and what responsibilities will remain with local authorities? We do not need a commission to answer some of those questions.
There is an important question about whether the savings anticipated from the triple lock will materialise in time to meet the ramp-up costs of establishing a national care service. As the Minister will appreciate, major reforms of this kind usually require an awful lot of up-front investment and then, in time, the annual costs hopefully will stabilise once the infrastructure and systems are in place. Is the Minister yet in a position to tell us whether the Government are confident that we will have sufficient funding available when it is needed? While I admire optimism, it seems to me rather optimistic to assume that the cost of establishing an entirely new service will neatly coincide with and be offset by the savings arising from the changes to the triple lock.
We must also be clear about what services the national care service will actually provide. We know that free personal care is not the same as free social care. Residential accommodation, nursing provision and other essential forms of support can represent substantial costs for individuals and their families. While the Government have provided some welcome clarification on accommodation costs, important questions remain on eligibility, the precise scope of support and the position of working-age adults who currently have care needs.
My second concern is the future of existing care provision. Our social care system is supported by a remarkable range of providers, charities, social enterprises, mutuals, co-operatives, family-run businesses and independent care providers, and they all provide essential services, often with deep roots in the community they serve. We welcome the Minister’s recent recognition that there will continue to be a role for different types of provider and that this will be commissioned at the local level, but we need to understand how that commitment will work in practice. Once again, is the Minister in a position to tell the House what the establishment of a national care service will mean for these existing organisations? What about the relationship with local authorities? Will that change?
As the noble Baroness, Lady Pitkeathley, said, there are important questions about the workforce. We all recognise the important dedication of those working in social care, as well as the millions of unpaid carers who provide indispensable support to their loved ones. We welcome the efforts to improve pay, training and career progression, but these commitments will have to be met with a credible assessment of their costs. In establishing the NHS workforce plan, will there be a corresponding national care service workforce plan? How will these two things fit together?
Baroness Merron (Lab)
My Lords, I am most grateful to noble Lords for bringing the important matter of social care before the Committee. I am sure that the noble Lord, Lord Kamall, knows that, as much as I would love to give him every dot and comma, there is a reason why that is not possible.
Amendments 42 and 44, tabled by the noble Baroness, Lady Tyler of Enfield, and spoken to by the noble Baroness, Lady Pidgeon, my noble friend Lady Pitkeathley and the noble Lord, Lord Scriven, relate to the Secretary of State’s role in respect of social care. I think we could not have been clearer—we have discussed the role of the Prime Minister today—about the strength of national leadership that is required. The noble Baroness, Lady Pidgeon, acknowledged that the Prime Minister committed to establishing a national care service in the next Parliament to sit alongside our National Health Service and to be linked with it.
On the matter of the amendments, the reality is—at the risk of sounding simply pragmatic in legislative terms, but I will take that risk—that adult social care already has its own statutory framework under the Care Act 2014, which is separate to this legislation. That Act provides legal duties on local authorities for the provision of care and support in England and gives the Secretary of State overarching supervisory and intervention responsibilities.
As we develop our plans for national care services, that is where we will consider the responsibilities, the accountabilities and where they will operate—to refer to some of the questions that the noble Lord, Lord Scriven, raised. As I have indicated, although they are linked, health and adult social care have distinct roles—complementary, yes, but distinct—and each is crucial in its own right to providing care for our citizens, as the noble Baroness, Lady Barker, described.
As plans for reform develop—I will come back to the point about the noble Baroness, Lady Casey—we will work with partners and stakeholders to consider how we can do exactly what noble Lords are rightly asking for: consider how accountability, funding flows and responsibilities can be clear and more consistent. But my noble friend Lady Thornton described this as a Bill of moving parts, which was a good description. On the basis that we are talking about moving parts, nailing down one before all the relevant parts have been dealt with will get us into more difficulty. Frustrating it may be, but that is the honest reality.
Lord Scriven (LD)
Following that logic, why are we nailing this part down before the others are ready?
Baroness Merron (Lab)
The reason is that we consider that these parts can sit on their own, and the Bill allows us to look forward too. It would not be acceptable—the noble Lord is not suggesting this—if we stopped all our work while we waited until everything was in place. Although my noble friend is right, I cannot really remember a time when we did not have a lot moving parts—or perhaps we had some parts that should have been moving more but were not, to be more precise.
I go back to the commission on adult social care of the noble Baroness, Lady Casey, about which the noble Lord, Lord Kamall, asked further questions. First, its work has already been brought forward by a year by Prime Minister Andy Burnham. We have already actioned the initial recommendations. As a reminder, we worked at pace on that and I emphasise that the review is independent, which by definition means that we are allowing the noble Baroness, Lady Casey, to do her work.
The other point, which has been absent in previous iterations of attempts at this work, is that we are committed to making this an all-party answer that can survive Governments. All Governments previously have failed to do that, and this is too big and too important an issue to fail to secure that backing. The early recommendations that we put straight into place were—oh, I see the noble Lord standing up; I thank him for being very specific.
Lord Kamall (Con)
I want to ask specifically what that cross-party approach means. For example, many noble Lords on all Benches have spoken about social care in this debate and at other times. There is great expertise in this House. When will they—including me, if I am considered worthy enough of “expertise”—be engaged in this cross-party approach?
Baroness Merron (Lab)
How might I put it? That will be down to the appropriate levels of the parties to decide who is included. However, I can say to noble Lords that, after the contributions that have been made not just in this Chamber but in the reports that have been made, I have been a number one advocate to my ministerial colleagues, including Secretaries of State, of looking to the expertise in this House—because the work that has gone on and continues to go on is extremely significant. The noble Lord can be assured of that.
I do not think that I referred to what the earlier recommendations were from the noble Baroness, Lady Casey, but, if I did, forgive the repetition. On dementia, adult safeguarding and motor neurone disease, we are also driving significant progress through £4.6 billion of additional funding available for adult social care in 2028-29, compared to 2025-26, which includes £500 million for the first ever fair pay agreement for care workers. We have said we will establish a national care service in the next Parliament, providing free personal care for older people.
On funding, I can only repeat what the Prime Minister and Chancellor have said, which is that it will be fully funded and made possible through adjusting the triple lock from 2030. I give the confirmation that we will not borrow to pay for reform, and we will continue to meet our fiscal rules. I think there is a proper conversation to be had, as the noble Lord, Lord Kamall, said, on the choices and trade-offs necessary to deliver a system that can work for everyone into the long term, as well as the immediate. That is exactly why the Prime Minister is continuing cross-party talks to achieve this. The other thing I would emphasise is that we are determined to deliver rapid progress on social care, and we want to work, and are working, in partnership with those who draw on care and support.
On Amendment 180, tabled by the noble Lord, Lord Kamall, as I have already indicated, I do not believe that we should pre-empt the commission’s recommendations on fundamental reform questions ahead of building a public consensus as well as a political one. We should not legislate for an implementation plan within a fixed timeframe.
With regard to a national care service work plan, the review from the noble Baroness, Lady Casey, will have important implications for the shape and skills of the future adult social care workforce. Noble Lords will recall that this Government have committed to a long-term workforce plan for adult social care, which will therefore need to be linked with the outcome of that review. I certainly welcome that workforce plan.
On the amendment on dementia tabled by the noble my noble friend Lady Ritchie, and spoken to by a number of noble Lords, including the noble Lord, Lord Weir, dementia, as with social care, touches the lives of many in and outside this Chamber. That is why I am glad that my noble friend welcomes the development of the modern service framework for frailty and dementia. We plan to publish the full MSF by the end of this calendar year, which was recommended by the noble Baroness, Lady Casey. The framework will set new national standards. However, until we finalise those standards, I think it would be premature to propose introducing a new annual report. The reason for that is that it would lack the necessary measurable metrics to support the meaningful analysis that I know noble Lords are looking for, as indeed I am. It is not about denying the role of data; it is about the process. We are looking at options for how we can reduce waiting times and improve diagnostics and care, including reviewing targets and metrics and, importantly, to the points raised by noble Lords, data. We will seek to develop a list of best evidenced interventions following analysis of this area.
Some of the data requested and referred to in the amendment is already available through the NHS or provided by charity partners. A new report would, unfortunately, be something of a duplication of this work. We must also have some regard to the demands of additional data collection. The assessment is that the additional data collection that would be required for this work would be somewhat onerous and would distract from the core task of improving dementia care. That said, I understand why noble Lords are raising this, and I can assure them that the points they have made will be considered as we look at our development of the modern service framework.
Baroness Pidgeon (LD)
I thank the Minister for her response to this interesting debate. Of course, we know that the plans for social care are under development. We have the review by the noble Baroness, Lady Casey, and we have the interest from the Prime Minister, so we are in a state of flux. However, on the so-called cross-party talks, the leaders met in July, during the Summer Recess, and there is talk of further meetings, but I do not believe that any of them have happened yet. If we want cross-party work, it needs to be active rather than just words.
I heard what the Minister said about where the legal duties are around care, but I still did not really hear an answer as to why the Secretary of State’s core duty and ministerial responsibility could not be extended to cover social care if, as the noble Baroness, Lady Pitkeathley, said, we going to increase the status of social care and make sure that we are explicit about that responsibility, as the noble Lord, Lord Patel, said. I do not feel that the Minister has addressed that. We will consider whether we wish to bring this back on Report, but at this point I withdraw the amendment.
Baroness Neville-Rolfe
“Promoting continuity of careIn the National Health Service Act 2006, after section 1A insert—“1AA Duty to promote continuity of careIn exercising functions in relation to the health service, the Secretary of State must promote continuity of care for patients by health professionals.””Member’s explanatory statement
This amendment seeks to ensure continuity of care for patients by health professionals, including by GPs and in hospitals.
Baroness Neville-Rolfe (Con)
My Lords, Amendment 43 proposes a duty to promote continuity of care for patients by health professionals, including by GPs and in hospitals. I am particularly grateful to the noble Baroness, Lady Gerada, and the noble Lord, Lord Patel, for supporting the amendment. They know much more than I do about the potential value of continuity of care and the costs and complexities involved.
There is much academic and anecdotal evidence that continuity of care improves health outcomes. My own medical experience supports that, although I acknowledge the problem posed by the tension between seeing patients quickly and seeing the same doctor—I will come back to this later. The noble Baroness, Lady Gerada, will address the issue from a more expert perspective, but I very much enjoyed her speech at Second Reading and her comment that
“Continuity of care is the golden thread of healthcare”.—[Official Report, 13/10/26; col. 186.]
and that evidence shows that a patient’s ongoing relationship with a clinician who knows them makes the “biggest difference” to success. We need to make that golden thread more of a reality. I believe that the best way to improve healthcare would be to restore the effectiveness of the GP service, which is now less well-resourced than hospital care, and that greater continuity of care would make a substantial contribution. It would also help in hospital care, especially for complex conditions, and indeed in maternity care and with health visitors.
The truth is we need an across-the-board effort. Once I have set out the case for change, I will come on to how best to achieve this. I have had the benefit of advice from the Library on academic research going back 15 years. According to Denis Pereira Gray and colleagues, numerous studies have found that higher continuity is associated with fewer hospital admissions. Some studies have shown lower mortality with higher levels of continuity. Others have shown continuity associated with patient satisfaction and better outcomes for patients with diabetes, better care for those with dementia and greater adherence to medical advice more generally. Patients reported greater involvement in decisions about their care and a greater readiness to manage their health in partnership with their GP. This all echoes my own family’s experience. Continuity improves patient confidence, less time is wasted as multiple professionals get themselves up to speed, and it mostly delivers better outcomes.
There are, however, exceptions; for example, analysis of the GP database found a seven-day delay in diagnosis for some cancers. The academics concerned thought this might be the result of GPs focusing on known diagnoses, but we rightly have new systems for cancer care and have made good progress as a result with lots of common cancers.
Against this academic background, continuity of care in the UK has unfortunately been falling to very low levels. This reflects the shortage of GPs, more part-time working and working from home, more mobile populations and more delegation to nurses. Mergers of GP practices leads to bigger practices, making it less likely for an individual to see the same GP. Yet with more patients living for longer and with multiple conditions, it is even more important.
Above all, I understand from a doctor friend that today’s problems with GP continuity reflect a highly bureaucratic system of targets. He believes that the single most effective healthcare intervention, without exception, is continuity of care. However, continuity of care has become extremely difficult largely because of the existence of other targets and the detail of funding arrangements. Slots are set aside for urgent cases and to reflect the need for a clinician to respond to all emails received each working day. Added to this, there are elaborate reporting requirements which act as a diversion. As a result, even the most devoted advocate of continuity of care, as he was, finds it difficult to achieve.
My research suggests that many other countries manage continuity better, including Canada, Belgium and Norway. With the resources of the NHS, we should be able to do so too, even if it means changing the targets and the GP contract.
As to hospitals, thanks to my employer, I have had access to private care for many years. This is based around continuity with your consultant. There is also more focus on efficiency and timeliness, and the results are better. Private consultants also have excellent records which they copy to the patient. I remember saving my husband from an emergency procedure at A&E at St Thomas’ by producing some coronary charts from his consultant. I have also had four lots of excellent NHS maternity care, but I know it is less well-resourced today.
I am personally familiar with cases where outcomes would probably have been better if it had proved possible to provide greater continuity of care in the NHS. I have also been influenced by doctor friends, such as the noble Lord, Lord Patel, as to the value of continuity in hospital care and by my own experience in a tricky maternity situation. Health visitors are often dealing with new mothers or vulnerable people, and the constant rotation of professionals is a highly negative factor.
I believe that we have a problem. It has three aspects, as a paper by Jeannie L Haggerty and others has argued in a multidisciplinary review. The first aspect is informational continuity: the use of information on past events and personal circumstances to make current care appropriate for each individual. We are making progress here with better NHS systems, the single patient record and the NHS app. The second aspect is management continuity: a consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs. There is more to do here as the Government’s reforms bed in. The third is relational continuity: an ongoing therapeutic relationship between a patient and one or more providers. This has been eroded in the British system. That is why I have proposed a new duty which I hope would improve care over time.
I suggest the evidence is sufficiently robust for us to seek to encourage continuity of care throughout the NHS system. But there are many bureaucratic details of that system which put obstacles in the way. I recognise that all these details were put there for a purpose, even if some of them have been found to be unnecessary over time. Certainly, it would be folly to advocate simply sweeping them away.
My conclusion is that the best course would be to require all within the NHS to have regard to the desirability of continuity of care and to use their best endeavours to achieve it. Amendment 43 has this intention, though I am sure the drafting could be improved. I would welcome help from all in improving it, including help from the Government, if they agree that a provision strengthening the role of continuity of care within the NHS is a desirable aim. This would lead to a change in culture and allow those concerned in any particular case to do their best to achieve continuity within the constraints that they face. In her recent letter to me, the Minister said that continuity of care was an important priority for the Government, but she recognised there was more to do. Therefore, I hope this will be the start of a productive conversation. I beg to move.
Baroness Gerada (CB)
My Lords, I will speak to my Amendment 61A before speaking to support Amendment 43. My amendment aims to increase transparency in ICB commissioning of community-based services that assess and manage urgent and minor eye conditions. At present, there is a significant and unwanted variation in access to these services: around one in four people cannot access them locally. The postcode lottery can persist even between neighbouring communities, where patients with the same condition may find that services are available on one side of an integrated care board boundary but not on the other. In some cases, these services are being decommissioned altogether.
Eye-related conditions account for 780,000 A&E attendances each year, yet analysis by the Association of Optometrists suggests that up to 400,000 of these can be managed in community optometry services. Importantly, the capacity already exists. Around 8,000 optometrists provide NHS care on high streets and in communities across the country, and are well-placed to assess and manage many eye conditions closer to home. This amendment does not seek to mandate commissioning decisions or require integrated boards to adopt a particular model of care. Rather, it seeks greater transparency on which services are available and whether commissioning decisions align to population need.
I am delighted to support Amendment 43, and I pay tribute to the convincing speech made by the noble Baroness, Lady Neville-Rolfe. I wholeheartedly endorse her point that continuity is one of the most researched interventions that we can implement to reduce premature mortality and improve health outcomes at a far lower cost to the NHS. As we have heard, this amendment would ensure that continuity is not merely an aspiration but a principle to consider whenever decisions are made about delivering NHS services. The NHS Act already places duties on the Secretary of State in relation to quality and reducing health inequalities. Continuity underpins both and deserves the same statutory recognition.
As a GP, continuity of care was the tool of my trade. It allowed me to remain close to my patients and to observe the onset and progression of illness within particular life contexts and stories. I came to understand that no two individuals ever experience illness or disease in the same way. Continuity allowed me to develop a rich understanding of the inconsistent relationship between suffering and pathology.
As I have just remarked, continuity was the tool of my trade. For patients, it is sadly now becoming the exception rather than the rule. In general practice, the end of personal lists marked a long drift towards anonymity, as described by the phrase “martini medicine”: any time, any place, anywhere, with on-demand access, transactional care, and plurality of providers. For too many patients, contacting their surgery has now become a call centre experience. They speak to whoever is free and tell their story again and again to people who do not know them. Even in hospitals, continuity is lacking. Patients are moved from wards, teams and shifts, often without anyone taking responsibility for their whole care.
I am also concerned that the development of neighbourhood health services and hubs risks creating a new form of fragmentation. We are increasingly organising services around particular conditions, age groups and needs. There are women’s health hubs, mental health hubs, children’s hubs, urgent care hubs and one I heard of today: genomic hubs. Each may have a good rationale, but consider a family with a woman attending a women’s hub for her menopause and a mental health hub for her depression, while her son attends a children’s hub for his asthma and her elderly father attends the urgent care hub—four front doors, four sets of clinicians and potentially nobody who sees the family as a whole. That is exactly what the family doctor used to do, and we must not confuse the integration of services with continuity of relationships. Joining up buildings, budgets and IT systems is not the same as ensuring that the patient has the same clinician each time.
Lord Scriven (LD)
My Lords, I feel like a mere iron filing after the magnet of wisdom and knowledge from the noble Baroness, Lady Gerada, on primary care and continuity of care, but I will be a little iron filing that does its best. I will speak to Amendment 60, which would insert a new clause after Clause 14, and Amendment 62 to Schedule 1. They are both in my name and I thank the noble Lord, Lord Holmes of Richmond, who is not in his place at the moment, for adding his name to them.
These amendments are about people who the NHS too often fails to see and who, too often, cannot see well for themselves. SeeAbility has campaigned on this for many years and I am particularly grateful to Scott Watkin and Donna O’Brien for their help, research and guidance on these amendments. Research for the Royal National Institute of Blind People and SeeAbility found that adults with a learning disability are 10 times more likely than the general population to be blind or partially sighted. Nearly one in 10 is blind or partially sighted and around six in 10 need glasses. For children with a learning disability, the risk of serious sight problems is 20 times higher.
The conditions are cataracts, glaucoma, diabetic retinopathy and keratoconus. The last of those conditions affects as many as one in 10 people with Down syndrome. According to the Down’s Syndrome Association, if it is not caught early it can take sight for good, yet those at greatest risk are among the least likely to be tested. Around half of adults with a learning disability have not had a sight test in the recommended two years.
When SeeAbility tested children in special schools, more than four in 10 had never had their eyes checked at all. Many people with a learning disability cannot tell us that their sight is failing; instead, it shows up as withdrawal, distress or falls, and too often this is put down to the learning disability itself. This is called “diagnostic overshadowing”: people labelled as challenging when the real problem was that they could not see.
When an adopted pathway was piloted in three London boroughs, over half of those tested had an eye problem that could lead to sight loss, and nearly two-thirds ended up in glasses. Amendment 60 would change Regulation 3 of the Primary Ophthalmic Services Regulations 2008, which lists who gets free NHS sight tests: children, people over 60—probably including many noble Lords—people with diabetes or glaucoma, and people over 40 with a family history of glaucoma. The logic is clinical risk. By that logic, people with a learning disability should be on the list. Today, an adult with a learning disability, however profound, gets a free eye test only by qualifying some other way, often through a means-tested benefit.
So my first question to the Minister is: what is the clinical justification for giving a free eye test to somebody over 40 with a family history of glaucoma but not an adult with a learning disability, who is 10 times more likely to go blind or be partially sighted? The amendment deliberately covers people eligible for the GP learning disability register, not those already on it. The registers undercount, and no one should be denied a test because a practice has not updated its list. It also links to the annual health check, where GPs can prompt for that eye test.
There is also a data problem. NHS sight test claim forms have not recorded disability, so we cannot know how many people with a learning disability get a test. Can the Minister confirm whether that data is now recorded and, if not, how the department can say it is reducing an inequality when it does not measure it? Will it add this field to the data collection?
Amendment 62 deals with assessing need and commissioning services, because a free test is necessary but not enough. The NHS sight test fee is £24.13, and the Association of Optometrists estimates that it covers only about half the cost of a standard test. It pays nothing towards the longer appointments or Easy Read results that many people with a learning disability need. Many are sent to overstretched eye hospital services that are not appropriate to their presenting need. The Easy Eye care pathway, with longer appointments from specially trained optometrists, works, but it is commissioned only in south-east London, parts of the north-west and Durham. Everywhere else, the system is literally blind to the need. Can the Minister say what the plans are to try to ensure that every integrated care board now commissions this type of test? What will the Government do to ensure that it becomes standard across England?
This Bill moves NHS functions, including primary ophthalmic services, to the Secretary of State. This amendment would require the Secretary of State to assess the need and to direct ICBs—I know what I have said previously, but it is still in the Bill—to improve and measure the eye health of people with a learning disability through targeted action. As I said, I am wary of open-ended powers of direction, but I have argued that the Secretary of State should set clear outcomes and hold the system to them. This is exactly the kind of outcome that I would like.
I give the Government credit: the Special Schools Eye Care Service has £12.7 million of recurrent funding to reach up to 165,000 children. However, schools must opt in, rollout is uneven and, at 19, these young people fall off the cliff edge into an adult system not built for them. Will the Minister confirm by what date the service will be available to every ICB in England and what will happen to those young people’s eyecare when they leave school?
The NHS rightly recognises that people with diabetes need regular eye checks because they are at higher risk. People with a learning disability are at much higher risk and far less able to tell us when something is wrong. These amendments would bring them into line with the clinical risk profile that they face with their eyes. No one should lose their eyesight because the system was not designed with them in mind. I hope the Minister will look favourably at these amendments and I look forward to her response.
Baroness Finlay of Llandaff (CB)
My Lords, I thank the noble Baroness, Lady Neville-Rolfe, for having brought this to our attention. As my noble friend Lady Gerada said, continuity of care is incredibly important. A relationship with a clinician is a two-way process. As a patient, you need to have confidence in that clinician and they need to understand the complexity of you as a person. It is very easy to think that this is all about facts that we write down: observations and things that go in patient notes. However, it is important to remember that about 80% of communication is non-verbal. Therefore, the way that you have seen a patient and the way that you observe them later on become absolutely critical.
In my own time when I was a GP, we used to take all our own calls up until midnight and then quite often we were in the pooled rota with other practices. However, that meant that whoever phoned up during the evening was somebody we already knew and understood, and I think we were able to give much more appropriate advice or decide to go straight out to see them than happens now with the 111 screening process.
In my own discipline of specialist palliative care, that continuity is incredibly important. We are looking after patients with very complex needs, often very young people, and conversations with children about the fact that their parent is dying is not something that you can have from one person to another. It has to be the same clinician, whether that is a specialist nurse, the doctor or a specialist social worker, who then follows through. Building up confidence with that family as they face the ultimate disaster is really important, and most of that is non-verbal and interpersonal.
We have seen the advent of Martha’s rule, which has come about because parents have observed that their child was looking and behaving less well, and they were alert even though the staff around had not noticed or picked up on the signs. In a terribly sad way, that is an overwhelming testament to the importance of some continuity, rather than simply looking at observations and exchanging facts.
I can see that perhaps the wording of the amendment could do with a little modification. However, we have raised a very important subject tonight and there is a core principle, and that will mean stripping out some of the bureaucracy that is stopping clinicians from having the continuity that they want to have and that their patients want from them.
The noble Baroness, Lady Neville-Rolfe, spoke about patients getting letters. In fact, it is now standard practice across the NHS in secondary care that a patient will get a letter. Sometimes it is dictated at the time when the patient is still in the room and then they will get the hard copy afterwards. Some clinicians will tape-record the conversation—although not so much now—and allow the patient to listen to it again at home later on, and then see them for questions to be asked. That has come about, but it does not substitute for this core principle of actually being able to have continuity. The one thing that is important is that we do not force patients to be locked into continuity with somebody who they do not feel comfortable with or have confidence in, and who, really, they never want to see again. They need to be able to choose to see somebody different.
Baroness Coffey (Con)
My Lords, I appreciate that continuity of care is seen to be the holy grail of what will make our country safer and healthier. There is some merit to having that understanding of what is happening in somebody’s life and what they have been through. However, I would hope that the single patient record can go a long way to understanding that.
I notice that the noble Baroness, Lady Gerada, is shaking her head in a negative way rather than in a positive way. I feel differently because when I am ill, I just want to be sure that I can see a doctor. The amendment tabled by the noble Baroness, Lady Pidgeon, talks about a seven-day guarantee to see a GP. That is potentially unrealistic in terms of some of the broader issues that people might want to see their GP about.
A few years ago, I set a target of 14 days. I got criticised at the time. There are those people who feel a lump or that something is not quite right, but it is not urgent. They do not go to their GP very often, perhaps only every five years, but they should feel that they can get something that does not feel right looked at. The seven days is admirable, but I am trying to imagine what it would be like. I appreciate that, among all noble Lords in the Chamber tonight, the noble Baroness, Lady Gerada, with her experience of the Hurley Clinic and others, recognises the day-to-day challenges that GPs experience in managing a significant practice.
I am very sad that the noble Baroness, Lady Janke, is not here—
Baroness Coffey (Con)
I apologise. I could see the head of the noble Lord, Lord Scriven, but not beyond it. I look forward to hearing what the noble Baroness has to say about pharmacies.
I intend to table some amendments to Clause 42 to understand the issue that the noble Baroness, Lady Janke, is going to raise. It may be that she has a particular experience. In my experience of pharmacies, I have not experienced a situation where a pharmacy provider has fallen apart unnecessarily. However, I have noticed a trend in more than one part of the country of GPs having done the traditional thing of the partnership buying a property, which they then sell. They then have a property for which they pay rent. They bring in a national pharmacy provider which will pay them rent. The independent pharmacist on the high street or nearby starts to fall apart because the natural tendency with these shiny new practices is that the sale of the old one has released capital but that rent needs to be paid. As a consequence, any subsidy to that from other willing providers is very welcome.
I am looking forward to hearing the issues but give fair notice to the Minister that I intend to return to Clause 42 in due course. I just have not had time to table the amendments.
Baroness Janke (LD)
My Lords, I thank the noble Baroness, Lady Coffey, for noticing my apparent absence and am happy to reassure her that I am here and in the flesh.
Amendments 63, 64 and 108 to 110 in my name underpin the importance of community pharmacies to local healthcare provision and the importance of maintaining continuity of the services that they provide —as well as reassurance for the pharmacy workers and residents. Pharmacies are the pillars of local healthcare and have become even more essential as waiting times for GP appointments have grown. However, the picture of local pharmacies is changing, as the noble Baroness, Lady Coffey, has said, for different reasons. More than 1,300 pharmacies have closed over the last decade and more are operating at a loss, leaving many communities risking a lack of access to a crucial front-line service.
Pharmacies, of course, are independent contractors, not public agencies, so the means of ensuring their continuation and continuity of care are perhaps going to be different. But, on this side, we feel that to maintain continuity of service in the light of the failure of local pharmacies, whether through financial or other difficulties, is essential. Amendments 63 and 108 would give stronger powers of intervention to ICBs when pharmacies are failing to provide their contractual services, whether through business failure or other reasons. They need to maintain their services, which are vital to their communities, and to address issues of availability of treatments and medicines.
Amendment 110 would require that staff be paid and protected during any intervention or remedial action that may take place in the operation of a pharmacy’s services. Staff do not need to lose confidence and leave what they see as an insecure situation, resulting in closure of the pharmacy through lack of staff. Amendment 109 would place an obligation on the Government and ICBs to support, in the event of failing, closed or disrupted pharmacies, new and independent pharmacies taking over to establish new relationships with pharmaceutical manufacturers and suppliers so that the continuity of the local service can be effectively maintained. Amendment 64 would require pharmacy funding to reflect the
“costs of providing services in rural and sparsely populated areas”.
These are often areas of low income, where the health of the local population is poor and pharmacy services are much needed, but where private pharmacy businesses have difficulty in being able to thrive.
These amendments are particularly relevant, as so many pharmacies are increasingly unable to sustain themselves as private businesses and changes to the operation of pharmaceutical services overtake them. These amendments, if accepted by the Government, would show a commitment to local pharmacies as essential providers of local healthcare and ensure that front-line services, which are very much in demand, are retained where and when they are particularly needed.
Baroness Pidgeon (LD)
My Lords, getting primary care right is absolutely crucial for our health service to work for patients and to ensure that neighbourhood health really delivers. Amendment 61 in my name would ensure that access to NHS sight tests remains nationally protected and is not subject to local variation once integrated care boards take on the commissioning of primary ophthalmic services. The national sight testing service remains the foundation of eyecare across the country and is one of the most effective public health services in the NHS. Primary eyecare in England provides more than 23.6 million appointments every year, covering sight tests, enhanced eyecare services and contact lens care.
Protecting vision means supporting people’s independence and safety, including from falls and accidents, and enables people to live well and work well. It is important, as raised by my noble friend Lord Scriven, for the needs of people with a learning disability. The national contract model is the most cost-efficient way of commissioning the service for the NHS. This is because the funding offered by the NHS, as we have already heard, does not come close to covering the cost of an eye test, and it is feared that any fragmentation of the commissioning route will only add more bureaucratic costs. This is a probing amendment, and I would be grateful if the Minister could confirm whether the national NHS sight testing service provided through this cost-effective national contract model will remain in place under the Bill. I also fully support Amendment 61A from the noble Baroness, Lady Gerada, on access to community-based, urgent and minor eyecare.
Amendment 218 in this group would give patients a new right in the NHS constitution to receive a GP appointment. Patients should be able to access primary care when they need it, and too many people across the country are forced to wait weeks for a GP appointment, only to see their condition deteriorate, which does ultimately place greater pressure on emergency departments and hospital services.
That is why these Benches are proposing a new right in the NHS constitution for patients to receive a GP appointment within seven days or within 24 hours if their need is urgent. This is not merely a target but a commitment to restore confidence in GP services and to ensure that timely access to primary care is recognised as a fundamental patient right.
General practice remains the front door to the NHS. Ensuring prompt access to a GP can lead to earlier diagnosis, more effective treatment and better management of long-term conditions, as we heard from the noble Baroness, Lady Gerada. Ultimately, it can reduce demand on overstretched hospitals. The amendment on continuity of care from the noble Baroness, Lady Neville-Rolfe, and supported by the noble Baroness, Lady Gerada, is really important to consider as part of the Bill.
My noble friend Lady Janke’s amendments on ensuring that community pharmacies are supported is important. Her challenge on the cost of medicines and how pharmacists are reimbursed is an important issue that was raised when the Public Services Committee looked at medicines security. I was quite astonished that pharmacies often provide medication at a loss; it is no wonder so many are going under. This group is really important, so I hope the Minister can assure the Committee.
Earl Howe (Con)
My Lords, this has been an illuminating discussion that has elicited some valuable contributions from across the Committee. I do not intend to add much to what other noble Lords have already argued so well, but I will underline how much I agree with my noble friend Lady Neville-Rolfe on all that she said about continuity of care. Continuity of care is something on which patients place enormous value, whether in primary care, in community settings or in hospital. My noble friend’s amendment rightly prompted a wider discussion about how we can strengthen those relationships across the health service.
At a time when many patients feel that their care is fragmented and impersonal, it is worth our looking closely at how the NHS can better support relationships between patients and the professionals who care for them. Continuity of care is not simply about patient satisfaction; as has been said, it undoubtedly contributes to better outcomes, often through earlier intervention and a more personalised experience of healthcare.
I have no doubt that the single patient record, when it is eventually rolled out, will be of huge benefit to the efforts of primary and secondary care clinicians to deliver seamless care to patients. However, the noble Baroness, Lady Gerada, was quite right: seamlessness of care is not the same as continuity of care. I agree with her and with my noble friend that, in this context, the more immediate focus for the NHS is that of primary care. More than 90% of patients’ direct experience of the health service is through primary care and, at the moment, many patients experience an NHS under increasing pressure.
The number of trained GPs has gone up over the last decade but, as we noted in an earlier debate, the number of full-time equivalent GPs has fallen. At the same time, despite GP practices employing more nurses, pharmacists and other healthcare professionals, the rise in patient demand has been unrelenting, especially in areas of the country that could fairly be described as underdoctored. These pressures make continuity of care particularly difficult to achieve within general practice. That is not to say that some GP practices do not still achieve it, but the demand curve does not look likely to flatten in the short or even medium term.
Baroness Merron (Lab)
My Lords, I am grateful for the contributions to the debate today and for the amendments that gave rise to the debate. Primary care is a key part of our health service, as we have heard. In view of the time, I am going to address directly the amendments and some of the comments made.
Amendment 218 was tabled by the noble Baroness, Lady Pidgeon. We recognise the importance of timely access to general practice, particularly when patients need urgent care. However, it is the case that not every patient will need an appointment within seven days, although I understand the intent, because there are a number of patients who seek to book routine appointments in advance. Where a doctor considers care clinically urgent, patients should be seen that day, and we have made changes to the GP contract to require that urgent requests be handled the same day. In August this year, nearly 78% of such requests were handled the same day.
I want to correct some of the representations made by the noble Earl, Lord Howe, as I have done previously when we have been debating this Bill. As of August 2026, there were more than 2,600 more GPs compared to July 2024. We have introduced a practice-level GP reimbursement scheme, worth £292 million, that allows practices to hire additional GPs or fund extra GP sessions with existing GPs. Our absolute intent, as I know is the noble Earl’s, is to improve access. We want to support GPs, improve patient satisfaction and boost capacity—something we are all signed up to.
On Amendment 43, tabled by the noble Baroness, Lady Neville-Rolfe, and spoken to by the noble Baronesses, Lady Finlay and Lady Gerada, the Government support the principle—if that could be regarded as a word of comfort—as sought by the noble Earl, Lord Howe. However, we regard the amendment as unnecessary because existing contractual and operational arrangements already strengthen continuity, which is the key point in this. That includes named GPs and team-based continuity in hospitals. The noble Baroness, Lady Gerada, asked whether there was a possibility of the splintering of community services through hubs. I would say that neighbourhood health provides the core framework that brings it all together into a single model very much focused on improving access and experience, which is at the core of all that the noble Baroness rightly seeks.
I turn to Amendments 63, 108, 109 and 110 from the noble Baroness, Lady Janke, about pharmacy care. I agree with all the comments about the vital contribution that pharmacies and their staff provide to patient care. I also acknowledge that, where a provider, particularly a larger chain, fails to meet NHS terms of service, the consequences can be significant for patients, communities and staff. The Bill will give ICBs responsibility for pharmaceutical services, including monitoring compliance and enforcing NHS terms of service. We are also streamlining appeals to ensure that we can resolve disputes more quickly. Where there is provider failure, our priority is to maintain the continuity of services for patients. ICBs can issue remedial and breach notices, remove contractors following repeated breaches and, with professional regulators, suspend providers where there are serious concerns putting patients or the public at risk.
I say to the noble Baroness, Lady Pidgeon, that the Bill strengthens arrangements to ensure continued access to pharmaceutical services and allows the Secretary of State and ICBs to support new providers taking over pharmacy premises, including financially. We of course sympathise with staff affected by provider failure, but the reality is that, as we have discussed on a number of occasions, community pharmacies are independent businesses responsible for employing and paying staff. Existing employment and insolvency law already protects employees, as in other sectors. Therefore, a separate regime, as suggested, would not be appropriate.
I feel that Amendment 64 would limit flexibility to balance rural access with wider patient and pharmacy needs. The distribution of pharmacy funding is determined through an established national process. All pharmacies receive the same NHS service fees, while eligible isolated pharmacies receive additional pharmacy access scheme funding.
I turn to Amendments 60 and 62 from the noble Lord, Lord Scriven. We recognise that people with learning disabilities are more likely to experience sight problems and may face additional barriers to eye care, exactly as the noble Lord described. He has already referenced this, but I emphasise that free NHS sight tests are already available to eligible groups, including people at increased risk of specified eye disease. Adults with learning disabilities may qualify through these routes, including via the NHS low income scheme, but there are no plans to review eligibility, as he sought.
Community optical practices also already provide services with reasonable adjustments where needed. Those who are unable to attend unaccompanied, and who are eligible because of illness or disability, may receive NHS domiciliary sight tests. As the noble Lord rightly said, children and young people with learning disabilities or autism can receive free eye tests in special educational settings, where locally commissioned. I heard the noble Lord talk about difference in provision, and I also thought I heard him acknowledge the potential for the Bill perhaps to assist in that regard.
On Amendment 61 from the noble Baroness, Lady Pidgeon, I understand the concerns that the Bill could lead to variation in eligibility for NHS sight tests, the scope of the service or the fees payable. However, ICBs already commission primary ophthalmic services under nationally set contractual terms, so eligibility and service scope are set nationally, and fees are set through national direction. The Bill does not alter the national framework or how eligible patients access sight tests.
On Amendment 61A by the noble Baroness, Lady Gerada, local planning begins with joint strategic needs assessments, through which health and well-being boards assess local population health and care needs. These assessments will then inform locally led neighbourhood health plans, which set out the approach to meeting the identified needs. ICBs, in their role as strategic commissioners of local health services, including eye care services, will focus on ensuring the best value in securing services and improving population health, reducing inequalities and improving access to high-quality services. Given these existing arrangements, we do not believe it necessary to prescribe service-specific reporting requirements in primary legislation.
Baroness Neville-Rolfe (Con)
My Lords, this has been a constructive debate. I am grateful for the convincing support of the noble Baroness, Lady Gerada, and my noble friend Lord Howe for an amendment of the kind that I have proposed.
I thank the noble Baroness, Baroness Finlay of Llandaff, for her perspective and her comment about the non-verbal advantages of continuity of care, which very much echoes with me. I remember my husband being saved by a perceptive GP when he had come out of an operation. I heard what the Minister said, and I thank her for it, but we need to do more on continuity of care as well as on continuity of services, so I reserve the right to return to this issue on Report.
As it is late, I will not delay the Committee on the other amendments, which have been well articulated by the noble Lord, Lord Scriven, and the noble Baronesses, Lady Janke and Lady Pidgeon. I agree with the noble Baroness, Lady Janke, that pharmacists can play a larger part in our National Health Service. I also agree with the noble Baroness, Lady Gerada, about the postcode lottery of eyecare. That is a concern, and the Minister may recall from our earlier debates that I thought it could perhaps be improved by the better use of the independent sector and community eyecare. For now, though, the time is late and I beg leave to withdraw my amendment.