Health Bill

Wednesday 28th October 2026 Lords Chamber

Committee (1st Day)

Northern Ireland, Scottish and Welsh legislative consent sought. Relevant document: 12th Report from the Delegated Powers Committee.

16:01

Clause 1 agreed.

Clause 2: Transfer schemes in connection with abolition of NHS England

Amendment 1

Moved by

[Baroness Merron]

1: Clause 2, page 1, line 16, at end insert—
“(1A) The Secretary of State may not make a transfer scheme transferring anything to—(a) a Scottish public body, without the consent of the Scottish Ministers;(b) a Welsh public body, without the consent of the Welsh Ministers;(c) a Northern Ireland public body, without the consent of a Northern Ireland department.”Member's explanatory statement
This amendment would require the Secretary of State to seek the consent of the appropriate devolved nation before making a transfer scheme which transferred property, rights and liabilities from NHS England to a Scottish public body, Welsh public body or Northern Ireland public body.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, as I said at Second Reading, the abolition of NHS England is being taken forward with the interests of patients firmly at its core. It will provide greater clarity for the system. It will restore democratic accountability and free up resources to be reinvested in the front line. It will also bring greater clarity about where responsibility lies, ensuring that Ministers are accountable for national decisions while devolving more power to local NHS organisations. Patients will benefit from faster and clearer decision-making, with less duplication and red tape, with staff being allowed to spend less time navigating bureaucracy and more time focused on care and delivery.

I will address the government amendments to Clauses 2 and 28 together. Amendment 1 and consequential Amendments 2 and 3 make additions to Clause 2, which empowers the Secretary of State to establish transfer schemes. These clauses provide a structured and transparent means of moving property, staff, rights and liabilities from NHS England to the Department of Health and Social Care, integrated care boards and other relevant bodies.

Following engagement with the devolved Governments, these amendments have been tabled to require the consent of the relevant devolved Government should a transfer be made to a Welsh, Scottish or Northern Ireland public body. Amendment 1 does not change the purpose of Clause 2 but provides assurance to devolved Governments that any transfers to their bodies can take place only with their agreement. I emphasise that there are currently no plans for transfers to be made to devolved Governments’ public bodies, but this amendment provides a proportionate safeguard if such circumstances arise in the future.

Likewise, Amendments 103 and 104 are technical amendments to Clause 28, this time in response to engagement with the Welsh Government. They make clear the territorial limit of the clause to ensure it could not be used to establish, or delegate functions to, a Welsh special health authority. I believe these to be sensible and proportionate amendments, and I beg to move Amendment 1.

[Baroness Finlay of Llandaff (CB)]

My Lords, I welcome the Minister’s discussions with the devolved Governments and her saying that nothing is going to be potentially imposed on them, particularly having had those discussions. But can she clarify what will happen to some of the prevention agendas that have been in place—such as the Couch to 5K programme, for which I understand no outcomes have been collected, but which has been part of NHSE and the department’s promotion of exercise—and whether these programmes will be increasingly promoted across England as part of the prevention agenda, and in discussion with the devolved Governments, so that we get consistency in prevention across the United Kingdom?

[Baroness Pidgeon (LD)]

My Lords, we welcome these Government amendments, which ensure that the devolved Administrations’ boundaries are protected and that there is proper consultation and agreement. But devolution must be integral to any legislation from the start, rather than an afterthought. Granted, there has been consultation with the devolved Governments, but these amendments were tabled very late and this is a worrying sign. It is an indication that aspects of the reorganisation and its governance implications had not been properly thought through at the start—through the lens of the devolved Administrations, rather than simply through that of Whitehall and civil servants centrally. The Minister’s words have provided some assurance, and I look forward to the devolved Administrations being at the start and the heart of legislation such as this in the future, rather than an add-on at a late stage.

[Earl Howe (Con)]

My Lords, it is a pleasure to begin our Committee consideration of the Health Bill, and I look forward to the discussions over the coming days. I am grateful to the Minister and to the Government for bringing forward these amendments, which we understand to be principally technical in nature, although there are questions we shall want to ask in later groups about cross-border patient referrals and related issues. We welcome the clarification these amendments provide regarding the consent of the devolved Administrations and the exercise of powers by devolved health bodies, and we are content to support them.

I hope the Committee will allow me to take this opportunity to acknowledge the letter sent by the Minister this morning concerning Healthwatch. Noble Lords across the House will welcome the Government’s decision not to proceed with its abolition, and I am grateful to the Minister for listening to the concerns raised in this House and elsewhere. This is a very positive example of the Government engaging constructively with the scrutiny of this Bill and showing a willingness to reconsider their proposals where legitimate concerns have been raised. That is precisely the spirit in which I hope we can continue our consideration of this legislation, and I welcome the approach the Government have taken on this occasion. I look forward to the Minister’s response.

[Baroness Merron (Lab)]

My Lords, I am grateful for this brief but important debate, and in particular for the support for these amendments. As the noble Earl, Lord Howe, says, they are technical amendments. I say to the noble Baroness, Lady Pidgeon, that this is absolutely nothing to be worried about: we work closely with the devolved Governments, and this is an extra layer of reassurance to them that we felt was helpful, because it is what they sought. These technical amendments are brought forward not as an afterthought but because that is what conversations have led us to think is the right thing to do. I know they very much welcome this, and I am grateful for their assistance.

I hear what the noble Earl, Lord Howe, said about the letter I sent out and the announcement in respect of Healthwatch. I am most grateful to noble Lords for their engagement as we have approached this point in the Bill. As the noble Earl acknowledged, we are always keen to listen. We cannot always do exactly what every noble Lord would want, but I am glad that the noble Earl welcomes the way in which the Secretary of State and the Prime Minister have approached this.

On the point raised by the noble Baroness, Lady Finlay —who also gave her support—about particular programmes, I am very happy to look into that. However, as I have set out, we intend for the programmes to which we are committed to be transferred to the department. What happens in the longer term on the prevention agenda is another consideration. We work very closely with the devolved Administrations on prevention, but, ultimately, healthcare is a devolved matter. I commend the amendment to the Committee.

Amendment 1 agreed.

Amendments 2 and 3

Moved by

[Baroness Merron]

2: Clause 2, page 2, line 14, leave out subsection (4)
Member’s explanatory statement
This is consequential on my amendment to Clause 2, page 2, line 21.

3: Clause 2, page 2, line 21, at end insert—
“(7) In this section—“Northern Ireland public body” means a public body whose functions are exercisable only or mainly in or as regards Northern Ireland and relate only or mainly to transferred matters (within the meaning of the Northern Ireland Act 1998);“Scottish public body” means a body that is a Scottish public authority with mixed functions or no reserved functions (within the meaning of the Scotland Act 1998);“the TUPE regulations” means the Transfer of Undertakings (Protection of Employment) Regulations 2006 (S.I. 2006/246);“Welsh public body” means a body that is a devolved Welsh authority as defined by section 157A of the Government of Wales Act 2006.”Member’s explanatory statement
This is consequential on my amendment to clause 2, page 1, line 16.

Amendments 2 and 3 agreed.

Clause 2, as amended, agreed.

Clause 3 agreed.

Amendment 4

Moved by

[Earl Howe]

4: After Clause 3, insert the following new Clause—
“Abolition of NHS England: transition plan(1) The Secretary of State must prepare and publish a transition plan in relation to the abolition of NHS England.(2) The transition plan must set out—(a) the objectives which the abolition of NHS England is intended to achieve;(b) the arrangements and timetable for transferring the functions, property, rights and liabilities of NHS England;(c) the bodies to which those functions, property, rights and liabilities are expected to be transferred;(d) the estimated gross costs associated with the abolition of NHS England and the implementation of the arrangements mentioned in paragraph (b); (e) the estimated costs of redundancies, voluntary exits, pension liabilities and other staff-related payments arising from—(i) the abolition of NHS England,(ii) the restructuring of the Department of Health and Social Care,(iii) changes affecting integrated care boards, and(iv) changes affecting commissioning support units;(f) the estimated costs associated with—(i) the transfer, retention or disposal of property,(ii) the transfer, variation or termination of contracts,(iii) the transfer of information technology, data, records and other systems,(iv) the establishment or modification of governance and accountability arrangements,(v) the recruitment and training of staff,(vi) the retention or replacement of specialist staff and expertise,(vii) consultancy and other external professional services, and(viii) any other activity required to implement the abolition;(g) the estimated recurring annual savings expected to arise from the abolition of NHS England; (h) the extent to which the savings mentioned in paragraph (g) are expected to constitute cash-releasing savings;(i) the methodology, assumptions and baseline against which the costs and savings mentioned in this subsection are to be calculated;(j) the financial year in which the total cumulative savings arising from the abolition of NHS England are expected to exceed the total cumulative costs of implementing that abolition;(k) the existing departmental, health service or other budgets from which transition costs are to be met;(l) the effect which meeting transition costs from the budgets identified under paragraph (k) is expected to have on—(i) the provision of health services,(ii) planned capital and technology expenditure,(iii) integrated care boards,(iv) workforce budgets, and(v) other departmental programmes;(m) the amount of any savings expected to be made available for the provision of front-line health services and the arrangements by which those savings are to be identified, transferred and monitored;(n) the principal clinical, financial and operational risks associated with the transition;(o) the measures to be taken to secure the continuity of services during the transition;(p) the measures to be taken to identify, retain and transfer staff with specialist knowledge or expertise;(q) the arrangements for the transfer and continued operation of nationally significant services, contracts, information systems and corporate holdings;(r) the measures by which the Secretary of State will assess whether the objectives mentioned in paragraph (a) have been achieved.(3) The estimates contained in the transition plan must distinguish between—(a) one-off transition costs,(b) recurring expenditure,(c) gross savings,(d) net savings, (e) cash-releasing savings, and(f) non-cashable efficiencies or avoided future costs.(4) The Secretary of State must arrange for the transition plan, including its financial estimates, methodology and assumptions, to be reviewed by an independent person with experience of public-sector finance, organisational restructuring or health service administration.(5) A person carrying out a review under subsection (4) must assess—(a) whether the estimates in the transition plan are reasonable,(b) whether the plan identifies the full costs of implementation,(c) whether the methodology and assumptions used to calculate costs and savings are reasonable and have been applied consistently,(d) whether the distinction between gross, net and cash-releasing savings is clear and supportable,(e) whether the expected break-even date is supported by the available evidence, and (f) whether the arrangements for managing risks and maintaining operational continuity are adequate.(6) The person carrying out the review must prepare a report setting out the conclusions of the review.(7) The Secretary of State must publish, alongside the transition plan—(a) the report prepared under subsection (6),(b) the name of the person who carried out the review,(c) a statement of that person’s relevant experience and qualifications,(d) a description of the process by which that person was appointed, and(e) a declaration of any interests which might reasonably be thought to affect that person’s independence.(8) The Secretary of State must lay the transition plan and the report prepared under subsection (6) before Parliament.(9) The Secretary of State must comply with subsections (1) to (8) before making regulations bringing section 1 or 2 into force.(10) In this section—“cash-releasing savings” means a reduction in expenditure which releases resources that may be reallocated without reducing the level or quality of services provided;“front-line health services” means services provided directly for the prevention, diagnosis or treatment of illness, or for the care of patients;“NHS England” means the National Health Service Commissioning Board.”Member’s explanatory statement
This new clause would require the Secretary of State to publish an independently reviewed transition plan before commencing the abolition of NHS England.

[Earl Howe (Con)]

My Lords, in moving Amendment 4, I express my appreciation to the noble Lord, Lord Kakkar, for adding his name to it.

I well recognise that Members of the Committee may be taken aback by the monumental size of this amendment, but its size is, to a very real extent, its point. The main raison d’être of the Bill—indeed, its starting point—is the abolition of NHS England and the reorganisation and reallocation of its functions and responsibilities. That is as monumental a process as it is possible to imagine, involving, as it does, just about every branch of the health service, from commissioners to providers to the training of doctors. More than that, the momentous decision to abolish NHS England came largely unheralded. The report from the noble Lord, Lord Darzi, on the state of the NHS, published in 2024, stated in terms that another top-down reorganisation of the NHS was the last thing that it needed. It seemed quite clear that the noble Lord, Lord Darzi, thought there were other ways of tackling the various issues in the NHS that he had identified.

Whether or not the decision to abolish was taken in haste, I am afraid that what has happened since has been a cause for criticism. The abolition was announced without any explanation given to NHS staff about what the Government were seeking to achieve, and without any provision for redundancy funding. Planning for how the new department would look took months to get off the ground. Even now, some 18 months after the decision was announced, there is still a fog of uncertainty around where a number of commissioning responsibilities are going to sit—whether they will be devolved to ICBs or transferred to the department. Some functions, especially regulation, will need to sit centrally but will require independence from ministerial control; others will need to be devolved nearer to the bodies responsible for delivering patient outcomes. There is, as yet, no clarity on the complete picture.

16:15

This matters, not just on a theoretical level but on a very practical one. One example is specialised commissioning. What is the appropriate footprint for commissioning and delivering services for rare or very rare conditions? We still do not know which of the current 170 specialised services will be commissioned centrally and which by ICBs, or what the logical basis for such decisions ought to be. Hand in hand with that, we still do not know whether there will within ICBs be sufficient capacity and expertise to fulfil the statutory duties that they are given to deliver those services. Up to now, the process of delegation to ICBs by NHS England has progressed unevenly across the country. At a time when ICBs are being told to shed large numbers of staff, the risks around this whole area of reform do not need spelling out.

The Government have said that abolishing NHS England will eliminate duplication, reduce bureaucracy and deliver savings. On a theoretical level, that is language that I am sure we all understand. However, what does it mean in practice? We hear that the abolition of NHS England will deliver savings of around £1 billion a year by the end of this Parliament. However, the Explanatory Notes to the Bill estimate that the cost of redundancy exits across NHS England, the department, integrated care boards and commissioning support units will be between £1 billion and £1.3 billion. That is an enormous sum of money to spend on restructuring before we have seen any of the promised savings.

The figures raise some fairly obvious questions. First, what is the full cost of the reorganisation? The Explanatory Notes identify the estimated costs of redundancy exits but say little or nothing about the wider costs of transferring functions, replacing systems, managing contracts, retaining specialist expertise and establishing new governance arrangements. For example, we are in the dark about which policy teams are to be reduced or even removed, and nor do we know whether there will be more or fewer commissioning support units than there are at the moment. Are all these costs included in the Government’s estimates, and can the Minister confirm whether the original estimates of costs and savings remain accurate?

Secondly, when do the Government expect the reorganisation to pay for itself? There is an important distinction between achieving annual savings of £1 billion at some point in the future and having actually recovered the substantial sums spent on delivering those savings. When will the cumulative savings exceed the cumulative costs of the transition, and when will those savings become available for reinvestment in front-line services?

Thirdly, where is the money to pay for all this coming from? Many have expressed the fear that the costs of this reorganisation can be met only at the expense of front-line services and/or planned capital investment and/or improvements in technology—or even to the detriment of the research or education budgets. Is the Minister willing to set out detailed answers to these questions in a letter to be placed in the Library, so that, between now and Report, noble Lords can gain a fuller picture of what is planned?

The health service is an extraordinarily complex and interconnected system. When we remove or relocate one part of that system, we need to be certain that we understand what depends upon it. The transfer of functions from NHS England will involve not only changes to governance and accountability but the movement of staff, contracts, information systems and specialist expertise between organisations. These are substantial undertakings in their own right and they will need to be managed while the NHS continues to deliver services to millions of patients. That process carries risks to the stability of patient services. That is why this amendment would require the Government to set out not only the financial implications of the transition but the principal clinical and operational risks, the measures that will be taken to maintain continuity, and the arrangements for retaining and transferring specialist staff.

Exactly how will the Government ensure that nationally important services, contracts, information systems and specialist functions continue to operate without interruption as responsibilities are transferred away from NHS England? Who will be responsible on a day-to-day level for managing these risks? In the final analysis, the risks involved in all of this are risks to patients. Long-term savings of £1 billion a year are certainly worth having, but the looked-for benefits of this major reform need to be balanced against the degree of risk that the Government are now placing on the lives and the health of patients in the course of achieving those benefits. We are at a moment when waiting times are already high, hospital wards are full and services everywhere are stretched. I can only express the hope on behalf of us all that Ministers and the good and capable officials, who are doubtless doing their utmost to deliver these reforms in one piece, prove more than equal to the huge task that they have been set. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome the amendment from the noble Earl, Lord Howe, because it enables us to go to the core of what this legislation is all about. Light-touch amendment it is not, but I think it goes to the heart of what we need to talk about.

As I said at Second Reading, I really welcome bringing NHS England essentially into the department. It restores ministerial accountability to Parliament and, for a £200 billion service, that is very important. Essentially, it seems to me that we are going back to a 1948 Bevanite model of the NHS. Of course, we do not recall his dictum, but it is very famous—that when a bucket of slops is kicked over by a maid in hospital in Tredegar, its echo should sound in the corridors of Whitehall. Bevan also said at the time, because of course he backed off Morrison, who wanted local government to control the NHS, that he wanted lots of decisions to be made locally through the hospital management committees and regional hospital boards that were set up. Of course, the moment it started, the Ministry of Health, as it then was, started to issue circular after circular. That is perhaps an inevitability of the way you get there, when you have a national health service funded simply through taxation.

There are some genuine issues around the relationship between the centre and the local National Health Service which we need to tease out. We had a round table at which the chief executive of the NHS Alliance spoke about the concern that the alliance has that integrated care boards will find that their room for manoeuvre is very limited. One response to that is that ICBs’ accountability was solely going to be to the centre. The Government’s decision to keep Healthwatch is very important in terms of having more local accountability—that is why it is so welcome. I know that noble Lords are concerned about Ministers taking over responsibility for the appointment of chairs and non-executives, but I think that we should also keep councils of governors of foundation trusts. They are local people, elected by members of those trusts, who do the current round of appointments. We will come to this later on in our debate on Clause 30. I am really looking for the Government to look at this again.

There are some real issues about the future relationship of the centre to the locality. I commend the brief that we have had from the King’s Fund, which poses some key questions. What should the boundary be between legitimate national oversight and routine operational management? What would prevent this broad power becoming a mechanism for day-to-day management from Whitehall? How will you deal with bottlenecks, and the practical risk that moving a large number of functions and decisions towards the Secretary of State could slow the NHS down rather than speed decisions up, particularly around the appointment of chairs and non-executives? Which of the Secretary of State’s most consequential intervention powers will be subject to intervention, advice or scrutiny? In what circumstances would Ministers expect to intervene in local service reconfiguration? What safeguards will ensure decisions that are often best made locally and on clinical grounds? How is the greater role for local government and mayors to operate alongside stronger central powers and require the Secretary of State to have regard to local decision-making? What statutory safeguards will there be in relation to the powers of the Secretary of State to appoint, suspend or remove the chair and other non-executive directors? For the Secretary of State’s most consequential intervention powers, is there a case for putting relevant decision-making criteria on the face of the Bill?

I do not know the answer to that, but I think that, by Report, it would be helpful if my noble friend could explain in a little detail how the Government think the new arrangements are going to work and how you will prevent unnecessary micromanagement from the centre.

[Lord Kakkar (CB)]

My Lords, I have added my name to the amendment in the name of the noble Lord, Lord Kamall, and the noble Earl, Lord Howe. In so doing, I remind noble Lords of my own declared interests, as chairman of King’s Health Partners and the King’s Fund.

I believe this to be a very important amendment and fundamental to the purpose of the Bill. Your Lordships’ House has taken, quite appropriately, the explanation, reassurances and logic behind the abolition of NHS England provided by the Minister at Second Reading. As the report commissioned by His Majesty’s Government identified very clearly, further reorganisation on a major scale of the NHS should have, at all costs, been avoided, as noted by the noble Earl, Lord Howe. There are clearly in the Government’s mind important reasons why this reorganisation must proceed, and it is important for your Lordships to respect that. It is a fundamental element of His Majesty’s Government’s policy.

However, in proceeding down this route, the other side of the coin is that His Majesty’s Government must be clear, and provide reassurance about the implications, both in the period of transition and thereafter, with regard to the important functions that have sat in NHS England and will now be brought back under central Secretary of State control. We have heard a number of those, and it would be interesting if the Minister could explain to your Lordships how the transitional arrangements that are going to be applied will reflect the ultimate structure of the newly defined function for delivering NHS England within the Department of Health and Social Care. For instance, how will the Secretary of State powers be exercised? What degree of delegation is there going to be? How will that be reflected in the transitional arrangements?

In terms of the broader government agenda with regard to devolution to a local level, is it consistent to have brought all these powers centrally and then expect, within a reasonable time period, proper devolved scrutiny and determination of local health needs to be reflected in the delivery of the NHS? What will be the arrangements for the operational management of the NHS in the intervening period between now and the final adoption of all measures? How is that going to work? What is happening at the moment? Is the Minister content that in the many issues on which there is, or has been, granular oversight within NHS England and its regional structures, that that kind of oversight is being, and will be, delivered in these transitional arrangements?

16:30

When there are crises, or when day-to-day delivery of the NHS at a local level starts to falter, there is a need for clarity and an ability to intervene. As we have heard from the noble Earl, Lord Howe, ultimately all these changes will impact patients. If we are not clear about how these arrangements are secure, how they will be governed and how those responsible will be held accountable, then we will be sanctioning potential situations in which patients may well be put at risk of harm. At the very least, when the application of valuable resources may not be applied in the fashion most efficient, patients may wait longer and be denied important interventions. The important progress in improving the delivery of healthcare and clinical outcomes, to which His Majesty’s Government are so strongly committed, will be inadvertently undermined through a programme of transition and reform that has not been properly laid out and described in organisational terms.

Beyond that, as the noble Earl has identified, there is the important question of the financial arrangements. At Second Reading, I noted that in 38 of the 40 years prior to 2020, the NHS failed to deliver services within its pre-agreed budget for the specific financial year in question. It usually overspent by about 1.3%. That was a historic reflection; it may be perfectly reasonable and there may be completely justified explanations. However, we now find ourselves in an economic and fiscal situation where it is going to be impossible for the Government to continue to increase settlements year on year for NHS expenditure.

Therefore, it is very important for us to understand how the costs associated with this reform will be met. Are they being met from current budgets? Are additional funds expected to meet the costs of delivering these reforms and the transitional arrangements before savings accumulate? If there are no additional funds available, will the funds be drawn, as we have heard, from front-line clinical services or from the education and training budget, which is often vulnerable, particularly since a previous reform has taken Health Education England into NHS England and that separation no longer exists? Will it undermine the capacity for the NHS to continue to deliver on its important research and innovation agenda? That may be seen as a part of the budget that might be sacrificed for a short period while arrangements are made to deliver this transformation and reform.

These are all fundamental questions. The answer to all of them may be no and there is no risk to any of this. That would be very reassuring, but it is something we need to understand. None of these questions should be taken as opposition to the abolition of NHS England. As I said earlier, that decision has been taken. The purpose of this Committee and the opportunity afforded by the Bill is to ask the questions that attend an absolute guarantee that the arrangements to be put in place will serve the purpose as defined and that those arrangements—in particular, these transitional arrangements—will serve the opportunity to secure the more fundamental longer-term questions about the powers of the Secretary of State, the opportunity for delegation, where operational responsibility in the NHS will ultimately lie, how this reform resonates with the devolution agenda and what the mechanism will be for the different elements of the newly organised NHS, under direct supervision of the Department of Health and Social Care, to function, be it centrally, regionally or at local level.

[Lord Stevens of Birmingham (CB)]

My Lords, I support the amendment in the names of the noble Earl, Lord Howe, the noble Lord, Lord Kakkar, and other noble Lords, because it draws attention to the fact that we are on the cusp of a huge reorganisation, yet there is a remarkable lack of clarity as to how it is going to be given effect.

First, can the Minister confirm to the Committee that it is still the Government’s intention that NHS England will be abolished on 1 April? There is a groundswell of discussion across the centre of government and the NHS which suggests that that is looking to be an increasingly impractical date. Can she confirm the Government’s concrete intentions on that? If she tells us that it is still going to happen on 1 April, then it ought to be entirely possible for the Government to accede to the amendment put forward by the noble Earl, Lord Howe, because, clearly, one could not, a mere matter of months away, be proceeding without already having the information that the amendment requests.

Dr Penny Dash, the outgoing chair of NHS England, was before the Commons Health and Social Care Committee five months ago, which was also exploring the question before us now. Dr Dash said that

“in a few weeks’ time a paper will be coming to the transformation oversight board, or whatever we call it, giving more detail”

on these questions. When asked whether the 50% reduction was a hard figure, she said:

“In terms of the NHSE and the DHSC … there was this sense that 50% was the right number to aspire to. The detailed work will get us to the point of determining what the numbers could and should look like”.


If 1 April is really the date, can the Minister tell us what those numbers will look like, whether it is 50% and how it is broken down, as requested in this amendment?

We already have signs that pragmatism is asserting itself in the Department of Health and Social Care, with the decisions on HSSIB and now Healthwatch. Will this be a further example of pragmatism or will the new Secretary of State stick to the plan, which is a perhaps a little half-baked, that she inherited? We already have the most centralised and politicised health service in the industrial world. Going down this path takes us yet further in that direction. If that is what we are going to do, it should at least be done well.

[Lord Lansley (Con)]

My Lords, I support my noble friend in his amendment. I do not want to revisit Second Reading issues, but will make one or two important points. First, along with other noble Lords, I say a big thank you to the Minister for some of the correspondence we have received and the way in which she and the Government have already been listening to the discussions in this House. I hope that we can continue to have a constructive discussion.

I do not entirely share the view of the noble Lord, Lord Kakkar, that the abolition of NHS England is a done deal and we should therefore accept it. It was not a manifesto commitment. Parliament has had no say in this matter. It is all the more important that, as we implement the Government’s intentions into law, we understand what we are doing and how. That is particularly true in so far as there is some speculation whether all these responsibilities will be incorporated into the department—the noble Lord, Lord Hunt of Kings Heath, sees it all as becoming engaged in the department and therefore accessible to Ministers. If many of these responsibilities are to be held in special health authorities outside the department, it is hard for some of us to understand what has been gained in accountability relative to the current situation between the department and NHS England. Of course, Ministers had powers under the previous legislation to exercise accountability over NHS England, not least through the process of a mandate, but often failed effectively to use them—sometimes the use of powers by Ministers is more important than other things.

The key point here is the transition. The Government have put into the legislation that there will be transition schemes, but we need to see what they look like and how the timing works. I recall that the gap between the passing of the 2012 Act and its implementation was almost exactly a year. That further strengthens the force of the questions that the noble Lord, Lord Stevens of Birmingham, just asked. We need to see what that timetable looks like.

From a curiosity point of view, I would be interested to know how these savings will be generated. Noble Lords often say that a great deal of money was spent on the 2012 reforms. The Written Ministerial Statement published on 21 July 2015, at the end of the 2010 to 2015 Parliament, told us what the outcome was: the cost totalled £1.38 billion, a little more than my noble friend Lord Howe said the Government anticipate that the overall cost of this reorganisation will look like, but not much more. By the end of the Parliament, the savings were £6.9 billion in cash. Not least in some of the debates, people tend to remember the cost but not the savings. It would be extremely useful for us to know in advance what is intended to be achieved, because that reorganisation, according to the data published in 2015, arrived in the final financial year of that Parliament at a £2 billion a year reduction in cost. The Government are not even attempting to achieve something as ambitious as that. Let us see what it looks like.

I make one suggestion, to which I hope the Minister will respond. It is not unknown for the National Audit Office to engage in a process of scrutiny not after the event but during the event. This is especially true for major projects. This is a major project, and over the course of the next year it would be good if the department volunteered itself to the National Audit Office for such a process of real-terms scrutiny of the value-for-money effectiveness of this reorganisation.

[Baroness Thornton (Lab)]

My Lords, I thought it would be appropriate for those of us who have been involved in this for the last 15 years or so to join in the debate a little. The noble Lord, Lord Lansley, is quite right: this is about transition. It is about a transition that affects two groups of people: patients and people who work in the NHS.

I am a veteran of the transitions that we have had so far, because I was abolished in 2020. I became a member of my local CCG, which I very much enjoyed serving on, having worked on the 2012 legislation that created it. I then took refuge as a non-executive director in my local hospital. I helped to create our local ICB, which is now being abolished with a super-ICB being created. I feel as if I have been at the governance coalface of the reorganisations for the last 15 years. This is an important debate, and I am in favour of the abolition of NHS England.

I intend to involve myself in Committee mostly with equality, social care, patient records and so on, but I have a question for my noble friend the Minister about the arrangements for the people who will move from NHS England into the department and where they stand right now. Those people are very precious to us, and many of them are very experienced. I would like to know how the TUPE arrangements are progressing, what the dates are for those arrangements and when we are likely to see some documentation about how that will actually happen.

[Baroness Nargund (Lab)]

My Lords, I understand and support the general thrust of this amendment. I have worked in the NHS for nearly 40 years and have worked very closely with NHS England. Having experienced all the transitions that have happened with local health boards, PCTs, CCGs and ICBs, and having worked with CCGs and ICBs across England as a provider and doctor and with NHS England, as I said at Second Reading, I wholeheartedly support the abolition of NHS England. It will cut the bureaucracy and the unnecessary layer. I support the Secretary of State taking back the power to give it away to ICBs where patients are treated. It also fits in with the neighbourhood health plan, because they are best placed to develop and deliver that.

16:45

I thank my noble friend the Minister for organising the round table on Monday. We got some clarity in discussions about ICBs. I was reassured to hear about seven offices being created, representing every region across England, taking control of resources, including for innovation, prevention and population health improvement. I was pleased to hear how these seven offices will function. Having worked with large merged ICBs such as those in the east of England for more than 12 years, I know how well they can function, how they can get more clarity and consistency with protocols and be less of a postcode lottery, as well as having large purchasing power to reduce costs and to deliver more to patients. I welcome all that clarity that was given to us in the round table on Monday on how ICBs jointly will deliver collaboratively for local regions.

However, this is about the transition period. I understand the anxieties and support some of the concerns that noble Lords have raised. We need clarity and a timeline regarding that. I support the abolition and the resources and power being given to ICBs. I have trust in these joint ICB functions to deliver what is needed locally and to work with local authorities and local stakeholders. The plan fits in with the 10-year neighbourhood health plan, reducing local inequalities and addressing wider determinants of health.

Can my noble friend the Minister tell us how the national standards of care, as well as costing and implementation of national tariffs, will be managed during this period? How will they be set, and by what date? How will they be monitored to ensure that the postcode lottery is not widened? How will we make sure that responsibility and accountability are not lost during this period and that the care does not slip for any patient, while expecting it to improve in the long term? Who will oversee these transitions? Who will be accountable for running them smoothly?

I do not believe this needs to be set out in legislation, but it is necessary to get this clarity as well as the timeline. Regarding the population health improvement plans, how will resources be allocated to ensure that inequalities are addressed and that there will be a joint system with local authorities as well as local stakeholders?

[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.

[Baroness Harding of Winscombe (Con)]

My Lords, it is a privilege to follow the noble Lord, Lord Mawson, and the noble Baroness, Lady Gerada, who between them have many decades more experience than I do of NHS and health and care reorganisation. I have only one major experience from the inside: the last time we were debating the restructuring of the NHS in 2021-22. At the time, as someone from the private sector, I was somewhat surprised to discover that the NHS got on with the reorganisation before the legislation was passed. It is even odder this time: the NHS has started before the legislation but without a plan itself.

Therefore, I welcome this amendment from my noble friend Lord Howe. It is essential that we understand the plan and the timetable, what it will cost and what benefits it will bring. It really is very straightforward. If that does not exist, the idea that it can be complete by 1 April next year is completely gobsmacking. Maybe I am just an innocent businesswoman who does not understand the ways of the NHS, but it just does not seem right. I think this amendment is basic common sense.

Much as I hear the words of wisdom from Don Berwick, I support merging NHS England with the Department of Health. I saw from the inside, particularly during Covid, how important it is to have clear political accountability. I support the basic premise, but I am very worried that the tendency will be to centralise rather than to push resource out to the regions and local communities. As the noble Lord, Lord Mawson, just said, it is at the local ground level that change really happens.

I am very supportive of seeing fewer people employed in organisations that bear the NHS brand but do not actually treat patients. There are tens of thousands of people who are all trying hard and doing valuable work, but they are a long way away from patients. As we bring NHS England into the department, I would love to see, as part of this amendment, a clear breakdown of the cost savings at the national, regional and local level, so that we have sight of whether we are really pushing accountability, and resource and capability, down to where change will bring the benefits that we all seek.

[Baroness Rafferty (Lab)]

My Lords, I will be brief. I support the point made by my noble friend Lord Hunt that the Minister should reconsider the abolition of governors. I have to declare an interest as a former governor of King’s College Hospital NHS Foundation Trust. I spoke at Second Reading about the value of governors and the extraordinary breadth and depth of feedback and accountability that they provide to trusts. We just ask the Minister to reconsider that decision, for I fear that, if governors are abolished, we will have to find some mechanism to reinvent them.

17:00

[Lord Crisp (CB)]

My Lords, I have been resisting the temptation to get involved in this debate, partly because I was not able to join the Second Reading debate, and I apologise for speaking now, having not done that. I start by making just one point, which is that at the beginning of this century, I was running both the NHS and the Department of Health. I had the two jobs, so I have seen some of what we are talking about from inside. I think some of it was extremely successful. On the point about regional offices, there are some models that I am quite sure can be followed.

The reason I stood up is that the noble Lord, Lord Mawson, spoke about prevention. What I realised when I was running the Department of Health is that, with a hospital management background, I had turned it into the department of the NHS, and we had lost some of our health focus. The future is about health, not just about healthcare. We have to focus not just on prevention but on creating health and the conditions to be healthy. I am not going to get into a Second Reading speech, but I want to ask how the Government are going to preserve the proper role of the Department of Health when it gets all this responsibility for the NHS.

The NHS, on which I speak as a former chief executive, runs 24 hours. You get contacted all the time. How will the important responsibility of leadership for health across government be managed? As the noble Lord, Lord Mawson, said, 80% is about housing, employment and the environment. The health system provides the other 20%, and I have to say it is a vital 20%—if you have a nasty cancer or your leg has just fallen off or something, you need that. My question to the Minister is, how are the Government going to preserve the proper responsibility of the Department of Health for all the health functions, as opposed to the NHS functions?

[Baroness Campbell of Surbiton (CB)]

My Lords, I had not intended to speak in this debate, but I have been listening very closely, and I think what is missing is what happens to people at the grass roots—patients who rely on their ICBs to behave and do the right thing in terms of their care and support. When I heard that NHS England was going to shut down, I have to say that my heart went in my boots. That is because I have been working with certain departments to look at ways that we can deliver NHS personal health budgets, from when they were first conceived to now. There was an awful lot of organisational expertise, memory, support and guidance from what was then NHS England to local ICBs across the country. In doing so, personal health budgets became a good way of delivering personalised care at home for people with complex impairments. I should probably declare an interest because I have been negotiating with my ICB for about 15 years. It is not easy. What I worry about in the transition is that we do not have a plan for what is going to happen to the people in NHS England who have all that expertise, history and know-how in supporting ICBs to deliver their support to complex patients in the community in the future.

I am afraid I am not that positive, because in the last two years, since we heard that ICBs were going to make 50% savings, ICBs have been behaving quite oddly towards people with complex and sometimes expensive care in the community. They are institutionalising them even though they were supported in their own homes quite happily; for example, doing their degrees. They are restricting where you can go with your personal health budget and PA and even whether you can be outside the home, because they have told me that it is unsafe. Something odd has been in the air since we knew that NHS England was going. I believe that there were only four people left in the department supporting those ICBs with their delivery and, quite frankly, they are going backwards. I would be keen to have a plan about what is going to happen when NHS England goes. Who is going to do this work? ICBs need ongoing guidance in this area. They do not have the expertise locally, but someone has to do it.

[Baroness Morgan of Drefelin (Lab)]

My Lords, I want to pick up some of the key points in the amendment regarding what the transition plan should look like and focus on.

I am thinking about the experience of cancer patients post the 2012 changes and what came along with them, which was the abolition of the comprehensive cancer networks that were set up around England to deliver the then cancer plan. There was a vacuum following that change, and it took years to establish the architecture that we now have in place for delivery of the current cancer plan. Given the news that NHS England is being abolished, I am really concerned that the momentum around the delivery of the current cancer plan is being impaired, so the points in Amendment 4 about setting out how the continuity of services during the transition will be maintained are important. My worries are about the cancer plan, how we will drive forward the service improvements set out in it and how all 100 recommendations will be progressed, because that is not the responsibility of any one ICB; it is currently driven forward by NHS England. How are the staff associated with that going to be transferred into the NHS? How do we make sure that there will not be a vacuum? We already had a disappointing delay in the appointment of the chair of the National Cancer Board that has been established.

We really need to make sure that this momentum continues. There is massive consensus around the cancer plan, which we should celebrate. There are 200 different types of cancer, more than 200 different types of cancer charity and many different specialities. One in two of us will get cancer at some stage in our lives. It is a massively important area for the health service, and we need to be confident that the transition will not fall between all the gaps, as it did in 2012, and then take years to re-establish the architecture that we need to deliver the ecosystem of success that we have in UK cancer services.

[Baroness Watkins of Tavistock (CB)]

My Lords, I thank the Minister for the meeting that she has arranged and for the progress we have made, and I hope that we will continue to do that as we debate this issue. However, I too am concerned about the costs and benefits in the timetable that is currently set out.

There are two questions that I want to ask. First, has the strategy—which I firmly believe in; we should move away from NHS England—been looked at against the NHS charter? I ask this because Principle 6 says:

“The NHS is committed to providing best value for taxpayers’ money. It is committed to providing the most effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves”.


How much this is costing and when it will be paid back are fundamental in terms of the charter.

The charter also talks about staff rights, and although I am not working in the health service, I have many friends and colleagues who are. This feeling of uncertainty has been going on for 18 months, and I can say as a mental health nurse that one of the worst things for mental health promotion is uncertainty. This amendment really is important in trying to move us forward on the real timetable. Can the noble Baroness say whether there is, as some rumours are implying, a kind of back-pedalling? Now that we have asked the noble Baroness, Lady Casey, to move forward faster, are we trying to get to a point where we have some of the care service strategy in our mind? What could be worse than making a lot of very capable people redundant, and then needing to re-employ them? The costs to society and the taxpayer would be enormous. I just wanted to make those points, and I welcome what the Minister has to say.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I agree that it is absolutely necessary to have clarity on the transition to the new system, and I add my voice to those noble Lords who have talked about the need for clarity for the staff. Successful reform, which we must have, both for patients and all staff, absolutely depends on retaining the expertise, experience and commitment of the staff. If we expect that commitment, we have to give them some security and knowledge of what will happen to their careers and their families—of whether they are going to be made redundant.

This is of course about the systems and cost, but it is also about the networks—the cancer network mentioned by my noble friend Lady Morgan. It is about the consultants, the doctors and nurses, and the people who keep the hospitals going: the cooks and cleaners, many of whom have been contracted out. Those contracts are bound to change as well. The clarity we are all asking my noble friend the Minister for is critical if we are going to ensure the success of this new enterprise.

[Lord Sentamu (CB)]

My Lords, first, I declare an interest in respect of my work with NHS England. I was appointed chair of the sickle cell and thalassaemia organisation, which was not easy work. We did not know whether the people who were coming to make their representations were from a particular trust or had the authority of the then chief executive of NHS England. It was not an easy job.

17:15

Some people were telling us that they did not have the money, and they did not think we would actually achieve screening for sickle cell. We persisted; we worked hard, and we consulted. Eventually, that was achieved after 12 years of work. I want to thank those doctors, nurses and workers who have been dealing with very, very sick people, because sickle cell disease is a tough one. The steering group handed over the work once the screening was accepted, and the joy I then had was that my daughter had a baby. During her pregnancy, she was tested for whether she was a sickle-cell carrier, and they found out that she was. Would the baby also end up with this? But the day our grand-daughter Abigail was born, there was a simple test, and it came back saying no, she was not a carrier. Years ago, that was not a possibility; so there are many things that the NHS has done.

I took part in the debate on the Bill that created NHS England, and there was exactly the same sort of regurgitation of fears, worries and concerns—“We need to do this”. Yes, there are some good things in Amendment 4, but the best thing to do is not to vote for it. Instead, before Report, the Minister and the people with great expertise in this area should have a conversation to sort things out, rather than leaving questions hanging, even though a particular amendment has been passed. That would be very helpful.

During Covid, I sometimes felt that we did not do a good job when we set up NHS England. The noble Lord, Lord Stevens, spoke with great clarity as the chief executive of NHS England. However, the chief executive of one particular trust seemed almost not to be on the side of those who were anxious about the situation, so that system needs to change. We do not need different executives representing the various bodies; there needs to be coherence. When the noble Lord, Lord Stevens, spoke, you knew that he was speaking for everybody, not a particular trust or chief executive. That leads to absolute chaos. I think that that is what the Government want to abolish. I wish they did not use the word “abolish”, because that always creates a lot of fear. I hope they were actually talking about the transformation of this thing called NHS England.

During our dealings with the NHS, we have had four very serious operations. Those operations were well done—it did not matter what hospital it was. But the number of people in the NHS who are not clinicians, support staff or health workers has grown. There are a huge number of managers, and somebody needs to look at this. There are good things in the amendment of the noble Earl, Lord Howe, but it does not answer the question that we all would like answered.

As we move towards transformation, what are the building blocks that must be put in place? To me, that is the question. People say that if a big thing needed to be done in China, it would say, “We are going to build this hospital here”. China does not suffer from this over-consultation, which often does not deliver the reality. I live in a democracy; I would not want to live in China at all. I live in this country, but this country does not grasp the real problem that needs to be dealt with. Therefore, I hope that the signatories to the amendment will find the time—some noble Lords are very good at this—to work out what the building blocks will be for a good transition.

We have fantastic staff in these lovely hospitals where we have been treated, but they are given a management that I do not think often works. This is the opportunity we have to grasp. We have to deal with it and not be the sort of people who are always very difficult and behave like turkeys that do not want Christmas to come.

[Lord Scriven (LD)]

My Lords, I thank noble Lords who have spoken in this rather revealing debate. I particularly thank the noble Earl, Lord Howe, for introducing this amendment in his normal calm and measured way. Importantly, he has given us all the chance to ask the most basic question of the Bill: where is the plan? It is pleasing that the Minister and the Government have been in listening mode, particularly regarding the Health Services Safety Investigations Body and Healthwatch. I hope that during Committee the Government will continue to listen and make other important changes to the Bill.

At Second Reading, I said the Bill was a power grab. The Nuffield Trust’s October briefing for this Committee puts it more politely. It describes new powers for the Secretary of State as being well beyond those that NHS England holds, which it says enables “more political control” and limits real devolution. The Government are entitled to decide whether they want NHS England’s functions in the department, under political hands. We on these Benches would caution on that, but the Nuffield Trust accepts that some duplication between the department and NHS England is real; the Minister must specify exactly what that duplication is. But if that is the aim, it has to be planned and costed.

I would also caution the noble Lord, Lord Hunt of Kings Heath, and the noble Baroness, Lady Harding, for suggesting that putting NHS England’s functions in the department will bring accountability to the Secretary of State. When we get to Clause 11, we may see that the accountability is missing but the powers are about to be transferred.

Noble Lords will know the architect’s maxim that form follows function, but not here—

[Lord Hunt of Kings Heath (Lab)]

Is the point not that at the moment, parliamentarians can raise issues with Ministers only to be told that something is the responsibility of NHS England? I accept what the noble Lord says about how this is going to work but, ultimately, now the finger is absolutely pointed at Ministers for everything that happens.

[Lord Scriven (LD)]

When we get to Clause 11, the noble Lord, Lord Hunt, will see that some of the powers that the Secretary of State now takes, beyond NHS England, will not come before this Parliament. They will just be at the signature of the Secretary of State’s pen.

In this Bill, form comes first and function will follow in due course. We have the demolition notice but are still to see the drawings of the new structure. Let me say how far behind the Government are. The Nuffield Trust, working with the Institute for Government, compared past public sector reforms and NHS abolitions. It found that the key factors for success are not in place here. The abolition was announced without plans to explain its goals to staff and without redundancy funding, which led to months of delay. Detailed planning for the new department began only in early 2026, almost a year after the announcement. Nuffield’s verdict is that the process has been “poorly handled”.

We are still short of very basic information. At Second Reading and in this Committee, the noble Lord, Lord Stevens, who I admit must know something about running the NHS, pointed out that the costs and benefits in the impact assessment are still marked as “not available”. There are also still a number of questions about the timing of when this reform will come in. We have the Government’s estimates that redundancy exits—across the department and NHS England, ICBs and the commissioning support units—will cost between £1 billion and £1.3 billion, to be met from existing allocations, but we must ask which allocations. Which services pay?

Then there is the timetable. On 15 October the Health Service Journal reported that abolition will have to be formally delayed beyond April 2027 unless decisions on future national structures are made within days. Have those decisions been made? Are staff now aware of where they will be transferred? The new operating model has been waiting for ministerial sign-off for months. Ministers are still weighing whether thousands of staff will go to the department or potentially, as we read, into a new stand-alone agency. This Bill sends nearly every function of NHS England to the Secretary of State, yet the Government have not decided where the people who will perform those functions will sit. The department says that it continues to plan for 1 April 2027, but planning a date is not the same as being able to meet it.

The planned 50% job cuts in the department appear to require moving the large majority of central policy and analytical staff. Or is it about cutting operational staff? As the noble Lord, Lord Crisp, said, we need clarity about which staff and which functions will be in the department. It is not clear that the figure is rested on rigorous assessment of who is needed and why. History tells us how this ends: after previous reforms that moved managers from commissioning bodies, the department consultancy spend peaked at over £600 million a year and the number of managers within five years was higher than going into the reorganisation. I fear that this will be another case of “cut first, rehire later and call it efficiency”.

As the noble Earl, Lord Howe, has said, we need not simply rely on the words of noble Lords in this debate. The Darzi review, commissioned by the Government and updated in May, concluded that a top-down reorganisation of NHS England and ICBs is “neither necessary nor desirable” and added:

“Constant reorganisations are costly and distracting”.


We have had six statutory major reorganisations in 30 years, none with clear evidence that the restructure has brought about improvement. The Government commissioned that review; they should read it and learn from it.

I have six questions for the Minister. When will the target operating model be published, and will that be before Report? Is the latest thinking to put transferred NHS England functions and staff into the department, or will the Government set up a stand-alone body? Will the Government publish a full, costed impact assessment, including benefits, and explain where the £1 billion to £1.3 billion comes from? What are the expected costs of disruption, and how will any further delay be limited? Are the Government confident that the 50% cut will not drive up consultancy spending by the end of this Parliament? If the Government do not accept the amendment from the noble Earl, Lord Howe, will they commit to laying a transition plan before Parliament and before Report? In substance, that is what this amendment is asking for.

We on these Benches are not defenders of the status quo. I started in the NHS in the early 1990s and lived through more reorganisations than I care to count. Every one promised less bureaucracy and a freeing up of the front line; none delivered it. If the Government want to put NHS operational matters into political hands, that is their choice, but they owe this House a plan and then a price and then a Bill, in that order. At present we have a Bill and we are still waiting for the other two. I look forward to the Minister’s reply.

[Baroness Merron (Lab)]

My Lords, I am most grateful to the noble Earl, Lord Howe, for moving this amendment, and to the noble Lord, Lord Kamall, for tabling it. As other noble Lords have observed, it is comprehensive and thorough. It makes the point, which a number of noble Lords have made, about the importance of ensuring that the right processes and assessments are undertaken as we move towards the abolition of NHS England—one of the key things in the Bill. As we are at the beginning of our deliberations, I say to noble Lords that I listen, and have listened, very carefully to the points that are made. I will endeavour to answer a number of points, but I will take some away and write to noble Lords. As ever—and as noble Lords will recall from previous Bills—those letters will be available to all Peers, because I want to do justice to those points.

17:30

First, I will address the amendment, which is the key point here. We agree on the importance of robust financial oversight throughout this transition—as noble Lords are rightly calling for—including understanding cost savings and overall value for money. My reflection is that this transition—the noble and right reverend Lord, Lord Sentamu, asked for the use of the word “transition”—is being carefully managed through existing financial planning and assurance arrangements, including consideration of transition expenditure and the savings that are expected from reducing duplication by bringing together NHS England and the department. Our priority, and that of noble Lords, is to ensure that resources are used effectively and, wherever possible, directed towards front-line services and improvement for patients, because that is at the core of this.

While I absolutely agree with the principle of transparency, this very detailed amendment would place in legislation additional requirements for an independently reviewed financial plan. It is at this point that I part company with the amendment. That provision would add an unnecessary process and constrain the Government’s ability to manage the transition flexibly and efficiently. I take the point behind the amendment, and I certainly take the points that noble Lords have raised, but I do not feel that placing these requirements in legislation will get us to where we need to be.

The noble Earl, Lord Howe, the noble Lords, Lord Lansley and Lord Scriven, and the noble Baronesses, Lady Manzoor, Lady Harding and Lady Watkins, raised costs and savings, and other noble Lords also referred to them. The noble Earl, Lord Howe, asked me to write with information; in view of the range of things that were raised, that would be very helpful. I can make some general points: we remain on track to deliver over £1 billion of savings per annum by the end of this Parliament. The whole point of a transition is that it is a process, so I want to make the point that the total saving will be determined by a number of things—including, for example, the number and seniority of staff who leave through exit schemes that are currently under way. I know that noble Lords understand that this transition is a moving process. That does not mean it is wrong to ask for information, but we must take account of the fact that this is something in development and movement.

The noble Lord, Lord Lansley, referred to the National Audit Office and extended a suggestion about volunteering. I understand why the noble Lord said that, but I observe that the National Audit Office is independent, rightly, and it is for it to determine its programme of work.

On the 50% reduction being a final figure, I say to the noble Lord, Lord Stevens—linking with comments I have just made—that, yes, our aim is to reduce staff numbers significantly across the department and NHS England. But, as I said, it cannot be a final figure because we have not gone through the process of identification, et cetera. I heard what the noble Lord read out, and in some ways that is true: it is an ambition and one has to set that. But I do not think anybody would be able to give the final figure with absolute precision. But we are working closely with trade unions and staff across the two organisations and will continue to consult them.

My noble friend Lord Hunt and other noble Lords raised questions about the role of the Secretary of State. As my noble friend indicated, we will return to that in rather more detail—I look forward to doing so—when we look at the power of direction in Clause 11.

On the points raised by the noble Lord, Lord Kakkar, on operational management, transferring NHS England’s functions will not require changes to established clinical audit programmes, NICE-supported diabetes technologies or specialist diabetes services. Those programmes operate through existing statutory and operational arrangements.

The noble Lord, Lord Stevens, asked whether it is still our intention to abolish NHS England by 1 April. Yes, that is our intention, and we recognise that that is a demanding timetable. Of course, as your Lordships will be very aware, it is subject to the parliamentary passage of this Bill.

I am glad that a number of noble Lords raised staffing, including the noble Lord, Lord Stevens, the noble Baronesses, Lady Watkins, Lady Manzoor and Lady Campbell, and my noble friends Lady Royall and Lady Thornton. Change within any organisation is an anxious time for all those who are potentially affected. The changes being proposed here are absolutely no reflection on the quality of the work carried out day in, day out by talented staff, and I am grateful to them. This is about getting the system working for patients and for the public, so we will ensure that people are treated properly and we will continue to communicate information about reforms to staff through the various internal channels, as we have done. I just mentioned our work on consulting recognised trade unions, and we are very grateful for their partnership because it is critical to how we approach this change—I say that as a former trade union official used to this level and kind of reorganisation.

There were questions about retaining the talent of staff, which is key. We have taken a number of measures to retain and to develop talent, including initiating a joint interim recruitment process between NHS England and the DHSC. It includes a focus on temporary lateral moves and internal promotion to retain skills. We are, through organisational development and design work, identifying the key skills and capabilities that we will need in the future. I anticipate that this will support a drive for a more expert department, because we will be focusing very much on the skills we need and on functions to ensure that we can develop and retain expertise.

The noble Baroness, Lady Campbell, used the example of personal health budgets. I am certainly aware, not least because of the campaigning work and experience of the noble Baroness herself in this area, that personalised care has a liberating effect on individuals. I very much look forward to specifically debating those issues when we come to Amendment 178, from the noble Lord, Lord Lansley.

My noble friend Lady Thornton asked about the TUPE regulations and arrangements. Like many noble Lords, I have received a considerable amount of correspondence on this matter. I want to put on record, and I am glad for the opportunity to do so, that the Bill does not remove TUPE protections from anyone. The circumstances where TUPE applies are, of course, set out in the existing Transfer of Undertakings (Protection of Employment) Regulations 2006.

My noble friends Lady Rafferty and Lord Hunt referred to the abolition of governors. I look forward to discussing that issue later in the Bill’s passage, at Clause 30.

In response to the noble Lord, Lord Scriven, I am aware that I am making a general response, and I will look closely at the specific questions that he has asked. I can say that the kind of duplication that we are speaking about includes HR, IT and communications. I have my own experience of this issue, as I am sure other noble Lords who have occupied my position before me will have. Actually, my noble friend Lord Hunt put it well, when talking about the tension—I will call it that —between what Ministers are expected to have control of but have no control of. That creates not just difficulty of duplication but immense frustration, which I also experience from noble Lords in this Chamber—and I understand that.

In those functions that I have just referred to as examples, many of them sat in the department prior to the establishment of NHS England. I do not think this is just a recreation of the pre-2013 system. A number of noble Lords made the point, which I completely understand, about their despair at reorganisations.

The noble Lord, Lord Lansley, also made the point that it was not in this Government’s manifesto. That is true. I recall that, when we came into government, on this very issue we did not want to, as the then Secretary of State made quite clear, enter into reorganisation. But the harsh reality was, as we worked through it and got into our stride, that we realised that it was unsustainable. When faced with what is unsustainable, we can either put effort, resource and energy—otherwise known as blood, sweat and tears—into trying to make something work that we know cannot work or can we bite the bullet. That is what we are doing here.

We are recasting the role of the centre, with respect to the rest of the system. We are making it smaller and changing the way it works, so that the centre does only what it must do, or can do, most efficiently, and so we can better serve patients through local decision-making. Again, we will return to that point, and the relationship between the two, later in the Bill.

17:45

I am most grateful to noble Lords who have engaged with me, through round tables and directly, and who have received the correspondence that I sent. I will be glad to continue to do that as we go through Committee and beyond. I reassure noble Lords that we remain committed to parliamentary scrutiny throughout the transition, and we will continue to publish updates as we move forward.

[Lord Scriven (LD)]

I asked one specific question, which the Minister may not be able to answer at this moment, but perhaps she could put it in writing. As the Minister has just pointed out to the noble Lord, Lord Stevens, is it the Government’s intention to transfer all the staff into the department or is a stand-alone body being looked at as a potential route for those staff?

[Baroness Merron (Lab)]

The intention is the former, but I will gladly write further to the noble Lord on this point.

[Earl Howe (Con)]

My Lords, I am grateful to the Minister for her wide-ranging response, and to all noble Lords who have contributed to this important debate, which has been very useful.

The Committee has spoken with one voice in underlining the scale and complexity of the task which lies ahead and the importance of ensuring that the abolition of NHS England, or its transformation, as the noble and right reverend Lord, Lord Sentamu, put it, is managed carefully, transparently and with proper accountability.

As I said at the outset, we are not opposed to efforts to reduce bureaucracy or to improve efficiency in the health service. However, we have to be confident that the Government have a clear understanding of the costs involved, the savings which can realistically be achieved and the risks associated with a reorganisation on this scale. Above all, we must not lose sight of the people whom these reforms are intended to serve. The ultimate measure of success must be whether patients receive better, safer and more timely care, rather than simply whether we have succeeded in changing the administrative structure of the NHS.

Despite what she said, I hope the Minister recognises that my amendment was put together as a giant probe of the Government’s transition plans, rather than as a model form of words to be written into the Bill. I therefore welcome her assurance that she will reflect carefully on the concerns that have been raised today, particularly around the need for a clear and independently assessed transition plan. We will consider the Minister’s response ahead of Report. However, for now, I beg leave to withdraw my amendment.

Amendment 4 withdrawn.

Amendment 5

Moved by

[Earl Howe]

5: After Clause 3, insert the following new Clause—
“Supply Chain Coordination Limited(1) Before making a transfer scheme under section 2 which relates to shares held by NHS England in Supply Chain Coordination Limited, the Secretary of State must publish and lay before Parliament a report on the proposed future ownership and governance of that company.(2) The report must set out—(a) the person to whom the shares are to be transferred;(b) the reasons for selecting that person;(c) the date on which the transfer is intended to take effect;(d) the person who will exercise the shareholder function during the transfer period;(e) the person who will exercise the shareholder function following completion of the transfer;(f) the arrangements by which the exercise of the shareholder function will be overseen and held to account;(g) any proposed change to the company’s articles of association, governance arrangements, objectives or operating model;(h) the arrangements for ensuring continuity in the procurement, storage, distribution and supply of medicines, medical devices, equipment and other goods required by the health service;(i) an assessment of the principal risks to procurement and supply resilience arising from the transfer;(j) arrangements for managing shortages, disruption or failure of supply;(k) the arrangements for retaining staff with expertise necessary for the continued operation of the company;(l) the contingency arrangements which will apply if the transfer cannot be completed or gives rise to a material risk of disruption;(m) a summary of any independent assurance obtained concerning the proposed transfer and the continuity and resilience of the services provided by the company. (3) The Secretary of State must consult such persons as the Secretary of State considers appropriate before preparing the report.”Member's explanatory statement
This new clause would require the Secretary of State to report to Parliament on the proposed ownership and governance of Supply Chain Coordination Limited before transferring the shares held in that company by NHS England.

[Earl Howe (Con)]

My Lords, Amendment 5 stands in my name and that of my noble friend Lord Kamall. I am grateful to the noble Lord, Lord Hunt of Kings Heath, for his Amendment 211 in this group.

Amendment 5 concerns the future ownership and governance of Supply Chain Co-ordination Limited following the abolition of NHS England. It is a rather more specific amendment than the one we have just debated, but it raises an important question about the wider process of transition, in particular how the Government intend to ensure that essential services and functions continue to operate effectively as NHS England is abolished.

As I emphasised earlier, NHS England sits at the centre of an extraordinarily complex and interconnected healthcare system, with responsibilities, contracts, assets and operational relationships extending throughout the NHS. When we interfere with one part of that system, we need to be certain that we understand what depends upon it. This is particularly important in relation to procurement and supply chains.

NHS England currently holds the shares in Supply Chain Coordination Limited, which plays a central role in the NHS Supply Chain arrangements through which hospitals and other healthcare providers obtain essential equipment, medical devices and supplies. These are functions which may not attract a great deal of public attention, but they are absolutely fundamental to the day-to-day operation of the health service. Hospitals depend on reliable access to medical equipment, consumables and other essential supplies in order to deliver treatment. When those supplies are disrupted, the consequences can obviously be very serious indeed. Procedures can be delayed, costs can increase and clinical staff can find themselves unable to provide the care that their patients need. It is therefore essential that, as the Government undertake this reorganisation, we do not inadvertently destabilise or create disruption in areas of the health service which are currently operating effectively.

That is the concern which this amendment seeks to address. As NHS England is abolished, its shareholding in Supply Chain Coordination Limited will need to be transferred. Our amendment does not seek to prevent that transfer, nor does it prescribe what the future ownership arrangements should look like. Instead, it asks the Government to set out clearly how that transfer will be managed, who will be responsible for the company afterwards and what measures will be taken to ensure that its operations continue without interruption.

There are some fairly straightforward questions here. First, who will assume ownership of the company and who will exercise the shareholder responsibilities, both during and after the transition? It surely cannot be intended that day-to-day control of the organisation will fall to the Secretary of State. But if not, then to whom and under what organisational structure? Secondly, pursuant to that, what governance and accountability arrangements will be put in place? Will there be any changes to the company’s operating model, and, if so, what assessment has been made of their potential consequences? Thirdly, and perhaps most importantly, what assurances can the Government give that the transfer will not disrupt the procurement, storage or distribution of essential supplies across the health service? I would be particularly interested to hear what assessment has been made of the risks involved in transferring these responsibilities and what contingency arrangements will be available if the process proves more complicated than anticipated.

Procurement and supply chain management depend on experienced people, established relationships and systems which have been developed over many years. We know that NHS reorganisation will involve staff cuts. To what extent will this organisation be subject to cuts in staff, and at what levels? What steps are being taken to ensure that the relevant expertise is retained and has any independent assurance been obtained about the resilience of these arrangements during the transition?

More broadly, I regard this amendment as representing a microcosm of the larger questions that surround the abolition of NHS England. The success of this reorganisation will depend not only on whether the Government can transfer functions and responsibilities on paper but on whether the systems that patients and clinicians rely upon continue to work in practice. I hope the Minister will be able to provide some reassurance on these points. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much agree with the noble Earl, Lord Howe, that procurement is important in itself, but that it is an illustration, in a sense, of how the new arrangements might play out. Where I disagree with him is that he was really implying NHS Supply Chain is doing a good job, and we do not want to disrupt it. Actually, there are a lot of concerns about the current performance of the supply chain, which I would like to come to, because this is an opportunity to improve what it does, and, in particular, to try and get the relationship between NHS Supply Chain and local NHS bodies on a much better footing.

My Amendment 211 is grouped with Amendment 5 and has the support of the noble Lord, Lord Markham, the former Health Minister, who has been a great advocate of value-based purchasing. I declare an interest as patron of the Health Care Supply Association, the organisation for professionals in health service procurement, who contribute so much to a very important function.

Procurement is there to ensure value for money for the health service, but it can do much more. We know since Covid of the essential need for supply chain resilience. Effective procurement can provide this, ensure investment in innovation and support UK industry. I believe it can link closely with the Government’s ambitions on matters of sovereignty, regional development and growth. NHS Supply Chain has a clear role in this, and it is absolutely right to scrutinise what the arrangements are going to be when the shares transfer from NHS England to the Department of Health.

In particular, I want to raise the shortcomings of NHS Supply Chain. The 2024 Public Accounts Committee report found that NHS England had been weak in its oversight and support of NHS Supply Chain. The PAC reported that neither NHS England nor the department had validated the savings the company reported, and that trusts’ satisfaction with the service was already “in steady decline”. Nor was the committee’s criticism confined to NHS England. It found that the department, which owned the company before 2021, had been “far too lenient” in its oversight.

Returning the shareholding to the department really does not change this one way or the other, but, as I said earlier, it is a chance to put the relationship between NHS Supply Chain, its shareholder, Ministers and the NHS organisation it serves on a much clearer footing. I want to make the point that it is there to serve the NHS. It does not, however, behave in a way that actually recognises that its customers are local NHS bodies. I should say here that there is a view that it is very arrogant in its dealings with NHS bodies. This is what we want to see changed, and I hope ministerial control will actually do something about it.

The ABHI has also reported to me that currently, NHS Supply Chain does not publish the agendas, papers and minutes of its board meetings. I find that very surprising. The noble Lord, Lord Scriven, will raise this in relation to Clause 11, but at the very least I hope to get some assurance that this will be put right.

I also ask the Minister whether, under the department, NHS Supply Chain will continue with its commitment to value-based purchasing. This is very important. I have long argued for it, and the noble Lord, Lord Lansley, is very much with me on this. The point is getting away from always going for the lowest price, and going for quality to improve patient outcomes. I acknowledge we are making progress, and the department itself is very supportive.

I want to quote one example. Value-based purchasing was launched this year to ensure a higher quality of healthcare by raising the standard of procurement. During a pilot in the South Tyneside and Sunderland NHS Foundation Trust, working with Essity, patients were provided with the most appropriate absorbent continence product for their clinical needs and preferences, even if that product was more expensive than other options under consideration. The results showed an 8% reduction in the number of continence products used and a 48% reduction in leaks, and 71% of patients said they would now find it easy to change the product themselves. This is a wonderful example of hugely improved patient outcomes because they did not go for the cheapest products—so this is what this is all based on.

18:00

We know that NHS Supply Chain has committed to this, but there is a tension. It has something called the core list, which enables it to manage the sourcing and supply of a core range of standard commodities on behalf of all providers—the key phrase here is “standard commodities”. When it is a question of scissors, clinical waste bags, batteries and pencil sharpeners, this is eminently sensible. However, a few days ago, NHS Supply Chain slipped on to its website—with no advance warning and no announcement to key trade associations such as the Urology Trade Association—a list of an additional 79 categories of product to be assessed for potential inclusion in future versions of the core list. This included urinary catheters and colostomy bags. These are not “standard commodities”; these are very personal things. I am worried that NHS Supply Chain, by doing this without any consultation at all, will reduce patient outcomes.

Clearly, this is a little aside from the core aim of this legislation, but the way this is handled will be an indication of how future arrangements are going to be. NHS Supply Chain should, first, commit to pursuing value-based purchasing, and, secondly, recognise that, although it is owned by the Secretary of State, or will be, its job is to help the local NHS and so it should not treat it in an arrogant way but, basically, as its customers.

[Baroness Finlay of Llandaff (CB)]

My Lords, I added my name to the amendment tabled by the noble Lord, Lord Hunt of Kings Heath, because this goes almost to the heart of the way that we account for what we do and what we buy in the NHS.

One of the problems is the accounting lines. A piece of equipment that might appear, at face value, to look expensive in fact saves enormous expenditure and lessens patient distress and morbidity, from a different budgetary line. The saving is a fallacy. I would welcome value-based procurement. I acknowledge the work that is being done by the medical technology and innovation directorate in the department and encourage that this goes across the whole of the NHS and social care system.

It is the clinicians who know that the cheapest is not necessarily the best, but, at face value, that may not always seem adequate. NICE has produced examples of where the cheapest is certainly not the best. Let me give one specific example, relating to something that is quite expensive: namely, cardiac pacemakers. Most cardiac pacemakers have wires. There are some which are eight times more expensive, but they do not have leads on them. That might seem a lot of extra money but, if patients have had radiotherapy to their shoulder and the left side of the chest, or if they are at very high risk of infection because they are on immunosuppressives or because they have a condition where they are immunosuppressed, then actually they are at high risk of getting infection on the leads because the leads are a foreign body in their body. The cost of managing sepsis, with patients in ICUs, vastly outweighs the cost of using different pacemakers for a small number of patients.

Think about urinary catheters. Patients who self-catharise may find that one type is much easier for them to use than another, and if they use it well and properly then their risk of infection is much lower. Generally, self-catheterisation is easier for men than it is for women, but certainly women who have a disability may find that they have got used to manipulating one type of catheter to self-catheterise. It becomes very cost-effective.

The clinicians are the ones who know what the outcomes are for particular devices, so that needs to be embedded in the tendering process. I hope that the voice of the clinicians determining the overall outcomes will be considered ever more as this goes forward. In Wales, we have the Value-Based Health and Care Academy, at Swansea University, which produces interesting work and is internationally recognised as a leader in the field because of its different way of thinking. I hope that there will be reporting to us on how this works when the change has happened.

[Lord Lansley (Con)]

My Lords, I want to speak briefly in support of Amendment 211, in the names of the noble Lord, Lord Hunt of Kings Heath, and the noble Baroness, Lady Finlay.

I declare an interest in that I am an officer of the All-Party Parliamentary Group on Access to Medicines and Medical Devices, which has held meetings on the value-based procurement of medical devices. I chair a group looking at breakthrough implantable devices, which has taken an interest in the procurement of just the kinds of devices that the noble Baroness, Lady Finlay, was talking about and in the importance of clinical input to understanding the potential value of such innovative devices.

Some Members of the Committee will know that I have been an advocate of value-based procurement and, where medicine is concerned, value-based pricing as an approach in the National Health Service. There is some good work being done in the department on promoting value-based procurement; we just need to make sure that it is understood and implemented correctly. I have been worried by evidence from some early tenders that the attitude is that the assessment of value should be conditional upon the achievement of a pricing threshold. Sometimes the pricing threshold is set at a point where the calculation of potential value is effectively nullified. If we are serious about understanding value-based pricing, we cannot put in a pricing threshold. You may well attach greater or lesser weight to the pricing element, but you cannot attach a threshold and believe that you are implementing value-based pricing. Quite often, part of the value assessment is to look at issues of patient experience, the outcomes that are to be achieved, the long-term life of a product and how it is used, to arrive at the overall value of a product. This is perfectly normal in commercial procurement. I do not think we are talking about something that should be regarded as exceptional to the NHS. It should be something that is regarded as normal and best practice in procurement.

It is slightly dispiriting in a sense, as I have seen an awful lot of progress on procurement in the NHS. Some 30 years ago, I was working with Unipart—before I came into Parliament—in trying to encourage the NHS, for example, to have just-in-time delivery and barcode-based procurement. That was an awfully long time ago and we have progressed a long way. It seems to me that, if we are keeping pace with the best procurement practices —and I hope the NHS will do that—we should be looking at a value-based system. I very much support what the noble Lord, Lord Hunt, said about that.

[Lord Scriven (LD)]

My Lords, I speak for these Benches on this short but important group. I thank the noble Earl, Lord Howe, for the amendment on Supply Chain Coordination Ltd and the noble Lord, Lord Hunt of Kings Heath, for his important amendment on value-based procurement.

These amendments may look technical, but they go to something that matters in every clinic and every operating theatre: how the NHS buys what it needs and who is accountable when things go wrong. NHS Supply Chain manages an estimated £8 billion a year of NHS spending on products, and, since 2022, it has carried out the department’s PPE programme. Yet under Clause 2, its shares can be moved by a transfer scheme at the Secretary of State’s discretion. There is no requirement to tell Parliament where they are going, who will exercise the shareholder role, or how continuity of supply will be protected.

Asking for a plan first seems modest. If the pandemic taught us anything, as the noble Lord, Lord Hunt, suggested, it is that supply chain resilience is first and foremost a patient safety issue.

However, a report is not a safeguard in itself. The real risk is that the transfer happens in the middle of a reorganisation, cutting the central headcount by half. The very people who understand how the company works may be gone before the scheme is made. The National Audit Office found that Supply Chain Coordination Ltd was meeting only seven of its 18 key performance indicators and that trusts spend more than £3 billion outside it. A company with that record needs careful handling, not a transfer done in a rush.

On value-based procurement, we welcome the direction of travel. As the noble Lord, Lord Lansley, just pointed out, this is not novel. We do not even have to take his experience of Unipart as an example. We can look at value-based procurement elsewhere: in Denmark, Canada, Italy and even Indonesia. There are models which the Government could use to look at how it is done.

The national guidance published in June is a genuine step forward, asking what delivers the best outcome across the whole patient pathway, rather than simply what the cheapest price is. But with NHS financial pressures, the temptation will always be to grab the lowest price today, without the skills, the capacity, and a finance regime that rewards long-term value. So I ask the Minister: what thinking is being done, not just for the pilots but as part of the new powers that the Secretary of State will have from the transfer of NHS England, on rewarding long-term value in the financial regime? What changes, if any, will the Government make to the financial regime?

There is a wider point that both amendments expose. NHS procurement still sits apart from the rest of the public sector. When the Procurement Bill passed through this House, my noble friend Lady Brinton, with support from all sides, including from the noble Lord, Lord Hunt, asked why the NHS should be treated differently. She warned that the NHS arrangements were not visible and that they were

“SIs at the discretion of any Secretary of State for Health”.—[Official Report, 28/11/22; col. 1578.]

Today, we have one regime for healthcare services and another for goods. NHS buyers are told to take legal advice on how the new value guidance fits both. With NHS England abolished, all that discretion will sit with the Secretary of State, and my noble friend’s warning has become even more relevant.

Therefore, I ask the Minister four simple questions. First, where will the shares in Supply Chain Coordination Ltd go, and when, and will Parliament see the plan before the transfer is made? Secondly, what independent assurance has been commissioned on the continuity of supply during the transition? Thirdly, after NHS England’s abolition, who will own value-based procurement and make sure that it is built into national service frameworks? Fourthly and finally, will the Government now review whether two separate procurement regimes for NHS services and goods still make sense, or will they at least publish how the boundaries between them will be policed, once the Secretary of State holds the pen on both? These are modest amendments, asking for sensible things, and I hope the Minister can give the Committee reassurance.

[Baroness Merron (Lab)]

My Lords, I most grateful to noble Lords for their observations and the way they have dealt with this. At the outset, I pick up the point that my noble friend Lord Hunt started with and others, including the noble Baroness, Lady Finlay, developed further. We are particularly concerned with personal products and products that need to be personalised. The illustrations that noble Lords have given have been most helpful. The reason for the changes is to see more of that.

18:15

I will address Amendments 5 and 211 together. Amendment 5 in the name of the noble Lord, Lord Kamall—I thank the noble Earl, Lord Howe, for moving it—highlights the importance of a clear and managed transition as we move towards the abolition of NHS England. In answer to one of the key points that the noble Earl, Lord Howe, raised, the intention is for the shareholding in Supply Chain Coordination Ltd —I am being very formal—which we refer to as NHS Supply Chain, to transfer to the department as part of the wider transition. The transfer of shares will have no impact on the services delivered by the company. NHS Supply Chain will continue, as it always has, to play its role in securing value for money and ensuring resilient supplies for the NHS.

To pick up some of the questions that were raised, I mentioned ensuring that there will be no disruption to storage and supply; the noble Earl, Lord Howe, raised this in particular. The transfer does not in itself alter operational responsibilities or contractual arrangements, and NHS Supply Chain will continue to provide services through the transitions. Our anticipation is that the current arrangements will remain broadly in place. As part of the new operating model, consideration will be given more widely to the efficient and effective management of shareholdings.

I heard my noble friend Lord Hunt express concerns about the way NHS Supply Chain currently operates. Consideration will be given to how management of the operation can be more efficient and effective. As I said at the outset, I heard very clearly the reasons for that, so I need no persuading.

My noble friend also asked about the commitment to value-based purchasing, which other noble Lords, including the noble Lord, Lord Lansley, have spoken positively about. NHS Supply Chain is fully committed to the adoption of value-based procurement and has moved to a “comply or explain” model for future frameworks. NHS Supply Chain also considers the application of pricing threshold approaches on a case-by-case basis, looking at specific market dynamics.

To answer the noble Lord, Lord Scriven, I will refer to Supply Chain Coordination Ltd’s strategy. The strategy focuses on the principles of—and I am lifting these words, so I ask noble Lords to bear with me—

“buying smart, supplying right, and partnering expertly”.

I am sure the noble Lord is familiar with that kind of terminology. I would translate that to prioritising the needs of patients, communities and outcomes in how we source and supply. That is key.

With regard to some of the questions that the noble Lord, Lord Scriven, raised about shares and the plan, NHS Supply Chain will continue, and it is going back to the department, which is where it was before. I will look at the other very specific points in considering this whole area.

To return to Amendment 5, it would introduce a new statutory requirement to publish and lay before Parliament a formal report before NHS England shares in the NHS Supply Chain could be transferred. As I have said, the department previously exercised that shareholder function, and the intention is to return to those arrangements. For that reason, we consider the amendment to be unnecessary.

On Amendment 211, I welcome that my noble friend Lord Hunt, the noble Lord, Lord Lansley, and other noble Lords have been long-time advocates of value-based procurement. I am grateful to your Lordships’ House for the ongoing support for this policy. In June, we delivered on the commitments made in the 10-year health plan and the life sciences sector plan to publish national guidance for value-based procurement for medical technology. I welcome that guidance having shifted the focus of procurement decisions towards value and—I emphasise—outcomes for patients, as well as towards the health system and the environment, rather than just towards the lowest cost. Publishing the guidance is just the first step. The department has set out its implementation plans, including commissioning independent monitoring and evaluation of the guidance, with annual reports over the next three years—which of course will be published—on the impact of the guidance. It is the intention that business as usual means value-based procurement when it comes to NHS procurement teams purchasing medical devices, consumables and services. Our existing reporting arrangements will help to ensure that this is the case.

[Earl Howe (Con)]

My Lords, I am grateful to the Minister for her response and to all noble Lords who have contributed to this debate. I am particularly grateful to the noble Lord, Lord Hunt of Kings Heath, for his insights into the performance of the NHS Supply Chain and its current shortcomings. I was also very impressed by his advocacy in favour of value-based procurement—which, incidentally, I would distinguish from value-based pricing, a policy in relation to which, as a former Health Minister, I bear the scars. I very much agree with the noble Lord, Lord Scriven, that we need reassurance that responsibility for value-based procurement will rest with NHS Supply Chain with active ministerial support. We heard the necessary reassurance on that from the Minister.

I admit that the criticisms of NHS Supply Chain voiced by the noble Lord, Lord Hunt, are ones that I chose to gloss over, because, as I said at the outset, my concern was simply to ensure that the abolition of NHS England does not disrupt the essential services and systems on which the wider health service depends. NHS Supply Chain is an important example of this, and we must be confident that its future ownership and governance arrangements are properly considered and that continuity of supply is protected throughout the transition. I was largely reassured by what the Minister had to say about this but will study her reply carefully. Ultimately, changes to the administration of the NHS must not come at the expense of its ability to deliver care to patients.

I hope that the Government in turn will reflect on the points raised today, but for now I beg leave to withdraw my amendment.

Amendment 5 withdrawn.

Clause 4: Reducing inequalities

Amendment 6

Moved by

[Baroness Jones of Moulsecoomb]

6: Clause 4, page 3, leave out lines 22 to 29 and insert—
“1C Duty to improve public health and reduce health inequalities(1) The Secretary of State must, in exercising functions in relation to the health service—(a) take all reasonable steps to improve the health of the people of England and prevent illness,(b) reduce health inequalities between the people of England,(c) take all reasonable steps to reduce inequalities in the ability to access health services and in the outcomes achieved through the provision of health services, and(d) address the social, economic and environmental determinants of health, including in relation to housing, education, employment, income and environmental conditions.(2) In discharging the duties under subsection (1), the Secretary of State must take account of the need to prevent ill health by addressing its causes, as well as by providing services for the treatment of illness.”Member's explanatory statement
This amendment strengthens the Secretary of State’s duties to improve public health and reduce health inequalities, including by addressing the social, economic and environmental determinants of health and preventing illness rather than relying on treatment alone.

[Baroness Jones of Moulsecoomb (GP)]

My Lords, I will speak to the four amendments in this group that are in the name of my noble friend Lady Bennett of Manor Castle. I shall speak also on behalf of the noble Baroness, Lady Whitaker, who is ill and unable to be here. She asked me particularly to mention that she supports Amendments 15, 16 and 17 in this group, on inequalities.

On Amendment 6, a duty of “must have regard to”, as is currently in Clause 4, is not much of a duty. We can have regard to many things, but it does not mean that we will do anything about them. I support the amendments in this group that want to strengthen that duty to something where we can see some action. The aim of this amendment is to strengthen it further and to put improving public health, reducing inequalities and addressing the social, economic and environmental determinants of health into the Secretary of State’s statutory responsibilities.

We talk a great deal about the pressure on the NHS. We talk about waiting lists, hospital capacity, workforce shortages and the money needed keep services going. These are all extremely important, but we need to ask some more fundamental questions. Why are so many people becoming ill in the first place, and why are some people so much more likely to become ill than others? As the noble Lord, Lord Crisp, said on an earlier group, we need to shift our focus from treating sickness to creating health. Health is not simply a matter of what happens when somebody walks into a GP’s surgery or a hospital. It is shaped by conditions in which people are born, grow up, work and live. It is shaped by whether somebody has a secure home, a decent income, good food, good education, safe working conditions and clean air to breathe.

These things should make up a health policy. A person living in a cold, damp home, especially near a busy road, as so many people do here in London, is more likely to suffer from respiratory problems. Someone who cannot afford nutritious food faces consequences for their lifelong health. A child growing up in poverty can face disadvantages that will affect their health for the rest of their lives. This amendment takes all that into account and would require the Secretary of State to take reasonable steps to do something about it, because here in the UK, those in the most deprived areas can expect to live almost 20 healthy years fewer than those in the least deprived areas. That is a staggering statistic.

Prevention will not eliminate the need for hospitals, medicines or specialist care, but a health service should not focus just on what happens after people become ill. Prevention means more than telling people to make healthier choices. It means making those choices possible. It means tackling food poverty and ensuring that people can afford nutritious food. It looks like investing in public health and early intervention. There is not much point in treating the consequences of poverty without addressing the circumstances that make people ill.

What is the point of treating respiratory disease while allowing people to live in damp homes or to breathe polluted air? Human health and the health of the natural world are connected. Cleaner air and water, access to nature, healthier food systems and action to protect us from the effects of the climate crisis are all public health measures. As we know, the benefits of a healthy environment are not shared equally. People on lower incomes are often least able to move away from pollution, poor housing and unhealthy surroundings. The inequalities that we see in health are therefore connected to inequalities in wealth, power and the quality of places where people live. The noble Baroness, Lady Nargund, also spoke about inequalities, a primary pressure on our beloved NHS.

The gap in healthy life expectancy between the most and least advantaged communities is a measure of inequality that the Government should actively try to reduce. A statutory duty will not by itself remove these inequalities, but the wording of a Bill does matter. It establishes what the Government are required to do rather than merely saying what they would like to do.

Amendments 15, 16 and 17 aim to strengthen the provisions in Clause 4 for all communities facing health inequalities. These amendments address three essential requirements—visibility in health data, recognition in decision-making and accountability for progress. For example, Gypsy, Roma and Traveller communities experience some of the most severe and persistent health inequalities in England. They face poorer physical and mental health, barriers to accessing healthcare and discrimination within healthcare settings. The 2021 census found that Gypsy or Irish Traveller people were more than twice as likely to report bad health or very bad health as the rest of the population of England and Wales overall—12.5% compared with 5.2%.

Nearly one in six reported being disabled and limited “a lot” in their daily activities by long-term physical or mental health conditions, compared with around one in 13 of the overall population. Research has found that Gypsy or Irish Traveller women in England and Wales are twice as likely to die by suicide as those in the white British women category. Yet a 2020 review by Friends, Families and Travellers found that of 79 local suicide prevention plans covering 113 areas in England, only five mentioned Gypsy and Traveller communities, and only two included action to address suicide inequalities.

18:30

Therefore, despite the inequalities in health outcomes, the communities’ needs are not being consistently identified in national health data or adequately reflected in the planning and delivery of services. Collecting properly disaggregated ethnicity data is essential. Gypsy, Roma, and Traveller communities are not a single homogenous group, and grouping them together under one category can obscure important differences in their health experiences and outcomes. Data should enable us to understand the distinct experiences of Gypsy, Roma, Irish Traveller and other communities, rather than masking inequalities within broad categories.

More broadly, the same challenges affect other inclusion health groups, including people experiencing homelessness, vulnerable migrants, people in contact with the criminal justice system, and victims of modern slavery. These groups often experience overlapping disadvantages, social exclusion and barriers to healthcare. Clause 4 provides an important opportunity to address these inequalities but, as it stands, a general duty to “have regard to” reducing inequalities and access to health services and health outcomes will not, by itself, ensure that the people experiencing the greatest inequalities are identified, considered and supported. These amendments would help make that duty effective in practice.

Amendment 15 would require national health data systems to collect, analyse and publish data sufficient to identify and monitor these inequalities. Amendment 16 would ensure that the particular barriers facing inclusion health groups are considered when the Secretary of State exercises the health inequalities duty. Amendment 17 would require annual reporting on progress, including action taken in relation to Gypsy, Roma, and Traveller communities—this is essential for transparency and accountability. These amendments are all complementary. They would help ensure that inclusion health groups are visible in the evidence used to make decisions. They build on existing commitments to reduce health inequalities, and they aim to ensure that the system we have is better able to recognise and respond to the needs of these communities. I beg to move.

[The Deputy Chairman of Committees (Lord Faulkner of Worcester) (Lab)]

I should advise the Committee that if this amendment were agreed to, I would not be able to call Amendments 7 to 15 for reasons of pre-emption.

[Lord Patel (CB)]

My Lords, we are entering the phase of debate on the Bill which I personally consider to be the most crucial part. Why do I consider it to be the most crucial part? It is because tackling health inequality is central to the revival, if not the survival, of the NHS and the broader economy.

I will speak mainly to my Amendments 7, 13 and 19, but before I do so, I want to say something because I feel strongly about it. I regret that consultants have decided to go on strike. No doctor should ever, under any circumstances, withdraw their services from the sick and the vulnerable. I think any doctor, and I hope every doctor in this House, would support that idea. They might have grievances, but they could settle those without going on strike, and they should not withdraw services. I hope the professional bodies, including the royal colleges, will align with that comment.

Having said that, my amendments about reducing inequalities are there because what we have in the Bill is a direct transfer of the issue of reducing inequalities from what was part of NHS England’s duties and was already in the duties of ICBs. There is nothing new in the Bill about reducing inequalities. It is a great pity that an opportunity is being missed by this Government to put a mark on how to reduce inequality. Why do I say “this Government”? It is because in the last 30 years, it was only once that we succeeded in reducing health inequalities, and that was from 2000 to 2010. An academic review, which was a proper assessment, demonstrated that, in mortality, infant mortality and ill health, the strategy devised by the then Labour Government managed to reduce health inequalities. But we have now come to a point where they are all rising for all kinds of reasons.

Who were the people who were responsible at the time? Their names were Alan Milburn; John Reid, now the noble Lord, Lord Reid; Yvette Cooper, now Secretary of State for Health; the noble Lord, Lord Darzi of Denham, who produced a report on the NHS; and Andy Burnham, the last Secretary of State for Health in that Government, and now the Prime Minister. Surely the present Government can find people of same calibre who can tackle health inequalities—or maybe not.

The strategy was a cross-governmental public service agreement—PSA—which was a legally binding framework used by the Treasury in the spending review process. It was as simple as that. It could be argued that my amendment is too strong. It would make the Secretary of State responsible, and I might be told that cannot be, because it removes the Secretary of State’s autonomy and flexibility, and therefore putting that in the Bill is not appropriate. If it is not, it does not make the policy of inequality strategy development inappropriate. As demonstrated between 2000 and 2010, the then Government found a way—cross-governmental ministerial responsibility—where, although the strategy was based on ill health, all the other Ministers were responsible for making sure that their ministries contributed to that improvement in reducing health inequality.

Therefore, if the Minister does not like my Amendment 19, there might be other ways for the Government to decide how the same could be achieved through another strategy; for instance, the same kind of agreement that Government did in 2000-10 or through Cabinet Secretary responsibility, as the Cabinet Secretary is responsible for making sure that all the Ministers and different government departments contribute and are mindful of a strategy that reduces health inequality.

In my view, if we do not do this, and there is no strategy coming forward, nothing will change. We will be talking about the same things that we have been talking about for the last 15 years, quoting the same statistics that have already been given about life expectancy being reduced in disadvantaged populations, how the time people spend being unhealthy will increase, how infant mortality will go up, how maternal mortality will go up, as it is doing now, and all the other things.

I thank the noble Baroness, Lady Cass, who might speak after me on children’s issues, and the noble Baroness, Lady Manzoor, who added her name to my amendment. I hope the Minister might agree to four things that I will ask her. I am not asking questions but asking her to agree that health equality and health outcomes are key to the overall welfare of the NHS and the broader economy; that now, after two decades, there has not been any improvement; that the improvement that previously occurred was as a result of a cross-government strategy; and that the increase in health inequality is being driven by rising ill health in England, but the Bill does not have a plan for the Secretary of State, a Minister of the Crown or Ministers in other Governments to demonstrate how they will reduce inequalities.

[Baroness Cass (CB)]

My Lords, I will be very brief. I support the amendments from the noble Lords, Lord Patel and Lord Hunt, and the noble Baroness, Lady Tyler. It will not surprise noble Lords to hear that I plan to focus on children yet again, but, as my amendments on inequalities in children come much later in the Bill, I will defer to other noble Lords to speak on this group. However, I will give noble Lords a spoiler alert: the Royal College of Paediatrics and Child Health’s State of Child Health report shows that inequalities are widening, particularly in marginalised groups, such as those living in deprived circumstances, or minority ethnic groups. There will be more of that anon; meanwhile, I defer to my colleagues.

[Baroness Tyler of Enfield (LD)]

My Lords, it is a great pleasure to follow the noble Baroness. As the noble Lord, Lord Patel, has already made very clear, this is a very important group of amendments: it gets to the nub of what we should be talking about for the NHS. If I am honest, quite a few of these amendments are calling for quite similar or interconnected things and outcomes. I do not mind too much how we get there, as long as we do.

I want to speak specifically to Amendment 18 in my name; I thank the noble Baronesses, Lady Royall, Lady Cass and Lady Lister, for adding their names. I will also briefly touch on Amendments 8 to 10, in the name of my noble friend Lady Walmsley, who, sadly, is unable to be in her place today, and to which my name is added. I will also speak—briefly, I hope—to Amendment 14 in the name of the noble Lord, Lord Patel of Bradford, who is also unable to be in his place; again, my name is attached. There are also other very important amendments in this group to which I am very sympathetic, in particular Amendment 20 in the name of my noble friend Lady Pidgeon.

The case is well known and has been well made already, so I will very briefly say why tackling health inequalities more effectively is so important. All the research shows that the nation’s health is under real strain. Analysis of healthy life expectancy internationally shows, sadly, that we are falling behind. We now have an 18-year gap in life expectancy between different postcodes in the UK. Of course, it is not just about health, important as that is to individuals, but about economics—what I like to call well-being economics. A nation cannot prosper while large parts of its population are having their lives cut short and while its most deprived communities are, on average, living only 52 years in good health. The number of people with a work-limiting health condition is rising, and poor health among young people is one of the drivers of the increasing number of 16 to 24 year-olds who are NEET—not in education, employment or training.

Before we get too despondent, if you flip it on its head, the good news is there is real potential for what I would call health-enabled growth. Modelling by the Health Foundation suggests that returning just to 2014 levels of health would see 600,000 people back in work, grow GDP by 2% and save the Treasury £70 billion nationally.

I think we all understand that health inequalities are driven not simply by how the NHS functions and operates but by wider social, economic and environmental factors, including poverty, poor-quality housing, lack of green space, poor working conditions and barriers to accessing affordable and nutritious food. I know that, if she were here, my noble friend Lady Walmsley would really want to emphasise that.

As others have already pointed out—the noble Lord, Lord Patel, made this point very strongly—there is a real opportunity to place in the Bill a stronger duty on the Secretary of State to improve health and reduce health inequalities, but that needs to be supported by a statutory framework for co-ordinated cross-government action and accountability. It is an overall package we need, if you like. Coupled with consistent joint working at national and local level, this could really support the shift that I think we all want to see from sickness to prevention. It is in the 10-year plan and the devolution agenda.

18:45

I turn to Amendments 8 to 10 in the name of my noble friend Lady Walmsley. Clause 4 currently transfers only existing duties on NHS England to the Secretary of State regarding equity in access and outcomes from healthcare services. The clause does not strengthen these duties in any way or address the wider determinants of health across government, as we have been discussing. This really is a missed opportunity and is why my noble friend’s Amendment 8 is so important. It would strengthen the Secretary of State’s duty on reducing health inequalities from a duty to “have regard” to the need to reduce them to a duty to “take steps to achieve” their reduction. Actually taking action will make the difference. My noble friend’s Amendments 9 and 10 are simply consequential on that, so I will not go into any detail there, but my final point on Amendment 8 is that a stronger health inequalities duty would send a signal to the Secretary of State and all Ministers that Parliament expects them to actively take steps to prioritise prevention alongside treatment, rather than just having regard to it.

My Amendment 18 is about requiring the Secretary of State to produce a health inequalities strategy and an annual report to Parliament on it. It is similar to Amendment 19 by the noble Lord, Lord Patel, but I have been a bit more generous: he gave six months and I suggest a year. The need for such a strategy was very well debated in the other place recently during the passage of the Bill, and by the Health and Social Care Select Committee. Both found that just changing a duty, although important and necessary, is not sufficient for achieving the goals that I think we all want to see. What is needed is action across government, nationally and locally. It took me back to my days, a very long time ago now, when I was director of the Social Exclusion Unit in government: I remember seeing how central co-ordination can support cross-government working on what you might call those wicked cross-cutting issues, such as homelessness, health inequality and other things, and really start to make a difference.

There was a time when strategies were slightly out of fashion, but maybe times change: we have seen a recent strategy on women’s health and child poverty, and I know and am very pleased that the Minister is herself developing a mental health strategy, which I very much look forward to. Perhaps the time has come for a cross-government health inequalities strategy with the proper parliamentary accountability built in.

I will finish by talking briefly about Amendment 14. I was pleased to put my name to this amendment in the name of the noble Lord, Lord Patel of Bradford; the noble Lord, Lord Hunt, has also added his name. I know that, if the noble Lord, Lord Patel, had been here, he would have very cogently set out the absolutely compelling case for recognising coastal health inequalities. I want to acknowledge his outstanding work.

I want to focus briefly on the consequences for prevention, mental health and young people. The difficulties facing coastal communities are not confined to the prevalence of illness. They reflect a combination of poorer health, economic disadvantage, restricted access to services, limited transport and, in many places, fewer opportunities for young people, and these factors compound one another. Poor access to prevention and early intervention can allow ill health to become more serious, and long-term illness can then push people out of employment. Economic inactivity and financial insecurity can worsen health and well-being, and it is a vicious cycle.

Mental health needs to be front and centre of any response. Many coastal communities face particular challenges in accessing timely mental health support, particularly for children and young people. In places where transport is difficult and specialist services can be many miles away, access to early intervention can become a serious problem. It is acute when it comes to suicide prevention. The relationship between mental health, isolation, economic insecurity and access to services is so important in these communities when support is difficult to reach. I am sure that if the noble Lord, Lord Patel of Bradford, had been here, he would have put it far better than I can, but his amendment would ensure that, in exercising health service functions, the Secretary of State has specific regard to reducing inequalities between coastal and inland communities, particularly in prevention, planning and commissioning and the health workforce.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Baroness, Lady Tyler, and the noble Lord, Lord Patel, made some important points about cross-government working. I was thinking back to what the noble Lord, Lord Patel, said, basically that what started under Tony Blair was continued under Gordon Brown. It was backed up by, first, a specific Cabinet committee, which underpinned the inequalities work, and, secondly, by what were called PSA targets, which tied different departments in. I think that was a good mechanism. In defence of the Government, though, the important work that is being undertaken in relation to health inequality by Alan Milburn, working with different government departments, is going to be pivotal because it embraces the terrible outcomes for so many people who come under the NEET category. It is also looking at the dreadful mental health support for children and adolescents, which goes to the heart of many of these issues. If we can pull this off, we can start to achieve some of the equality issues that we have been talking about.

Like the noble Baroness, Lady Tyler, I am here to say a few words about coastal health because the noble Lord, Lord Patel of Bradford, told us we must. Five years ago, the Chief Medical Officer devoted his 2021 annual report to health in coastal communities. He identified high levels of poor physical and mental health, an ageing population with increasingly complex needs and serious challenges in recruiting and retaining the healthcare workforce. The noble Lord, Lord Patel, basically has three asks, on which I want to reinforce what the noble Baroness, Lady Tyler, said. Five years after the CMO’s report, we have no strategy. First, will the Government publish a substantive account of progress against his recommendations? Secondly, how will the Government ensure that coastal populations are separately identified? Unless we do that, we do not have the data on which to plan and strategise and see whether improvements can be made. Thirdly, will the department work across government to develop and test commissioning prevention workforce models suited to the distinctive geography and needs of coastal communities? I would be very grateful if my noble friend would agree to meet the noble Lord, Lord Patel of Bradford, to discuss this further, because it is an important consideration.

My Amendment 11 relates to the terrible distribution of GPs in England currently and asks for a much more equitable distribution. I am grateful to the noble Baronesses, Lady Gerada, Lady Hodgson and Lady Manzoor, for their support. Last week I was very fortunate to have a meeting with Minister Dame Diana Johnson and her officials, which I found extremely helpful, and I was grateful to her officials for the way they have been prepared to communicate on this.

This morning, the RCGP published the State of General Practice 2026 report. Chapter 4, about fair and sustainable general practice care—equitable care—makes clear that action is needed. One area where I believe we need action is what the noble Lord, Lord Darzi, described as

“huge and unwarranted variations in the number of patients per GP”.

Data from the NHS general practice workforce team shows that the national average list size of fully qualified full-time equivalent GPs hovers at around 2,200 patients. John Gooderham, a retired civil servant who once worked for me, undertook a number-crunching exercise showing that the differences in average list sizes are almost unbelievable. His evidence, which was published by the Institute of Health and Social Care Management, showed at least 20 areas with an average list size ranging from 8,300 to 4,400 patients, almost four times as many as the national average. All of them are clearly severely underdoctored. At the other end of the scale, there are 20 areas with an average list size ranging from 1,000 to 1,444 patients.

The trouble is that there seems to be no approach or system to rectify this. We used to have the Medical Practices Committee, which was set up by Nye Bevan in the 1946 Act and lasted until 2001. I have to confess that I took through the legislation abolishing the MPC. Mea culpa—it was a mistake. At the time, the line that I took—I looked it up—was that area health authorities would sort it all out. Where are area health authorities? They did not, and none of their successors has. I think we need to go back to a system that identifies areas that are overdoctored or underdoctored to consider how we can justify this situation. It cannot be allowed to continue. I know that officials feel that the kind of MPC system we had is not fit for today’s more modern circumstances, but one way or another, either through financial incentives or through some restrictions, we have to do something about this. I hope the Government will be sympathetic.

[Baroness Manzoor (Con)]

Noble Lords will know that I am passionate about improving the health of all. The National Health Service is the National Health Service, not the ill service. So many disadvantaged, marginalised groups are not receiving the care or the health that they need. I will not go back into the disparities and the health inequalities. I have put my name to the amendment from the noble Lord, Lord Patel, who spoke very clearly. It is a simple amendment but would be a pivotal, key amendment to the Bill.

I also support the amendment in the name of the noble Lord, Lord Hunt, because without having the first line of defence of GPs, marginalised groups do not have the access to doctors that they desperately need. Everybody knows the effects of inequalities on the economy, the NHS and individuals. The Government have a great opportunity to enhance the Secretary of State’s power and strengthen it, rather than transfer the current power.

As I indicated earlier, in my region we had a duty to bring down inequalities in a deprived area. I worked closely with Alan Milburn and other Ministers, including the then Prime Minister, Tony Blair. It worked when that key emphasis, monitoring, duty and strategy were put in place. We need a health strategy, as the noble Lord, Lord Patel, indicated. I leave the question on the table for the Government. This is a fantastic opportunity. It is not about all the structural change that we have been talking about; this is about making a real difference to people’s lives and to the health of our nation.

19:00

[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.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I am very pleased to support many of the amendments in this group, and I absolutely acknowledge that there is a difference between health inequalities and healthcare inequalities, but both need to be addressed. I shout out to my own GP practice, Chatfield Health Care, which is utterly brilliant and serves a very mixed economy. The noble Lord, Lord Patel, rightly said, in my view, that unless we address the issues pertaining to inequalities, then the healthy survival of the NHS is in question. Currently, I do not think that we are in a fit state to address the inequalities; this Bill is a golden opportunity to do that, and we absolutely must.

I go back to the Labour manifesto of 2024, which promised

“a fairer Britain, where everyone lives well for longer”.

It promised a shift to prevention and that Labour would halve the gap in HLE between richest and poorest regions through tackling the social determinants of health. This was followed up by the 10-year plan. Both of these have an excellent vision, but I fear that, too often, short-term pressures hinder long-term plans. I regret, for example, that the Mission Delivery Unit was disbanded and that long-term prevention no longer seems to be prioritised. That is why it is crucial that in this Bill we strengthen the duties on health inequalities.

I welcome the Government’s devolution agenda, about which we hear so much, including the English Devolution and Community Empowerment Act 2026 that we passed earlier this year, and the strong duty in that Act on strategic authorities to improve health and tackle health inequalities. The amendments before us today would place the equivalent duties on the Secretary of State for Health, with a requirement that Ministers across government have regard to them.

I agree that health inequalities should be addressed locally and that power being devolved to strategic authorities and local authorities will help enable those who are well placed to address the wider determinants. However, in a devolution-first world, the responsibilities and budgets of Whitehall departments mean that central government has a pivotal role and responsibility in addressing the many policies which have a profound impact on health that have been mentioned in this debate. Your Lordships supported and achieved parity of esteem for mental health, and the duty before us today would create a parity of esteem for prevention. It would be embedded as a shared goal across national, regional and local government. It is crucial.

The Government have made great progress in some areas, such as the smoke-free generation or ending the two-child limit. These changes will have a long-term benefit for health and reducing inequalities, but they do not represent a strategic across-government approach. In other areas, there have been good ambitions, such as a healthy food standard, but implementation has been slow and there have been loopholes. Such a patchy approach will not achieve health in all policies and will allow inequalities to keep widening. The approach must be across government.

As the noble Lord, Lord Patel, and my noble friend Lord Hunt said earlier, from 2000 to 2010 we made great progress thanks to that cross-government approach. Indeed, the Prime Minister was a part of that Government and in 2010 as Secretary of State he launched the Marmot review and subsequently made Greater Manchester the first Marmot city region. He has pledged to tackle regional inequality with good growth in every postcode, as we know, and to rewire the state in favour of prevention. We have heard many facts and figures today which demonstrate that this pledge must become a reality if our country is to fulfil its potential. I pay tribute in passing to Sir Michael Marmot, whose work is transformatory.

My noble friend might well speak of additional burdens, but she herself tabled amendments to the Health and Social Care Bill in 2022 requiring consultation and regular planning and reporting on the health and social care workforce. These amendments take a similar approach. They do not create a lot of processes. In fact, they codify what Ministers have already committed to but which is too often deprioritised. There are several precedents for creating accountability frameworks for cross-government agendas that are much more cumbersome, I would say, such as the Climate Change Act and the Child Poverty Act—not that they are not important; they certainly are.

My noble friend has certainly been in listening mode, and it is a pleasure to have interacted with her in so many meetings. I strongly urge her not just to listen to the arguments made this afternoon but to act and to amend the Bill so that we have a duty to address inequality and that it is done on a cross-departmental basis. It will make such a difference to the life and the health of the citizens of our country and consequently to the economics of our country.

19:15

[Baroness Nargund (Lab)]

My Lords, it is an honour to follow my noble friend Lady Royall. I support Amendment 18 from the noble Baroness, Lady Tyler, to publish a cross-governmental strategy to reduce health inequalities in England. This debate has been extremely humanitarian because addressing health inequalities is a matter of social justice and human dignity.

Health is not created in hospitals or GP clinics; it is created in homes, workplaces and our communities. Health is so fundamental, as Martin Luther King said:

“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman”.


That is what we are talking about—addressing something of a humanitarian nature by addressing health inequalities around our country.

The noble Baroness said about the NHS being criticised. It has often been criticised as not being a national health service but a national sickness service. If we really want to transform our NHS to become a national health service, we have to address health inequalities. These do not lie within hospitals or clinics but in our society and the social determinants of health.

I declare an interest as a founder and trustee of the charity the Health Equality Foundation which works in this area. I also have had the honour of working with Sir Michael Marmot in helping to address the social determinants of health. One of the greatest challenges we face is this nearly 20-year gap in healthy life expectancy, and this cannot be addressed by one department alone nor simply by hospitals. Like the child poverty strategy, we need a whole-government approach to tackling the wider determinants of health—where we are born, how we live and the conditions in which we grow up—which account for 80% of health outcomes.

After having served in the NHS for nearly 40 years, with over 30 years as an NHS consultant, I have treated the consequences of inequality, but I was not able to address the causes of inequality. We have a huge opportunity to address that. I welcome the Government’s manifesto commitment that my noble friend Lady Royall mentioned and the 10-year plan commitment to address health inequalities and the wider determinants of health around our country. The commitment to address health inequalities—not that I know previous Health Bills well—has never been stronger.

The economic case is as compelling as the moral one. If the north of England achieved the same health outcomes as the rest of the country, it could add £18.4 billion to our economy each year. Poor health reduces productivity, increases welfare spending and constrains growth. We know if we want good growth in every postcode, we need good health in every postcode, not just good healthcare in every postcode, which we all know is also essential.

I support this amendment from the noble Baroness, Lady Tyler, because of the need for a cross-government strategy. I have previously spoken in this Chamber about the need for a cross-government taskforce or board; I have also written about that. I believe a cross-government strategy and a taskforce are needed to address our health inequalities and that that taskforce would go beyond this to tackle wider and general determinants of health.

If we want to seriously address this, we must have a cross-government strategy. I recognise the important work already undertaken by the Government in this Bill and the 10-year health plan, but given that many of the underlying causes of poor health sit outside our health service, has the Minister given any consideration to developing a cross-government strategy and potentially a taskforce similar to the one created in respect of the child poverty strategy to address the wider determinants of health? Are there any lessons from that approach that could be applied to tackling wider health inequalities? I am really honoured to have spoken in this debate.

[Baroness Lister of Burtersett (Lab)]

My Lords, I am honoured to follow my noble friend Lady Nargund. I have added my name to a number of the amendments in this group calling for a clear duty on the Secretary of State to take action to reduce health inequalities and produce a cross-government health inequalities strategy. I also support the other amendments on this theme, including that in in the name of the noble Baroness, Lady Bennett of Manor Castle. As we have heard, her amendment makes specific reference to inclusive health groups, including Gypsy, Roma, and Traveller communities, who experience some of the poorest health outcomes of any group in England, as the noble Baroness, Lady Jones of Moulsecoomb, spelled out.

As Just Fair points out, there is a right to health under the International Covenant on Economic, Social and Cultural Rights. In its 2025 concluding observations, the UN Committee on Economic, Social and Cultural Rights raised a number of concerns about the provision of health services in the UK, including inequalities in access to care, as we have heard about.

At Second Reading, I and a number of other noble Lords spoke in favour of a clear duty on the Secretary of State to tackle health inequalities and a cross-government health inequalities strategy that would underpin the preventive approach that the Government, rightly, initially favoured and, indeed, that the Chancellor referred to in his Budget speech today. Our interventions reflected calls from a wide range of health and other bodies, many of which support the Health Equals campaign to put tackling health inequalities on a statutory footing and to reboot the Government’s emphasis on a preventive approach. It also reflected the position of the Health and Social Care Committee in its scrutiny report on the Bill.

The Government themselves have emphasised the importance of addressing health inequalities in their child poverty strategy, as I pointed out at Second Reading. Indeed, the strategy declares that addressing healthcare inequality is at the heart of their health mission. Moreover, in September, the Minister for Women and Equalities, in announcing the establishment of a new class unit, described it as

“a pivotal step in embedding a focus on socio-economic inequality into the heart of government”,

as part of their drive to tackle entrenched inequality. Given all that Ministers have said about inequalities, I am puzzled as to why they seem so reluctant to translate this commitment to tackle entrenched inequality into a statutory duty in this key legislation.

In the Commons, Minister Smyth failed to give a convincing explanation as to how mere empowerment is more effective than a duty to address health inequalities, which she herself said remained a government priority. However, it might not be a priority for a future Government, so warm words are not enough. In the Second Reading debate in your Lordships’ House, my noble friend the Minister reiterated the Government’s commitment to working for greater equality but did not engage with the arguments put by a number of us and explain why a power is better than a duty to achieve this. I therefore hope that she has been able to reflect on what was said and on the growing pile of evidence on health inequalities, especially among children, some of which we have heard about today, and that she will be able to respond more positively and commit to bringing forward a government amendment on Report that meets the objectives of the various amendments debated today.

[Lord Lansley (Con)]

My Lords, I may be the first speaker not to have signed any of these amendments, but that does not mean that I do not agree with them; a great deal has been said with which I agree. The importance of this debate can hardly be overstated.

I just want to contribute one thought, which is that in taking all these issues and understanding how they relate to this Bill, we have to put it in the context of what is already in the National Health Service Act. I want very quickly to outline that.

The Bill before us is an improvement on what is in the NHS Act as far as the Secretary of State’s duties are concerned, because it extends the duty from equal access to healthcare services and facilities to seeking to reduce inequalities and securing equity in outcomes from healthcare services. That is what is in the Bill; I think that is a significant improvement. The Bill focuses at this point on what the National Health Service is doing to secure the prevention of illness and the promotion of successful treatment. It is not about the improvement of public health at that point.

The noble Baroness, Lady Tyler of Enfield, talked about the Bill transferring a duty to the Secretary of State. In fact, the NHS Act has the same duty on both the Secretary of State and NHS England: they are concurrent duties. Therefore, we are not transferring the duty; this is not part of a transfer from NHS England to the Secretary of State.

Under Section 2A of the NHS Act, the Secretary of State has a duty for the protection of public health, which are all those things to do with vaccination, immunisation, et cetera. Section 2B, which was inserted by the 2012 legislation, as my noble friend on the Front Bench will recall, inserted into the Act a duty as to the improvement of public health, and that is on both local authorities and the Secretary of State. It is not, I think, phrased as we would want it to be; more needs to be done to look at that.

I suggest—and this picks up the point made by the noble Baroness, Lady Royall of Blaisdon—that when we talk about wider determinants of health, we are looking at a strategy that relates not only to the Secretary of State—i.e. to the Government—but to local authorities, and she made that point very rightly. But it is in the NHS Act. Local authorities have a duty to improve public health in their area and take such appropriate steps as they can to achieve that, and the Secretary of State has such a duty to improve public health in Section 2B—unaffected, as I understand it, by this Bill. Therefore, when we come to look at it on Report, I hope that those who are thinking about how we might create the right strategy for the improvement of public health do not just think that it is done by attaching it to the responsibilities of the Secretary of State in relation to the NHS but also look at Section 2B.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I am grateful to the noble Lord for giving way. I recently read Section 2B of the NHS Act. I think one would find that it states that local government and strategic authorities “must” improve health and reduce inequalities, but the Secretary of State only “may” improve health. I think that is very interesting to look at. Perhaps that is a wrong that we ought to right.

[Lord Lansley (Con)]

The noble Baroness is absolutely right: local authorities “must” take such steps as they consider appropriate; the Secretary of State “may” take such steps as they consider appropriate. I think I was right in saying—and she has illustrated it—that we can improve what is in Section 2B. I would just make the point that, when we come to Report, it is necessary not only to look at what is in this Bill but to look at how the improvement of public health is promoted through the NHS Act, including Sections 2A and 2B.

19:30

[Baroness Thornton (Lab)]

My Lords, I do not intend, by and large, always to follow the noble Lord, Lord Lansley, if I make a remark to your Lordships’ House, and I will not go into the reasons for health inequalities, because they have been spoken to very adequately by the noble Lord, Lord Patel, and my noble friends Lady Royall, Lord Hunt and Lady Nargund. However, I want to say something about social care because, although the noble Lord, Lord Lansley, is quite right about public health and the need for prevention, none of this is going to work or be delivered—I make no apologies for saying this and I will keep saying it—including the 10-year plan and integrated care, unless we also address the issue of social care inequalities. As I am chair of the Social Care Institute for Excellence, the Committee would be expecting me to talk about that.

We recently did research, which has been published, about the inequities experienced by people who use social care. I thought it might be useful to remind the House what that said, because it will sound very familiar when we are talking about health inequalities. It was about people with lived experience, because our work in SCIE is based on people with lived experience, and co-production. It said:

“These policy and practice implications are reflected … by participants: a named point of contact to help them navigate the complex system … better continuity of carers to improve the quality of care and reduce the burden of having to explain one’s needs”,


as we hear time and again,

“clearer and more proactive information to ensure everybody is aware of their entitlements … investment in the workforce to encourage greater professionalism and retention … more consistent provision across areas to reduce the postcode lottery”.

We could be talking about the inequalities we have just been debating; the same applies in social care. The reassurance I seek from my noble friend the Minister is that that will be recognised as we go through this legislation.

[Lord Mawson (CB)]

My Lords, I found this an interesting debate, and I am sympathetic to the amendment of the noble Baroness, Lady Bennett, and particularly that of the noble Lord, Lord Patel, because he is right that very little is actually being learned. My colleagues and I have listened, over the years, to lots of conversations about health inequalities. When you spend your life in very challenging housing estates and see very little changing, you know about the distance between all the words and the practice.

That is why, many years ago, we decided to focus on practice and the doing of things, rather than the talking about things. We began to realise what every parent knows: that you only really learn by doing. When I started to work with GPs, originally in east London, they began by telling me that was how you became a GP. You saw one, you did one and then you taught one; it was a very practical matter. Businesses and entrepreneurs nowadays know that you learn by doing things. Yet in the state, which often feels so out of date in the NHS, there is no learning by doing culture. There is a learning by writing very fine reports, often at 60,000 feet, that seem very unengaged with practice.

Over the years, it has been interesting to observe what happened through practice. The Bromley-by-Bow model is well known, so I will not use it, but the noble Earl, Lord Howe, knows that I was also responsible for the transformation of a street following a murder and 10,000 illegal injections being given out in a housing estate. There were some terribly violent circumstances going on at the time. When I brought the first key people on the street together, all of them—the GP, the school and the housing association—were saying, “We cannot deal with this on our own. We need to do it together. These things are so interconnected”, and we built together the St Paul’s Way Transformation Project, which started with nothing and led to a new £40 million school, a £16 million health centre, 600 homes and now a new primary school.

We joined it up, and Professor Brian Cox and I led our 14th science summer school in June this year, with a masterclass at the end of it on quantum physics, for the children from the same housing estates. It is the same children and same families, and now they have one of the best performing schools in Tower Hamlets. The noble Earl, Lord Howe, helped us greatly at one key point with learning by doing, when he met the whole group—housing, health and education—when the NHS was getting in the way of us completing on the deal for the health centre. He was very helpful in enabling that to actually happen.

It was Duncan Selbie, the chief executive of Public Health England in 2015, who gave me £20 million and said, “Andrew, take this culture that you’ve been developing into the north of England”. We built 10 learning by doing innovation platforms in Rotherham, Bradford, Doncaster and Bootle, all of which were about bringing people together to learn about these matters. It was interesting that when I met the public health officials in each of these places, who were lovely people quoting all the same data that I had heard many times before, and said to them, “What are you actually going to do about that data?”, there was absolute silence. It was not their fault. They did not have the skills to know how to turn fine words into practice for some of the most challenging communities in this country.

It is my view that one of the things being missed in this moment is the serious need to get real about innovation and learning by doing. My colleagues and I—I declare my interests—are at the moment creating at place, on the ground, with local people and professionals, what we call these learning by doing innovation platforms, so that we bring together the actual GP, business person and local resident, and you begin to explore these issues together because in the modern world, health is everybody’s business. It is not just a matter for GPs. It is interconnected and we need to explore what that means.

My concern about where we are at the moment in discussing this Bill, which is a fantastic opportunity for this Government, and this country, to move into a form of health that is of this century and not last century, is that we are going to end up building a lot of biomedical boxes around this country that do not explore these interfaces in some of our most challenging communities. The noble Lord, Lord Patel, is right; we need to worry about why he is right and why things are not being learnt.

I finish with the thought that it is our experience over the years that, sadly, we have to say that, in so many respects, the NHS is not a learning organisation. We must have hosted 70 Government Ministers to our work over the years. They all come and say, “Wow, this is fantastic, we need to do more of it”. I can name the four who did anything practical about that, and the other 66 sit on a list in this pocket. This is not to do with bad people. It is about whether, as a nation, we are now going to get upstream into prevention and health creation and create a learning by doing environment in which we all learn together, and in which local people are part of all of that process.

[Baroness Pidgeon (LD)]

My Lords, this is a very important group of amendments, and it has been a really excellent debate. One of the most pressing issues facing us is the widening gap in health outcomes between different communities. Healthy life expectancy has fallen in recent years and the gap between the most and least deprived areas of England, as we have heard, now stands at almost 20 years.

The point made earlier by the noble Lord, Lord Crisp, when he talked about the role of the department being one of leadership for health across government, not just running the NHS, is really important as we approach this group of amendments. We have heard clearly that the current legislative framework places relatively weak duties on government to address these wider determinants of health and tackle inequalities.

The House of Commons Health and Social Care Select Committee, in its scrutiny of the Bill, called for a stronger focus on improving the nation’s health and tackling inequalities, emphasising the need for clearer accountability and a more robust approach to prevention across government. Many of the amendments in this group would help to achieve that aim by ensuring that reducing health inequalities becomes a central objective of health policy, and that progress is measured and reported transparently.

My noble friend Lady Walmsley’s amendments, spoken to by my noble friend Lady Tyler, and Amendment 7 from the noble Lord, Lord Patel, would strengthen the duty on the Secretary of State to take steps or action, rather than simply “have regard to”. That is really important. Amendment 14, tabled by the noble Lord, Lord Patel of Bradford, and supported by so many Members of the House today, would require the Secretary of State

“to have specific regard to reducing inequalities”

in coastal communities. The point has been made clearly about the added complexities for such communities, whether those are workforce related or in local service provision. Those are really important.

My Amendment 20 looks at health inequalities in urban areas and requests a strategy and an annual report. Impact on Urban Health, which is part of Guy’s & St Thomas’ Foundation, recently reported its State of Urban Health research and found that preventable mortality is 2.7 times higher in the most deprived urban neighbourhoods in England than in the least deprived. Urban areas also face some of England’s starkest health inequalities, with people living just streets apart experiencing significant differences in health. You have only to look over the river to the London Borough of Lambeth, where Impact on Urban Health is based: females who live just over a mile apart face an eight-year gap in life expectancy. As we have heard, these inequalities are driven by unfair and avoidable differences in everyday environments. These include exposure to air pollution, differences in housing quality and access to healthy, affordable food. I pulled this area out for specific attention: rather like the coastal communities amendment, it needs specific action.

My noble friend Baroness Tyler spoke strongly to Amendment 18, which would require a cross-government health inequality strategy and subsequent annual reports to Parliament on progress. That would focus minds and energy across government and would address the key point from the Health and Social Care Select Committee, as well as many of our suggestions in amendments and today’s debate.

If we are serious about narrowing the gap in healthy life expectancy and giving everyone the opportunity to live a healthier life, then action on the wider determinants of health and tackling health inequalities must sit at the heart of the Bill, not at its margins. I look forward to hearing the Minister’s response.

[Baroness Cash (Con)]

My Lords, I begin by thanking all noble Lords who tabled amendments in this important group and for the high quality of debate. At this time in the evening, it falls to me to be as brief as possible. As the quality of debate and the points made have been so thorough, I will try not to repeat anything.

We are all very much agreed: from these Benches, we have heard from the noble Lord, Lord Lansley, from the noble Baroness, Lady Manzoor, and from the noble Baroness, Lady Hodgson. We care a great deal about the inequalities in health outcomes in this country, but I am very grateful to the noble Baronesses, Lady Gerada and Lady Royall, for drawing the distinction between healthcare inequalities and health inequalities. It is important, and it is important for the purpose of the Bill and the duties that ought to be placed on the Secretary of State for Health.

It is incredibly challenging and painful to hear the data regarding ongoing inequalities. We know, of course, that healthcare is not the reason why it is in that state. The factors that play a part sit in different departments, which is why these Benches welcome the amendments which ask for a strategy. I hope that the Minister will consider joining up some of the significant work being done by the Government in the Fonagy review and the Milburn review to look at all these issues together.

It would be helpful to hear from the Minister about the specific actions the Secretary of State would be expected to undertake to ensure the duty as it is currently drafted, and how Parliament would be able to assess those decisions. We have heard from the noble Lord, Lord Lansley, about how we might improve on the current legislation, and it is important that we hear how that might be done. The inequalities in general practice are significant and challenging, and I look forward to hearing from the Minister about the Government’s plans to address them, such as through incentives to serve in different areas, targeted work plans and ensuring that enough training, development and recruitment is going on in those areas. I hope that all these issues will be subject to consideration by the Minister.

We cannot expect to reduce health inequalities without addressing these disparities in primary care. We look forward to hearing what might be done and what might be included in this Bill to do that. In the end, we must judge success by whether patients have access to the healthcare needed at the point of delivery. I look forward to the Minister’s response.

19:45

[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.

[Baroness Merron (Lab)]

I am sorry to hear that it is cold, but I am glad the noble Baroness is here. I appreciated the useful distinction that she drew regarding what we are talking about when we talk about inequalities.

Amendments 18 and 19, tabled respectively by the noble Baroness, Lady Tyler, and the noble Lord, Lord Patel, have regard to new strategies for tackling health inequalities. I know that your Lordships’ Committee is aware, but it is worth saying again that we remain absolutely committed to our comprehensive 10-year health plan. It was drawn up with a very wide range of input and, importantly—as has been referred to on this group and elsewhere—it was underpinned by the independent investigation of the NHS by the noble Lord, Lord Darzi. Tackling inequalities is at the very core of the 10-year health plan, which dictates everything that we do. It is therefore important that we focus on practical action rather than diverting towards developing new strategies. To assure noble Lords, I repeat that tackling inequalities is what I call core business; it is not an add-on or a sidecar—it is absolutely key.

The noble Lord, Lord Patel, put a number of observations to me and asked whether I agreed with them. My answer is that I appreciate them all and agree with most. I particularly welcome the acknowledgement by the noble Lord, Lord Patel, the noble Baroness, Lady Manzoor, and a number of my noble friends, of the achievement of the last Labour Government—which was somewhat exceptional in the period we have been talking about. The only point I would make to the noble Lord, Lord Patel, is that when he was running off a list of Ministers at the time, I hoped he might mention me—but I am doing so.

[Lord Patel (CB)]

I was going to do so after I heard the Minister’s response.

[Baroness Merron (Lab)]

I was very proud to have been part of that as Public Health Minister, working with Andy Burnham. But it is not enough to just rest or delight on one’s memories; we must take what worked and bring it into the current time.

I agree with the noble Lord, Lord Patel, that tackling health inequalities is key to not just the NHS but the broader economy—and, of course, the well-being of people. I agree with all noble Lords who said that a cross-government approach is crucial. That is why we are taking that approach, underpinned by the 10-year health plan. Tackling inequalities, for example, informs the key initiatives of the 10-year health plan, such as neighbourhood health centres. On that, we are starting in the most deprived communities. We are not going to the communities that are easier to work with; we are starting where there is the most challenge. I welcome that radical approach.

I believe accountability is extremely important. I assure noble Lords that the department will continue to report on action taken to address health inequalities as part of its annual report, alongside a whole range of published metrics, including the health inequalities dashboard. The dashboard’s measures cover 20 indicators, including—I will give noble Lords a couple of examples —the prevalence of adult and childhood obesity, and healthy life expectancy at birth.

My noble friend Lady Nargund supported the call for a cross-government strategy, which we are already working on. Recent cross-government action in this area includes the warm homes plan, the Keep Britain Working review and the homelessness strategy—all of which speak to the points that noble Lords are calling for. That is one of the reasons why I caution against putting in the Bill a duty to develop some independent strategy, when in fact it is core to what we are already doing.

Amendments 13 and 14 were tabled respectively by the noble Lords, Lord Patel and Lord Patel of Bradford. My noble friend Lord Hunt asked whether I would meet the noble Lord, Lord Patel of Bradford; I would be very pleased to do so, and I open that meeting up to other noble Lords who are interested in coastal and rural areas. Amendment 20 was tabled by the noble Baroness, Lady Pidgeon. These amendments are concerned with tackling health determinants and inequalities in coastal and other areas.

Health is determined not just by our health and care system but by our wider environment. We know that geographical variation has grown over a number of years, and this Government seek to tackle it. That variation runs from housing and employment to education and our local high streets, to name just some. It has informed the content of our 10-year health plan and the overall guiding aim that we pursue: to halve the gap in healthy life expectancy between the richest and the poorest—to which noble Lords referred. That is why we are introducing the neighbourhood health centres, to which I referred, where they are needed most. We are now going further by devolving power to local communities so that those who know their areas best can make sure that the services are there for them. I remind noble Lords that ICB funding allocations, for example, are already adjusted for health inequalities and take account of factors such as an ageing population and deprivation. The Core20PLUS5 approach gives ICBs a range of tools to tackle inequalities, and we will—and do—hold ICBs to account for their progress.

I am grateful to my noble friend Lord Hunt for tabling Amendment 11 on accessing GP services—an area raised by other noble Lords, including the noble Baroness, Lady Gerada. I agree that equitable distribution of GPs is crucial to ensuring that people in all areas get timely access to care. When I say that, I mean not that every area should have exactly the same number but that the distribution should be sensitive to the needs of an area. Progress is being made: there are 2,600 more GPs than in July 2024—the highest figure since 2015; the average number of patients per GP practice is improving; and we continue to boost recruitment through the practice-level GP reimbursement scheme in 2026-27. Because GPs—like other professions —are more likely to practise where they trained, we are delivering 1,000 more GP training practices by 2028, targeted towards the areas of greatest need. We are also reviewing the Carr-Hill funding formula because, to reduce health need, we have to ensure that resources are allocated much more accurately—as noble Lords expect.

The noble Baroness, Lady Hodgson, also commented on this area. We are uplifting the GP contract by £601 million for 2026-27, which builds on last year’s £1.1 billion of additional investment. In the year to August 2026, 15.8 million additional appointments—including Covid vaccinations—were delivered, compared with the previous 12 months. This is the way we are going. When I make these points, I am not saying that the job is done, but I am showing movement and improvement.

20:00

My noble friend Lady Thornton spoke rightly about having regard to social care. I know my noble friend knows this, but adult social care has its own statutory framework under the Care Act 2014, which is separate from the Health Bill. That said, I absolutely agree with her that social care and the NHS are inextricably linked, which is why we have committed to establishing a national care service alongside our National Health Service.

My noble friend referenced his meeting with my ministerial colleague the Minister for Public Health and Patient Safety to talk about concrete actions, which are key, rather than additional legislation. I am glad that he found that helpful and constructive, and I will certainly feed that back.

I am grateful to the noble Baroness, Lady Bennett, for recognising the significant inequalities experienced by a range of inclusion health groups, including Gypsy, Roma and Traveller communities, which the noble Baroness, Lady Jones, spoke to. I know that, had noble friend Lady Whitaker been here, she would have done likewise. Disadvantaged populations, including Gypsy, Roma and Traveller communities, are already explicitly recognised within the NHS’s inclusion health and Core20PLUS5 approaches, and we will continue to deal with this approach.

We should have regard to better data, as has been raised a number of times. NHS England’s ethnicity recording improvement plan is certainly strengthening the quality and consistency of that data, and the Office for Health Improvement and Disparities has established a national inclusion health data and intelligence resource. If I had to summarise my points, I would say that we believe that the existing statutory duties are a more flexible and proportionate basis for addressing these inequalities, rather than specifying individual populations and reporting arrangements in primary legislation.

Amendment 6 was tabled by the noble Baroness, Lady Bennett, and spoken to by the noble Baroness, Lady Jones. I have a lot of sympathy with its intentions, but I believe that a broader duty, as described, is unnecessary. The Secretary of State has an existing duty to take steps to protect the public from disease and other dangers to health, as well as powers to take appropriate steps to improve people’s health—noble Lords have spoken about that. Under Section 1 of the NHS Act 2006:

“The Secretary of State must continue the promotion … of a comprehensive health service designed to secure improvement … in the prevention”—

as called for by noble Lords—

“diagnosis and treatment of physical and mental illness”.

The recognition that health is influenced by a range of socioeconomic factors is very much at the heart of our commitment to achieve a long-desired left shift to prevention.

We have had a wide-ranging debate, and I will of course reflect on the points raised. This Government are committed to practical action, and I have given some examples of that and of the way we are moving. This primary legislation, as currently drafted, gives us the necessary legislative basis for what noble Lords seek. I actually think that our biggest challenge is to deliver that.

[Lord Patel (CB)]

The Minister did what I thought she would do: point to areas in the legislation that might help reduce inequalities in health and in outcome, and therefore inequalities in healthcare provision. She mentioned the 10-year health plan, but she was not able to point to where it says the gap is, which is around cross-government action. Neither did she mention examples in the Bill that demonstrate that there is cross-government action. She said she did not agree with me in one area—maybe it was that one.

[Baroness Merron (Lab)]

Oh, no—I agree with the noble Lord about the need for cross-government action. I simply part company with the idea that it needs to go into primary legislation. That would not be usual, because that is a process. I also referred to examples of where we already have cross-government action to deal with health inequalities, as distinct from healthcare inequalities—the noble Baroness, Lady Gerada, referred to that.

[Lord Patel (CB)]

Why not, when, as she mentioned, the Minister was previously so successful as part of the Government who demonstrated how they could implement cross-government action and reduce inequality?

[Baroness Merron (Lab)]

I am not sure we are that far apart on this. I am just picking up the point about primary legislation, rather than the intent of the noble Lord, which I agree with.

[Baroness Jones of Moulsecoomb (GP)]

I will stand up before anybody else does.

I thank the Minister for her replies; I really admire the positivity in there. I have been using the NHS since 1949, and it is absolutely amazing. My working-class parents were incredibly delighted by its introduction, but I rather suspect that my age cohort has had the best of it—I hope that that is not true. I would love to respond to a lot of the points, including on coastal communities, which often suffer from huge environmental pollution in rivers, along seashores and so on. This has been a fascinating debate, and I can see an exciting Report stage in the offing. In the meantime, I beg leave to withdraw my amendment.

Amendment 6 withdrawn.

Amendments 7 to 11 not moved.

House resumed. Committee to begin again not before 9.07 pm.