Health Bill

Baroness Gerada Excerpts

Committee stage
Wednesday 28th October 2026 Lords Chamber

[Baroness Manzoor (Con)]

My Lords, I thank the Minister very much. I am absolutely delighted that the Government have listened with regards to Healthwatch and HSSIB, which are two very important legs of the NHS in terms of independence, patient safety and patient voice. I welcome that and thank the Minister; I know that she is also passionate about those areas.

I thank my noble friend Lord Howe and others who have spoken on his amendment. Irrespective of what one feels about NHS England—I will certainly share my views—it is right that there is an operational plan and a transitional plan. No business would move to such a major reorganisation without having such plans and risk assessments, with key performance indicators and clarity around outcomes in relation to budgets and finance.

My key question is that if savings are to be made, when will they made and how will they be reinvested into direct patient care? With all these changes, what does it mean for the patient? How do they benefit, so that we are not just talking round and round to ourselves about reorganisations?

I have been involved with the NHS for nearly over 40 years—the noble Lord, Lord Hunt, and I have been around a long time. I chaired a health authority when I was in my 20s, and I chaired one of the eight regional offices of the NHS. My region was northern and Yorkshire, and we had a budget of £3.5 billion. I have some experience of transformation and of the difficulties, challenges and risks that will be involved. If we do not have these plans or clarity, things will go wrong. That will adversely affect patient care, when trying to improve patient care is what the Bill is really about.

I do not like to see lots of duplication in services. I like direct and simplified governance structures in the NHS. We had them when we had the regional offices. I recollect—it was a Labour Government at that time—that the eight regional chairs rocked up to the Department of Health, I think quarterly although the memory has faded a bit, and sat down with the Secretary of State, the Permanent Secretaries and the chief executive of the NHS Executive. We went round to find out what the finances were within our regions, which hospitals were performing well and which were not, and where there were real issues about waiting lists. It really concentrated the mind. Then we went back and fed it to all the 60 or 80 chairmen within our regions and their respective chief executives. I am not too worried and concerned that there will be a lot of haters, but we must have very clear plans to enable this to happen.

Last but not least, I want to talk about the governance structures; I mentioned them in my speech previously. If we do not have clarity around governance structures and accountability, we really will not deliver. If there is one plea that I can make, can it be that? I totally support the amendment tabled by my noble friend Lord Howe.

[Baroness Gerada (CB)]

My Lords, one of the people who I have most admired over the years is the American paediatrician, Professor Don Berwick—some of your Lordships may know him—who is an international expert on healthcare and a great advocate of the NHS. In fact, he led the Mid Staffs review in 2013. In the States, he led Medicare and Medicaid under President Obama. It always struck me that Don Berwick wrote us a birthday card on the NHS’s 60th birthday. It was a long card and I urge your Lordships to read it one day. He offered a simple prescription for the NHS: “Stop restructuring”. He warned that successive reorganisations drained the workforce’s “energy and confidence” and argued that stability makes improvement easier. Does the Minister agree that his advice would be well taken?

[Lord Mawson (CB)]

My Lords, I welcome this debate and I certainly support the amendment. I am encouraged by the letter that we received today that there is an open mind within government and a proper discussion taking place about these very important issues. I am a practitioner, as many of your Lordships know, and we are involved in trying to build some of this new health infrastructure around the country. Indeed, today I have been involved in quite an exciting conversation about a health innovation campus in Huddersfield that we are supporting, which has major implications for this Government’s direction of travel—a lot of which I support—around place, collaboration and other things that the Prime Minister has talked about.

However, we are also in touch at the front end with what is actually happening on the ground, and the word I keep hearing from colleagues across the country is “chaotic”, which is a worrying word to be hearing. Therefore, this debate and the detail that is being discussed today really matter for the NHS, for patients and for those of us who are trying to build this infrastructure. Therefore, I am encouraged that the Minister is starting off in an open, transparent and conversational manner in Committee. It is very helpful.

One of my concerns about the changes taking place at the moment is that there does not seem to be a clear vision about prevention. Those of us who have been involved in this space—in my case, I have been involved in east London, and now nationally, for over 40 years—know that on the ground, in very challenging communities, the real determinants of health often have nothing to do with doctors. If you asked our GPs in Bromley-by-Bow, they would tell you that a person getting a job does more for a person’s health than anything to do with doctors. That is why, in Bromley-by-Bow, we ended up building 97 businesses with local people, because we got real about the social determinants of health. It is about whether you have a decent home that is not damp. It is why we built a housing company, which now has 10,000 properties and owns 34% of the land in Poplar. It is to do with whether your relationships in your family are in a good place and whether you feel part of a community—all these things. The numbers that people far cleverer than me come up with say that the impact of all this is 70% to 80%.

I am not clear, with this real opportunity to reform the NHS in this century and with the things we now know, what this Government are saying about the prevention agenda and how clearly they are or are not joining the dots around the social determinants. Part of this conversation is really important, but part of it needs to be about the prevention agenda. As we work our way through Committee, we need far more clarity about what that will mean in practice and in detail in communities across this country.

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[Baroness Gerada (CB)]

My Lords, I rise to support Amendments 11 and 14 in the names of the noble Lords, Lord Hunt and Lord Patel of Bradford, who also asked me to speak to this amendment.

First, I want to say that I find it helpful—and, in listening to this debate, even more helpful—to separate out health inequalities and healthcare inequalities. Health inequalities are due to the social determinants of ill health, as we have heard, such as housing and employment, which require cross-government involvement to address—the lowering of the unwanted teenage pregnancy rate was a fabulous cross-government initiative that had fabulous outcomes—while healthcare inequalities are due to the distribution of healthcare services, which is what I am going to address. I get very confused if I do not separate out those two, and I think sometimes we get in a muddle, because it is not for the NHS to deal with housing. I take the point about Bromley-by-Bow, but the NHS is there to deal with health, ill health, prevention and so on, although of course it should be involved in cross-government work.

I shall start my speech with a GP. In 1971, Julian Tudor-Hart, a fabulous Welsh GP who worked in a mining village in south Wales, wrote a pivotal paper in the Lancet. In it, he described what he called the inverse care law: the availability of good medical care tends to vary inversely with the need for it. Put simply, those who need care are least likely to receive it. That was some 50 years ago, and I would love to tell the House that it was now a historical curiosity, but it is not. If anything, that situation is getting worse. I shall talk about two particular places where we see that most clearly, general practice and our coastal towns.

I shall start with general practice. The noble Lord, Lord Hunt, has given some figures, and I am going to highlight a few more showing why it is so important to have an equitable distribution of general practitioners. Many of the indices of ill health are due to the drop in numbers of GPs. If noble Lords want to debate with me about that claim, I can show that there is an absolute line towards that.

As the noble Lord said, this week the Royal College of General Practitioners published—the first time it has ever done so—its State of General Practice Report 2026. We have to take its findings very seriously if we are going to address our population’s needs. To pull out just one figure from the report, which the noble Lord mentioned, as of September 2026 there were only 36 more full-time equivalent GPs than in September last year—so slightly better than when I made my speech at Second Reading, but not much. British Medical Association data shows that in the same period the number of hospital doctors has grown by nearly 50%. Those figures are reflected in the number of patients GPs care for, such that the average number of patients per full-time GP has gone up by 12% and at the same time, according to data in the British Medical Journal, the number of patients per consultant has fallen by 18%.

GPs are doing their best to meet the demand. Over the last 12 months, approximately 388 million appointments were carried out in general practice—by the whole team, but largely by GPs. Some 45% of those appointments were booked for the same day, 82% of them within two weeks, and 60% of them were face to face, excluding home visits. That is tens of millions of appointments more than before the pandemic.

The Government have rightly said that care should move out of hospital and into the community, but we have moved the patients without moving the resources. So it is perhaps not a surprise that the Royal College of General Practitioners survey showed that three-quarters of GPs say their workload is compromising patient safety, while the GPs themselves have the highest burnout rates of all the professional groups.

Here is the part I find difficult to understand. Thanks to government initiatives, we now have over 5,000 doctors in general practice training, the highest figure for years, but BMA analysis shows that half of those who finished training between 2018 and 2024 were not working in a GP practice a year later. It is not that the practices do not want them; they just cannot afford to employ them. This is the contradiction at the heart of the problem: demand is rising yet the workforce has not kept pace. As Tudor-Hart predicted, those who lose out most are those in most need.

According to the Health Foundation, after accounting for increased workload and higher health needs in poorer communities, practices in deprived communities receive roughly 7% to 10% less funding than those in affluent areas—and I now know where, in a way, that has come from, and I thank the noble Lord, Lord Hunt. We are not just failing to tilt the playing field towards needs; we are tilting it the wrong way. That is the case for Amendment 11. If we are serious about reducing healthcare inequalities, general practice distribution must reflect the population’s needs.

That brings me to Amendment 14. As we have heard, the Chief Medical Officer’s report on coastal communities found that those living in seaside areas have shorter lives and spend more of those years in poor health. We have heard about the challenges they have—poor transport, geographical isolation, older population. Noble Lords might expect the health service to send more staff to areas with higher levels of illness, such as coastal areas, but too often it is the opposite. In Hastings, a lovely place, each GP cares for more than 3,700 patients, the highest number in England. In Kingston upon Hull, which again is a lovely place, there is roughly one GP for every 3,000 patients, but in Kingston upon Thames the figure is roughly 1,900—similar names but very different experiences.

The GPs and nurses who work in those places describe it vividly. In Skegness, an area where I spent many of my childhood holidays, staff told researchers about constant firefighting, burnout and isolation, and about patients who could not get their appointments because of poor transport. The problem extends beyond general practitioners to community nursing, where recruitment and pay parity have fallen even further than for GPs.

The evidence is clear that reducing healthcare inequalities requires services and workforce planning to reflect the needs of the communities they serve. That is why Amendment 14 matters. It would explicitly place the need to reduce healthcare inequalities between coastal and inland communities within the Secretary of State’s duties under the Bill. Funding must reflect the health needs of the population, not merely the number of patients on a practice list. As care moves out of the hospital and into the community, staff and resources must move with it.

These amendments are not seeking preferential treatment for GPs. They are seeking fair treatment according to need. Robust evidence spanning more than 50 years shows that more GPs per head of population means better health outcomes, fewer premature deaths, a better patient experience, more preventive work and a lower cost to the NHS.

I hope the Minister will recognise that these amendments would give practical effect to the Bill’s ambitions to reduce healthcare inequalities. The inverse care law was identified 50 years ago but we should not accept that it remains patients’ experience today. They did not choose to live in the deep end, but we can choose whether to leave them there.

[Baroness Hodgson of Abinger (Con)]

I too put my name to Amendment 11. I do not want to repeat everything the noble Lord, Lord Hunt, and the noble Baroness, Lady Gerada, have said, but it is so important that people have access to a GP. Too often we hear that people cannot get to see their GP. That is one reason why A&E departments in hospitals are becoming overwhelmed—because people then go there. I too am concerned that GPs are being asked to see far too many patients. Many patients cannot be dealt with in just 10 minutes, and the stress of all this is creating burnout for GPs, as we have heard. So please can we ensure that everyone has access to their GP without having to wait weeks or fight with the receptionist?

Patients need continuity of care. We all know that, when GPs know their patients, the outcomes are hugely better. I am not medical, but it is common sense that if a patient can get to see a GP quickly, things can often be resolved sooner and conditions picked up earlier, making treatment easier. We need to ensure equality of access. If we can get the GP system functioning better everywhere, that will help to deal with some of the enormous strain placed on other parts of the national healthcare system at the moment.

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[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Baroness, Lady Jones, for opening the debate on this group, starting with the amendment laid in the name of her noble friend, the noble Baroness, Lady Bennett. I am grateful to all noble Lords for their consideration on a topic that is key to this Bill and to all our work. I will return to this, but it includes the 10-year health plan, which provides the framework for all that we do.

I start with Amendments 6 to 11 and 13 to 20. I assure your Lordships of our commitment to tackling inequalities. We have debated this several times in this Chamber and rightly so. I certainly agree with the comments made, including those from the noble Baroness, Lady Cash. This is about people’s ability not just to access services but to achieve the right outcomes for them regardless of who they are, their background or where they live.

I turn to Amendments 8 to 10, tabled by the noble Baroness, Lady Walmsley, and spoken to by the noble Baroness, Lady Tyler, and Amendment 7 in the name of the noble Lord, Lord Patel. These test whether the duty on the Secretary of State is strong enough. It is right to discuss that point. I appreciate the intention—which was emphasised by my noble friends Lady Royall and Lady Lister, and the noble Lord, Lord Lansley—to ensure that we are taking action, because that is ultimately what we are here to do. However, I would caution against amending the Bill in the way that the amendments seek to do. As a number of noble Lords will be aware, the “have regard” formulation in legislation has a number of precedents across the statute book, and it is familiar to government departments and to decision-making in the public sector.

There was an exchange between the noble Lord, Lord Lansley, and my noble friend Lady Royall over Sections 2A and 2B of the NHS Act. I tread with some trepidation at this stage, but we do not believe that it is necessary to change “may” to “must”, certainly for the duty in Section 2B. This is for the reason I have just outlined about risking confusion because it is moving away from the usual way of doing things. It would also potentially reduce the ability of Ministers to make decisions about priorities. There is no practical intention to reduce the importance of tackling inequalities. The noble Baroness, Lady Gerada, has moved from her place.

[Baroness Gerada (CB)]

It was cold down there.

Health Bill

Baroness Gerada Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[Baroness Gerada (CB)]

My Lords, I also welcome the amendment tabled by the noble Baroness, Lady Shawcross-Wolfson. I will speak to Amendment 253, which is in my name. Before I do, I will say that when I started in general practice in 1991, 80% of the GP workforce were men. We now have a reversal of that, so part of the issue is the feminisation of the GP workforce. Women get pregnant and care for small children and our elders. This was predictable. When I was a GP leader, I said that we needed to replace every retiring male GP with 2.4 GPs—men and women, for various reasons. Nevertheless, I digress.

I will speak on district nurses, who are our generalist practitioners in patients’ homes. I will paint a little picture. It is a wet Tuesday evening in November and somewhere in a village, town or city near any of us a district nurse is parking outside a terraced house. Inside is an elderly man with a leg ulcer that will not heal. Down the road there is a woman with diabetes who cannot manage her insulin on her own. A few streets further on a family is sitting with their mother in her final days, frightened and exhausted. The district nurse is the only one who can put up a syringe driver. This district nurse will visit them all. She will dress their wounds, check their blood, ease their pain and hold their hands. Tomorrow, she will do it again. District nurses are there every day of the year, in every corner of this country, at almost every hour of the day and night.

Successive Governments have promised to shift care out of hospitals and into the community. This Government have done the same, and I welcome that. But that shift will be extremely difficult without district nurses. They are not an optional extra; they are the linchpin. Neighbourhood health without district nurses is a building without a foundation. As the Nursing and Midwifery Council has said, district nursing is key to the achievement of the shift in healthcare that this Government seek.

I will remind your Lordships of some of the figures—we have heard a lot of figures today, so I will cut them back. According to analysis by the Nuffield Trust, in 2009 there were some 7,600 full-time equivalent district nurses in the NHS. By 2024, there were 4,322, a fall of 43%. Put simply, for every seven district nurses we had in 2009, we now have four. Over the same period, the number of adult nurses working in hospitals rose by 43%. The contrast is striking. We have said that we want care closer to home, but our workforce has continued to develop in favour of the hospital.

Some will say that this is an artefact of how we count the data because, around 2011, some community services moved to voluntary and independent providers, and some district nurses consequently stopped appearing in NHS figures. That is true, but it does not explain a decline that has continued over 15 years. The picture is even more concerning when we take population growth and ageing into account. On that basis, district nursing has fallen by 55%. The decline is continuing. The Care Quality Commission’s latest State of Care report found that the number of qualified district nurses fell by a further 5% between 2024-25 and 2025-26.

The problem is not just numbers; there is also the question of skills and experience. More than one in four of those recorded as district nurses are employed below band 6, which is the grade at which qualified district nurses would normally start. So we are losing not just numbers but the expertise on which this whole community service depends. What does this mean for patients? When district nurse teams are stretched, the first things to go are the things that matter most and are seen least: psychological support, prevention—such as looking at trip hazards and adequate lighting—and continence care. That care is now too often delivered less well, not delivered at all or pushed on to services that are already at breaking point. Investing in district nursing is not simply an investment in better care; it is an investment in preventing avoidable deterioration, unnecessary hospital attendances and expensive admissions.

The pressure is set to increase further. The Nuffield Trust estimates that the demand for district nurses could rise by 34% by 2040, based on the projected population numbers. So demand has grown but the service has contracted. This is not a failure of district nurses, who have held the line with extraordinary dedication. It is a failure of planning, as we have heard, as well as priorities and political will. That is exactly why this amendment matters. We cannot keep promising to move care into the community without first asking how many people we need to deliver it.

District nurses are indispensable. We cannot deliver neighbourhood health, safely shift care out of hospitals and provide dignified care at home without a properly trained and adequately staffed district nursing workforce. We know what happens when plans fail, and we will see the numbers of patients admitted to hospital. My question to the Minister is: will the Government commit to assessing the number of district nurses needed to meet current and projected demand, identifying the shortfall and setting out a funded plan to address it?

[Baroness Barker (LD)]

My Lords, I will add to what the noble Baroness, Lady Gerada, said. A very high percentage of our district nurses come from other countries. Therefore, what will the Minister do, talking to the Home Office, about the supply of district nurses that we will undoubtedly need in the future?

I will make one or two brief points, following on from what the noble Baroness, Lady Harding, said about planning. If any member of the Committee has spoken to anybody currently employed by an ICB, they will know that seared in their minds is the date on which they were told, about 18 months ago, that their jobs were going to go. For the last 18 months, they have continued to work under that threat. I do not know any other employer that would do that to a workforce and expect to retain it. I talked to members of staff who work for ICBs. I had the misfortune to ask them, “How are you?”, and 25 minutes later I knew how they were—it was not good. I rather suspect that the biggest demand for mental health services at the moment is coming from members of NHS staff, because they have been living with this uncertainty for 18 months.

I am not being flippant but, if the Minister cannot share great detail with us, can she at least tell us the Government’s working assumptions about the number of staff there will be in the future who are members of ICB staff now? I suspect that the attrition rate will be enormous, especially given the age profile of some members of ICB staff, in particular, who have built up specialist expertise over many years. Secondly, what working assumptions are the Government making about members of staff, particularly nursing staff, who will move out of the acute sector and into the community?

Health Bill

Baroness Gerada Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

Moved by

[Baroness Gerada]

29: Clause 7, page 4, line 31, at end insert—
“(1A) In discharging the duty in subsection (1), the Secretary of State must ensure that education and training for persons employed in the health service in England includes training on recognising, preventing and responding to antisemitism and other forms of racism.”Member's explanatory statement
This amendment seeks to ensure that the workforce education and training duty transferred from NHS England will include training on antisemitism and racism, as recommended by the Lord Mann review (recommendations 32 to 36).

[Baroness Gerada (CB)]

My Lords, in moving Amendment 29 in my name I will also speak to Amendments 79, 258 and 259. I thank the noble Lords, Lord Hunt of Kings Heath and Lord Austin of Dudley, for adding their names. I also thank the noble Lord, Lord Mann, for his review of antisemitism and other forms of racism in the NHS, and the Government for accepting all 36 of its recommendations. These amendments do not seek to reopen that decision; they aim to ensure its implementation.

According to the 2025 NHS staff survey, as reported in the review of the noble Lord, Lord Mann, 13% of Jewish staff reported discrimination from managers or colleagues, compared to 11% from patients or the public. Jewish staff are the only group for whom discrimination from within the workforce exceeds that from patients. The review heard evidence that staff no longer wish to work in the NHS. This is unacceptable and must never be accepted as normal. The review also found that some Jewish patients are putting off the care they need. A consultation works only if a patient can tell their doctor about themselves without fear. When that trust goes, it is a question not only of equality but of patient safety.

For many years, I led the NHS’s Practitioner Health service, to which over 40,000 doctors, dentists and other healthcare staff turned for help with their mental health problems. My work has taught me that doctors who do not feel they belong become unwell, and doctors who become unwell leave—and we cannot afford to lose them. These findings concern Jewish staff and patients, but the principle at stake is far broader. A health service that makes any group of patients hesitate to seek care, or any group of staff feel unsafe at work, fails us all. That is why these amendments address antisemitism alongside every other form of racism.

Why bring them to this Bill? Much of the work required to deliver the review rests on guidance, contracts and programmes already owned by NHS England, even if the Bill transfers its functions elsewhere. Commitments that exist only in guidance can be quietly lost when the body that wrote them is wound down. These amendments will place the essentials in statute.

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[Baroness Merron (Lab)]

They should absolutely have regard to the law in respect of protected characteristics. That is the fullest answer I can give at this moment.

[Baroness Gerada (CB)]

My Lords, I am grateful to noble Lords who have spoken and to the Minister for her assurances. I just want to make a few very brief comments, because I am aware of the time.

I was struck by the noble Lord, Lord Shinkwin. If I heard him correctly, his orthopaedic surgeon was on the last Kindertransport out of Prague. Our own noble Lord, Lord Dubs, was also on the last Kindertransport from Prague, as was my father-in-law. Such are the coincidences that happen in this life.

I am not Jewish, but I have been subject to antisemitism. I suspect that is because people assume I am Jewish. I have been left fearful, hurt and angry, with all those emotions and not knowing where to take them. If I experience that, I can see that my Jewish colleagues experience it in spades. I work in the NHS, and I can tell noble Lords that antisemitism has become normalised. Although the figures we have seen—13% and 11%—are pretty awful, I suspect it is considerably higher than that. It has become almost de facto that one can abuse Jewish colleagues, although not necessarily Jewish patients because you are subject to greater regulatory forces. Certainly, in the last 12 to 18 months Jewish staff have been subjected to quite appalling behaviour from colleagues with whom they work. Antisemitism has been normalised and almost accepted.

Nevertheless, I thank the Minister. I hope that the training does not become a tick-box exercise and includes the issues that we heard about from the noble Lord, Lord Shinkwin. I may wish to return to this issue on Report, but at this stage I beg leave to withdraw the amendment.

Amendment 29 withdrawn.