Monday 9th November 2026
(1 day, 13 hours ago)
Lords ChamberHealth Bill 2026-27 View all Health Bill 2026-27 Debates Read Hansard Text Watch Debate Amendment Paper: HL Bill 52-III(b) Amendments for Committee (Supplementary to the Third Marshalled List) - (9 Nov 2026)
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 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.
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.
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.
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 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 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.