Health Bill

Baroness Pidgeon Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[Baroness Nargund (Lab)]

My Lords, I understand the concerns that have prompted the noble Baroness, Lady Tyler, to table her amendment, and I support her fully. Many times in this very Chamber I have raised the issue of the burden of unpaid caring on one’s health, well-being and finances. The majority of unpaid carers are women who sacrifice their own health and well-being needs to care for others. It is very important that we care for them. As many noble Lords said last week, we know that many unpaid carers do not identify themselves, but women are less likely to do so. Identifying carers is important, but they must not simply become another statistic, because behind every carer there is a family. Identification should and must lead to meaningful support for carers and their families.

As the noble Baroness, Lady Tyler, has already pointed out, there is evidence of under-identification of unpaid carers. Analysis by the Nuffield Trust of 13 million GP records found that only 1.4% of patients were recorded as unpaid carers in GP systems, compared with the census estimate of approximately 8.8%. That means that for every unpaid carer identified by GP practices, roughly four were not identified. In other words, around 1 million unpaid carers were missing from GP records.

I welcome Action 102 in the Renewed Women’s Health Strategy for England, which pledges to support unpaid carers to balance their work and care. The single patient record can be an important enabling tool to identify unpaid carers and record all their caring responsibilities. Therefore, can my noble friend the Minister say whether the single patient record will be set up to systematically identify unpaid carers, and whether ICBs will have a clear responsibility to act on that information to protect their health and well-being? Will the Renewed Women’s Health Strategy for England be joined up to this to support women who are unpaid carers? We owe it to them.

[Baroness Pidgeon (LD)]

My Lords, this debate, though it started last week, has highlighted the extraordinary contribution made by unpaid carers across the country. Every day, millions of people provide care, often around the clock, enabling their loved ones to live with dignity and independence. Their contribution is not only invaluable to the individuals they support; it is fundamental to the sustainability of the health and care system as we know it. As my noble friend Lady Tyler rightly pointed out last week, and as the noble Lord, Lord Hunt, pointed out today, the unpaid care provided by an estimated 4.7 million carers in England is worth some £152 billion a year—a figure comparable with the NHS budget. Without those carers, our health and social care services would be unable to cope.

Throughout this debate, noble Lords have highlighted the stark reality that carers too often remain invisible to the very systems that rely most heavily upon them. For too many carers who are not identified by health services, this means that they miss out on support, advice and interventions that would protect their own health and well-being as well. Amendments 88 and 89 would help to address these issues.

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On a practical level when we as a country and the NHS are in such a difficult financial position, I mentioned at Second Reading that the NHS currently spends £90 million a year on unused rooms in health buildings, many of them primary care buildings. Indeed, we have unused rooms sitting there that are costing the NHS all this money. There are deals to be done here with the independent, social and charitable sectors that make financial sense and health sense. I raised this question at Second Reading but got no reply: what are the Government going to do about that opportunity? How do we grasp that nettle of £90 million and turn empty rooms into opportunities for patients in the NHS?

[Baroness Pidgeon (LD)]

My Lords, I am grateful for the support for this group of amendments from noble Lords across the Committee. If the health service is to be truly patient-centred, patient choice needs to be a key part of this. Different patients will have different needs. Therefore, choice is a key part in having ownership of their care and treatment.

My Amendment 23 in this group picks up a key issue as we move to greater use of digital health. The NHS app will start to play a greater role. My amendment picks up the potential loophole that if a patient is seen in person, they may be referred for treatment or diagnostics by their GP or other primary care practitioner and given a choice of where to go for their referral. However, if this is done virtually, via an app or online, patients may not have the same choice that they would have received in person. This amendment seeks to ensure that there are no closed lists and that patients are referred to one provider only. Amendment 24 is similar in its aims.

Amendment 67 in my name, Amendment 22 in the names of the noble Lord, Lord Kamall, the noble Earl, Lord Howe, and the noble Baroness, Lady Neville-Rolfe, and Amendment 68 in the names of the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, are similar. My amendment specifically pushes for patient choice for non-consultant-led community services, including optometry-led glaucoma care and community urgent eye care services. The amendment seeks meaningful choice from providers available in an ICB area for out-of-hospital services. We know that waiting lists have increased for community services, yet these are often preventive services. I have raised in this Chamber before that 600,000 people are on hospital waiting lists for eye care services, yet we have optometrists on every high street who could be used to help address this and bring routine treatment nearer to people’s homes, thus leaving specialists able to deal with patients who need their services in a more timely manner.

Audiology, as we have heard, is another really important area. As the noble Earl, Lord Howe, highlighted, NHS community audiology services are commissioned across the whole of an ICB area in just 42% of ICBs. This means that the majority of patients are being denied choice. Often, patients are required to attend hospital-based services and experience long waits for services which could be offered safely and in a more timely manner in the community. This could be nearer to home or to a family member’s home—somebody who helps them get to an appointment and helps them with transport—giving them genuine choice. If we are serious, as we debate the Bill, about shifting care out of hospitals and into the community then patients must be given the same right to choose their provider for community services as they currently have for consultant-led hospital care.

Community waiting lists have now reached record levels, with around 1.25 million people waiting for treatment. Patients should be empowered with clear information on waiting times and location, allowing them to choose the provider that best meets their needs. By placing choice in the hands of patients rather than commissioners, which it too often is, we can improve access to timely treatments and actually deliver on the Government’s ambition of more personalised care closer to home. I look forward to the Minister’s response.

[Baroness Merron (Lab)]

My Lords, I will address the wider principles underpinning Clause 5 and Amendments 22, 23, 24, 67 and 68. I am grateful to noble Lords for their contributions and consideration of matters that are key to patient choice—a concept that is, as I know noble Lords are aware, neither new nor innovative but is absolutely at the core of the Bill.

Clause 5 introduces new duties to require the Secretary of State to promote the involvement of patients, their carers and their representatives in decisions relating to the prevention or diagnosis of illness, care or treatment. This applies where the Secretary of State exercises her health functions. As I said, this is absolutely core to the Bill and I am sure that noble Lords will welcome that.

The clause also requires the Secretary of State to act with a view to enabling patients to make choices about the health services provided to them. I hope that noble Lords are aware that the Government are committed to involving patients and carers in decisions about their care, as we discussed in the last group. One of the reasons is that we know it supports better experiences of care and in many cases leads to a better outcome. It is not just a “nice to have”, but a “necessary to have”.

I refer the noble Baronesses, Lady Manzoor and Lady Coffey, and the noble Earl, Lord Howe, to the new Choice Charter, which will strengthen this approach by setting out—this is key—what patients can expect so that they can make informed decisions about their health and care. There is no point in just expressing a wish to have patient choice if we are not equipping patients to make that choice. That is why we are protecting the patient’s right to choice and the duty to involve them in decisions. As I said, that will remain a central principle of the health system. I was glad to hear noble Lords across the Chamber welcoming the move from hospital to community provision. As the noble Baroness, Lady Pidgeon, set out, many services can be provided better in the community than they can in hospital. I welcome that support.

Amendments 22, 23, 24, 67 and 68 have been tabled by the noble Lord, Lord Kamall, and the noble Baroness, Lady Pidgeon. These amendments would go further than Clause 5 currently does by expanding patients’ right to choice to a wider range of out-of-hospital services and onward referrals by virtual and integrated health services, and by prescribing how this must operate in practice. I reconfirm our commitment to strengthening patient choice as part of our wider agenda to improve access to care and reduce waiting times. It might be helpful to remind your Lordships’ House—the noble Earl, Lord Howe, might be particularly interested in this—that existing choice rights already apply to some consultant-led out-of-hospital services where the regulatory conditions are met. These include dermatology, pain management services, gastroenterology and diabetes services.

The noble Lord, Lord Patel of Bradford, made a number of key points. Community services are by their very nature designed differently from hospital services. I assure him that those who need help to exercise their choice will get it around what their needs are. They will not simply be expected to manage with one size fits all. The points that have been made are fair and I take them on board but, as a point of principle, we do not think that this level of operational detail, important though it is, is appropriate for primary legislation. Our preference is to use secondary legislation to set out the services covered by choice rights and the detailed requirements for offering choice. The key thing is that that will allow that framework to be updated as services, evidence and system capability develop, because we are not going to be stuck in one place and healthcare will develop as we go along. I say to the noble Lord, Lord Patel of Bradford, that we will continue to look at the scope of the choice rights and ensure that we are provide the most effective offer to patients.

I say to the noble Baroness, Lady Coffey, and the noble Earl, Lord Howe, that we are taking the practical actions they seek, as set out in the elective reform plan. We are empowering people to take control of their health by making the NHS App and the “Manage Your Referral” website the default route for patients to choose their provider. To enable patients to make an informed choice, we are improving the information available to them, following the point I made earlier, including on waiting times. The noble Lord, Lord Patel, was right to say that not everybody can use online access. We completely understand that, and I emphasise that online tools are in addition to traditional channels. We will ensure that people who need help to make a choice receive that support and information in the way that suits them, as raised by the noble Baroness, Lady Pidgeon.

On the point made by the noble Baroness, Lady Neville-Rolfe—this might also be helpful to other noble Lords—patients will continue to be able to choose any provider that holds a contract to deliver NHS services. As I said in my letter to the noble Baroness, that includes independent sector providers, within set circumstances. It is the responsibility of ICBs to ensure that their processes comply with the right to choose. That includes any qualifying contract requirements, clinical appropriateness and eligibility criteria. There is guidance for the use and implementation of indicative activity plans and activity management plans. That is detailed in the NHS standard contract technical guidance. If the noble Baroness would like more information, I will be happy to ensure that it is there.

The noble Baroness, Lady Manzoor, talked about the need for real choice to be strengthened. The government guidance on choice makes it clear that GPs, dentists and optometrists have clear duties to ensure that patients are offered a choice of where they go to their first out-patient appointment. I totally agree with her that a right is only as good as the information and confidence that you have. That is why we are taking these steps.

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With respect to audiology, I will be pleased to write to noble Lords with further detail on that point.

[Baroness Pidgeon (LD)]

Before the Minister sits down, she mentioned that the Government are minded to use secondary legislation rather than amendments to the Bill. Are the Government minded to include the non-consultant community services we have been discussing in the Chamber today in such secondary legislation, for genuine patient choice?

[Baroness Merron (Lab)]

Secondary legislation will ensure patient choice across all NHS services, so that will be included.

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[Baroness Thornton (Lab)]

My Lords, I had not intended to speak in this debate—I was saving myself for social care and those other issues—but I was very moved by the interjection by my friend, the noble Lord, Lord Patel, and I disagreed with the noble Baroness, Lady Coffey. This is an important suite of amendments, because comprehensive integrated care has to include end of life—of course it does. I know that the noble Lord and the Minister will be discussing how best to do that; it may not be to put it on the face of the Bill, but it definitely has to be included in this legislation. The amendment from the noble Baroness, Lady Pidgeon, is a very good one, and I completely agree with it.

[Baroness Pidgeon (LD)]

My Lords, I thank the noble Lord, Lord Patel, and my noble friend Lady Barker for their very personal and raw contributions, as recent carers, on the recent losses of loved ones.

I am grateful for the support from the noble Baroness, Lady Thornton, for my Amendment 230 in this group, which also has the support of Marie Curie and Hospice UK. At its heart is the principle that people approaching the end of life should be able to have their wishes, preferences and priorities for care understood, recorded and respected. Advance care planning enables people with terminal illness to express how and where they wish to be cared for. It supports more proactive and personalised care and, as we have heard, it has been shown to improve patient and family satisfaction while reducing the likelihood of crises, avoidable hospital admissions and the need for emergency care out of hours. I have seen at first hand how, in Devon, the system seems fairly well set up to support people in their own homes, and to have these very difficult conversations with a hospice at home service, with people who have real skill in communicating and talking about these difficult topics at a time when someone may have just learned that they have a terminal illness and when lots of things are going around their mind. It is important for them to be able to get some clarity, going forward, about what they wish for and do not wish for. As we have heard, other parts of the country do not work so well.

Importantly, the evidence suggests that advance care planning does not increase costs to the health and care system, and may in some cases reduce healthcare expenditure by ensuring that care is delivered in accordance with patients’ wishes. We will come on to the single patient record on a later date, but I flag here that advance care planning can be effective only if the information is available to those providing care when it is needed. The single patient record offers a significant opportunity to improve co-ordination and continuity of care, but its success will depend not simply on sharing data but on ensuring that advance care planning is routinely embedded in clinical practice so that people’s wishes can be accessed, understood and acted upon, wherever and whenever care is provided.

The other amendments in this group from the noble Baronesses, Lady Finlay and Lady Coffey, highlight the many issues with the current landscape of palliative care and specialist palliative care services, and the difficulty in getting access to those services. I look forward to the Minister’s response to that, and her response to the trick or treat challenge.

[Lord Kamall (Con)]

My Lords, this has been an important and timely debate, coming not long after the Terminally Ill Adults (End of Life) Bill and the Prime Minister’s remarks. While these amendments address a range of issues, they all point to the same conclusion: palliative and end-of-life care must have a central place in this conversation.

If the Government are serious about shifting care from hospitals into communities, supporting people to remain closer to home—notwithstanding the comments from the noble Baroness, Lady Barker—and delivering truly patient-centred care, palliative care must be part of that vision from the outset. The need for action is clear. Marie Curie estimates that each year around 170,000 people in England die with unmet palliative care needs, equivalent to almost one person every three minutes. We must ensure that those approaching the end of their lives can access the support they need, when and where they need it. This is closely linked to my noble friend Lady Coffey’s amendment. She spoke movingly of her mother’s experience and the need to ensure that patients have access to high-quality palliative care, wherever they happen to live and choose to die.

If the Government’s proposed national care service is to succeed, it cannot simply be a discussion about structures, responsibilities and reorganisations. It must be about the experience of those who rely on care. No group demonstrates that more clearly than people approaching the end of their lives. Palliative care is perhaps one of the clearest examples of where health and social care are inseparable. While clinical support may be provided by the NHS, the ability of a person to remain at home or close to home, to maintain their dignity and spend time with loved ones, often depends just as much on the availability of social care. For many families, social care provides the day-to-day support on which good end-of-life care depends. Evidence shows that when effective support is available in the community, people are more likely to be cared for and pass away in a place they choose, rather than in hospital. As the noble Baronesses, Lady Finlay and Lady Hollins, said, this will also reduce hospital deaths, save the NHS money and make more beds available.

Palliative care does not begin and end with the NHS; it depends upon social care providers, community services, carers, local authorities, hospices and voluntary organisations working together around the individual and their family. When those services are joined up, people are more likely to receive care in the setting they choose and with the support they need. When they are not joined up, it can profoundly affect those approaching the end of their lives.

In that context, I welcome the amendment from the noble Baroness, Lady Finlay, which recognises that good palliative care depends not on any single organisation but on effective collaboration across the NHS, adult social care and the voluntary sector. Too often, services that support people approaching the end of their lives are commissioned, funded and delivered separately, despite the fact that patients and families experience them as part of a single journey. The amendment would help to ensure that integrated care boards take active steps to bring those services together, whether through access to specialist hospice care, shared equipment, medicines, workforce development or closer collaboration between providers.

Crucially, the amendment recognises the vital contribution of hospices and charitable organisations to the delivery of palliative and end-of-life care. These organisations are not peripheral to the system; they are an essential part of it. If the Government are serious about creating a national care service and a neighbourhood health service that are genuinely joined up for patients, the expertise and capacity of the voluntary sector must be properly integrated into the way care is planned and delivered.

Indeed, some of the most important services available to people at the end of their lives are delivered by hospices and charitable organisations. For decades, as the noble Lord, Lord Hunt, said, the voluntary sector has not merely supplemented statutory services but has been fundamental to the provision of specialist palliative care. But too often it is forced to operate at the margins of the system, dependent on local arrangements, local funding decisions and local fundraisers, and subject to tax rises, such as employers’ national insurance, from which state providers are understandably exempt. The noble Baroness, Lady Bennett, shared examples of recent hospice closures.

If the Government wish to build a neighbourhood health service and develop a national care service, integration must mean integration not only within the NHS but between the NHS, adult social care and the voluntary sector. Ultimately, the measure of success will not be the structures we create but whether individual patients receive seamless support at one of the most difficult moments of their lives and for their families.

The issue of patients having a conversation about their end-of-life care, addressed in the amendment in the name of the noble Baroness, Lady Pidgeon, was illustrated by the very moving stories from the noble Lord, Lord Patel, the personal experience of the noble Baroness, Lady Barker, and the concerns raised by the noble Baroness, Lady Grey-Thompson. These amendments seek to move us towards that goal. I hope that the Minister will give careful consideration to the issues that have been raised during the debate.

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[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?

[Baroness Pidgeon (LD)]

My Lords, since taking over as our spokesperson, I have lost count of the number of times the Minister has talked about the workforce strategy that will at some point emerge from the department. I am not sure whether we will be given a season this evening, but hopefully it will be published soon.

My Amendment 253, which the noble Lord, Lord Stevens of Birmingham, and the noble Baroness, Lady Gerada, have added their names to, would require the Secretary of State, within 12 months of Royal Assent, to publish

“a health and care workforce strategy for England”.

I have included “care” on purpose because the two are so importantly linked. It must assess the staff needed to meet current and projected demands, expressly including registered nurses and primary care practitioners, and it must contain a funded plan to close staffing gaps. Annual progress reports would be laid before Parliament, keeping that issue on the agenda for us all. Putting staff in is an important marker too. We need to properly plan and invest in our workforce, both health and care, hand in hand.

The Royal College of Nursing supports this amendment, as do a number of representatives of primary care. Too often, primary care seems to be forgotten in the debate on workforce, but it is critical: GPs and district nurses—we have just heard passionately from the noble Baroness, Lady Gerada, about their role—as well as optometrists, dentists and pharmacists. As the Government look to shift services into neighbourhoods and hospitals—something I think we all support—this is really important. The early years workforce is important as well, as are health visitors.

The other amendments in this group, including that of the noble Baroness, Lady Shawcross-Wolfson, all require similar reports, perhaps on different timescales. Some are focused on really important areas such as the mental health workforce, the education and training that is needed alongside a workforce plan, and continuing professional development. Noble Lords have flagged the current vacancy rates in a number of roles, as well as skills shortages and the need for independent scrutiny of the workforce plan.

My noble friend Lord Scriven rightly stressed, using his personal family experience, the need for nurses for people with learning disabilities and the investment in that workforce, as well as the need to understand the whole workforce, looking at models in, for example, the Netherlands. The noble Lord, Lord Stevens, and the noble Baroness, Lady Gerada, talked about the complexity around primary care and the challenges with part-time workers, with perhaps more women coming into the workforce, as well as the challenges of work-life balance. Some people want to work part-time rather than full-time. These are key questions for the Government on this issue of workforce. I look forward to a comprehensive response from the Minister, and possibly a date, a season or a hint of when we might at last see that workforce strategy.

[Lord Kamall (Con)]

My Lords, this has been a crucial debate, and I am grateful to noble Lords for tabling and speaking to their amendments, which raise fundamental questions about the future of the NHS workforce, the quality of care patients can expect and the Government’s ability to deliver health service reform.

The amendments from my noble friend Lady Shawcross-Wolfson and the noble Baroness, Lady Pidgeon, go to the heart of a simple but vital question: how can this Government, or indeed any Government, credibly plan for the future of the NHS without an independently verified assessment of the workforce that we need? As my noble friend said, the previous Conservative Government, albeit belatedly, recognised the importance of this challenge when we published the first NHS Long Term Workforce Plan in 2023. This was a baseline step in establishing a long-term approach to workforce planning, with clear ambitions to expand domestic training, improve retention and reduce our reliance on international recruitment.

We recognised then, as we must recognise now, that workforce planning cannot be conducted from one spending review to the next. Training doctors, nurses and other healthcare professionals takes years, and decisions made today will determine the quality and availability of care for patients a decade, or decades, from now. Yet we are still waiting, as other noble Lords said, for the Government’s new 10-year workforce plan. The noble Lord, Lord Patel, offered some possible reasons for the delay.