House of Lords
Introduction: Baroness Ashley of Lambeth
Introduction: Lord Lehrfreund
Business Hiring Intentions
(1 day, 9 hours ago)
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Lord Hunt of Wirral
To ask His Majesty’s Government what assessment they have made of current business hiring intentions and their impact on the wider economy.
The Parliamentary Under-Secretary of State, Department for Business and Trade (Lord Leong) (Lab)
My Lords, the UK labour market and economy remain resilient despite geopolitical uncertainty. The UK had the joint fastest-growing economy in the G7 in the first half of 2026. All the labour market and ONS data show that there are 356,000 more people in work than a year ago, and the Business Insights and Conditions Survey shows that more than 80% of businesses intend to either maintain or increase their staff levels in October 2026.
Lord Hunt of Wirral (Con)
My Lords, the Office for Budget Responsibility has just concluded that the Employment Rights Act 2025 will have a negative economic effect—something that we on these Benches and all employers have been warning about for a very long time. Does the Minister agree with the OBR and, if so, what is he going to do about it?
Lord Leong (Lab)
My Lords, I say in the nicest possible way to the noble Lord and to noble Lords opposite that supporting business enterprise means combining a hard head with a soft heart. The Employment Rights Act strengthens provisions, protections and security for working people, but legislation can only set minimum standards. The law establishes the floor; good businesses should compete to raise the ceiling. No Act of Parliament can make an employer care about their staff. That comes from leadership, values and culture. In my experience, looking after your people is fundamental to business success. We respect the OBR’s independent judgment. It expects a negative economic impact, as the noble Lord has said, but finds no clear evidence that it would exceed 0.1% of potential output, so it has made no explicit forecast adjustment.
Lord Fox (LD)
My Lords, as the Minister is talking about hard edges to business, it is two years since the then Chancellor made a surprise increase in national insurance contributions for UK businesses. Can the Minister tell us how many more jobs there would have been if this had not been brought in? How many SMEs have gone to the wall as a result of this, tipping them over the edge, and how much investment has been deferred because of this measure?
Lord Leong (Lab)
My Lords, I recognise the pressures on employers. We took the difficult decision to stabilise the public finances and fund essential services, while increasing employment allowance to £10,500 to protect smaller businesses. We are also supporting recruitment through the youth jobs grant of up to £3,000 and apprenticeship hiring payments of £2,000. Our aim is to help businesses create opportunities and give young people the skills and experience to build lasting careers.
Baroness Ritchie of Downpatrick (Lab)
My Lords, does my noble friend agree that it is important to be positive about these matters and that the Employment Rights Act, along with today’s announcement about the potential SPS agreement, will underscore the importance of our food exports, our food industry and the many jobs in it, and the potential for new employment?
Lord Leong (Lab)
I totally agree with my noble friend. The labour market is changing, and the provisional ONS figures for the year to September 2026 show that the payroll has increased by 66,000 in administrative and support services, by 20,000 in education and by 19,000 in health and social care. The wholesale and retail sector lost 71,000, accommodation and food services lost 46,000 and manufacturing 32,000. We are backing investment into skills and sector jobs plans to help businesses recruit and people move into secure long-term employment.
Lord Bilimoria (CB)
My Lords, as chair of the International Chamber of Commerce in the UK and a former university chancellor, it saddens me that almost a million young people are not in education, employment or training. What are the Government doing to help university graduates get jobs? They are really struggling to find jobs at the moment and they deserve to get them.
Lord Leong (Lab)
My Lords, I fully accept that the labour market is failing too many graduates. Repeated rejection wastes talent and damages confidence. We are investing £7.8 million in university AI courses and graduate traineeships and our £20 million early careers jobs alliance helps employers maintain routes into work as technology changes. The digital and technologies jobs plan targets 20,000 entry-level jobs annually. Our responsibility is to turn those commitments into interviews, paid opportunities and lasting careers.
Lord Leigh of Hurley (Con)
My Lords, will the Minister take this opportunity to disassociate himself from the remarks of the Chief Secretary to the Treasury, who said that employers are not “working people”? Thousands of small businesses and employers like myself take great exception to this because it goes to the mindset and attitude of the Government.
Lord Leong (Lab)
Employers, employees and suppliers are part of the ecosystem, and we need to support the employers and suppliers as well. The way to tackle unemployment is by working with employers and looking at pathways into growing industries. Professional and business services firms have pledged to create 22,400 apprenticeships for young people under the age of 25 over the next five years. Construction aims to create 10,000 job opportunities each year, while digital and technology employers are targeting 20,000 entry-level jobs. These sector jobs plans will link investment to skills and recruitment, and our focus is on turning those commitments into lasting careers.
Lord Spellar (Lab)
My Lords, as we have just heard, there are a million youngsters who are not able to get into work. Many are university graduates, who then face the questions: “Have you got a degree? Have you got two years’ experience?”. How are they going to get two years’ experience if employers will not take them on? That is just one example of dysfunctionality in the labour market. What are the Government doing actively to engage with employers to get a rational labour market that will enable our youngsters to get into work at all levels of jobs?
Lord Leong (Lab)
My Lords, we are determined to tackle youth unemployment and look forward to receiving Alan Milburn’s recommendations. In addition, we have committed a further £2.5 billion to the youth guarantee and growth and skills levy, helping nearly 1 million young people aged 16 to 24 move into jobs, education and training. This will create 200,000 jobs, provide £3,000 for youth jobs grants and £2,000 in apprenticeship hiring payments and guarantee jobs for young people claiming universal credit who have been unemployed long term.
Lord Harper (Con)
My Lords, I am surprised that the Minister could not answer my noble friend Lord Leigh’s question, because the Chancellor slapped down the Chief Secretary for her ridiculous comments, and I am glad that he did. The Minister gave a good answer to the question from the noble Lord, Lord Spellar, about how to deal with the 1 million young people out of work. How does he think importing up to 80,000 young people from the European Union under the youth mobility scheme will help British young people get into work?
Lord Leong (Lab)
Settlement is based on contribution, not just on time served, as it was under the last Government. We have cut net migration to 82% below its peak under the last Government. We will not leave young British people behind, which is why we are investing an additional £2.5 billion, as I said in my previous answer, to support almost 1 million young people into education, employment and training.
Baroness Uddin (Non-Afl)
My Lords, is the Minister aware that yesterday an industry guide was published by UKAI which finds a distinct lack of progress in the promised advanced technology jobs, particularly for women in many inner-city areas? Will the Minister look at the report and its findings and consider meeting the group?
Lord Leong (Lab)
I have not had a chance to look at the report, but I definitely will. AI is automating repetitive tasks, and we take the risk to entry-level jobs seriously. The £20 million for the early careers job alliance that I mentioned earlier is helping employers redesign roles while maintaining routes into work. Through our AI skills boost, we aim to equip 10 million people with practical AI skills by 2030. Our priority is adoption that supports workers, improves productivity and opens opportunities. Technological progress must give young people a better future, not close the door.
Parthenon Sculptures
(1 day, 9 hours ago)
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The Earl of Clancarty
To ask His Majesty’s Government what assessment they have made of proposals for the permanent return of the Parthenon sculptures held by the British Museum to Greece.
The Parliamentary Secretary, Cabinet Office, and Parliamentary Under-Secretary of State, Department for Digital, Culture, Media and Sport (Baroness Twycross) (Lab)
The Government have made no assessment of the proposals for the permanent return to Greece of the Parthenon sculptures held by the British Museum. We welcome the fact that the British Museum is in discussions with Greek Ministers, seeking a constructive partnership.
The Earl of Clancarty (CB)
My Lords, we hear the legal and nationalistic arguments for return, but surely the key argument is the aesthetic one. If, for example, Picasso’s “Guernica” were to be cut into pieces and displayed in different museums, there would be an almighty clamour to get those pieces reunited. Should not the same consideration be given to Phidias’s masterwork? Secondly, the Government say that this is a matter for the British Museum, except that its hands are tied by the British Museum Act. Will the Government amend the Act in a limited way so that a decision can be made?
Baroness Twycross (Lab)
The British Museum and the Government recognise the strength of feeling on this. The British Museum has consistently stated that it would consider a loan request for the sculptures on the condition that the British Museum’s ownership is acknowledged and that a binding undertaking is given to return them. In relation to the Charities Act 2022, which I think is what the noble Earl was alluding to, the Department for Digital, Culture, Media and Sport has committed to review the implementation of Sections 15 and 16 as part of the post-implementation review of the whole of that Act. This review is due to report in February 2027.
Viscount Hailsham (Con)
My Lords, given that our museums are stuffed full of artefacts acquired from abroad, frequently in rather doubtful circumstances, returning the sculptures will be a most unfortunate precedent.
Baroness Twycross (Lab)
We have a clear view that museums are independent of government; this is one of the principles that we adhere to. There are clear examples of museums returning items. As I said, however, the current position is that the British Museum is not planning to permanently return the Parthenon marbles, and that remains its position.
Lord Dubs (Lab)
My Lords, many of us have long argued that the Parthenon sculptures should be returned to Greece, notwithstanding what the Minister just said. Can the Minister clarify something? Does she believe that the present legislation—that is to say, Section 5(1)(c) of the British Museum Act—would be sufficient to return the sculptures, or does it require new legislation?
Baroness Twycross (Lab)
The British Museum Act 1963 prevents the museum disposing of items in its collection. There are limited exceptions for duplicates and objects that are not fit for retention, with specific exemptions created in legislation for objects taken during the Nazi era and for human remains that are less than 1,000 years old. We welcome that the British Museum is in discussion with Greek Ministers to seek a constructive partnership. The director of the museum has alluded to the Bayeux Tapestry loan as a potential model. That is an interesting idea. The loan of the tapestry is proving a huge success story.
Lord Addington (LD)
My Lords, can the Government assure us that if an agreement is reached by the British Museum with Greece, any legislation that is required will be passed within this Parliament?
Baroness Twycross (Lab)
At present, there is no agreement for us to lean into in that way but, as I said, the British Museum recognises the strength of feeling on this. It is working very hard to find an arrangement that works within the current legal framework. I refer noble Lords to the point that I made earlier around the implementation of Sections 15 and 16 of the Charities Act, which is part of the review. However, we are open to the museum exploring a loan agreement if that is agreeable to Greece’s Ministers and population.
Baroness Chakrabarti (Lab)
My Lords, if some of the crown jewels had been pinched, we would not be so glad of a loan agreement. Given what my noble friend the Minister said about this being a matter for the British Museum, will the British Museum Act be amended to untie the hands of the museum?
Baroness Twycross (Lab)
We have no plans to review the British Museum Act. It was not in the King’s Speech. However, we recognise the strength of feeling on this. I can only stress that the British Museum is working extremely hard and discussing possible solutions with Greek Ministers.
The Earl of Effingham (Con)
My Lords, over 6 million people every year enjoy viewing the Elgin marbles. The British Museum’s stance is clear. It is of far greater concern that this Government are considering allowing mayors to introduce a holiday tax on British and international visitors, such as those to the British Museum. It will weaken tourism and put jobs at risk. Why are the Government intent on yet another tax levy that will hurt the economy?
Baroness Twycross (Lab)
I am slightly surprised that the noble Earl is taking this line of questioning. The Government are empowering mayoral strategic authorities and strategic authorities to introduce a potential visitor levy on short-term overnight accommodation in their regions in order to drive economic growth, including full support for the visitor economy. Personally—I know this will be the case for many noble Lords across your Lordships’ House—I think very little of an additional fee when I pay for hotel accommodation overseas routinely. We are clear that local leaders will be setting out plans for how the revenues will be invested by early 2028. There will be plenty of time to discuss how the levy would work and the potential impact. We are clear that this is a positive step to enable mayors to drive their local economies.
Lord Ricketts (CB)
My Lords, referring back to a previous answer by the Minister, can she reassure the House—and any international partners who may be listening—that the Government’s intention is to permanently return the Bayeux Tapestry after its sensational run here? I understand that it has had more than 200,000 visitors.
Baroness Twycross (Lab)
I assure the noble Lord, not least because of his role in ensuring that we were able to bring the Bayeaux Tapestry to the UK for the first time in more than 900 years, that there is no intention to keep the Bayeux Tapestry in this country. It would be over my dead body.
Lord Sahota (Lab)
My Lords, I wish all noble Lords a happy Diwali, which is at the weekend. When Britain annexed the Sikh Empire in 1849, the koh-i-noor diamond was taken from its young maharaja, Duleep Singh—he was only 10 years old—and subsequently presented to Queen Victoria. Many Sikhs have long maintained that the diamond was taken under duress and rightfully belongs to their heritage. Will the Government consider returning the koh-i-noor diamond to the Sikh community as this was an act of historical injustice?
Baroness Twycross (Lab)
I thank my noble friend for raising this issue, and I share his best wishes to everyone celebrating Diwali. I recognise the historical significance for the Sikh community. The diamond has a contested history. However, it remains the UK Government’s long-standing position that the koh-i-noor diamond should remain in the UK.
Baroness Jones of Moulsecoomb (GP)
My Lords, as a former archaeologist, I have some sympathy with the Greek Government, who argue that the sculptures were actually bought from the Ottoman Empire, not the Greek Empire. Therefore, perhaps there is a strong argument for returning them. I have visited the Parthenon and there are some quite naked bits where the sculptures ought to fit back.
Baroness Twycross (Lab)
I can only reiterate that the UK has a really strong relationship with Greece that is built on shared values and history. We greatly value the friendship that exists between our people today. The Government do not have any plans to change the law or introduce legislation to permit the Parthenon sculptures to be returned permanently. However, we recognise, as the British Museum does, the strength of feeling on this and support the museum in its stating that it would consider a loan request for the sculptures should that be agreeable.
Captain of the King’s Bodyguard of the Yeomen of the Guard and Deputy Chief Whip (Baroness Anderson of Stoke-on-Trent) (Lab)
My Lords, based on numbers so far, it is the turn of the Lib Dems.
Baroness Hussein-Ece (LD)
My Lords, the Greek Government have been trying to negotiate the return of the Parthenon marbles for decades, and we need to acknowledge that they are an integral part of Greece’s cultural heritage. A museum has been purpose-built near the site of the Parthenon where the sculptures were originally displayed for 2,000 years. The noble Lord on the Conservative Benches put his finger on it: the British Museum is stuffed full of artefacts from around the world. In fact, I understand that there is much that is not displayed in the basements and vaults. Maybe it would be an opportunity to bring some of those artefacts out if the museum returned the Parthenon marbles to Greece.
Baroness Twycross (Lab)
I can only reiterate that we have no plans to legislate to do that at the moment, but we genuinely understand the strength of feeling, as does the British Museum.
National Brain Cancer Lead
(1 day, 9 hours ago)
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Baroness Paul of Shepherd’s Bush
To ask His Majesty’s Government what progress they have made towards appointing a national lead for brain cancer, and what measures are in place to ensure that the role supports improvements in research funding, clinical care, treatment pathways and patient outcomes across the United Kingdom.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, last month the Government confirmed plans to recruit a national brain tumour lead, with details to follow. As announced by the Prime Minister, the national lead will co-ordinate action and drive forward work to improve outcomes for brain tumour patients, supported by our rare cancer clinical and research leads and working with the National Cancer Board.
Baroness Paul of Shepherd’s Bush (Lab)
My Lords, I congratulate 25 year-old Archie Goodburn, the Commonwealth medallist living with a currently incurable brain tumour, on securing this commitment from the Prime Minister for a clinical lead on this devastating disease. Brain tumours are the biggest cancer killer of children and young people under 40, but despite this, there has been no change or progress in treatment in over 40 years. Does the Minister agree with me that the only way to change outcomes is to accelerate at pace the number and range of clinical trials taking place so that there is a chance of a cure for Archie and other patients?
Baroness Merron (Lab)
I know how much the Prime Minister appreciated his meeting with Archie. Indeed, the Prime Minister has acknowledged that enough progress has not been made in this area and committed, as my noble friend said, to a number of actions. I certainly would agree with my noble friend’s view on the importance of clinical trials. I can say to my noble friend that, as we set out in the national cancer plan, we are committed to ensuring that the UK supports new clinical trials for brain cancer and boosting participation in research. Both of these really need to be pushed forward, and we are fast-tracking clinical trial set-up times to 150 days to ensure that more patients can access innovative treatments in our country.
Baroness Pidgeon (LD)
My Lords, I pay tribute to the swimmer, Archie Goodburn, for his courage in campaigning for people affected by brain cancer. I welcome the Government’s commitment to commission an expert review. Will they ensure that it will set out clear, time-bound recommendations, with named bodies responsible for delivery in this area, and that progress against them is published?
Baroness Merron (Lab)
We are keen to be open about this. The immediate expert review, which will take just three months, will be led by Professor Anthony Chalmers. It will examine progress since the 2018 brain tumour research report. I look forward to that review being published within three months. A national action plan, which I am sure will refer to the points that the noble Baroness made, will then help us to move discoveries from the laboratory into treatments and clinical care much more quickly. That is where we need to be.
Baroness Finlay of Llandaff (CB)
My Lords, what powers will the appointment have, given that 74% of patients are diagnosed in A&E because of delays in diagnosis in primary care? This results in 45% of patients being told in A&E that they have a brain tumour. Even when they have a biopsy, there are inadequate freezing facilities for biopsies to be taken and kept so that personalised medicine can be developed and entered into studies.
Baroness Merron (Lab)
On the point about brain tissue freezing, NHS England has, as the noble Baroness may be aware, just completed a freezer capacity gap analysis and is in the process of working with sites to ensure additional capacity. I share her view that identification in an emergency setting is not the best place, although that will sometimes be the case. All this movement is to reduce that incidence.
Baroness Mattinson (Lab)
My Lords, I want to pick up two aspects of this very welcome new appointment. The first is the degree to which the patient’s voice—so often overlooked in this area—will be heard, and that listening to it will be part of the remit. The second is about timing. Can the Minister reassure us on the speediness of the appointment, given that most brain cancer patients have 12 to 18 months to live after diagnosis? They do not have the luxury of time on their side.
Baroness Merron (Lab)
I think that has been acknowledged by the Prime Minister in this review being so rapid—delivered within three months—and in the fact that he is taking personal oversight of this work. Again, that is to be welcomed. On the patient’s voice, one of the outcomes from discussions is that the Secretary of State will be convening researchers, clinicians and charities to identify practical ways to increase participation in brain cancer trials. Certainly, the Prime Minister has asked patients, families and charities to work with us to help raise awareness and support participation in clinical trials. For me, the patient’s voice is absolutely critical and I know that it will be at the heart of this.
Lord Patel (CB)
My Lords, we recognise that outcomes for people with brain tumours and cancers, particularly children, is a survival time of no more than 13 months to five years. Although it is important to do clinical trials using drugs, the problem we have is the blood-brain barrier, which protects the brain from being affected by these drugs. We need to find novel ways of treatment. Some are being researched; for instance, focused ultrasound, micro-RNA treatments and personalised vaccines developed for particular patients for each of their tumours. We need to support these novel ways of finding treatments for brain tumours that do not apply to other diseases.
Baroness Merron (Lab)
The noble Lord is right. That is why we have to work so much more quickly to move discoveries from research into treatments and clinical care. That has been sadly lacking, which is why the points that the Prime Minister announced include an accelerated review by the MHRA of the regulatory arrangements for rare disease medicines, known as orphan drugs—I mention that just as one example—that would see that work completed in two years rather than three. We understand the need for speed and acknowledge that we are in a position, sadly, where not enough progress has been made in this area.
Lord Kamall (Con)
My Lords, I too welcome the Government’s commitment to establishing a dedicated national brain cancer lead. My question is about accountability, going back to the question from the noble Baroness, Lady Pidgeon. Will the Government publish a set of measurable objectives for the national lead, particularly for access to treatment and patient outcomes, so that this House and others can assess whether the role is achieving the real progress that patients and families want to see?
Baroness Merron (Lab)
I mentioned a national action plan that will be informed by the three-month review, and I confirm that the Government will publish that national action plan. I would expect to see the markers that the noble Baroness and the noble Lord have called for within that.
Baroness Linforth (Lab)
My Lords, I am very pleased that my noble friend Lady Paul asked this Question today as our great friend Baroness McDonagh died of a glioblastoma in 2023. I understand that the NHS is currently running 35 clinical trials related to brain cancer, of which nine are related to glioblastoma, the most aggressive form of brain tumour. Will the Minister either tell the House today or write to me setting out how many patients have been recruited to each of those trials?
Baroness Merron (Lab)
I am grateful to my noble friend for honouring the memory of Baroness McDonagh, as other noble Lords have done, and Baroness Jowell. I know that many noble Lords are affected directly or indirectly by this and will be feeling the weight of that as we discuss this matter. To answer my noble friend’s question, the number of glioblastoma patients who have been recruited into specific trials is not centrally held. There is a reason for that. It is because many studies enrol patients who have more than one type of brain cancer, and the data is managed by study teams and sponsors. I also note that some data for commercial trials is considered commercially sensitive. Each trial will have its own inclusion and exclusion criteria that are set out by the study team. Having said that, if there are particular things with which I can assist my noble friend, of course I will be pleased to do so.
Binance Security Breach: Consumer Exposure and Interim Safeguards
(1 day, 9 hours ago)
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Lord Nagaraju
To ask His Majesty’s Government, in light of the security breach at Binance, what assessment they have made of the exposure of UK consumers to that incident; and what interim cybersecurity safeguards they plan to introduce before the new cryptoasset regulatory regime takes effect in October 2027.
Lord Nagaraju (Lab)
My Lords, I declare my interests in AI and technology as set out in the register, and I beg leave to ask the Question standing in my name on the Order Paper.
The Parliamentary Secretary, HM Treasury (Lord Pitt-Watson) (Lab)
I welcome this Question. The Government are closely monitoring developments following the Binance security breach and are engaging with the Financial Conduct Authority and other authorities to assess the implications for the UK. Binance is not authorised or registered to provide crypto asset services to the UK. However, it is possible that UK customers may still have been affected, and the Government are currently working to understand the associated impacts and risks.
Lord Nagaraju (Lab)
My Lords, given that a large number of UK consumers engage with crypto assets and that the new regulatory regime will not take full effect until October 2027, will the Minister commit today to working with the FCA, the National Cyber Security Centre, the Bank of England and other relevant authorities to put effective transition arrangements in place now and publish a clear interim cyber security and consumer protection plan with a timetable before the end of this year?
Lord Pitt-Watson (Lab)
We are looking to learn from what happened at Binance, but I am not clear that it makes sense to put in an interim arrangement. By October next year, we will have a comprehensive FCA regime for crypto assets, including disclosure, market abuse and resilience. To put that in place requires changes by the firms, and it then requires authorisation. There will be an iterative process there, and I think it might not be helpful to have an interim regime in the middle of that. It would perhaps slow things down.
Baroness Kramer (LD)
My Lords, the hacking of Binance demonstrates that large-scale theft is far more possible in a crypto world. At present, UK banks are resisting providing accounts, financial services and credit lines to crypto service providers, but that is expected to change in the next year when the FCA’s crypto providers authorisation scheme kicks in. What would be the consequence to bank stability of such a heist happening after that authorisation and the relationship created between the banks and the crypto world? Would the banks be covering the losses? It is certainly unclear who is covering the losses now.
Lord Pitt-Watson (Lab)
I am not quite sure what heist the noble Baroness has in mind. We can say that, right now, the Financial Stability Board does not believe that crypto assets are a systemic risk to the financial system, but if she would like to write to me with her thoughts on how this heist might come about to affect one of the large banks, I would be very interested to read that.
Lord Ranger of Northwood (Con)
My Lords, I bring to the attention of the House my registered interests in AI businesses and digital assets.
Digital assets operate across borders, as do cyber security threats, as we have seen in the issue with Binance. Given the considerable progress being made internationally on regulatory co-operation, does the Minister agree that there should be an increased amount of discussion about that co-operation on regulatory compliance? Also, does the Minister agree that the Government should commit to making digital assets a security and regulatory priority as part of our G20 presidency next year?
Lord Pitt-Watson (Lab)
Digital assets and cryptocurrencies are two related things. As regards digital assets, this is something that the Government are promoting through our industry group with Chris Woolard. He has been quite successful in thinking how we do that safely and well to make the UK a centre that can take advantage of digital assets and tokenisation.
Lord Alton of Liverpool (CB)
My Lords, will the Minister ask his officials to provide for him a copy of the House of Lords Written Question HL4338 from December 2017? That contained warnings about the ability of North Korea to hack cryptocurrency and to commit cyber robbery—2017 being the year of the attack by North Korea on our National Health Service. Will the Minister ask his officials what notice was taken of those warnings? In light of the evasion of sanctions and the recycling of revenues into nuclear weapons and ballistic missiles programmes, what progress is being made in tracing the stolen assets and identifying those responsible? Will the Minister agree to meet the officers of the All-Party Parliamentary Group on North Korea and the All-Party Parliamentary Group on Crypto and Digital Assets?
Lord Pitt-Watson (Lab)
I would be very happy to meet, but I wonder whether there is a misunderstanding here. Binance, which is the institution that has been hacked, is not authorised in the UK. It is not registered in the UK; it is a foreign entity. While I am sure that there will be lessons to be learned from the issues that the noble Lord is talking about, what happened with Binance did not happen under any registration in the UK.
Baroness Neville-Rolfe (Con)
My Lords, this incident shows that society as a whole faces very serious risks from cyber crime and that lessons need to be learned, as the Minister has said. I know that the Minister is concerned about financial education. Will he use his influence to ensure that the prevention of fraud in all its aspects, including cyber crime, plays a full part in plans to improve financial education?
Lord Pitt-Watson (Lab)
I would be more than happy to do that, and to do it jointly with the noble Baroness.
Lord Vaux of Harrowden (CB)
My Lords, the Government are issuing digital gilt instruments, and I believe that the first trades are expected to happen in Q1 of next year. What lessons are we learning in terms of the security for DIGIT from this hack?
Lord Pitt-Watson (Lab)
The DIGIT is a digital gilt instrument which we are experimenting with. The hack, of course, was to an exchange, which is rather different, so I am afraid I do not have an answer to that question. If the noble Lord would like, I could write when the evidence is in about what happened on Binance and any relevance it might have for DIGIT.
Lord Fox (LD)
My Lords, to help the Minister’s bewilderment at my noble friend Lady Kramer’s question, he is right to say that Binance is not registered in the United Kingdom at the moment. But under the conditions of change, as outlined by my noble friend, there is every reason to believe that Binance or an equivalent organisation will be registered after the changes next year. Her question was: in the event of that, how would such a theft be dealt with? Would it be by the banks or the exchange, and where would the Government and the Bank of England sit in that position?
Lord Pitt-Watson (Lab)
I do not know the details of what happened at Binance, but my understanding is that the money came from custodial operations at the exchange itself, not from a bank. Perhaps I could get back to the noble Lord if I am wrong on that.
Lord Bellingham (Con)
My Lords, following the question asked by the noble Lord, Lord Alton, the Minister will probably be aware that yesterday the US Treasury announced that it had overwhelming evidence that it was rogue North Korean state actors who perpetrated this appalling fraud. Given the number of UK investors in this particular exchange, what can he and his department do to work with the US Administration to pursue this?
Lord Pitt-Watson (Lab)
I am not sure that we know how many UK investors there were because, as I say, Binance was not authorised or registered to provide crypto asset services to the UK. But when we discover that, which we are looking to do today, I am sure we will want to co-operate with all regulatory authorities in making sure that this cannot happen again.
The Earl of Kinnoull (CB)
My Lords, North Korea has form in attacking financial markets to fund its foreign currency requirements. It attacked the London reinsurance markets 15 years or so ago, when there were heavy losses for London reinsurers and losses for German reinsurers. This is a pattern of attack by North Korea. Can the Minister tell us whether we are co-operating internationally, not just with the Americans but with the Germans in this instance, to try to make sure that we can stamp out this abuse by North Korea?
Lord Pitt-Watson (Lab)
Indeed we are. We have been taking some powers to trace, seize and recover, and we have been getting financial institutions to do more about disclosure and know your customers. I am not aware of the specific conversations that we have had with individual countries, but if that is of particular interest to the noble Earl, perhaps I can write to him.
Border Security, Asylum and Immigration Act 2025 (Specified Purposes Related to Policing) Regulations 2026
(1 day, 9 hours ago)
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Lord Collins of Highbury
That the draft Regulations laid before the House on 2 September be approved.
Considered in Grand Committee on 28 October.
Health Bill
(1 day, 9 hours ago)
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Baroness in Waiting/Government Whip (Baroness Hyde of Bemerton) (Lab)
My Lords, before we continue to debate Amendment 21, I remind the Committee that this is an adjourned debate. Therefore, unless you were present at the start of consideration of the group, you are not able to contribute. The Clerk at the Table has a full list of those who were present.
Lord Hunt of Kings Heath (Lab)
My Lords, as I moved the first amendment in this group, it might be helpful if I recap the nature of the debate last week. The noble Baroness, Lady Tyler, spoke to a number of amendments on carers. She said that there are
“4.7 million unpaid carers in England”.—[Official Report, 28/10/26; col. 1234.]
They lack support. One of the reasons for that is that we do not have a system of identifying who they are. This was backed up by the noble Lord, Lord Young, who spoke about young carers. He spoke of
“15,000 schoolchildren spending more than 50 hours a week looking after their parents or siblings, and 3,000 of those were aged between five and nine”.—[Official Report, 28/10/26; col. 1237.]
They face many disadvantages in the field of education, as the noble Lord, Lord Young, identified. They are rarely identified by the relevant authorities until, on average, three years have passed since they first began caring.
My amendments run in parallel to those tabled by the noble Baroness, Lady Tyler. They are about introducing a new legal right to ensure that no one is cut off from relatives and friends in care homes, hospitals and other care settings. This would mean that anyone relying on health and care services, either in the short or longer term, would have the right to nominate a trusted relative, friend or paid carer to provide essential in-person support. Their access will be protected and their advocacy respected. During Covid in particular, but subsequently too, there was a lot of evidence that, when a carer, relative or friend raised concerns about their loved one in a residential care home, in some cases they were told that they were not allowed to visit again. There have been some cases, too, where the resident was required to be removed from the home. The noble and learned Baroness, Lady Hallett, recognised the importance of this in her recent Covid-19 inquiry report:
“In a future pandemic, visits from essential carers should be available to all residents where possible and should be distinct from considerations regarding general visiting”.
Her report recommended this protection be framed as a right.
Baroness Morris of Bolton (Con)
My Lords, it is sometimes frustrating when sitting on the Woolsack or at the Table during Committee when a debate is taking place and you wish you could jump up and say something—a situation I found myself in on Wednesday night. I was very glad when the Committee adjourned the debate on Amendment 21; in fact, I think I was the person who adjourned the debate, which allows me to say just a few words today on this group of important amendments.
I must admit to noble Lords that I have not spoken on a health Bill since I was the Opposition health Whip to my noble friend Lord Howe many years ago. I was also the shadow Minister for what was then the department for children, schools and families. In that capacity, I met many young carers. I was humbled by their dedication and the sacrifices they willingly accepted; my admiration for them—then and now—knows no bounds.
I wish to add my voice to the powerful speeches already made on this group, particularly in support of respite care. In doing so, I have just one question for the Minister. I recognise from the Government’s unpaid carers action plan that much work is going in to the collection of data and identification of unpaid carers by bringing together multiple services, but, from my own experience, many young carers are wary of official services, fearing that they may think them unable to cope. However, many will turn to the wonderful charities who are active in this space, such as Action for Children. Therefore, can the Minister say whether the voluntary sector will also be included in this bringing together of services to improve the outcome for young carers—indeed, all carers—and their families? Will carers also have a voice?
Baroness Nargund (Lab)
My Lords, I understand the concerns that have prompted the noble Baroness, Lady Tyler, to table her amendment, and I support her fully. Many times in this very Chamber I have raised the issue of the burden of unpaid caring on one’s health, well-being and finances. The majority of unpaid carers are women who sacrifice their own health and well-being needs to care for others. It is very important that we care for them. As many noble Lords said last week, we know that many unpaid carers do not identify themselves, but women are less likely to do so. Identifying carers is important, but they must not simply become another statistic, because behind every carer there is a family. Identification should and must lead to meaningful support for carers and their families.
As the noble Baroness, Lady Tyler, has already pointed out, there is evidence of under-identification of unpaid carers. Analysis by the Nuffield Trust of 13 million GP records found that only 1.4% of patients were recorded as unpaid carers in GP systems, compared with the census estimate of approximately 8.8%. That means that for every unpaid carer identified by GP practices, roughly four were not identified. In other words, around 1 million unpaid carers were missing from GP records.
I welcome Action 102 in the Renewed Women’s Health Strategy for England, which pledges to support unpaid carers to balance their work and care. The single patient record can be an important enabling tool to identify unpaid carers and record all their caring responsibilities. Therefore, can my noble friend the Minister say whether the single patient record will be set up to systematically identify unpaid carers, and whether ICBs will have a clear responsibility to act on that information to protect their health and well-being? Will the Renewed Women’s Health Strategy for England be joined up to this to support women who are unpaid carers? We owe it to them.
Baroness Pidgeon (LD)
My Lords, this debate, though it started last week, has highlighted the extraordinary contribution made by unpaid carers across the country. Every day, millions of people provide care, often around the clock, enabling their loved ones to live with dignity and independence. Their contribution is not only invaluable to the individuals they support; it is fundamental to the sustainability of the health and care system as we know it. As my noble friend Lady Tyler rightly pointed out last week, and as the noble Lord, Lord Hunt, pointed out today, the unpaid care provided by an estimated 4.7 million carers in England is worth some £152 billion a year—a figure comparable with the NHS budget. Without those carers, our health and social care services would be unable to cope.
Throughout this debate, noble Lords have highlighted the stark reality that carers too often remain invisible to the very systems that rely most heavily upon them. For too many carers who are not identified by health services, this means that they miss out on support, advice and interventions that would protect their own health and well-being as well. Amendments 88 and 89 would help to address these issues.
Earl Howe (Con)
My Lords, the Committee will undoubtedly be grateful to the noble Lord, Lord Hunt, and the noble Baroness, Lady Tyler, for bringing forward these important amendments and for highlighting the vital contribution that unpaid carers make to our health and care system.
It is an obvious truth, but a truth worth stating, that carers are the people who know the person they care for best. They provide not only practical support but continuity, reassurance and an understanding of individual needs that can make a real difference to the quality of care. I very much welcome the recognition of the key role that carers play and the need to ensure that they are, first, identified—as many noble Lords have emphasised—and then listened to and appropriately involved in decisions about the people they support, while at the same time respecting the wishes and rights of patients themselves.
Carers are often family, friends and neighbours, and they usually do not foresee the duty happening upon them. They demonstrate the most admirable qualities in fulfilling that duty. The pressures that caring responsibilities can place on individuals and families are frequently very considerable, which is why we must never lose sight of the need to support carers’ own health and well-being, including opportunities to take a break from caring, as the noble Baroness, Lady Pidgeon, mentioned.
Amendment 21 would enshrine the right of carers to be involved in patients’ decisions, which seems eminently sensible and right. Carers, with patient consent, already have the right to be involved in discussions with clinicians. At the same time, clinicians will always need to make a judgment according to the situation, because it is just as important to go back and check the wishes of the patient and to make sure, for example, that they have privacy when they want it. Without wishing to downplay in the slightest the value of these amendments, it would be helpful to have confirmation from the Minister that a patient has the right to withhold from a carer sensitive information in their medical records that they might not want shared.
We will be debating the Government’s proposals for a national care service in a later group, but I wonder whether the Minister can give us a sense of how the Government view the position of unpaid carers in the context of those proposals. In what way do they think a national care service could or should affect the status of family carers? I ask because, with the concerns that noble Lords have raised during the debate, it seems doubly important that we do not inadvertently sideline or devalue the extraordinary contribution to society, and indeed to the economy, that unpaid carers make, or overlook the practical support and respite that carers need.
Unpaid carers are the backbone of so much of our health and social care system. Carers can be of any age. My noble friend Lord Young of Cookham rightly emphasised the role of young carers. Their contribution is immense, as are the burdens they carry, yet so often those things go unseen. Caring is a profoundly challenging role that, over time, will undoubtedly affect a person’s mental and physical health. The support for carers that noble Lords have so often called for can come in different forms: the noble Baroness, Lady Watkins, referred to the vital importance of respite and the part that care homes play in providing it. My noble friend Lady Morris has just reminded us that there are many great charities operating in this field. I wonder whether the Minister could give us a sense of what the Government’s vision is for how such support and respite should be delivered: whether they see it as primarily a role for the state or whether there is a broader palette of provision that is right and sensible to avail of.
Whatever the future structure of our care system, we must not lose sight of the people who give so much to care for others. Their voices and needs must be recognised.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I am most grateful to my noble friend Lord Hunt and the noble Baroness, Lady Tyler, for initiating this important debate about carers, and indeed health and care partners. The points that have been made in the debate on this group were well made and well heard, and I know they are very much rooted in personal as well as professional experience. I too pay tribute to the vital work that carers, friends, families and neighbours all do to support their loved ones, often in the most challenging circumstances. I particularly note the reference to young carers by the noble Lord, Lord Young, the noble Earl, Lord Howe, and my noble friend Lord Hunt.
I turn first to Amendments 21, 214, 173 and 174, in the name of my noble friend Lord Hunt. Integrated care boards have an existing duty to promote the involvement of patients, and their carers and representatives, in decisions relating to their care or treatment. To the point the noble Earl, Lord Howe, has just raised, carers are the patient; they are the key person and they have control, as long as they are able, to make decisions about what is appropriate and what is not, as is usual. In addition on these particular amendments in this group, local authorities are required by the Care Act to have regard to the importance of people participating in decisions and being provided with information. I point out that the Health Bill also introduces a duty on integrated care boards to promote opportunities for visiting and a duty for local authorities to have due regard to the importance of individuals being able to involve other people in decisions about their care and about being able to receive visitors.
Regulation 9A already provides legal protections by placing a duty on care home, hospital and hospice providers to facilitate visits and accompaniment in a way that meets the person’s needs. As I just said, at the centre of all this are the needs of the individual. To clarify, a visit includes somebody providing physical support or companionship in person, and encompasses the support envisaged from a health and care partner.
My noble friend Lord Hunt and the noble Baroness, Lady Finlay, raised this matter in the earlier part of the discussion. The existing legislation intentionally avoids establishing a distinct term of “health and care partner”, simply because a single definition may not appropriately reflect the range of relationships that there may be and those that apply across different health and care settings. Also, the reference in Clause 57 to “other people” encompasses family, friends and carers and would already include a health and care partner.
The proposed amendments may inadvertently constrain how contact and support are provided and would inadvertently fail to provide for exceptional circumstances where offering support becomes a significant risk to the health, safety or welfare of a person using the service or on the premises. Instead, we are building on existing protections through non-legislative measures, including through the development of the NHS health and care partner policy. I hope that will meet the intentions behind these amendments.
Amendments 89, 175 and 176 tabled by the noble Baroness, Lady Tyler, relate to unpaid carers. The existing legal framework already requires the system to support carers. The Care Act 2014 places requirements on local authorities to assess and meet eligible needs. Carers are also explicitly referenced in the NHS constitution, and local authorities and NHS bodies have a duty of co-operation.
As for Amendments 175 and 176, existing legal duties establish a framework where needs assessments and subsequent care planning focus on the individual and their circumstances, rather than prescribing a particular service or solution such as respite care—something to which the noble Earl, Lord Howe, referred.
Amendment 88 tabled by the noble Baroness, Lady Tyler, raises a point that a number of other noble Lords have spoken to, including the noble Baroness, Lady Pitkeathley. It is of course important that carers are properly recorded and identified in the system. However, we do not believe that setting explicit requirements is appropriate for legislation, important though that is. We are making clear commitments in the 10-year health plan and are taking practical steps to improve identification, recording and support.
My noble friend Lady Nargund asked specifically about the single patient record. The Bill contains powers that will enable regulations to make patient information available to people other than patients on the patient’s behalf, if that is required. That can include all carers. The main point here is that we want to ensure that carers who act on behalf of those they care for can also get full benefit from the single patient record.
There is also guidance to support general practice to better identify and record which patients are unpaid carers. There is ongoing work to improve identification by promoting more consistent coding of unpaid carers by GPs.
Baroness Finlay of Llandaff (CB)
My Lords, can the Minister confirm that the partner policy that she referred to—which is being developed as guidance and would avoid anything going into statute—will include a requirement that the carer providing principal care for someone when they are discharged from a unit will be assessed for how much they can and are willing to do in providing care and will be taught procedures that may make the care of the person easier? This includes simple things such as how to help someone get up from a chair, how to manage if someone falls on the floor and even how to give injections for breakthrough medication, such as for pain relief if that is indicated—so that carers are not left feeling that they do not know what to do when the person they are caring for comes home.
Baroness Merron (Lab)
The noble Baroness makes extremely fair points. The discharge process takes account of whether somebody can be safely and properly discharged. The care that is provided, whether by a professional or an unpaid carer, has to be absolutely right. She is right to make the points and I am sympathetic to them.
Lord Hunt of Kings Heath (Lab)
My Lords, in seeking leave to withdraw my amendment, I thank noble Lords who have taken part in this debate both today and last week. I particularly thank the noble Baroness, Lady Tyler, for her amendments.
The noble Baroness, Lady Morris, made an important point for us to consider on respite care for young carers, as did the noble Baroness, Lady Nargund, on the identification of women carers. The noble Baroness, Lady Pidgeon, made the point that intervention before crisis occurs is so important. The noble Earl, Lord Howe, spoke about the pressures facing carers more generally.
My noble friend the Minister is resistant to legislation because of the existing needs assessment framework. On the recording of people, she felt that the 10-year plan, alongside the action plan she mentioned, would meet those needs. One must take that as a positive response.
We have been here before, though, and a huge number of carers, faced with the bureaucracy of the local system, find it very difficult to get support. Respite care, in a sense, is a visible indication of the issues that we face. I am sure noble Lords will wish to come back to that.
On my amendments, I am grateful to the noble Baroness, Lady Finlay, for her support last week, and also to Care Rights UK and to John’s Campaign, which have been campaigning for a long time to see some statutory protection for loved ones and partners who see and have concerns about the way their loved ones are treated in a care home. They have faced vindictive action by the people operating those care homes for raising legitimate concerns.
I take the Minister’s point about definitions; obviously, that is something to reflect upon. I also take the point about the current statutory duties. However, I think that people need some protection against the behaviour of so many care homes, when faced with legitimate questions about their loved ones. I hope, because the noble and learned Baroness, Lady Hallett, produced her recommendation on this only recently, that the Government will consider legislation in the light of it. Having said that, I beg leave to withdraw my amendment.
Earl Howe
“(1) In exercising functions in relation to the health service, the Secretary of State must act with a view to enabling patients to make choices with respect to aspects of health services provided to them, including to make choices as to the provider of those services.(2) For the purposes of subsection (1), the Secretary of State must ensure that patients who are referred for a service to be provided outside a hospital setting (“out-of-hospital services”) are offered a choice of provider of that service from among the providers available in their integrated care board area and, where relevant, in neighbouring areas, in accordance with regulations made under section 14Z45B.(3) Regulations under section 14Z45B must provide that, where an out-of-hospital service is to be provided to a patient, the integrated care board must—(a) offer the patient a meaningful choice of at least two providers capable of providing the service, which may include NHS bodies and independent sector providers approved to provide that service under arrangements with the integrated care board,(b) provide the patient with information to support an informed choice, including for each available provider—(i) indicative waiting times,(ii) the location at which the service would be provided,(iii) the quality ratings or outcomes data applicable to that provider for that service where such data is available, and(iv) whether any costs would be incurred by the patient in travelling to or receiving the service at that provider,(c) not exclude from the list of available providers any provider approved solely on grounds of commercial interest or organisational type, and(d) take all reasonable steps to give effect to the patient's choice within a clinically appropriate timeframe.(4) For the purposes of this section, “out-of-hospital services” means services—(a) provided in community, primary care or ambulatory settings rather than in a hospital inpatient or outpatient department, and(b) which the Secretary of State specifies by regulations as being within the scope of the choice obligation under subsection (2), and may include diagnostic services, audiology and hearing aid care, podiatry, dietetics and nutrition, physiotherapy, ambulatory cardiac monitoring and such other services as the Secretary of State may specify.(5) In specifying services under subsection (4)(b), the Secretary of State must have regard to—(a) the potential for the expansion of choice to reduce waiting times for the relevant service,(b) the availability of sufficient independent and NHS providers to make genuine choice meaningful, and(c) the desirability of ensuring access to choice for patients in all parts of England, including in rural and deprived areas. (6) The Secretary of State must publish, and lay before Parliament, within 12 months of the day on which the Health Act 2026 is passed, a statement setting out—(a) the out-of-hospital services for which choice obligations under subsection (2) will initially apply,(b) the timetable for extending the choice obligation to further services, and(c) the support that will be made available to patients, in particular those with limited digital access or literacy, to exercise the choices to which they are entitled under this section.(7) The Secretary of State must review and update the statement required by subsection (6) at intervals of not more than two years.”Member’s explanatory statement
This amendment strengthens the new patient choice duty inserted by Clause 5 to provide a specific right to choose between providers for out-of-hospital services.
Earl Howe (Con)
My Lords, in moving Amendment 22, in my name and that of my noble friend Lord Kamall, I will speak also to Amendments 24 and 68. I am also grateful to the noble Baroness, Lady Pidgeon, for tabling Amendments 23 and 67.
These amendments concern a principle which we on these Benches have long supported and which I believe ought to be central to our thinking about the future of the health service: how we can give patients greater choice over their care and make better use of the full range of healthcare services available to them.
Those services are what I would describe as a wider healthcare ecosystem—a complementary system in which the NHS works alongside independent healthcare providers, community organisations, charities and other bodies to deliver services in the way that best meets patients’ needs. The principle behind this is straightforward: many services do not necessarily need to be delivered in a hospital or by an NHS organisation, in an area where other qualified and appropriately regulated providers are capable of delivering them. These might include diagnostic services, physiotherapy, audiology, eye care or other forms of community-based treatment. Where those services can be provided safely and effectively by organisations outside the traditional hospital setting, we should surely be looking at how we can make use of that capacity.
There are several potential benefits that flow from this approach. It can allow patients to receive treatment closer to home and it can reduce unnecessary journeys to hospital. It can also provide access to services more quickly. At the same time, it can relieve some of the pressure on hospitals and specialist services, allowing them to concentrate their resources on the patients who need them most. Where services can be delivered more efficiently, they may also provide better value for the taxpayer.
I appreciate that some noble Lords may have concerns about what they might regard as encouraging the privatisation of the health service, but I want to be very clear that that is not what we are proposing. We are not suggesting that patients should be required to pay for their treatment, nor that core NHS services should be replaced by private provision. We are arguing that the NHS should have the fullest possible range of resources available when it comes to treating patients, and that patients should be able to benefit from those resources regardless of the organisational structure of the provider. The important question is whether a service is safe, clinically appropriate and accessible, and provides good value, rather than whether it happens to be delivered by one particular type of organisation.
This brings me to the question of patient choice. There is a risk in the present system that patients are not always given the opportunity to make decisions that they are well placed to make themselves; for example, a patient may be entirely happy to travel further for a particular service or may prefer to receive treatment closer to home. They may be willing to wait for one provider or prefer to be treated more quickly by another. These are reasonable choices and, wherever clinically appropriate, patients should be supported in making them. However, the watchword of “choice” means very little if patients are not told what alternatives are available or if the way that services are commissioned prevents them from accessing those alternatives in the first place.
Amendment 22 therefore seeks to strengthen the provisions in the Bill relating to patient choice, specifically in relation to out-of-hospital services. Amendments 23 and 24, meanwhile, raise an important question about what happens when a patient is referred onwards by a hospital, an NHS online service or another integrated healthcare provider. As more care is delivered through digital services and integrated pathways, we need to be certain that patients do not lose the choices that would otherwise have been available to them, had they been referred directly by their GP. Amendment 68 explores how we might extend meaningful choice into community services, which can provide an alternative to hospital-based care.
Some of the amendments in the name of the noble Baroness, Lady Pidgeon, mention optometry services. Another good example is audiology. Adult hearing loss affects 11.6 million people in the UK. It is the third leading cause of years lived with disability, and it impacts all aspects of people’s lives. Unlike most other hospital services, audiology is not consultant-led. Currently, choice over elective care applies only to consultant-led NHS secondary care services. As a result, NHS community audiology services are being commissioned in fewer than half of ICB areas. Patients often endure long waits and attend hospital when services could often be offered safely and more swiftly in the community.
The Government’s stated ambition is to move more care out of hospitals and into communities. It is a good ambition, but if we are serious about moving care closer to patients, we must also be serious about making use of the organisations, including independent providers, capable of providing that care. It would be helpful if the Minister could use this debate to tell us a little more about the Government’s plans in this area. What further steps are being taken to empower patients to exercise meaningful choice, particularly in relation to community and out-of-hospital services? I will press her, if I may, on primary care audiology provision in particular, which seems an especially salient example, given the statistics on hearing loss I have just mentioned. What is the position? Are integrated care boards being encouraged to make full use of the healthcare capacity available in their local areas, including through independent charitable and community providers? What barriers might stand in the way of this?
Much of our debate on the Bill thus far has concerned the savings that the Government hope to achieve through structural reform, but I hope we can agree that the structure of the system should not be such as to dictate or otherwise limit the choices available to patients. There is surely an opportunity both to make savings and to improve services, by looking more closely at how care is actually delivered. I look forward to the Minister’s response. I beg to move.
Baroness Neville-Rolfe (Con)
I thank the Minister for her helpful letter last week, answering the range of questions I had raised at Second Reading. I think that that is a symptom for a wide variety of policy issues that this important Bill raises.
I have added my name to Amendment 22, on choice, which was so persuasively and sensitively introduced by my noble friend Lord Howe. I believe that private care can complement NHS care, allow treatment nearer to home, and cut waiting times. I particularly support the “have regards” in proposed new subsection (5). I also favour the follow-up review, although there should be more focus on the value and usefulness of the independent sector in a health system that, frankly, is under so much pressure. I have had very positive experiences at Specsavers, which is contracted to do eye and audio tests in a number of NHS trusts.
Baroness Manzoor (Con)
My Lords, I support the amendments in the group, particularly Amendments 22 and 24, in the names of my noble friends Lord Kamall and Lord Howe. I say to the Minister that patient choice needs to be significantly strengthened, particularly in three important areas.
Currently, there is choice, but we need to make choice much more meaningful, rather than simply theoretical, by giving patients greater control over access to services and their care pathways and ensuring that choice is available across the whole of the NHS and the health ecosystem, not just elective hospital treatment, as was clearly outlined by my noble friend Lord Howe. Patients are not always aware that they can choose which hospital or provider they attend. In practice, patients may simply accept the hospital suggested by their GP or referral system, without being told about alternatives.
How do we improve this? I passionately believe that GPs should have a duty to routinely explain patients’ rights to choose, and patients should be offered a meaningful range of clinically appropriate providers. They should be provided information about waiting times, quality, outcomes and location, as Amendment 22 suggests. Patients should be supported to make informed decisions, rather than being directed towards a single provider. The NHS England guidance recommends currently that referrers should shortlist an average of five provider choices where it is practical, clinically appropriate and preferred by the patient.
Choice is particularly relevant in relation to NHS 111 and A&E attendance. Patients contacting NHS 111 are often given a recommended pathway, but their ability to access alternative services may be limited. For example, a patient might be advised to contact their GP, attend an urgent treatment centre, access a community pharmacy, receive a telephone or face-to-face clinical assessment, or attend A&E if clinically necessary. The problem is that a recommendation is not necessarily a genuine choice if the alternative service is unavailable.
Improvement is needed. There needs to be better access to same-day GP appointments, wider choice in the NHS and wider health ecosystem, more accessible urgent treatment centres, greater availability of evening and weekend services, better integration between NHS 111 and local urgent care providers, and much greater transparency about where patients can receive treatment. The key principle should be that patients are given practical alternatives, not simply redirected from one service to another—audiology has already been mentioned. Amendments 22, 23 and 24 would enable this. I know that this can happen, because, back when we had regions, we had the ability to refer patients to other providers where waiting times could be reduced, and it worked very well. Of course, we must not allow cherry-picking, which is a danger, and we must clearly define what outcomes are to be expected.
Baroness Coffey (Con)
My Lords, I agree with the amendments. The original duty included by the Government feels a bit lightweight and almost declaratory, rather than anything of substance. That it is why it is proving a useful debate, through the variety of amendments, to look at putting more substance to this.
In the real world of the NHS, in my experience as a patient and previously as an advocate, what is convenient for the NHS is more important. We will come to this in a broader sense later in the Bill, but it is vital that we try to help patients, as with the earlier duty in the clause that is not being changed, to have more involvement in their healthcare. As my noble friend Lady Manzoor just said, patients are often not aware of the availability of other services. It would be useful to get an understanding of how the Secretary of State intends, through this clause, to make patients more aware.
At the same time, as my noble friend Lady Neville-Rolfe points out, in effect, probably due to budget constraints, rationing has started by not allowing patients to take advantage of provision in the interests of trying to manage budgets. I am not saying that the NHS is a bottomless pit—it is not—but we have to come back to what the NHS is there for. The constitution is quite clear that patient choice is a key element. That is reasonable in order to try to make sure that we have a healthier society. As my noble friend pointed to, quite a lot of illnesses are stopping people working, or working to their full potential. That is no good. A lot of illnesses mean children are not allowed to reach their full potential and are spending time out of school.
We need to consider such factors when carefully considering the amendments tabled by my Front Bench and that of the Liberal Democrats to beef up what it means to ensure that other provision can be readily accessed to have a healthier society. I hope that my noble friends will bring this back on Report if we do not have any satisfaction today.
Lord Patel of Bradford (Non-Afl)
My Lords, I support the aims of Amendments 22 and 24 and welcome the intentions of Amendments 67 and 68 in this group.
I want to concentrate on what these proposals would mean in practice for patients and families. The question is whether choice is meaningful, accessible and protected throughout their care. For patients, the questions are straightforward: where can I receive appropriate care, how long will I wait and how will I get there? Amendment 22 rightly draws attention to the information that is needed to make those decisions, including waiting times, location, quality and travel costs. Simply presenting someone with a list of providers does not necessarily give them a meaningful choice. A service offering an earlier appointment may be difficult to reach, while a nearby service may involve a much longer wait. Patients need help to understand those options and decide what works for them.
Does the Minister accept the case for strengthening patient choice in services outside of hospital? Whether she accepts Amendment 22 or not, how will the Government ensure that patients receive the information and practical support that is needed to exercise choice, particularly those patients who cannot readily use digital services, have communication needs or require help with transport?
Amendments 23 and 24 raise an equally important question about onward referrals. A patient’s ability to choose should not depend on which door they entered through, or which organisation happens to make the next referral. As services become more integrated and virtual services play a greater role, we must ensure that patients are told about the choices that are available to them. Integration should make their journey easier, while preserving access to suitable providers beyond the organisation arranging their care. Can the Minister explain how patients will be protected from being directed automatically to a closed list of preferred providers without being offered the choice to which they are entitled?
Amendments 67 and 68 raise a related issue about choice in community services, including eye care and audiology, very eloquently expressed by the noble Baroness and the noble Earl, Lord Howe. Moving care closer to home should bring benefits to patients. We should ensure that a change in the setting or organisation of care does not unnecessarily narrow their options. For a family seeking an ADHD or autism assessment, choice can also have very practical consequences. Where choice rights apply and an eligible provider can offer appropriate care sooner, families need to know that this option exists and understand what the service includes. They should also have the confidence that their choice will be respected as referral pathways change.
As the noble Earl said, choice must operate within appropriate clinical criteria, with providers meeting the required standards and regarding the sustainability of local services. It must also be available fairly, rather than depending on a patient’s confidence or ability to navigate the system. Can the Minister explain how existing choice rights will be protected as services are reorganised, how compliance will be monitored and what remedy a patient will have if available choice is denied? The practical test is whether patients can reach appropriate care sooner, with clear information and continuity of treatment. I hope that the Minister will respond to the concerns behind these amendments and explain what the Government will do to make meaningful patient choice a reality.
Lord Mawson (CB)
My Lords, I too support Amendment 22 and am encouraged by this debate, which definitely needs to happen. Indeed, the GPs I work with in the East End of London would definitely want to open up these very choices to patients from many different backgrounds, because sometimes one can get a sense on the ground, certainly in challenging communities, that the NHS can be quite condescending to people in assuming they do not want these kinds of choices. Yet if you go into East End housing estates you will find lots of different people living there from lots of different backgrounds who do want choice. This is a really important message and needs to be grappled with and taken seriously.
Baroness Pidgeon (LD)
My Lords, I am grateful for the support for this group of amendments from noble Lords across the Committee. If the health service is to be truly patient-centred, patient choice needs to be a key part of this. Different patients will have different needs. Therefore, choice is a key part in having ownership of their care and treatment.
My Amendment 23 in this group picks up a key issue as we move to greater use of digital health. The NHS app will start to play a greater role. My amendment picks up the potential loophole that if a patient is seen in person, they may be referred for treatment or diagnostics by their GP or other primary care practitioner and given a choice of where to go for their referral. However, if this is done virtually, via an app or online, patients may not have the same choice that they would have received in person. This amendment seeks to ensure that there are no closed lists and that patients are referred to one provider only. Amendment 24 is similar in its aims.
Amendment 67 in my name, Amendment 22 in the names of the noble Lord, Lord Kamall, the noble Earl, Lord Howe, and the noble Baroness, Lady Neville-Rolfe, and Amendment 68 in the names of the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, are similar. My amendment specifically pushes for patient choice for non-consultant-led community services, including optometry-led glaucoma care and community urgent eye care services. The amendment seeks meaningful choice from providers available in an ICB area for out-of-hospital services. We know that waiting lists have increased for community services, yet these are often preventive services. I have raised in this Chamber before that 600,000 people are on hospital waiting lists for eye care services, yet we have optometrists on every high street who could be used to help address this and bring routine treatment nearer to people’s homes, thus leaving specialists able to deal with patients who need their services in a more timely manner.
Audiology, as we have heard, is another really important area. As the noble Earl, Lord Howe, highlighted, NHS community audiology services are commissioned across the whole of an ICB area in just 42% of ICBs. This means that the majority of patients are being denied choice. Often, patients are required to attend hospital-based services and experience long waits for services which could be offered safely and in a more timely manner in the community. This could be nearer to home or to a family member’s home—somebody who helps them get to an appointment and helps them with transport—giving them genuine choice. If we are serious, as we debate the Bill, about shifting care out of hospitals and into the community then patients must be given the same right to choose their provider for community services as they currently have for consultant-led hospital care.
Community waiting lists have now reached record levels, with around 1.25 million people waiting for treatment. Patients should be empowered with clear information on waiting times and location, allowing them to choose the provider that best meets their needs. By placing choice in the hands of patients rather than commissioners, which it too often is, we can improve access to timely treatments and actually deliver on the Government’s ambition of more personalised care closer to home. I look forward to the Minister’s response.
Baroness Merron (Lab)
My Lords, I will address the wider principles underpinning Clause 5 and Amendments 22, 23, 24, 67 and 68. I am grateful to noble Lords for their contributions and consideration of matters that are key to patient choice—a concept that is, as I know noble Lords are aware, neither new nor innovative but is absolutely at the core of the Bill.
Clause 5 introduces new duties to require the Secretary of State to promote the involvement of patients, their carers and their representatives in decisions relating to the prevention or diagnosis of illness, care or treatment. This applies where the Secretary of State exercises her health functions. As I said, this is absolutely core to the Bill and I am sure that noble Lords will welcome that.
The clause also requires the Secretary of State to act with a view to enabling patients to make choices about the health services provided to them. I hope that noble Lords are aware that the Government are committed to involving patients and carers in decisions about their care, as we discussed in the last group. One of the reasons is that we know it supports better experiences of care and in many cases leads to a better outcome. It is not just a “nice to have”, but a “necessary to have”.
I refer the noble Baronesses, Lady Manzoor and Lady Coffey, and the noble Earl, Lord Howe, to the new Choice Charter, which will strengthen this approach by setting out—this is key—what patients can expect so that they can make informed decisions about their health and care. There is no point in just expressing a wish to have patient choice if we are not equipping patients to make that choice. That is why we are protecting the patient’s right to choice and the duty to involve them in decisions. As I said, that will remain a central principle of the health system. I was glad to hear noble Lords across the Chamber welcoming the move from hospital to community provision. As the noble Baroness, Lady Pidgeon, set out, many services can be provided better in the community than they can in hospital. I welcome that support.
Amendments 22, 23, 24, 67 and 68 have been tabled by the noble Lord, Lord Kamall, and the noble Baroness, Lady Pidgeon. These amendments would go further than Clause 5 currently does by expanding patients’ right to choice to a wider range of out-of-hospital services and onward referrals by virtual and integrated health services, and by prescribing how this must operate in practice. I reconfirm our commitment to strengthening patient choice as part of our wider agenda to improve access to care and reduce waiting times. It might be helpful to remind your Lordships’ House—the noble Earl, Lord Howe, might be particularly interested in this—that existing choice rights already apply to some consultant-led out-of-hospital services where the regulatory conditions are met. These include dermatology, pain management services, gastroenterology and diabetes services.
The noble Lord, Lord Patel of Bradford, made a number of key points. Community services are by their very nature designed differently from hospital services. I assure him that those who need help to exercise their choice will get it around what their needs are. They will not simply be expected to manage with one size fits all. The points that have been made are fair and I take them on board but, as a point of principle, we do not think that this level of operational detail, important though it is, is appropriate for primary legislation. Our preference is to use secondary legislation to set out the services covered by choice rights and the detailed requirements for offering choice. The key thing is that that will allow that framework to be updated as services, evidence and system capability develop, because we are not going to be stuck in one place and healthcare will develop as we go along. I say to the noble Lord, Lord Patel of Bradford, that we will continue to look at the scope of the choice rights and ensure that we are provide the most effective offer to patients.
I say to the noble Baroness, Lady Coffey, and the noble Earl, Lord Howe, that we are taking the practical actions they seek, as set out in the elective reform plan. We are empowering people to take control of their health by making the NHS App and the “Manage Your Referral” website the default route for patients to choose their provider. To enable patients to make an informed choice, we are improving the information available to them, following the point I made earlier, including on waiting times. The noble Lord, Lord Patel, was right to say that not everybody can use online access. We completely understand that, and I emphasise that online tools are in addition to traditional channels. We will ensure that people who need help to make a choice receive that support and information in the way that suits them, as raised by the noble Baroness, Lady Pidgeon.
On the point made by the noble Baroness, Lady Neville-Rolfe—this might also be helpful to other noble Lords—patients will continue to be able to choose any provider that holds a contract to deliver NHS services. As I said in my letter to the noble Baroness, that includes independent sector providers, within set circumstances. It is the responsibility of ICBs to ensure that their processes comply with the right to choose. That includes any qualifying contract requirements, clinical appropriateness and eligibility criteria. There is guidance for the use and implementation of indicative activity plans and activity management plans. That is detailed in the NHS standard contract technical guidance. If the noble Baroness would like more information, I will be happy to ensure that it is there.
The noble Baroness, Lady Manzoor, talked about the need for real choice to be strengthened. The government guidance on choice makes it clear that GPs, dentists and optometrists have clear duties to ensure that patients are offered a choice of where they go to their first out-patient appointment. I totally agree with her that a right is only as good as the information and confidence that you have. That is why we are taking these steps.
Baroness Pidgeon (LD)
Before the Minister sits down, she mentioned that the Government are minded to use secondary legislation rather than amendments to the Bill. Are the Government minded to include the non-consultant community services we have been discussing in the Chamber today in such secondary legislation, for genuine patient choice?
Baroness Merron (Lab)
Secondary legislation will ensure patient choice across all NHS services, so that will be included.
Baroness Neville-Rolfe (Con)
I think the Minister’s answer showed that this local variation is a problem, partly because of the standards, contracts and framework that she described. Some of this may be in future secondary legislation, as the Minister has just said. I would like to pursue this a bit further to see if one can tap the capacity that could reduce waiting times in these important community areas of medicine. I am worried that the existing system is not providing the incentive for that. I would like to understand a little more detail, perhaps in a meeting before we get to Report.
Lord Scriven (LD)
I have been listening very carefully and, in answer to my noble friend, the Minister has just said that secondary legislation will be for all NHS services by choice. What stops that being put on the face of the Bill?
Baroness Merron (Lab)
This is the point I have just raised: we feel that secondary legislation is the better place to put it for flexibility and future-proofing; it is not appropriate, in a static way, for primary legislation.
Lord Scriven (LD)
As I am sure the Minister agrees, that would make sense if you were putting the operational services down. If you were making a commitment in Clause 5 that all NHS services in secondary, primary and community services will be accessible for choice, it would then give discretion within that boundary. I do not understand what stops the Government putting those principles on the face of the Bill, rather than making the operational amendments, which the Minister said were too restrictive.
Baroness Merron (Lab)
I think we just have a difference of approach to and opinion about the roles of primary and secondary legislation. I respect what the noble Lord is saying and I will of course review the points that have been made, as I always do; however, the position is exactly as I have described.
Earl Howe (Con)
My Lords, I am most grateful to the Minister for her response and, indeed, to all noble Lords who have contributed to this debate. This has been a valuable opportunity to explore how we can give patients greater choice while making better use of the resources and expertise available across our wider healthcare system. In particular, services such as optometry and audiology have been highlighted.
I was encouraged by much of the Minister’s response, particularly her reference to the need to empower patients, not least to optimise patient outcomes. She is right that there are already several consultant-led NHS services delivered in the community. It would be helpful, though, if she could reflect on the issues I raised about audiology, which is not consultant-led. Perhaps she could consider what could be done to increase audiology provision in the community. As I said at the outset, our intention is not to undermine the NHS but to support it. Where independent charitable and community providers can deliver high-quality care closer to home and more efficiently, we should be making full use of that capacity.
My noble friend Lady Coffey rightly said that politicians of every colour all too easily make declaratory statements about choice, but that we do not do enough to bring meaningful choice to the attention of patients. I confess that I worry sometimes that the absence of choice in certain situations may, in part, not be wholly unintentional. As we heard from my noble friend Lady Neville-Rolfe, it sometimes seems to suit NHS commissioners not to bring down waiting times. The primary reason for that, I suspect, is the way commissioners channel and direct their commissioning budgets. It is important, though, to keep in mind, and perhaps remind commissioners, that out-of-hospital services can often be less expensive to provide than services delivered in hospital.
Having said that, I hope the Government will take these points away and give further consideration to how patient choice can be strengthened as this Bill progresses. For now, I beg leave to withdraw Amendment 22.
“(5) The Secretary of State must establish a transformational fund, within a year of the date on which the Health Act 2026 is passed, to enable improvements in access to specialist palliative care and its support to generalist services.”Member's explanatory statement
This amendment would require the Secretary of State to create a dedicated palliative and end of life care transformation fund to support service redesign by scaling proven models of care that help deliver the government’s intended shift from hospital to community care for people at the end of life.
Baroness Finlay of Llandaff (CB)
My Lords, I am most grateful to my noble friends Lord Patel and Lady Hollins, and the noble Baroness, Lady Bennett of Manor Castle, for having added support to my amendments. I declare my interests as a vice-president of Marie Curie, an international adviser to the Cicely Saunders institute and professor of palliative medicine at Cardiff University.
Amendment 26 proposes a transformational fund to improve palliative care by scaling models for which there is strong evidence of proven benefit. Amendments 279B, 242 and 78 state what must be commissioned to rectify current deficits. These amendments are all important.
It is a rare finding in health economics to know that if you invest in a health or care service, people’s well-being and quality of life will improve, while overall NHS costs are likely to fall. The evidence for this benefit is strong. We know such care works; there is very clear and robust evidence of good benefit from specialist palliative care, for all conditions. When home-based, it improves symptoms and increases the likelihood of home death, when preferred. In hospitals, specialist teams reduce in-patient bed days, deaths in hospital and healthcare costs, while improving simultaneously quality of life. In 2022, specialist palliative care supported more than 20,000 people in England to die outside hospital, saving 1.5 million hospital bed days and £117 million in healthcare costs. Currently, one in three people in England and Wales die with unmet palliative care needs; by 2040, this is predicted to increase by over 23% if nothing is done.
This unmet need in a third of all expected deaths relates to both general and specialist palliative care provision. Specialist palliative care is essential for those with complex needs and for upskilling generalists. Failures in care lead to poor outcomes, more hospital deaths, and higher health and care costs. Shifting from hospital to community will require upfront investment; hence the call for a transformation fund to deliver longer-term savings and better care by investing in proven interventions of home-based care with specialist support.
Of those dying from non-sudden causes, one in five people with cancer and four in five with dementia or heart conditions cannot access the specialist palliative care input they need. Difficulties getting care, challenges navigating a complex system and poor co-ordination lead to a lack of physical and psychological safety. Patients and their carers feel that care at the end of life in the community is unco-ordinated and insupportive. As a result, over half of people approaching the end of life resort to A&E to get the help they need.
Despite the Health and Care Act 2022 stating that palliative care services are core, less than a quarter of integrated care system strategies have this as either a priority of focus or an ambition. In 2023, only three ICBs could state that they commissioned core components of the relevant NICE guidelines. Almost half of ICBs realised they could not meet palliative care needs even moderately. Implementation of the NICE recommendations made over a decade ago remains patchy. The 2025 National Audit of Care at the End of Life—NACEL—in hospitals found poor access to palliative care.
Yet crises and difficulties occur at all hours. For those at home, only one in three UK areas have a designated phone advice line at all hours despite NICE guidance, and such lines are often charitably funded. Only one in five ICBs commission 24/7 access to advice, and fewer than one in 10 actually have access to a specialist nurse overnight—although access is a bit better at weekends and bank holidays. Fewer than two-thirds of hospitals provide face-to-face specialist palliative care seven days a week. This is hardly surprising, as the consultant staffing levels range from one per 154 hospital beds to one per 3,673 beds. Only a third of areas provide direct admission to hospice out of hours.
For children, only a third of paediatric palliative care teams meet NICE staffing guidance. Some tertiary children’s hospitals, such as Manchester and Leeds, and hospitals with paediatric intensive care units, such as King’s, still do not have a consultant lead. For babies, children and young people at home, only 31% of ICBs could evidence commissioning 24/7 end-of-life care to national quality standards.
This data shows that ICBs clearly do not know whether they are meeting their populations’ palliative care and end-of-life care needs. Some 65% of people across the UK being worried about access to such care, and 41% thinking too little resource is allocated to it. The evidence strongly supports specialist palliative care being stipulated in the Bill, as in my Amendments 279B and 242.
Covid revealed how integrated palliative care teams cared better for patients and contributed across health and care. Those in community and in publicly managed services appeared better able to respond to escalating needs. We must collate person-centred outcomes; outcomes are not the same as experience. People cared for with kindness and compassion may report a good experience, even if their care fails to manage their pain or other symptoms optimally. Data on unmet holistic palliative care needs and gaps in access is essential to service improvement. Robust national post-bereavement surveys can capture the voices of recipients and those who represent those who were very sick and dying.
Increasingly, electronic systems share information, although sometimes slowly, between NHS and charitable hospices on discussions and decisions people have had about their care. Such conversations guide advance care plans, which are the advance statement of wishes in the Mental Capacity Act, for which the noble Baroness, Lady Barker, is to be commended. Sensitive holistic conversations are part of good care. They must be at the person’s own pace, respecting ambivalence and changes, and not risk becoming a tick-box exercise.
Care improves through evidenced innovations. The IMPACT centre’s digestible research summaries foster the adoption and spread of innovation and inspire researchers whose outputs contribute to our economy. Evidence from the NIHR policy research unit is that specialist palliative care increased quality of life with reduced costs at home of £7,900 per person and reduced hospital costs of around £6,500 per person who dies.
We know that specialist palliative care works. The evidence is clear and robust: it reduces hospital bed days, deaths in hospital and healthcare costs, while improving quality of life. We have a moral and economic duty, and an opportunity, to ensure that access to specialist palliative care is improved. I beg to move.
Baroness Coffey (Con)
My Lords, I tabled Amendment 45, which refers to “Promoting palliative care equitably”. In particular, it refers to the need to be
“accessible to all regardless of wealth or geography”.
I am very fond of the Minister. Nobody can get grumpy with the Minister, but I am getting grumpy with the Department of Health and Social Care, and other Ministers, because we still do not have the modern service framework for end-of-life and palliative health care, which has been going on for some time. I think the latest Written Answer, published in September, said that it would be published in the autumn. To be generous to the Government, that normally means right up until Christmas Eve, but I hope we will see this framework; it is a long time coming. The stories that we hear, such as that which we just heard from the noble Baroness, Lady Finlay of Llandaff, illustrate that access to palliative care often seems to be a postcode lottery.
When I first moved to Suffolk, I became aware of the Halesworth Community Nursing Care Fund—it no longer exists, having been absorbed into the Pear Tree Fund, which is still in Halesworth. The local people, frankly, got fed up of waiting for a hospice, and there are still valiant efforts to try to have a building. I appreciate that hospice at home is a key element of the modern hospice service. Nevertheless, it was felt that, unless there were people with deep pockets or those who run marathons around the country, or take part in other ways of raising funding, too often either that nearby hospice would never open or its continuing support would collapse. That is why I welcome the proposals and ongoing targets—I think aimed at 2029—regarding this in the neighbourhood health plans, but we still need the substance. Living in a rural community, I am very conscious that not everything will be on hand, but that does not mean that it should be so far away that it more or less becomes irrelevant. I would like to understand more about how the Government will consider the provision of such care in rural settings.
Amendment 230, tabled by the noble Baroness, Lady Pidgeon, would, as I understand it, require a conversation about end-of-life care once a terminal illness has been diagnosed. The amendment as drafted provides that such a conversation would need to be offered but the person would not necessarily have to take it up. However, another provision in the proposed new clause suggests that, where the person does not or cannot take up the offer, the family must be offered it instead.
I appreciate that having conversations about the end of life can be very tricky. We should bear in mind what happened in the not-too-distant history to people who were nearing the end of their lives. I think of the heinous Liverpool care pathway, where people were, in effect, starved and not allowed water. That was horrific. I was pleased when the recommendations of the review by the noble Baroness, Lady Neuberger—it is good to see her here—were followed by the Government, and that was cast to history.
There is also the wide-ranging element of do not resuscitate, and here I will share a personal anecdote. I recall that, when my mother broke her hip, they constantly tried to get her to do a DNR but then told her that the consultant could do it anyway. It is not very encouraging. When she was finally, sadly, diagnosed in hospital, they did not know exactly what was wrong with her but told her that she had less than a month to live—which was true; that is what happened. It was very clear that, for my mother, her patient choice was that she was desperate to die at home. To be fair, a particular nurse tried everything and was successful, but there was argy-bargy to get it done. For a woman who was dying, I was prepared to shove her in my car and drive home, although eventually we got the agreement for an ambulance to take her home. Even then, all of a sudden, as we were ready to leave, the DNR was there, and I knew my mother did not want it. They went and found her; she was not speaking very much by then, but she shook her head to show that she did not want it. It involves an element of trust, and, frankly, I do not know how many people necessarily have confidence that end-of-life care will be provided.
My mother was a woman of faith, and a priest from the local Catholic church, Father Joseph Welch, happened to be on duty. He came in, and that conversation, more than anything, helped a woman of faith who was scared of dying to effectively be reconciled. It is important, in a different way, to recognise that this is not just about the NHS saying, “Let’s have a chat about the end of your life”, because I am afraid that there is still nervousness about where that will end up.
I am conscious that, when debating another Bill in this House, we spent a lot of time on the fact that people are scared, towards the end of their lives, and that there may be pressure to take a particular pathway. We need to be careful, and how we get that judgment right is important. That is why, although I understand the sentiment behind Amendment 230, I would be pretty nervous about putting it in the Bill and about how delivering it could be done in a way that is absolutely right for everybody. Can we get the quality and a real understanding that this would work to the benefit of the patient, albeit perhaps in their final weeks?
Baroness Hollins (CB)
My Lords, I thank my noble friend Lady Finlay for making the strong economic case for specialist palliative care and for these thoughtful amendments. I have added my name to several of them.
On Amendment 78, ICBs already have responsibility for commissioning palliative care. That came about following amendments to the 2022 health Act, which my noble friend Lady Finlay introduced, but there is insufficient accountability for whether and how they are meeting the needs of their local populations. The House of Commons Health and Social Care Committee’s recent inquiry found no clear standards or reporting requirements for ICBs for the provision of palliative and end-of-life care.
Geographic inequality is striking. In 2023, the proportion of people dying in hospital varied from 36% to 52% between ICB areas, and the proportion dying at home varied from 26% to 33%. Why are there so many differences between different areas? We cannot improve what we do not properly measure, and palliative care at the end of life is an essential component of healthcare, not an optional extra. This amendment would require annual performance assessments regarding the standard of palliative and end-of-life care provided.
Amendment 26 would require urgent investment in palliative care through a transformational fund. The Health and Social Care Committee considered the specialist palliative care workforce to be in a critical situation. It described 78 consultant vacancies and around 40% of hospitals not providing a seven-day face-to-face specialist palliative care service. More funding would support the Government’s intended move towards more care in the community and help to avoid needless prolonged hospital admissions.
Amendment 242 would ensure that NHS and hospice services can work together effectively, with timely information sharing and the access to beds, medicines, equipment and appropriately trained staff that patients need and deserve. At the moment, it is so fragmented; it is very hard for people trying to co-ordinate and manage their own end-of-life care at home, as I know only too well after my husband died last year.
The scale of the voluntary sector’s contribution is considerable. In 2024-25, hospices across the UK provided palliative and end-of-life care to 310,000 people, alongside direct support to 89,000 family members, friends and carers. But the financial pressures they face are significant, and of course they rely heavily on charitable donations and fundraising. However, voluntary sector providers are not peripheral to our health and care system; they are essential partners.
The Public Accounts Committee in the House of Commons has estimated that 300 hospice in-patient beds have been lost due to lack of funding. It would be very timely to agree all these amendments and I give my wholehearted support to them.
Baroness Bennett of Manor Castle (GP)
My Lords, I commend all the amendments in this group. As the noble Baroness, Lady Finlay, said when introducing it so powerfully, I attach my name to the noble Baroness’s Amendment 26, which would provide for a transformational fund for improvements in access to support service redesign by scaling proven models of care, supporting also the planned shift from hospital care to community care.
As the noble Baroness, Lady Coffey, alluded to, we have to consider this group of amendments in the context of the Terminally Ill Adults (End of Life) Bill, generally known as the assisted dying Bill. I spoke at its Second Reading in your Lordships’ House and my noble friend Lady Jones covered Committee. It is worth noting that, the second time the Bill was presented in the other place, Andy Burnham said, in a very influential intervention, that before assisted dying is considered in England and Wales, the funding of palliative care should be fixed. That is what the amendments in this group, in their various ways, seek to achieve. The Government often say they will do this when legislative time allows. We have the opportunity before us at this moment.
We have covered many of the points already, but it is worth noting that, by 20 October, more than 100,000 people had signed a petition, which was delivered to No. 10, calling for sustainable hospice funding to be made a national priority. At that event, the Shakespeare Hospice chief executive said:
“Our ask is simple: a fair and sustainable long-term funding model that ensures everyone can access high-quality hospice care, regardless of where they live”.
The fact is, of course, that, in many ways, hospice care and provision is not only a postcode lottery but is going backwards in many parts of the country. On average, about 270,000 people each year receive hospice care, but only 40% of the funding comes from government sources: 60% of the funding comes from people—very often pensioners—standing at train stations rattling buckets. We have a reliance on charity shops, but that funding model is in significant difficulty, in part because of fast fashion and other changes. We have a cost of living crisis that means many people who may have made contributions before are simply not in a position to make contributions now.
I have spoken in your Lordships’ House previously about the very sad closure of the Richard House hospice in east London in 2025. I note as one further example the Queenscourt Hospice in Southport, which has been going for 35 years. In the middle of this year, it cut its in-patient provision by 50%, decreasing bed capacity from 10 to five. It also reduced out-patient services, therapies and hospice-at-home clinical provision. Associated with that was the loss of 20 full-time equivalent medical posts.
I note also that the Royal College of Nursing, at its congress in May, supported overwhelmingly a resolution that the RCN advocates for decent coverage of hospice care. That should not be necessary. We have before us a Bill that gives the possibility for the Government to put this into a legislative statutory framework to support proper palliative care, which the Prime Minister has said that he wants to do.
Lord Patel (CB)
My Lords, I have put my name to Amendments 26, 78 and 242, tabled by the noble Baroness, Lady Finlay, and support everything that has been said by the noble Baronesses, Lady Finlay and Lady Hollins, and others. They have highlighted the serious problem of the underfunding of palliative care, whether that is specialist, community or hospice palliative care.
To make my points, I need to personalise them, which I hope I can do successfully. What impressed me most when I had to experience the provision of palliative care was the personalised care plan that was written by the team who were going to look after my wife when she died last year. That was so fundamental for the family and for the patient. The other important bit was the compassion that was shown. I do not know of any other branch of medicine in which I personally feel that compassion is so paramount. It is a person who is dying. There can be nothing more final than death. If we cannot show compassion at that time, then we fail.
The next bit was communication: with the patient, with the team who were going to look after her, and with the family—and the inclusion of family in that communication was extremely important. The team was identified: it was the GP, the district nurses, and the specialist palliative consultant, who, in the end, did not need to provide her services but who none the less was available.
The other important bit was the co-ordination. There was total co-ordination of Macmillan nurses, district nurses and the GP, importantly to assess the medication that was required on a daily basis, 24 hours a day, seven days a week. What I learned, although I am a doctor of long standing, was that for patients who are dying, medication tends to change hour by hour, because their symptoms change. There are not just the symptoms of pain; there are other symptoms that make them uncomfortable, and they need to be relieved of those. In the middle of the night, that service was available. At 2 am, by phone call, somebody appeared five minutes later to provide that medication and care by the team.
The next factor was continuity of care. It was the same GP who visited every day, and the same district nurses, including at the weekends, day and night. That continuity of care was provided all the time.
The next bit was comfort. It is difficult to understand how much comfort is important to these patients when they are dying. They are uncomfortable because of pain, because of the disease that is killing them, and because they have developed symptoms that are difficult, such as retching, vomiting and other symptoms. That requires treatment at the time. If that is not available, the patient who is dying suffers.
Choice—patient autonomy—was another factor: that patients have a say, even though they are dying, as to what would help them. That was important. Furthermore, it was about control, that the patient was helped to achieve their goals. They do have goals, even though they are dying. They know what they want, in terms of comfort and other issues.
Any palliative care proposals and frameworks developed must address this issue, paramount in which should be compassion. If we fail to do this, then we fail. We should not rely on funding from charities organising fêtes and coffee mornings; we should fund the service appropriately and demonstrate that we are a compassionate society.
Lord Hunt of Kings Heath (Lab)
My Lords, I take a rather different view from that of the noble Lord, Lord Patel. We need to look back at the foundation of the hospice movement—it was founded within the charitable sector. It has always been valuable that a lot of the funds to run them have been raised by hospices themselves. That has given them a certain degree of independence, which they clearly would not have if they were funded entirely by the state. It also meant that they brought innovation into palliative care in a way that directly funded services would have found difficult.
There is, however, a need now for more support from government. I acknowledge and welcome the resources the Government have put in in the last two years. I hope my noble friend can say when the framework is coming. As I understand it: one of the issues about hospice funding is that it is so hand to mouth. For some reason ICBs, and their predecessors, have seemed to be incapable of giving longer-term contracts and certainty—they always give short-term contracts and operate hand to mouth.
In a sense, this takes us to the heart of the Bill. So many of these amendments are really because we do not trust ICBs to do the job properly. Their main focus is on waiting times and financial performance. With the huge variation in the funding of palliative care, can we have any confidence that, even with the modern framework, we are actually going to get a more comprehensive package of long-term services for hospices?
Of course, there is a wider challenge of palliative care in the NHS itself, which the noble Baroness, Lady Finlay, referred to. Some reassurance on the hospice issue—that the framework, when published, will mean that ICBs have to sort this out, that they have to give long-term certainty and deal with some of the variation in funding that we see at the moment—would be welcome.
Lord Stevens of Birmingham (CB)
My Lords, the noble Lord, Lord Patel, spoke movingly and others spoke powerfully to make the case for palliative and end-of-life care, and I will not seek to repeat what they said. The whole of Parliament has expressed that view extensively over the last 18 months.
I will comment briefly on whether the provisions should be in the Bill or should rely on action by the Government. I anticipate that the Minister will make the case that this does not need to be specified in primary legislation; it can be done by an administrative or political act from the Department of Health and Social Care. I believe that to be the case. In principle, there is no need for new Secretary of State powers or administrative reorganisation to allocate funding to meet unmet need in palliative and end-of-life care. However, the question before the Committee is: are the Government actually going to do it? What we can do is give the Minister a bit of leverage inside the department between now and Report by perhaps sending a signal that if the modern service framework for palliative and end-of-life care has not emerged by then, it is possible that your Lordships’ House will take a more stringent view on the need for primary legislation.
The Minister told us in writing on 4 June that we will see this modern service framework for palliative and end-of-life care in the autumn—as the noble Baroness, Lady Coffey, pointed out. We are now in November: the nights are drawing in; the clocks have gone back; Guy Fawkes night is this week; and Halloween has been and gone. Is the promise of an autumn modern service framework trick or treat?
Baroness Grey-Thompson (CB)
My Lords, I will speak briefly on this group of amendments because they have an impact on amendments that I have in other groups. I read with interest Amendment 45 in the name of the noble Baroness, Lady Coffey, which seeks to ensure equitable palliative care regardless of wealth or geography. I am not entirely sure whether disability would be included in this, but I am keen that disabled people are not forgotten in the Bill.
Last week I spoke to an organisation that works with wheelchair users. It was a very worrying conversation about the impact on general NHS services and specialist services from changes in spinal units and the support they give people who have had a traumatic accident, and about the lack of accessibility to a number of services that we take for granted, particularly breast cancer screening and smears. A number of disabled women have been in contact with me to say that they have been refused those basic treatments because they are disabled or because of the inaccessibility of the machines. I have had to have several mammograms over the years, and the machines are just not designed for somebody who cannot stand. Last time I had one, three nurses had to lift me up into the machine, which was not particularly easy or useful, but they managed to make it work for me. I am worried about the number of people for whom it is not made to work, who might end up in palliative care services far earlier than they need to because of the lack of treatments they are able to access. The postcode lottery is layered on top of that. I am keen that there is a real understanding of the quality of life of disabled people as part of this, to ensure that they get the right support at the right time.
It is really difficult to discuss this Bill without mentioning my recent experience of three stays in hospital since August. The first and second times, I had cellulitis. Interestingly, the papers that I took home with me when I was released the second time had my DNAR status on them. Luckily, it said “no”, but it was interesting that that was not discussed with me; I would not have expected to have that discussion, based on the condition I had, but a number of disabled people worry when their DNAR status is put on their documentation with or without a discussion.
That leads to Amendment 230 in the name of the noble Baroness, Lady Pidgeon, and the conversations it would require. Whether it is one conversation or many, it is about making sure that the right time is made available so that they are properly carried out. In this group, I am keen to focus on the specialist aspect of palliative care: it is about not just generalist education but making sure that we are absolutely able to raise the bar for the specialist palliative care that is available to everyone, to make sure they get the right support at the time they need it.
Baroness Barker (LD)
My Lords, like the noble Baroness, Lady Morris, I spend a lot of time sitting on the Woolsack. I did not take part in the debates on the assisted dying Bill; I could not, because I was caring for somebody who, as I said at Second Reading, died in June. I am actually very pleased that I did not take part, because I do not think that I could have done so with the composure required. I listened to a lot of the debates, and that Bill did a substantial amount of damage to this House in many ways.
One of the things it did was to damage the reputation of the House among carers’ groups, because several speeches on that Bill really denigrated carers—“some carers”, I imagine the people who made those speeches would say—leaving the impression that many in this House believe that carers can be unfeeling and mercenary, without any evidence to substantiate that. When we go on to look at what happened with that Bill, as we must, we will need to think carefully about things like that.
I say that because my experience and the experience of my wife was completely different from that. My wife was diagnosed with a condition that she knew would be terminal. At the point that that happened, she made her advance choice direction and she stuck to it; she did not want to be resuscitated. My experience and hers—she was always in charge, as far as I was concerned—was that every healthcare professional she came across asked her about that. They did not argue about it but, time and again, they asked her whether she still wanted it. She was quite clear; her statement was as clear as it could be. Yes, she would be treated for something that was treatable and could be reversed but, no, she did not want to be revived if she was dying.
Baroness Thornton (Lab)
My Lords, I had not intended to speak in this debate—I was saving myself for social care and those other issues—but I was very moved by the interjection by my friend, the noble Lord, Lord Patel, and I disagreed with the noble Baroness, Lady Coffey. This is an important suite of amendments, because comprehensive integrated care has to include end of life—of course it does. I know that the noble Lord and the Minister will be discussing how best to do that; it may not be to put it on the face of the Bill, but it definitely has to be included in this legislation. The amendment from the noble Baroness, Lady Pidgeon, is a very good one, and I completely agree with it.
Baroness Pidgeon (LD)
My Lords, I thank the noble Lord, Lord Patel, and my noble friend Lady Barker for their very personal and raw contributions, as recent carers, on the recent losses of loved ones.
I am grateful for the support from the noble Baroness, Lady Thornton, for my Amendment 230 in this group, which also has the support of Marie Curie and Hospice UK. At its heart is the principle that people approaching the end of life should be able to have their wishes, preferences and priorities for care understood, recorded and respected. Advance care planning enables people with terminal illness to express how and where they wish to be cared for. It supports more proactive and personalised care and, as we have heard, it has been shown to improve patient and family satisfaction while reducing the likelihood of crises, avoidable hospital admissions and the need for emergency care out of hours. I have seen at first hand how, in Devon, the system seems fairly well set up to support people in their own homes, and to have these very difficult conversations with a hospice at home service, with people who have real skill in communicating and talking about these difficult topics at a time when someone may have just learned that they have a terminal illness and when lots of things are going around their mind. It is important for them to be able to get some clarity, going forward, about what they wish for and do not wish for. As we have heard, other parts of the country do not work so well.
Importantly, the evidence suggests that advance care planning does not increase costs to the health and care system, and may in some cases reduce healthcare expenditure by ensuring that care is delivered in accordance with patients’ wishes. We will come on to the single patient record on a later date, but I flag here that advance care planning can be effective only if the information is available to those providing care when it is needed. The single patient record offers a significant opportunity to improve co-ordination and continuity of care, but its success will depend not simply on sharing data but on ensuring that advance care planning is routinely embedded in clinical practice so that people’s wishes can be accessed, understood and acted upon, wherever and whenever care is provided.
The other amendments in this group from the noble Baronesses, Lady Finlay and Lady Coffey, highlight the many issues with the current landscape of palliative care and specialist palliative care services, and the difficulty in getting access to those services. I look forward to the Minister’s response to that, and her response to the trick or treat challenge.
Lord Kamall (Con)
My Lords, this has been an important and timely debate, coming not long after the Terminally Ill Adults (End of Life) Bill and the Prime Minister’s remarks. While these amendments address a range of issues, they all point to the same conclusion: palliative and end-of-life care must have a central place in this conversation.
If the Government are serious about shifting care from hospitals into communities, supporting people to remain closer to home—notwithstanding the comments from the noble Baroness, Lady Barker—and delivering truly patient-centred care, palliative care must be part of that vision from the outset. The need for action is clear. Marie Curie estimates that each year around 170,000 people in England die with unmet palliative care needs, equivalent to almost one person every three minutes. We must ensure that those approaching the end of their lives can access the support they need, when and where they need it. This is closely linked to my noble friend Lady Coffey’s amendment. She spoke movingly of her mother’s experience and the need to ensure that patients have access to high-quality palliative care, wherever they happen to live and choose to die.
If the Government’s proposed national care service is to succeed, it cannot simply be a discussion about structures, responsibilities and reorganisations. It must be about the experience of those who rely on care. No group demonstrates that more clearly than people approaching the end of their lives. Palliative care is perhaps one of the clearest examples of where health and social care are inseparable. While clinical support may be provided by the NHS, the ability of a person to remain at home or close to home, to maintain their dignity and spend time with loved ones, often depends just as much on the availability of social care. For many families, social care provides the day-to-day support on which good end-of-life care depends. Evidence shows that when effective support is available in the community, people are more likely to be cared for and pass away in a place they choose, rather than in hospital. As the noble Baronesses, Lady Finlay and Lady Hollins, said, this will also reduce hospital deaths, save the NHS money and make more beds available.
Palliative care does not begin and end with the NHS; it depends upon social care providers, community services, carers, local authorities, hospices and voluntary organisations working together around the individual and their family. When those services are joined up, people are more likely to receive care in the setting they choose and with the support they need. When they are not joined up, it can profoundly affect those approaching the end of their lives.
In that context, I welcome the amendment from the noble Baroness, Lady Finlay, which recognises that good palliative care depends not on any single organisation but on effective collaboration across the NHS, adult social care and the voluntary sector. Too often, services that support people approaching the end of their lives are commissioned, funded and delivered separately, despite the fact that patients and families experience them as part of a single journey. The amendment would help to ensure that integrated care boards take active steps to bring those services together, whether through access to specialist hospice care, shared equipment, medicines, workforce development or closer collaboration between providers.
Crucially, the amendment recognises the vital contribution of hospices and charitable organisations to the delivery of palliative and end-of-life care. These organisations are not peripheral to the system; they are an essential part of it. If the Government are serious about creating a national care service and a neighbourhood health service that are genuinely joined up for patients, the expertise and capacity of the voluntary sector must be properly integrated into the way care is planned and delivered.
Indeed, some of the most important services available to people at the end of their lives are delivered by hospices and charitable organisations. For decades, as the noble Lord, Lord Hunt, said, the voluntary sector has not merely supplemented statutory services but has been fundamental to the provision of specialist palliative care. But too often it is forced to operate at the margins of the system, dependent on local arrangements, local funding decisions and local fundraisers, and subject to tax rises, such as employers’ national insurance, from which state providers are understandably exempt. The noble Baroness, Lady Bennett, shared examples of recent hospice closures.
If the Government wish to build a neighbourhood health service and develop a national care service, integration must mean integration not only within the NHS but between the NHS, adult social care and the voluntary sector. Ultimately, the measure of success will not be the structures we create but whether individual patients receive seamless support at one of the most difficult moments of their lives and for their families.
The issue of patients having a conversation about their end-of-life care, addressed in the amendment in the name of the noble Baroness, Lady Pidgeon, was illustrated by the very moving stories from the noble Lord, Lord Patel, the personal experience of the noble Baroness, Lady Barker, and the concerns raised by the noble Baroness, Lady Grey-Thompson. These amendments seek to move us towards that goal. I hope that the Minister will give careful consideration to the issues that have been raised during the debate.
Baroness Merron (Lab)
My Lords, I can certainly confirm to the noble Lord, Lord Kamall, that I will give complete consideration to the points raised.
As other noble Lords have acknowledged, I thank the noble Baroness, Lady Barker, and the noble Lord, Lord Patel, for bringing their loved ones’ stories into the Chamber for the benefit of others, and for their willingness to share with us such a painful but realistic time. I believe that many people will identify with what the noble Baroness and the noble Lord said, and it will mean so much to so many.
Baroness Merron (Lab)
The noble Lord says “conditionally”. I would I expect it always to be conditional, but I thank him for clarifying.
To address the concerns of the noble Baroness, Lady Coffey, as we have already discussed in Committee, Section 1C of the NHS Act 2006 states:
“In exercising functions in relation to the health service, the Secretary of State must have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service”.
This is a deliberately overarching duty that applies across the whole of the health service, so we do not consider it appropriate to create separate versions of that duty for individual services. That would risk duplication and make the legislative framework overly prescriptive.
The much talked about modern service framework for palliative care and end-of-life care was referred to as a “trick or treat” test by the noble Lord, Lord Stevens —I will leave him to conclude, when I finish. I also assure the noble Baroness, Lady Coffey, that no one in this Chamber wants her to feel grumpy, and I am sure that nobody in the department wishes her to feel grumpy.
The modern service framework will focus on reducing inequalities. It will identify, measure and reduce inequalities, and reduce unwanted variation in access, experience and outcomes—I say to the noble Baroness, Lady Grey-Thompson, that that absolutely includes in respect of disability. The modern service framework is indeed anticipated in the autumn, which we remain in. I know that we are all keen to ensure that everyone can receive high-quality and personalised care in the right place at the end of life. I look forward to the modern service framework giving us the best way forward on that.
I turn to Amendment 78, also in the name of the noble Baroness, Lady Finlay. As per Clause 21, the Secretary of State is already required to undertake an annual performance assessment of each ICB in discharging its statutory functions. Again, that was spoken to by my noble friend Lord Hunt. I say to the noble Baroness, and to the noble Baroness, Lady Hollins, that the latest report for 2024-25 was published on 17 December last year. Future assessments will continue to consider how ICBs are discharging their statutory palliative care duties. I very much understand the calls from noble Lords across the Chamber and their emphasis on how important this is.
The modern service framework will indeed build on the ambitions set out in the neighbourhood health framework, which includes increasing the identification of those approaching end of life by 10% and reducing non-elective admissions and hospital bed days by 10% for those at end of life. I take the point that the noble Baroness, Lady Hollins, made about measurement and ambition in particular. On the NICE guidance in this area, in keeping with all NICE guidance, although it is not statutory or legally binding, as local healthcare professionals need autonomy to make clinically appropriate decisions in relation to their patients, there is an expectation that commissioners and service providers take it into account when they make those decisions on how to meet the reasonable needs of their populations.
On Amendment 230, tabled and spoken to by the noble Baroness, Lady Pidgeon, alongside the existing statutory framework that I have already outlined, the already published universal principles for advance care planning promote opportunities for individuals, including those with a terminal diagnosis, to discuss their wishes, their preferences and the clinical recommendations. Health and care professionals are expected to provide appropriate opportunities for individuals to engage in advance care planning. This area was spoken to by the noble Lords, Lord Kamall and Lord Patel, as well as the noble Baroness, Lady Barker.
These principles explicitly recognise the importance of involving a person’s family, carers and those who are important to them. I emphasise the point that those who are important to us do not always come neatly packaged. They are to be involved in discussions, including through the nomination of a named spokesperson. The outputs of these discussions may include one or more of the following: an advance statement —I have heard how helpful that is, along with the importance of an advance decision, where it is to refuse treatment—context-specific treatment recommendations and lasting power of attorney, where it is appropriate, in line with the Mental Capacity Act 2005.
Additionally, for those nearing the end of their life, the Government’s priority is to provide people with financial support quickly and compassionately. The noble Lord, Lord Patel, and the noble Baroness, Lady Barker, both spoke to the absolute importance of compassion being at the core of everything that is done. In a practical sense, the main way that this is done is through the special rules for end of life, which apply to five key benefits, including the personal independence payment.
I move on to the points on medicines access raised under Amendment 242, tabled by the noble Baroness, Lady Finlay. The pharmacy quality scheme forms part of the community pharmacy contractual framework. The scheme’s palliative and end-of-life care domain aims to ensure sufficient arrangements are in place so that patients, relatives, carers and healthcare professionals can obtain medicines in a timely manner—again, something spoken to very clearly by the noble Lord, Lord Patel. ICBs commission out-of-hours dispensing arrangements where there is a need for patients to access medicines outside core pharmacy hours.
Finally, I will address Amendment 26, tabled by the noble Baroness, Lady Finlay, on which we heard a number of contributions. Funding for palliative and end-of-life care is available through existing NHS funding arrangements and, as I have outlined, ICBs have statutory responsibility for commissioning. Indeed, as we have discussed on a number of occasions, local commissioners are best placed to determine how funding should be allocated according to the population need, local service provision and the best use of available resources. The ring-fenced fund proposal, which would mean establishing it in primary legislation, would, we believe, risk being overly prescriptive and would limit the flexibility of local commissioners to determine how resources are best used.
On the point about hospices and funding, I very much recognise, as have noble Lords, the absolutely vital part that voluntary sector organisations, including hospices, play when providing support to people at the end of life, but also to their loved ones. It is also worth noting that the majority of palliative and end-of-life care is provided by NHS staff and services, to whom and for which we are also most grateful. It is true that the amount of funding for each charitable hospice will vary but, by definition, that depends on the demand in local areas and on the type of palliative care provision. My noble friend Lord Hunt made the point that hospices value their operational independence—that is something that I have found in my discussions with them—and they are great innovators. I understand the point about funding, as I do in this whole area. However, when I have looked at this and spoken with hospices, that ability to operate independently is one that they really value.
The modern service framework will ensure that palliative care and end-of-life care is well within a strategic commissioning model. Importantly, there will be clear and transparent contractual arrangements, which I hope noble Lords will welcome.
Baroness Finlay of Llandaff (CB)
My Lords, I am extremely grateful to all noble Lords who have spoken in this debate, particularly my noble friend Lord Patel and the noble Baroness, Lady Barker, for sharing recent experiences, and my noble friend Lady Hollins and the noble Baroness, Lady Coffey, who have also drawn on their experiences. Everybody in this Chamber has experienced being bereaved: it is a universal experience, and we all carry with us the mark of whatever happened.
Lord Kamall
“Access to health innovation networks(1) The Secretary of State must make arrangements for a wide single national point of access to the health innovation networks in England.(2) The arrangements must enable a person to—(a) make a single request for support,(b) be directed to the appropriate health innovation network or networks, and(c) receive coordinated support where an innovation has potential application in more than one region.(3) The Secretary of State must publish information about the operation and performance of the arrangements.”Member's explanatory statement
This new clause would require a single national point of access through which innovators and other organisations could obtain coordinated support from the health innovation networks in England.
Lord Kamall (Con)
My Lords, let me make it clear that I recognise that what I am asking for does not need to be in the Bill and does not need legislation. However, my frustration at the lack of progress, both when I was the relevant Minister and as shadow Minister, has forced me to table this probing amendment.
I often meet entrepreneurs and tech companies who claim that they have an innovative product or solution that could transform healthcare. They ask me how they can have a conversation with the relevant person within the NHS. When I was a Minister and I asked my officials about this, they would give me an email address I could share. However, two things stayed with me. First, why was this email address not widely advertised and known by more people? Secondly, when I asked such entrepreneurs whether anyone from DHSC or NHS England had replied, the answer was no.
In opposition, I began thinking, “How can I help more innovators into the NHS?” It was suggested that I meet the Health Innovation Network, which told me that it is the front door for innovation. However, once again, many tech entrepreneurs have never heard of it. I was surprised to read on the Health Innovation Network’s LinkedIn page that it has “501-1K employees”. How about that for precision? Speaking to noble Lords and others interested in health innovation, I have heard a range of opinions about the local networks—that some are good, some are bad and some are in the middle. While some regional health innovation networks are good, others are not so good and coverage is patchy. This brings me to my question. What is the Health Innovation Network’s remit, and what assessment have the Government made of local networks’ effectiveness? What plans do the Government have for the networks in the reorganisation?
I recognise that there is a fantastic clinical entrepreneurs programme led by Tony Young, an NHS surgeon and clinical entrepreneur. He has always been very open and has encouraged me to send on to him clinical entrepreneurs who have approached me, in order to have further conversations. The question relating to this amendment is: what about entrepreneurs who are not clinicians, but who have an innovative solution that could transform health or social care? For them, there is no obvious front door to the NHS or one-stop shop. What do they do? They spend ages trying to get into the system at primary care, trust or ICB level, sometimes wasting their time but also clinicians’ precious time. Sadly, they then give up or go abroad, meaning that the UK loses out on British innovation.
In July, during an Oral Question, I asked the Minister to ask the DHSC Minister for technology and innovation to create such a front door or one-stop shop to triage those who approach it. That front door could distinguish those salespeople who have no minimum viable product, telling them what they need to come back with to be taken seriously. Secondly, what about those who have a solution but need more support, so that they can be signposted to someone who can advise them on coming up with a more feasible approach? Thirdly, there are those who have potentially a fantastic solution that could transform healthcare and need to be piloted as quickly as possible.
I was grateful when noble Lords from all Benches later told me that they agreed that this was a practical idea. Has any progress been made since I asked that question in July. If not, what are the reasons why? Time and again I hear the same concerns from entrepreneurs, researchers and businesses: the system is difficult to navigate, and numerous organisations are involved in supporting innovation, all with different remits, processes and points of entry. Expertise clearly exists throughout the system, but identifying the right door to knock on can be a challenge in itself.
This amendment seeks to address that problem through a simple but important principle: that there should be a single national point of access through which innovators and other organisations can obtain co-ordinated support. The purpose is not to create another bureaucratic layer; on the contrary, it is intended to reduce complexity, improve co-ordination and ensure that innovators spend less time navigating the system and more time developing solutions that could benefit patients. The principle behind the amendments mirrors one that the Government have embraced elsewhere in the health service. The concept of a single point of access, or a single front door, is designed to simplify routes into services, triage inquiries effectively and direct people to the most appropriate expertise at the earliest opportunity. Rather than forcing patients to navigate multiple pathways, the system assumes responsibility for guiding them to the right destination.
My Amendment 27 applies precisely that same logic to innovation. Instead of requiring innovators to work their way through a maze of organisations and programmes, a single front door would provide a clear route into the system, supported by intelligent triage to the most appropriate person in the Department of Health and Social Care or the NHS. It could be, but not necessarily, one of the 501 to 1,000 people who work for the Health Innovation Network. I beg to move the amendment.
Lord Scriven (LD)
My Lords, I thank the noble Lord, Lord Kamall, for moving this amendment and for the very short debate that has followed. I believe that the frustration is real, but the Committee deserves answers to two questions: what is in place now and would the proposed new clause make it better?
As the noble Lord, Lord Kamall, said, there are 15 health innovation networks, each serving its own region, but there is already a national point of access. The NHS Innovation Service, as the noble Lord, Lord Kamall, said, has been running since 2022, when it was set up by a very forward-thinking junior Health Minister—the noble Lord, Lord Kamall. NHS England describes it as a single entry point. An innovator completes one record. Experts from within the network review it within 10 working days, give tailored advice and can refer the innovator to one or more local networks. More than 2,000 innovations have had support through that service.
Proposed new paragraphs (a) and (b) of proposed new subsection (2) in this amendment largely describe something that already exists. Does it work? As a front door, it appears to do so in some regions for some people. The problem is that if the amendment from the noble Lord, Lord Kamall, was accepted, it would create two front doors for people to come through, which would probably not be a wise thing to do.
I believe that the front door is not the main problem here; the problem is spread. Adoption is one trust taking up a good idea; spread is that everything gets to the patient, no matter where they live. The Health Innovation Network’s own evidence to Parliament says adoption is
“slow, uneven and overly dependent on local early adopters”.
It describes what it calls
“a postcode pattern of spread”,
and warns that
“proven technologies do not spread through evidence alone”.
An innovation proven in one place can face the same hurdles all over again in the next, so I do not believe that we have a front door problem.
Therefore, I must be honest. As drafted, this proposed new clause would help only at the margins and it could hinder. It could create a second door beside the one we have, unless it simply puts a statutory label on the existing service. It would write an operational arrangement into primary legislation, when the way innovators are supported should be one that changes quickly. It would place duties around networks that neither the Bill nor the proposed new clause define.
There are two parts that I welcome. Proposed new subsection (3) would require published information on performance, and we should be told how many innovations spread beyond their first site and how far. Proposed new subsection (2)(c), on co-ordinated support across regions, goes closer to the real issue, but the network says that spread needs systems with
“the resource to redesign pathways, train staff and evaluate impact in practice”.
A referral service does not provide that.
The amendment’s most important contribution is the question it raises. NHS England runs the innovation service. The network’s national commission comes from NHS England, with the Office for Life Sciences. However, the Bill abolishes NHS England. Clause 6 gives the Secretary of State a duty to promote innovation and a power to award prizes, but it says nothing about the networks. A prize will not help a company stuck between a successful pilot and its second trust.
I have a few questions for the Minister. Who will run and fund the innovation service, and commission the networks, once NHS England has gone? Can she guarantee that there will be no gap? Will the Government publish performance data, including on adoption and spread, which is lacking, whether this amendment is accepted or not? Who, after abolition, will be responsible for making sure that proven innovation spreads across the whole NHS, not just to the early adopters?
A single door is a reasonable aim and we largely have one. What patients need is for it to work in one part of the NHS and then to reach all of it. I look forward to the Minister’s reply.
Baroness Merron (Lab)
My Lords, I am grateful to the noble Lord, Lord Kamall, for bringing this debate before the Committee. I commend his honesty that this is born out of frustration and a wish to improve things, rather than seeking a legislative response—something the noble Lord, Lord Scriven, also observed in looking at the amendment. I agree with the noble Lord, Lord Scriven, that the amendment raises important points to be considered more broadly, so I assure the noble Lord, Lord Kamall, of that consideration.
I will make a few points that may be helpful. The NHS Innovation Service already provides a wide national point of access. The way it works is that an innovator makes one request, creates one product record and is referred according to product type, maturity and location. More than 2,200 products have been registered with and have received support through the service, including 710 innovations in the 2025-26 financial year. All health innovation networks participate alongside 11 other organisations. That means that innovators have access to a broad range of expertise through a single service. Almost all products reach at least one health innovation network and are referred to four organisations on average. Innovators may also approach a network directly. Support can span several networks and regions, with onwards referral requiring no new application. Uptake is already reported at a high level while, of course, protecting commercial confidentiality.
I hope that the noble Lord, Lord Kamall, will understand that funding a second route—or, as I believe the noble Lord, Lord Scriven, said, a second front door, which would confuse us—where an effective national service is already in place may not exactly represent what we might call the most effective use of public resource. The amendment’s core aims are therefore already met. Prescribing an operating model in legislation could limit its ability to evolve—something I know the noble Lord understands.
The noble Lord, Lord Kamall, asked about health innovation networks. I can confirm they are subject to performance and impact monitoring. They also produce impact reports to show what their local impact is. The noble Lord, Lord Scriven, asked what would happen following the abolition of NHS England. Nationally funded health innovation networks’ work will continue and will be overseen by the Secretary of State. I will look at the other points that have been raised, because they are all certainly relevant and will be drawn to the attention of my colleague, the relevant Minister, Chris McDonald.
Lord Kamall (Con)
My Lords, I am grateful to the very many noble Lords who queued up to speak in this debate—I obviously raised a very important point. I am also grateful to the noble Lord, Lord Scriven, for reminding me how innovative I was when I was the Technology and Innovation Minister. In fact, I set up the very service that I am now asking for many years later. It does beg a question, because even I, as the person who set it up, still did not know that this service existed. When I speak to people in NHS England and elsewhere and say, “You know what you need? You need a front door for innovators”, they say, “You’re absolutely right; we haven’t got one”. So even people in NHS England do not know that this exists.
I was up front that I knew this was not meant to be in the Bill. I just wanted to get discussion. It probably helped to prompt my memory as well—my thanks to the noble Lord, Lord Scriven—but it is really important that more people know about the NHS Innovation Service. Perhaps the Minister could write to me and the many other noble Lords who are interested in this topic to let us know what the Government intend to do to promote the NHS Innovation Service, so that more people are aware and so I do not ask for the same thing next time we have a health Bill.
The Deputy Chairman of Committees (Lord Young of Cookham) (Con)
Does the noble Lord wish to withdraw his amendment?
Lord Kamall (Con)
I thought the logical conclusion would be that I beg leave to withdraw my amendment.
Baroness Shawcross-Wolfson
“(1A) The Secretary of State must publish an independently verified long-term assessment of the workforce needs of the health service and a ten year education and training plan to deliver on those needs.(1B) The first assessment and plan under subsection (1A) must be published within one month of the day on which this Act is passed. (1C) The Secretary of State must keep the assessment and plan under review and revise both at least once every five years.”Member’s explanatory statement
This amendment would require the Secretary of State to publish an independently verified assessment of the long-term workforce needs of the health service and a ten-year education and training plan to meet those needs, with the first assessment and plan published within one month of Royal Assent.
Baroness Shawcross-Wolfson (Con)
My Lords, I am grateful to the noble Lord, Lord Patel, and the noble Baronesses, Lady Harding of Winscombe and Lady Cass, for their support for this amendment. In moving Amendment 28, I want to make a very simple argument. The Bill gives Ministers direct responsibility for training and educating the NHS workforce. I believe that it should also make Ministers responsible for setting out what workforce they believe the NHS requires and for developing a training and education plan to deliver that workforce.
This is not a controversial proposal—Amendments 92, 252 and 253 in this group make a very similar case—nor is it a new proposal. In 2022, your Lordships’ House passed a very similar amendment to the Health and Care Bill, not once but twice, with support from the Labour Benches, the Liberal Democrat Benches and the Cross Benches. In 2023, the Conservative Government published a long-term workforce plan and asked the National Audit Office to scrutinise the modelling behind it. In 2024, the Labour Party manifesto promised “regular, independent workforce planning”, and Ministers subsequently committed to producing a new workforce plan with independent scrutiny.
Therefore, in theory, we all agree. But in practice, we are now more than two years after the election and Ministers have set aside the Conservative Government’s 2023 plan, understandably, but have still not published their own. In June, Ministers said it was coming imminently. We are now told that it will arrive in due course.
An insufficient NHS workforce is a problem that has been many years in the making. At the end of June, the NHS in England had more than 100,000 vacancies. But vacancies are not the whole story. Since 2015, the number of patients registered with GP practices has risen by more than 10%, but the number of fully qualified full-time GPs has gone down. Others in this House can describe far better than I can what workforce shortages mean on the front line, so I will not talk about how hard it is to plan services when you have insufficient staff to deliver them or the toll on healthcare professionals when we constantly ask them to cover gaps or the impact on patient care. But I hope that others in this debate will do.
Instead, I want to talk about how we ended up here. I believe that all Governments understand the importance of NHS workforce planning. But experience shows that very few are able to develop and deliver a comprehensive plan. That comes down to the very simple fact that training must be paid for today and the benefits of training are realised only in the future. It takes three years to train a nurse, around 10 years to train a GP and up to 15 years to train a consultant. So Ministers constantly face a choice between the pressures of today and the prospect of a better NHS in three, 10 or 15 years’ time. Every £1 spent on a GP for 2035 is £1 not spent this winter or on this year’s political priorities. At any one moment, choosing to prioritise today makes sense. But, repeated year after year, that choice leaves us with a workforce that cannot possibly meet the demands it faces.
Of course, politicians can and sometimes do take long-term decisions. As chair of the Health and Social Care Committee, Sir Jeremy Hunt championed independent workforce forecasts. As Chancellor, he was in a position to fund an NHS workforce plan and did so. That 2023 plan was backed by over £2.4 billion. It set out ambitions to double medical school places, increase GP training places by half and almost double adult nursing training places. It was not a perfect forecast, and the NAO kindly pointed that out when it was asked to scrutinise it, but it was a baseline and it showed that, when the political will exists, it is possible to plan for and invest in the future. However, hoping for sufficient political will is not a strategy. We will not often have a Chancellor who was previously Health Secretary.
This amendment would make long-term workforce planning a duty and not a matter of personal commitment. It would require independently verified assessments of what staff the NHS needs and a 10-year plan to train and educate the staff needed. The first assessment and plan would have to be published within one month of Royal Assent to the Bill. Both the plan and assessment would be kept under review and would have to be revised at least every five years.
In 2022, the noble Baroness, Lady Merron, told the House that
“without mandated forecasts of staff numbers, meaningful workforce planning—something that every other efficient organisation undertakes—cannot take place”.—[Official Report, 26/4/22; col. 223.]
I really agree with her and hope that she will support this principle from the Government Benches as she did from the Opposition Benches, and back this amendment or one along similar lines.
I would be grateful if the Minister could also answer two questions. First, when will the Government publish their own workforce plan? Secondly, who will undertake the independent scrutiny of that plan?
Every Government must have the right to set their own spending priorities. But every Government should be transparent about the workforce they believe the NHS needs and what the decisions they are making today about education and training will mean for tomorrow’s workforce. I hope the Committee will agree. I beg to move.
Baroness Hollins (CB)
My Lords, I am grateful to the noble Baroness, Lady Tyler, and the noble Lord, Lord Singh of Solihull, for co-signing my amendments in this group.
I will start with Amendment 252 because it relates to the points made by the previous speaker. It would place a duty on the Government to publish a follow-up mental health workforce plan within 12 months of the highly anticipated publication of the next 10-year NHS workforce plan. It would require detail on how the mental health workforce will be effectively retained and recruited to meet the scale of the mental health demand. Retention and recruitment measures, combined with a clear commitment to the resources required, would help to assure many patients and people across the mental health sector about how the Government’s ambitions in this area will be matched by a strategic approach to delivery. The sector is looking for tangible outcomes for patients, particularly those who live with a serious mental illness.
Mental health and well-being support for NHS mental health staff is integral to the plan, including developing occupational mental health capacity and investing in staff mental health and well-being hubs nationwide. Staff sickness figures reveal that anxiety, stress, depression and other psychiatric illnesses continue to be the most reported reasons for sickness absence among the NHS workforce. In the 12 months up to and including May 2026, those conditions accounted for more than 8.3 million days of sickness absence, equivalent to 29% of total sickness absence over that period. So, while I welcome the commitment in the 10-year health plan to introduce staff treatment hubs for NHS staff, I am keen to understand how the hubs will interact with existing NHS staff mental health and well-being hubs. A dedicated NHS mental health workforce plan would help to ensure that the hubs are as effective as possible.
Amendment 92 would require ICBs to assess and report on mental health workforce efficiency for their local area every two years and propose measures to address the challenges faced by their workforces in delivering services for the communities that they serve. This takes me back to the discussions during the passage of the Mental Health Bill about the need for sufficient community services for people with learning disabilities, and autistic people, to avoid unnecessary and lengthy admissions to hospitals.
Localised focus is vital. Organisations across the mental health sector are concerned that the NHS 10-year plan is too vague about how ICBs are expected to both successfully manage system pressures and, at the same time, meet the ever-growing need for an expanded mental health workforce. Does the Minister agree that requiring ICB-led assessments would be an effective way to ensure that the Government’s programmes of national reform can be matched with local plans so that the ambitions of the 10-year health plan can be delivered?
Baroness Manzoor (Con)
My Lords, I support the thrust of the amendments in this group, particularly Amendment 28 in the name of my noble friend Lady Shawcross-Wolfson. She has put her case forcefully and clearly, so I will not detain the Committee for long.
Poor long-term workforce planning creates significant challenges for NHS staff and patient care. Inadequate forecasting, insufficient investment in training and recruitment and poor staff retention contribute to persistent vacancies and skills shortages. This increases workforce loads, stress, burnout and sickness absence, resulting in low morale and higher staff turnover. The NHS becomes increasingly reliant on expensive agency workers and international recruitment, placing additional pressure on budgets. Consequently, services experience longer waiting times, reduced productivity, compromised continuity of care and potential risks to patient safety.
NHS England estimates an existing workforce shortfall of approximately 150,000 full-time equivalent staff, potentially rising to 260,000 to 360,000 by 2036-37 if there is no intervention. Effective long-term planning is therefore essential to develop a sustainable workforce, improve staff well-being, strengthen retention and ensure safe, high-quality patient care. I strongly urge the Minister to support this amendment. Ministers should be held accountable for the delivery of this workforce plan.
Lord Patel (CB)
My Lords, I strongly support the amendment in the name of the noble Baroness, Lady Shawcross-Wolfson, and I have added my name to it. She spoke so eloquently and made her case so strongly that I have put aside what I have written down because it would have been a repetition of what she had already said. I am going to take a slightly different tack but make the same point.
The noble Baroness quite rightly linked education, training and workforce planning. You have to know what workforce you might require for the health service you plan to have. I guess one can say that the Government’s 10-year health plan and the 10-year cancer care plan outline the kind of health service that the Government wish to see develop over the next 10 years. If that is the case, we need to address what kind of training and education and what kind of people we will need to deliver that plan.
I am guessing now that the reason why the 10-year workforce plan is delayed is because the premise on which it was to be formulated was that technology such as AI and digital technology would free a lot of clinical time, and hence the headcount need not be so high. That is a false assumption. It is false because we need to train people to use AI and digital technologies. The assessment is that, if you use these technologies, you might free about 40 minutes a day for front-line clinicians. With the pressure that the NHS now faces and the needs of the workforce it now faces, that time will be used to deliver better care to patients, particularly as the 10-year health plan identifies that technologies such as genomics and personalised medicine will be the way healthcare will go. There is an ambition by 2040 to have 50% of patients with some idea of their genomics, and the treatment is therefore based on that.
If you add all these together, and the Secretary of State now has responsibility for education, training and workforce planning, you ask the question: why is the workforce plan delayed? It is delayed because maybe the penny has dropped that, if you do not count the numbers and do not present a case about how technologies will reduce front-line clinical time, then you cannot plan the workforce.
Furthermore, I wonder whether the Bailie review of productivity in the NHS is based on the premise that greater productivity will be delivered in the NHS because of using technologies such as AI and digital technologies. We do not know that that will happen, but we have to wait until the Bailie review comes out. I wonder whether that is another reason—the Minister might comment on that—why the workforce plan is delayed.
It might be political pressures, it might be fiscal pressures or it might be the pressures from not knowing how to get the workforce numbers that we would require to deliver the 10-year plan and the cancer care plan that are holding up workforce planning. However, as the noble Baroness, Lady Shawcross-Wolfson, pointed out, if we do not have a plan, things will get worse. We will introduce technology, which will not be across the board, and we will then look for workforce that is not trained to deliver it. I hope the Minister will give us some answers about where we are going.
Baroness Tyler of Enfield (LD)
My Lords, I was very pleased to add my name to the two amendments tabled by the noble Baroness, Lady Hollins, Amendments 92 and 252, regarding the mental health workforce. More generally, I was very taken by the way this important group of amendments was introduced by the noble Baroness, Lady Shawcross-Wolfson, because she is right that all the things that we have been talking about in this Bill so far—all the things we all want to see to improve the health of this country, and all the things we want the NHS to be able to do with, yes, efficiency and increased productivity but also with great care and compassion—will none of them be achieved unless we have the right workforce with the right skills and the education and training in place. That is why I think this is such an important group of amendments.
As I said, I was very pleased to add my name to the two amendments tabled by the noble Baroness, Lady Hollins, on the mental health workforce. She set out the case clearly, so I do not need to do it again. I simply reiterate that, once we have the long-awaited NHS workforce plan, this will be vital. I would be grateful if the Minister could make some commitment here about how quickly we will see a follow-up mental health workforce plan. We need to see some detail about how the mental health workforce will be recruited and retained and will be able to meet the scale of the mental health demand, which we have debated so many times on so many occasions. That is critical. Both those amendments are important in that respect.
My final point is that, during the passage of the Mental Health Bill, in which many noble Lords here were involved, we all quite rightly thought how important it was that as many mental health services as possible should be located in the community. We all agreed with that; it was the premise, as it were, on which the rest of that legislation was built. As important as the consultants and psychiatrists and so on are—of course they are; it is a wide-ranging workforce and includes mental health nurses and others as well—unless we have that workforce in the right place, in the community, appropriately skilled, educated and trained, we will never be able to deliver those community mental health services, which are so vital. So I was very pleased to support these amendments.
Lord Kakkar (CB)
My Lords, I support the amendment in the name of the noble Baroness, Lady Shawcross-Wolfson. It is an important amendment raising two fundamental questions, which I hope the Minister will be able to answer. The first is this: ultimately, in preparing a workforce plan that will enjoy broad confidence, there must be external scrutiny of that plan. It would be most helpful if the Minister could confirm how His Majesty’s Government’s healthcare workforce plan will be independently scrutinised. Also, how will His Majesty’s Government be able to reconcile potential differences generated as part of that independent scrutiny with what they consider to be deliverable at this particular moment in time?
The second issue is how a mechanism will be secured—now that the functions independently exercised in NHS England will become the responsibility of the Secretary of State for Health—in respect of long-term workforce needs and short-term financial pressures. As we have heard, investment in the workforce is a long-term investment, and Ministers will always be faced with short-term financial problems and crises. Historically in the NHS, the education and training budget has been periodically sacrificed when there have been other service, access and delivery demands on NHS institutions.
In providing an opportunity now with this Bill, how will the Government address that fundamental tension and secure a mechanism both for independent scrutiny and to ensure—with all the powers now lying in the hands of the Secretary of State for Health—that the education and training budget that secures the long-term development of the workforce cannot be sacrificed for short-term exigencies?
Lord Scriven (LD)
My Lords, I will speak mainly to Amendment 252 in the name of the noble Baroness, Lady Hollins. I apologise for not putting my name to it; I wish I had.
But I wish to speak first on two other amendments. The amendment from the noble Baroness, Lady Shawcross-Wolfson, is useful, and I thank her for the way that she presented it. An independently verified assessment and a 10-year plan is exactly what is needed. But I do have a word of caution. Publication within one month of Royal Assent could be a real challenge, even considering the amount of time that we have been waiting. Also, a plan that is produced that quickly risks being inaccurate, and an inaccurate workforce plan is worse than none at all, because people will make training and funding decisions on it. The amendment from my noble friend Lady Pidgeon offers a better timescale of 12 months from Royal Assent as well as an assessment of the staff needed, a funded plan to close the gap and an annual report to Parliament.
Amendment 252 matters because it names people who are easily forgotten in workforce planning: that is, the staff who care for people with a learning disability. Let me start with why that matters. The latest—in fact the last ever—national LeDeR report found that the median age at death for adults with a learning disability was 62.8 years, compared with 81.8 years for the general population. That is a gap of 19 years. Many noble Lords will know that my own wonderful nephew, Myles, who was 31 years old, is part of that terrible, tragic statistic. Some 39% of deaths of these adults were judged to be avoidable, against 21% for the general population. No workforce plan can fix that alone, but no plan that ignores it is worth having.
Baroness Rafferty (Lab)
My Lords, Amendment 279J seeks to increase the transparency of continuous professional development in terms of the funding and protected time allowed, and requests that the Secretary of State report on and review both those variables within six months of the passing of this Act. Continuous professional development, or CPD, is the mycelium—the material—that nourishes and sustains professional development and progression for nurses and midwives. It is also an evidence-based intervention for staff retention. Were the noble Baroness, Lady Watkins, here, she would have added allied health professions to our group, but she will speak to that point on Report.
I am sorry to say that, too often, CPD is paid for by nurses and midwives themselves or treated as an optional extra, although core to training and career development for doctors. Unlike doctors, nurses and midwives lack a predictable career pathway underpinned by training support, despite many elegant models for implementation. Funding has been at the heart of this dilemma, with fluctuations reflecting the buoyancy of the health economy, but a lack of transparency means that such funding is often shrouded in mystery regarding what is available where, when and for whom.
Our amendment seeks to place a responsibility on the Secretary of State to report on funding and, just as important, as I mentioned, on protected time for training, for the first time. This change will open the black box of CPD support from which helpful benchmarking can ensue, putting what has hitherto been hidden on a more secure footing.
Baroness Harding of Winscombe (Con)
My Lords, I too support my noble friend Lady Shawcross-Wolfson on Amendment 28, to which I have added my name. My first experience of workforce planning in the NHS was when I applied to be chair of NHS Improvement in 2017. I can remember asking the then Permanent Secretary, who is not in his place at this moment, if there was a plan for the workforce in the NHS. I came from retailing, where we spent a lot of time worrying about long-term people planning. I was absolutely gobsmacked at the time to be told, “Oh no, we don’t really do that here”.
Fast forward two years to 2019, when I was asked by the then Prime Minister to develop a people plan for the NHS. Again, maybe rather naively, I thought, “Good, this is an obviously sensible thing to do”. I remember speaking in this Chamber in 2022 when that people plan had not yet been published. That was not because the numbers had not been run; they had. It was because the Treasury and the Department of Health and Social Care could not agree on whether it would be a good idea to actually publish them.
I do not think it is an accident that there was a workforce plan published in 2023. It was because of the work we all did in this House with the last health Bill. I see the noble Lord, Lord Stevens, nodding his head, and the Minister was herself instrumental in that pressure that together we put on the then Government to publish a workforce plan. So here we all are again, in slightly different positions in this Chamber, but with basically the same problem that my noble friend set out so beautifully. We must not settle for what we did in 2022, which is just a commitment to publish a workforce plan. There are huge structural disincentives for any Government to publish it, as the Minister is undoubtedly feeling at this moment, which is why we have to put it in the Bill.
The first rule of solving a problem is naming it. If you do not acknowledge the problem of the escalating demands for a growing workforce in our health and care system, you cannot even begin to solve it. I am afraid that by not acknowledging it, we also lose the faith and trust of that very workforce. Go and speak to any junior doctor, and they know there is a problem with this. They know that if we do not find better ways of working in health and care, we will all be working in the NHS by the time we die. We have to name it, but I recognise the very real political problems that naming it presents.
Unless we legislate for this, nothing will change, so this is a very important group. I am sad that, once again, the people of our NHS warrant discussion in only one group in the Bill. Frankly, it should be multiple groups so that we really dig deep on how we not just plan for the numbers but change the culture and leadership in the NHS; but it is where we are for the moment. I very much hope that when we come back on Report, we will find a combined amendment. I recognise the challenge from the noble Lord, Lord Scriven, about Amendment 28 being quite speedy, but it would require a regular five-yearly update, which Amendment 253 would not. Maybe we could all align around some combination of those two amendments. I would very much welcome a discussion with the Minister, because I know that she thought deeply about this when she was sitting in another place in this Chamber.
Lord Blencathra (Con)
My Lords, Amendment 240 stands in my name and that of the noble Lord, Lord Patel. My amendment is much more narrowly focused than the excellent debate we have had so far. Nevertheless, I am surprised that this issue has not been addressed before, but it is terribly important and needs to be addressed now. This proposed new clause would require statutory regulators of health and care professions to remove permanently from their professional register any individual found to have committed sexual misconduct. It would also make it clear that erasure from the register is a mandatory sanction and cannot be replaced by a lesser penalty.
At the heart of this amendment lies a simple proposition. Sexual misconduct by a healthcare professional is not merely a disciplinary failing; it is a profound abuse of professional trust. Healthcare professionals occupy positions of exceptional authority. Patients are often frightened, vulnerable, in pain, under sedation, partially clothed or entirely dependent on the judgment and integrity of the clinician before them. Society grants doctors, nurses and other healthcare professionals access to situations and circumstances unlike almost any other profession. With that privilege comes an obligation to maintain the highest standards of conduct. When a healthcare professional exploits that position for sexual purposes, they do more than violate professional rules. They betray the trust on which the entire healthcare system and relationship depends.
The current system does not always reflect the gravity of the breaches taking place. Recent analysis by the Royal College of Surgeons has highlighted a disturbing gap between what the medical regulator believes is necessary for public protection and what tribunals ultimately decide. An examination of cases involving proven sexual misconduct found that nearly one in four doctors whom the General Medical Council argued should be struck off were instead given suspensions and allowed the possibility of returning to practice. The cases involved serious misconduct including sexual assault, harassment, grooming and the exploitation of vulnerable individuals.
That raises fundamental questions. What message does it send to patients when a doctor found guilty of serious sexual misconduct is merely suspended, rather than permanently removed from practice? What confidence can patients have in the regulatory system if findings of grave sexual wrongdoing do not automatically lead to removal from the profession? What reassurance can be offered to those contemplating reporting abuse if they believe that their abuser may eventually be allowed to resume professional practice?
Regulation exists first and foremost to protect the public. Of course, regulators must be fair to practitioners and due process must be observed. Of course, allegations must be thoroughly investigated and misconduct properly proved. But once serious sexual misconduct has been established, the primary duty of the regulator must be the protection of patients and maintenance of public confidence.
Too often, arguments were produced that an individual should be allowed another chance because they had an otherwise distinguished career, because they possessed valuable clinical skills which the NHS needed, or because they expressed remorse or there were mitigating personal circumstances. Such considerations may have relevance in cases involving competence, judgment or less serious professional failings, but they should carry very little weight when the issue is sexual misconduct involving an abuse of professional trust.
The question is not whether the individual remains clinically competent; it is whether they remain fit to hold a position that requires vulnerable patients to place complete trust in their integrity and professionalism. Many professions recognise that certain forms of misconduct are fundamentally incompatible with continued membership of that profession. The deliberate abuse of a position of trust for sexual purposes should be regarded in exactly the same way within the healthcare profession.
The amendment we propose seeks to establish a clear statutory principle. Where sexual misconduct is proven, removal from the professional register should follow automatically—not sometimes, not usually, not subject to different interpretations by different panels and not dependent on which tribunal happens to hear the case, but always. Some may argue that this removes discretion from regulators and tribunals. I would respond that Parliament frequently determines that certain conduct is so serious that a clear and consistent consequence must follow. Consistency is not an enemy of justice. In cases involving abuse of professional trust, consistency can be an essential component of justice. Others may argue that regulators are already reforming their procedures. I welcome these reforms if they are actually happening. I hope the Minister can elucidate on that.
Baroness Coffey (Con)
My Lords, I find it extraordinary that we might have to legislate to get what seems very sensible work done. I commend my noble friend on raising this important issue. I also say to my noble friend Lady Harding: just wait until group 45 when we have another opportunity to develop this in more detail. I look forward to leading that group in due course.
I generally support these amendments, particularly the amendment tabled by my noble friend Lady Shawcross-Wolfson. There is no doubt that trying to come up with a workforce plan for more than 1 million people, who are working either directly as employees of the NHS or as contractors, may seem overwhelming. But I put it to the Committee that it is absolutely necessary to deliver what is expected and the promises made. I am conscious that a lot of the mechanisms in the Bill are about the Secretary of State effectively taking over the functions of NHS England. Nevertheless, I think it is great. I enjoy this Bill and would like to see even more in the hands of Ministers in trying to make stuff happen. I am a great believer in the Nike model, “Just do it”. At times it was JFDI—please do not put that in Hansard. It is a case of trying to get momentum going.
Even in the short time I was in the Department of Health and Social Care as a Minister, we tried to get certain things moving. I will give an example of what may seem extraordinary and why it still seems to take an unnecessarily bureaucratic way of getting stuff to happen. I was astonished to find out that dentists in Scotland could not automatically come and practise in the NHS in England. We had to do some regulations to enable the General Dental Council to do something, then there was some other local commissioning, instead of just making the rule that anybody who is qualified to work in the NHS as a dentist in any part of the United Kingdom can also do it in England. There is no doubt that we should be thinking about how we ensure that qualifications we recognise from other parts of the world—we need to be careful—match the standards of the NHS in this country. But I would hope that we can agree it, at least among the United Kingdom, without too much effort, without regulation and without bureaucracy.
My noble friend referred to the more than 100,000 vacancies. A lot of those are filled by agency and bank, which we know is very expensive. I give credit to the Government as I think they put a lot of focus at the beginning of their administration on working with NHS England to bring that down. Undoubtedly, that huge cost should be unnecessary in a well-run organisation, particularly where management should be highly rated and world-class. Unfortunately, what we see in reality is often very different. People will leave the NHS or turn to these other forms of helping patients because of the inflexibility across the system, which is a real tragedy.
We see this in a different way when we look at the sickness rates of people who work for the NHS, particularly in secondary care. It continually surprised me that the sickness rates are a lot higher for non-clinical staff than for clinical staff. Something is not right there. I would hope that the level of detail that future Ministers will have at their fingertips to try to understand this, or at least to be able to see the analysis and ask the questions, will prompt a thorough workforce plan.
My noble friend suggested that the NAO is the right body to do this. That could be right. I often find that the NAO is great at looking backwards rather than forwards. In trying to understand some of the operational challenges, it varies. When 40% of our annual budget for day-to-day spending is consumed by the NHS—the Barnett formula makes that even higher in other parts of the United Kingdom—it is right that we have a parliamentary body through the NAO involved in scrutiny to give confidence to the scrutiny of both Houses and to give an element of independence that is not so far from reality. This is so that it can be seen as credible and not necessarily wishful thinking by the Government. Sometimes think tanks will come up with a lot of wishful thinking on what should happen.
I turn to how we get the workforce in, how we keep the workforce—I have already briefly touched on that—and what is happening with the exit. After Covid there was a huge spike—a surge—in people wanting to go to university and train as nurses. It was roughly 22,000 per year for 2022, 2023 and 2024. The sad reality is that a lot of those people who are graduating have not found jobs within the NHS as there have been recruitment freezes. Something has gone fundamentally wrong there. It should not be a surprise to us, sadly, that the attrition rate for nursing degrees is about 20% to 24%.
On the other hand, we have quite a modest number of people going through the nursing apprenticeship degrees—about 2,500 to 3,500 per year on average over the last five years. The advantage those people have is that they have a guaranteed job; they are already working in the NHS. That is concerning, such that the Government put out a nursing graduate guarantee scheme, but I do not think there is any evidence that it has had any impact whatever. I may be wrong on that, and I would be happy to hear from the Minister, but I appreciate that she has a lot to cover in her 20-minute reply. I would be grateful if she could write to me if that information is not available now.
My successor made it a degree requirement to become a paramedic, which had been pushed for by the Royal College of Paramedics and other chief executives. I am still at the stage of questioning why, over the past 15 to 20 years, there has been a massive push to require degrees for lots of public services, such as to be a police constable, whereas when we challenge the private sector and other professionals, we say it is outrageous that you must have a degree if you want to become a solicitor. We need to get our thinking caps on and work with the brightest and the best.
I commend my noble friend Lady Harding. She gave up a lot to run NHS Improvement and work alongside other people there, particularly during challenging times. This can be done. I know that the noble Lord, Lord Stevens of Birmingham, was also exemplary in his running of the NHS during his time there. Not everybody has all the skills, but together we can make it better. That is why I support something as serious as this being in the Bill. As I mentioned, it is something that I will explore in a later group.
The noble Baroness, Lady Pidgeon, has filled the missing gap regarding the care service being part of the workforce plan. That is understandable, given the ongoing work on the creation of a national care service. It was Jeremy Hunt who requested that health and social care be put together. He recognised that having these work together was part of the same desirable outcome, and that it made sense to broaden that. However, I appreciate that that risks a strategy that will cover between 3 million and 3.5 million people in England alone, which is challenging.
I appreciate that when a new Secretary of State comes in they may be in the middle of a Bill that they never dreamed of doing and must now look at the detail of the NHS 10-year workforce plan. That is why “imminent”, which normally means that the Government are waiting for a grid slot, becomes “in due course”, which means it has almost certainly been completely rewritten from word one. This will take a bit of time, but the clock is ticking. We know there was a change made on waiting lists and that we need the staff to get that done. That is why, for the benefit of patients, I support my noble friend’s amendment.
Lord Stevens of Birmingham (CB)
I also strongly welcome the leadership that the noble Baroness, Lady Shawcross-Wolfson, has shown in tabling her amendment, which is before the Committee. To paraphrase her speech, the proposition, in essence, is that Parliament should help save the Government from themselves. When it comes to these workforce questions, the dual pathologies of short-termism multiplied by wishful thinking equals the problem that we have. There is a need to do something better. In supporting other amendments in this group, I will briefly illustrate why that might be the case in respect of mental health and primary care.
On Amendments 92 and 232, which concern mental health, I think we can all recognise there is quite a degree of uncertainty as to what mental health services will have to address on the demand side over the course of the next decade. It is not just the review, which recently took place and has partly concluded, on the increase in self-reported mental health problems and the question around unmet need and diagnostic fluidity. Look at the NEETs problem, the huge fiscal crunch that the country faces and the spending review next year, which will be a slaughterhouse.
Solving that problem will require much greater flexibility in offering targeted services and support, rather than simply putting people on to benefits. That will require a movement from what our colleagues in Grand Committee, who are noting Fortifying the Fiscal Framework, will know as AME spending into DEL spending and translating automatic entitlement to benefits into services. Some of those services will have to be mental health services, which will require a workforce. Therefore, we need a much more forensic approach to some of the scenarios and how we will respond to this from the point of view not just of the NHS but of the fiscal sustainability of the United Kingdom. It is high stakes getting this stuff right.
Primary care is less a demand-side question and more of a supply-side conundrum. In my opinion, a lot of what is happening in the gulf between the increased population and the decreased availability of GPs has been misdiagnosed. However, a very useful quantitative analysis published by the BMJ in 17 September last year shows that part of what is going on is that a much higher proportion of GPs and consultants who come through training are choosing to work part-time, and that gap has widened over the course of the past decade. In 2015, the ratio of FTs to GP headcounts was 0.81—in other words, the typical GP in general practice was working four-fifths of the week in NHS general practice. That had fallen to about 73% by 2024, whereas, throughout that period, NHS consultants were working over 90% of their week in their hospital or in specialist care.
Baroness Gerada (CB)
My Lords, I also welcome the amendment tabled by the noble Baroness, Lady Shawcross-Wolfson. I will speak to Amendment 253, which is in my name. Before I do, I will say that when I started in general practice in 1991, 80% of the GP workforce were men. We now have a reversal of that, so part of the issue is the feminisation of the GP workforce. Women get pregnant and care for small children and our elders. This was predictable. When I was a GP leader, I said that we needed to replace every retiring male GP with 2.4 GPs—men and women, for various reasons. Nevertheless, I digress.
I will speak on district nurses, who are our generalist practitioners in patients’ homes. I will paint a little picture. It is a wet Tuesday evening in November and somewhere in a village, town or city near any of us a district nurse is parking outside a terraced house. Inside is an elderly man with a leg ulcer that will not heal. Down the road there is a woman with diabetes who cannot manage her insulin on her own. A few streets further on a family is sitting with their mother in her final days, frightened and exhausted. The district nurse is the only one who can put up a syringe driver. This district nurse will visit them all. She will dress their wounds, check their blood, ease their pain and hold their hands. Tomorrow, she will do it again. District nurses are there every day of the year, in every corner of this country, at almost every hour of the day and night.
Successive Governments have promised to shift care out of hospitals and into the community. This Government have done the same, and I welcome that. But that shift will be extremely difficult without district nurses. They are not an optional extra; they are the linchpin. Neighbourhood health without district nurses is a building without a foundation. As the Nursing and Midwifery Council has said, district nursing is key to the achievement of the shift in healthcare that this Government seek.
I will remind your Lordships of some of the figures—we have heard a lot of figures today, so I will cut them back. According to analysis by the Nuffield Trust, in 2009 there were some 7,600 full-time equivalent district nurses in the NHS. By 2024, there were 4,322, a fall of 43%. Put simply, for every seven district nurses we had in 2009, we now have four. Over the same period, the number of adult nurses working in hospitals rose by 43%. The contrast is striking. We have said that we want care closer to home, but our workforce has continued to develop in favour of the hospital.
Some will say that this is an artefact of how we count the data because, around 2011, some community services moved to voluntary and independent providers, and some district nurses consequently stopped appearing in NHS figures. That is true, but it does not explain a decline that has continued over 15 years. The picture is even more concerning when we take population growth and ageing into account. On that basis, district nursing has fallen by 55%. The decline is continuing. The Care Quality Commission’s latest State of Care report found that the number of qualified district nurses fell by a further 5% between 2024-25 and 2025-26.
The problem is not just numbers; there is also the question of skills and experience. More than one in four of those recorded as district nurses are employed below band 6, which is the grade at which qualified district nurses would normally start. So we are losing not just numbers but the expertise on which this whole community service depends. What does this mean for patients? When district nurse teams are stretched, the first things to go are the things that matter most and are seen least: psychological support, prevention—such as looking at trip hazards and adequate lighting—and continence care. That care is now too often delivered less well, not delivered at all or pushed on to services that are already at breaking point. Investing in district nursing is not simply an investment in better care; it is an investment in preventing avoidable deterioration, unnecessary hospital attendances and expensive admissions.
The pressure is set to increase further. The Nuffield Trust estimates that the demand for district nurses could rise by 34% by 2040, based on the projected population numbers. So demand has grown but the service has contracted. This is not a failure of district nurses, who have held the line with extraordinary dedication. It is a failure of planning, as we have heard, as well as priorities and political will. That is exactly why this amendment matters. We cannot keep promising to move care into the community without first asking how many people we need to deliver it.
District nurses are indispensable. We cannot deliver neighbourhood health, safely shift care out of hospitals and provide dignified care at home without a properly trained and adequately staffed district nursing workforce. We know what happens when plans fail, and we will see the numbers of patients admitted to hospital. My question to the Minister is: will the Government commit to assessing the number of district nurses needed to meet current and projected demand, identifying the shortfall and setting out a funded plan to address it?
Baroness Barker (LD)
My Lords, I will add to what the noble Baroness, Lady Gerada, said. A very high percentage of our district nurses come from other countries. Therefore, what will the Minister do, talking to the Home Office, about the supply of district nurses that we will undoubtedly need in the future?
I will make one or two brief points, following on from what the noble Baroness, Lady Harding, said about planning. If any member of the Committee has spoken to anybody currently employed by an ICB, they will know that seared in their minds is the date on which they were told, about 18 months ago, that their jobs were going to go. For the last 18 months, they have continued to work under that threat. I do not know any other employer that would do that to a workforce and expect to retain it. I talked to members of staff who work for ICBs. I had the misfortune to ask them, “How are you?”, and 25 minutes later I knew how they were—it was not good. I rather suspect that the biggest demand for mental health services at the moment is coming from members of NHS staff, because they have been living with this uncertainty for 18 months.
I am not being flippant but, if the Minister cannot share great detail with us, can she at least tell us the Government’s working assumptions about the number of staff there will be in the future who are members of ICB staff now? I suspect that the attrition rate will be enormous, especially given the age profile of some members of ICB staff, in particular, who have built up specialist expertise over many years. Secondly, what working assumptions are the Government making about members of staff, particularly nursing staff, who will move out of the acute sector and into the community?
Baroness Pidgeon (LD)
My Lords, since taking over as our spokesperson, I have lost count of the number of times the Minister has talked about the workforce strategy that will at some point emerge from the department. I am not sure whether we will be given a season this evening, but hopefully it will be published soon.
My Amendment 253, which the noble Lord, Lord Stevens of Birmingham, and the noble Baroness, Lady Gerada, have added their names to, would require the Secretary of State, within 12 months of Royal Assent, to publish
“a health and care workforce strategy for England”.
I have included “care” on purpose because the two are so importantly linked. It must assess the staff needed to meet current and projected demands, expressly including registered nurses and primary care practitioners, and it must contain a funded plan to close staffing gaps. Annual progress reports would be laid before Parliament, keeping that issue on the agenda for us all. Putting staff in is an important marker too. We need to properly plan and invest in our workforce, both health and care, hand in hand.
The Royal College of Nursing supports this amendment, as do a number of representatives of primary care. Too often, primary care seems to be forgotten in the debate on workforce, but it is critical: GPs and district nurses—we have just heard passionately from the noble Baroness, Lady Gerada, about their role—as well as optometrists, dentists and pharmacists. As the Government look to shift services into neighbourhoods and hospitals—something I think we all support—this is really important. The early years workforce is important as well, as are health visitors.
The other amendments in this group, including that of the noble Baroness, Lady Shawcross-Wolfson, all require similar reports, perhaps on different timescales. Some are focused on really important areas such as the mental health workforce, the education and training that is needed alongside a workforce plan, and continuing professional development. Noble Lords have flagged the current vacancy rates in a number of roles, as well as skills shortages and the need for independent scrutiny of the workforce plan.
My noble friend Lord Scriven rightly stressed, using his personal family experience, the need for nurses for people with learning disabilities and the investment in that workforce, as well as the need to understand the whole workforce, looking at models in, for example, the Netherlands. The noble Lord, Lord Stevens, and the noble Baroness, Lady Gerada, talked about the complexity around primary care and the challenges with part-time workers, with perhaps more women coming into the workforce, as well as the challenges of work-life balance. Some people want to work part-time rather than full-time. These are key questions for the Government on this issue of workforce. I look forward to a comprehensive response from the Minister, and possibly a date, a season or a hint of when we might at last see that workforce strategy.
Lord Kamall (Con)
My Lords, this has been a crucial debate, and I am grateful to noble Lords for tabling and speaking to their amendments, which raise fundamental questions about the future of the NHS workforce, the quality of care patients can expect and the Government’s ability to deliver health service reform.
The amendments from my noble friend Lady Shawcross-Wolfson and the noble Baroness, Lady Pidgeon, go to the heart of a simple but vital question: how can this Government, or indeed any Government, credibly plan for the future of the NHS without an independently verified assessment of the workforce that we need? As my noble friend said, the previous Conservative Government, albeit belatedly, recognised the importance of this challenge when we published the first NHS Long Term Workforce Plan in 2023. This was a baseline step in establishing a long-term approach to workforce planning, with clear ambitions to expand domestic training, improve retention and reduce our reliance on international recruitment.
We recognised then, as we must recognise now, that workforce planning cannot be conducted from one spending review to the next. Training doctors, nurses and other healthcare professionals takes years, and decisions made today will determine the quality and availability of care for patients a decade, or decades, from now. Yet we are still waiting, as other noble Lords said, for the Government’s new 10-year workforce plan. The noble Lord, Lord Patel, offered some possible reasons for the delay.
Baroness Merron (Lab)
My Lords, I am grateful for the debate we have just had. Unsurprisingly, but not exclusively, a lot of it focused on the promised workforce plan, so I will address that straight off. There has been lots of thought about why it is “in due course”, and that is the situation. I am glad that the noble Baroness, Lady Coffey, appreciated the impact, without blame, of a new Secretary of State: she is well placed to speak to that point.
Let me say that, first, our absolute commitment to the workforce plan for the NHS remains. There is no shift in that. I also say that, as I mentioned, the reason we await it and it is “in due course” is that, as is absolutely reasonable and right, a new Secretary of State has to be allowed to provide views; that is the situation. I hope that clarifies the position.
With permission, I will address Amendments 28, 92, 240, 252, 253 and 279J together. Amendments 28 and 253 have been tabled by the noble Baronesses, Lady Shawcross-Wolfson and Lady Pidgeon. I absolutely agree that the health and care workforce is fundamental. It is fundamental to everything we are doing and to this entire debate, and it is fundamental to the interests of patients, which is why we will publish the 10-year workforce plan. As most noble Lords spoke to the plan, I will emphasise that the Secretary of State already has duties to ensure effective planning and the delivery of healthcare, education and training—as has been called for, rightly—and also has a duty to report on the system for assessing and meeting NHS workforce needs.
To the noble Lords, Lord Kakkar, Lord Stevens and Lord Kamall, I can say that an expert panel of external stakeholders has scrutinised the 10-year workforce plan approach to workforce planning. To the noble Baroness, Lady Hollins, I can confirm that sickness absence is indeed factored in to the workforce planning process. I heard the noble Lord, Lord Stevens, talking about the way in which the workforce has changed; that is absolutely right and, again, the plan will reflect that.
The noble Lord, Lord Kakkar, and the noble Lord, Lord Stevens, raised points about short-termism versus long-termism in workforce planning, and so on. I am sure noble Lords will understand that decisions about the education and training of healthcare professionals will continue to be driven by data, based on evidence and intelligence led. That will be through the new restructured system. The point here is to make sure that we have the right people in the right places, with the right skills, to care for patients when they need it.
The noble Baroness, Lady Hollins, asked about a bottleneck in medical training pathways. I can say on that point that noble Lords will recall the passage of what became the Medical Training (Prioritisation) Act, and we are easing competition for medical training by prioritising UK-trained graduates for foundation specialty training places, alongside some other groups. The recently agreed 2026 resident doctors deal also significantly expands specialty training places by up to 4,500 over three years, including 1,000 next year.
The noble Baroness, Lady Gerada, made a very strong, and correct, point about the role of district nurses, borne out by the noble Baroness, Lady Barker. Through NHS England, we are actively monitoring future nursing and midwifery student numbers and will continue to assess the 2025-26 graduate guarantee as a mechanism. There is a wide range of measures to support students, educators and universities with the transition into employment, including Student Hub, which offers guidance and resources for students and newly qualified practitioners.
To the point made by the noble Baroness, Lady Barker, I will be pleased to speak to colleagues in the Home Office about the supply of district nurses, if not directly then through the appropriate Minister.
The noble Baroness, Lady Shawcross-Wolfson, in her opening comments made reference to numbers of GPs. We have committed £292 million for GP recruitment this year, which translates to 1,600 GPs, and there are 4,100 more GPs than a year ago. It is important to note that, while we wait for a workforce plan, we have not waited in taking action. For example, we have resolved the long-running doctors’ dispute and we have published a set of core NHS staff standards.
On adult social care, and the point made by the noble Baroness, Lady Harding, that was another point I pushed when we last debated this matter and when we were in Opposition. There was also a comment about legislating on planning duties. That would pre-empt the vital work to develop a national care service which will follow from the recommendations of the noble Baroness, Lady Casey, which we will receive in the summer. That work will have important implications for the shape and skills of the future adult social care workforce. I agree with noble Lords: it is inextricably linked with the NHS workforce, which is a point I have made over a number of years. In the meantime, we will commit to publishing a workforce plan and we will set out immediate action to further support and develop the adult social care workforce.
My noble friend Lady Rafferty tabled Amendment 279J on continued professional development for nurses and midwives. I agree that that is critical for patient safety and outcomes. That is why we are investing in their professional development, with £181 million of continued professional development funding allocated for nurses, midwives, nursing associates and allied healthcare professionals in 2026-27 as part of a three-year cycle and to support equitable access to professional development. To respond to her questions, I can tell my noble friend that organisations are responsible for the planning and governance of their CPD, to ensure that staff have a fair opportunity to benefit from the funding. We expect employers to provide support, supervision and guidance, and to foster a culture of continuous learning, which, again, we would expect throughout the NHS.
Baroness Shawcross-Wolfson (Con)
My Lords, I am grateful to everyone who has taken part in this debate. In the interests of time, I will keep my remarks as short as possible. I am grateful to the Minister for answering so many questions and setting out so comprehensively what the Government are already doing in this space.
The Minister mentioned external scrutiny of the Government’s workforce plan. It was not totally clear to me whether that meant published scrutiny. I would be grateful if she could pick that up in writing to explain what independent scrutiny has been and will be done, and what is going to be published.
I am taking a leaf out of the book of the noble Lord, Lord Stevens, in that I would like to quote the noble Baroness, Lady Merron, of 2022—she put it better than I could:
“This powerful debate has focused on two simple truths. First, without the full team of people in place at the right time, it will not be possible to provide the health, social care and public health services we need. The second simple truth is that this will not just happen on its own”.—[Official Report, 3/3/22; col. 987.]
I am afraid that everything I have heard this evening suggests it is even more important that we put this amendment in the Bill. I am very glad that this Government remain committed to producing a workforce plan in due course. I would like to ensure that all Governments are committed to producing workforce plans in a timely manner and with the independent scrutiny that is required. For the moment I beg leave to withdraw the amendment, but I would like to return to this on Report if the Government do not produce their own recommendations, which I hope they will do.
Prison (Governor’s and Adjudicators’ Punishments) (Amendment) Rules 2026
(1 day, 9 hours ago)
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20:45 - Division on Lord Farmer’s Motion - Ayes: 30 / Noes: 67 - Lord Farmer’s Motion disagreed.
Lord Farmer
That this House regrets that the Prison (Governor’s and Adjudicators’ Punishments) (Amendment) Rules 2026 remove and restrict social visits as a punishment despite (1) the potential effects on rehabilitation, prisoner behaviour and family relationships, (2) prison governors’ hesitancy, and (3) the lack of an assessment of likely impacts.
Relevant document: 9th Report from the Secondary Legislation Scrutiny Committee (special attention drawn to the instrument)
Lord Farmer (Con)
My Lords, I thank all noble Lords who have put their names down to speak and have made time to take part this evening.
The Victims and Courts Act 2026 gave judges the power to impose in-prison punishments for non-attendance at sentencing hearing. The MoJ gave these new judicial sanctions a big push in the media last month when they were laid as the Sentencing Act 2020 (Prison Sanctions) Regulations 2026. I agree with the MoJ’s intent to make:
“Cowardly killers who dodge sentencing face tough new prison punishments”.
These punishments include no visits for up to 27 days and restriction of social visits to once every 28 days for up to 84 days. For these prison sanctions to have effect, the Sentencing Code requires that they correspond to the punishments that may be imposed by a governor under prison rules, so governors who oversee them need parallel powers—hence the Prison (Governor’s and Adjudicators’ Punishments) (Amendment) Rules 2026. These are the subject of my regret Motion because they give governors new disciplinary powers that do not correspond to judges’ very limited sanctions but far exceed them. Whereas a judge can restrict visits at the very beginning of a sentence, governors are now able to do so at any point to punish any offence.
The prisoner discipline procedures adjudications policy framework sets parameters as to the seriousness of the offence but, first, these could change and, secondly, why are such sanctions generally available? Removing visits for non-attendance at sentence hearings is reasonable and hard to disagree with. However, the measure has been expanded beyond this initial justification and prison rules changed in a way that was not made clear during passage of the parental Act. The Government might claim they are being tough on crime, but at best it is an ineffective measure to that end and at worst a counterproductive measure. It is not being soft on crime to oppose it but the opposite.
Social visits can restrain bad behaviour because prosocial relationships improve rehabilitation—the lack of such relationships is a criminogenic need. These are an individual’s characteristics, traits, problems or issues that directly relate to their likelihood of reoffending. Offender assessment system data says that 72% of all offenders in custody have a relationships need, and 80% of women in prison. Obviously, governors are immediately concerned with reoffending that happens inside their jails. This is the justification for making harsher punishments available. However, I saw during my first review for the Government how family visits can turn around dreadful behaviour.
The mother of one young man complained to the deputy governor of a prison I visited about allegations of unfair treatment made by her son. The deputy helped her understand that the shoe was actually on the other foot. On her next visit this mother put her son right and told him to get a grip—his behaviour changed utterly. This anecdote is backed up by the MoJ’s own research on reoffending, which found that the protective factor of positive family relationships can moderate risk factors including having an attitudinal criminogenic need: a way of thinking, belief or attitude likely to lead to further offences. That young man would probably be among the 85% of male prisoners in that category.
Prisoners who have family visits are significantly less likely to reoffend than those who do not. The old MoJ figure of 39% dwarfed the effectiveness of other rehabilitation pathways such as education, employment and drug treatment. It was the reason they asked me to do the reviews, first for the male estate and secondly for all female offenders. HMPPS’s commitment to implementing all my reviews’ recommendations since 2017 has gone far beyond words on the page. It knows that the greater prize is to shift the culture towards a greater emphasis on improving relationships, whether between officers and prisoners, between senior officers and junior officers they are mentoring or between prisoners themselves. The transforming prisons directorate is reconceiving prisons and designing new builds around the need for relationships.
Yet, despite 10 years of progress, social contact is now a disciplinary sanction. The Prison Reform Trust says that this devalues family members, treats them as instruments of prison discipline and completely neglects the impact on family members despite them having done nothing wrong. Thankfully, those with children will not be so punished, but such prisoners already have a far greater incentive to keep out of trouble in prison. Category A prisoners in HMP Frankland told me they walk away from conflict because their families and children will hear of altercations and will want to know that they are safe.
Indeed, I have heard that governors do not want to use this sanction as they see it as counterproductive to running a safe regime. The report on prison riots in 1989 by the noble and learned Lord, Lord Woolf, warned that messing with the ability of families to visit was one of the most resented acts the Prison Service could take.
To conclude, this is the recurring problem that Governments of all colours face: how to appear tough on crime—which this is not—without turning our prisons into overcrowded places where rehabilitation becomes impossible. With attention on capacity pressures and early release, I fear measures are being introduced that make regimes appear tougher on crime but that are simply tougher on prisoners and more toxic to a rehabilitation culture. If this increases in-prison and community reoffending, our prisons will simply fill up.
King and Willmott’s Honest Politician’s Guide to Prisons and Probation tracked 40 years of tough penal policy and the personalities responsible for crafting it. They found time and again that once politicians had moved on from the justice portfolio, they would acknowledge the futility of bowing down to public opinion instead of doing more to shape it. I am grateful to the Minister for making herself available to discuss this SI, and I wonder if there might be room for manoeuvre. The Government could rewrite and reissue it, so that removal of visits could be used only as the judge-imposed sanction for non-attendance at sentence hearing. This could be achieved by taking it out of Rule 55, covering governor punishments for any offence, and by following the example of Rule 55AB, which specifically requires a prisoner to pay for damage to prison property once found guilty. This could then be new Rule 55AC. I hope this will be considered and I beg to move.
Baroness Gill (Lab)
My Lords, I normally back wholeheartedly initiatives that improve rehabilitation of prisoners. However, in this instance, I beg to differ from the noble Lord, Lord Farmer, because I believe that we must look at these new rules through the lens of fundamental justice, public confidence and the rights of victims’ families.
These new rules counter a disturbing trend of offenders refusing to leave their cells to face the court at the time of their sentencing. Let us remind ourselves that the public and victims’ families are demanding action. We saw the murderers of nine year-old Olivia Pratt-Korbel, Zara Aleena and Sabina Nessa refusing to face the families whose lives they had destroyed. This trend is becoming increasingly common; it was adopted by the serial killers at the Countess of Chester Hospital and the Southport murderer. Grieving families sitting in a courtroom watching an empty dock because a perpetrator simply chooses to opt out is an intolerable insult. It makes closure extremely difficult for them and makes a mockery of our justice system.
Traditional internal punishments, such as adding days to a sentence, mean absolutely nothing to a murderer already facing a whole life or half a century behind bars. If a prisoner deliberately defies the authority of the court, there must be immediate, tangible loss of privileges within the prison estate. I know that critics argue that these rules risk damaging rehabilitation, but true rehabilitation cannot begin without accountability. An offender who refuses to look their victims in the eye is actively rejecting the first step of reform and rehabilitation.
The Government have approached this issue with care. There are vital safeguards: the rules explicitly exempt an offender’s children from these restrictions. Wider privileges are being targeted—visits must be earned through compliance with our justice system. We need to back the Government in restoring this vital lever of authority; however, we must ensure that its implementation has checks and balances to avoid abuses. So I have a question for my noble friend the Minister: how do the Government plan to monitor the implementation of these rules—in particular, how the prison governors are using them, and that there are no violations?
In recognising that public confidence in our courts is fragile, these rules protect children, target defiance and ensure that court orders are respected. I urge the House to reject this Motion.
Lord Thomas of Cwmgiedd (CB)
I thank the noble Lord, Lord Farmer, for bringing this matter before the House and for all he has done over the years in trying to improve rehabilitation in prisons. However, I also have great sympathy with the Government, because they are faced with the action of both political parties in winding up the prison population, which is probably the root cause of all these problems. I will not say anything about that tonight.
I want to raise the point that shines through the excellent report of the Secondary Legislation Select Committee, which is that we do not seem to understand two things. First, what is the cause of the inexorable rise in the number of disciplinary offences and their sanctions, which have had to be increased? Secondly, if you can find out what the cause is, it is normally useful to try to understand the most effective way of preventing it. It is very clear that we need a proper examination of the cause and the best way of trying to deal with the problem.
It might be thought that we should set up some Grand Committee or ask people to look again and take a year or so to resolve this. I do not believe that is necessary. We have two expert charities—the Prison Reform Trust and the Howard League—and, as the Minister knows, we have admirable governors in our prisons and other experts in penology.
What is called for, as soon as is practicable, is an answer to the question of why prison indiscipline is getting worse, what the best way of preventing it is and how what is proposed in this statutory instrument is working. Instinctively, I feel that cutting off social relations is bad for prisoners. I also believe that incentives are probably more effective, but that is a belief; it is not based on evidence. Experience has taught me that you need to find out the why, the solution and the best way to deal with a problem. We cannot afford to make a mistake, because adding days to prisoners is increasing our prison population and we cannot afford not to seek rehabilitation through visits by families. The two policies seem wrong, but I do not know and we need to know why.
Lord Stewart of Dirleton (Con)
My Lords, the Prison Rules 1999 already provide prison governors with an extensive suite of disciplinary measures. Prisoners who offend against prison discipline may be cautioned, suffer forfeiture of privileges, be excluded from work that they carry out in the prison estate, suffer a deduction or loss of earnings, be confined to their cells, suffer removal from the wing upon which they are located or experience payback punishment. What do these existing measures have in common? They are all directed against the offender himself—his privileges, earnings, freedom of movement on the wing or opportunity to work. Prisoners serve terms of imprisonment because of things they have done; we punish people for the crimes they commit, not the crimes others commit.
My concern is that this amendment to the rules will punish not only the prisoner but those who would seek to visit the prisoner—those on the outside who have just as much interest in his rehabilitation as any. Those people, those loved ones, have not offended or breached prison discipline but, just as the prisoner will be punished by being deprived of their society, they will be punished by being deprived of the society of the prisoner.
It is undesirable to impose penalties on a person for something that someone else has done. Prison discipline is exercised summarily, necessarily and responsibly by prison governors, but I emphasise summarily. It may well be that a prison governor contemplating the use of this punishment could easily be expected to overlook the effect on someone outside who would wish to pay a social visit—a parent, relative, good friend or genuine well-wisher. Let prisons help prisoners amend themselves for the better. Let us not punish people on the outside for the disciplinary lapses of those inside prisons whom they love.
Baroness Fox of Buckley (Non-Afl)
My Lords, I thank the noble Lord, Lord Farmer. When we debated the Victims and Courts Bill, I had qualms about the targeted punishment of withdrawing social visits, even from those prisoners despicably refusing to attend sentencing hearings. I do not like the families, even of selfish, cowardly perpetrators, being used as a stick. Then I thought of the families of the victims, shown such contempt by such prisoners, and I swallowed my concerns.
But if ever there were an example of why we should beware laws passed here being weighed down by secondary legislation powers, it is the dangerous slippery slope on display here. It shows another type of contempt: contempt for democracy. No one in Parliament agreed to this mission creep that has amended the Prison Rules to allow restrictions on family visits as a general disciplinary punishment. None of us gave permission for that. Why would we, when it shows politicians’ contempt for any of the common-sense advice or on-the-ground expertise of prison officers and criminal justice campaigners about how real discipline works in prisons?
One of the most effective restraints on bad behaviour or criminal activity inside, or indeed on release from prison, is the influence of families and loved ones. Does the Minister understand that the way for a prisoner to have any sense of regret or shame for past crimes, or to be inspired to change, is via their mum, their fiancé, their kids? Not letting them down can be a powerful antidote to getting into further trouble. These social visits can lead to encouragement, even to tellings off, and while it cannot conquer all of the toxicity and brutality of prisons, having to face down your mum can do a hell of a lot.
Cutting off this pro-social influence is inexplicably foolish, and it is performative toughness. If the Government really want to be tough on the chaos in too many prisons, then do the hard jobs: tackle the thriving drugs industry behind bars; take on the unchecked growth of Islamist gangs; expose how human rights laws are being deployed to limit staff’s ability to exert authority and impose rules. Do not take the soft option of weaponising family visits. If only the Government used their executive powers to tackle cuts in purposeful activity and prison education, to invest in training and support for inexperienced, overworked staff.
I have been involved in the prison project Debating Matters Beyond Bars. The most moving moments have been those prisoner debaters beaming at their certificates because they cannot wait to send them home, and the letters from their wives and their kids saying “It helped him see another future: something to be proud of for his family”. Families are the best rehabilitation aid ever; they are cheap, and you dispense with them at your peril.
Baroness D'Souza (CB)
My Lords, irrefutable evidence from the academic sector, independent reviews, Government-led inquiries and the Ministry of Justice itself demonstrates that maintaining family and social relationships is fundamental to prisoners’ wellbeing, rehabilitation and successful reintegration. It is therefore puzzling, to say the very least, that the Government choose to introduce a punishment that risks undermining the very conditions necessary for safer prisons, improved behaviour and successful rehabilitation.
The lack of adequate consultation with prison groups is also of great concern. Many have expressed doubts on the proposed restrictions, pointing out the possible negative consequences. These include the damaging effect on children, who are innocent and for whom keeping in touch with relatives in prison may be an important means of emotional stability and support.
Prisoners, especially those from minority groups, tend to convey instances of bullying, unfair treatment and other inequalities to family members during visits, which are then reported onward by those family members. Financial hardship, geographical distance and other inequalities already significantly restrict family visits. Do the Government really believe that removing a prisoner’s source of emotional support is likely to improve behaviour, or will it remove one of the strongest incentives for positive change?
The new powers are disproportionate, they infringe prisoners’ fundamental rights to family life and they are counterproductive. They directly contradict the Government’s wider objectives of improving aspects of prisons and of prisoners’ lives. Family contact must be recognised as an essential component of rehabilitation and not simply as a privilege that can be withdrawn as punishment.
Baroness Jones of Moulsecoomb (GP)
My Lords, I would like to thank the noble Lord, Lord Farmer, for bringing this. I hate staying up late, but this is worth it, because this is a cruel idea. The Government say that they want to tackle rising indiscipline and violence in prisons, and of course they do; nobody wants to see prisoners or prison staff living in unsafe conditions. But I am against this decision to take away social visits as a punishment, not least because the Government’s own evidence tells us that family contact is one of the things that helps people behave better, supports rehabilitation and reduces reoffending.
Plus, we should not pretend that violence and indiscipline in prisons have appeared out of nowhere; they have to be understood in the context of years of pressure on the prison system, overcrowding, poor conditions and staff shortages—and the staff who are there are often inexperienced. What is the Government’s response? More punishment.
The Ministry of Justice produced its research into the impact of social visits on reoffending, self-harm and accommodation after release. It found that people who receive visits were significantly less likely to have a proven reoffence within a year of release. They committed fewer further offences and took longer to reoffend. They were also less likely to self-harm and more likely to have accommodation when they left prison, and the more visits people received, the lower the reoffending rate.
In March, HM Inspectorate of Prisons published its thematic review and found that regular family contact was associated with better mental health, improved behaviour and greater feelings of safety. People who received regular visits or social video calls were less likely to be at risk of suicide or self-harm. They were also less likely to experience bullying and victimisation, and less likely to be restrained or held in segregation. The inspectorate was clear that family contact should be treated as an essential part of prison safety and rehabilitation, so why are the Government taking away something that their own evidence says helps make prisons safer?
We constantly hear the refrain that prisons have to be a place of punishment, but you cannot keep making punishments harsher; it just does not work like that. At some point, you end up filling up more prison spaces with extra days—days when prisoners should be on licence and supervised. I ask the Government to please rethink this. It is a very nasty move.
Lord Garnier (Con)
My Lords, the Government advanced two inconsistent reasons for the statutory instrument. First, they say that the incidence of violence and rule-breaking in prisons is going up, and therefore governors and independent adjudicators need harsher or stricter options available to punish the serious and repeat rule-breaking. Secondly, they say that, because the Sentencing Act 2026 reduced the amount of time that prisoners will serve on their sentence, governors need to have the ability to keep them in.
It strikes me as odd and sad that the central question asked by the noble and learned Lord, Lord Thomas, has not been thought about by the Government: has anybody asked themselves why prisoners commit acts of indiscipline or break the rules in the first place? It is largely because they are incarcerated for 23 out of 24 hours a day, in a multi-occupied cell, they essentially live in a public lavatory, and they are largely mentally ill, illiterate and innumerate. The Minister used to work in Holloway prison, so she will know that everyone who spoke this evening, apart from the noble Baroness, Lady Gill, said some quite sensible things.
If you keep people in those conditions and fail to give them a sense of purpose and to rehabilitate them, you not only let them down, and endanger the lives and working conditions of the governors and the prison staff, but you waste taxpayer money and do not provide us with the requisite safety that we require of a rehabilitated prisoner—because they come back just as they went in, and so they reoffend. I ask the Government to be a little more intelligent and think a little more strategically about this, and not to resort to the usual government rubbish of reacting in a knee-jerk way without having applied their minds to the problem in front of them.
It is not surprising that, when prison governors and other prison group directors were asked about these measures, they were hesitant and sceptical. If the Minister believes that this will be a good idea, when the professionals in the business clearly think it will not, she needs to have another think.
I will not complain about the English of the Explanatory Notes, but when the Government say:
“Engagement with internal stakeholders to explore the impact on external policy areas, such as prisoner family and relations, trade unions, and third sector stakeholders, has commenced and will continue to occur prior to this instrument coming into force”,
I ask myself, first, what on earth that means, secondly, has it happened, and, thirdly, when will we hear about the result. Please do not allow this House to be fooled into thinking that this is a good idea; it plainly is not.
Baroness Wheatcroft (CB)
My Lords, the noble Lord, Lord Farmer, is quite right to draw the attention of the House to this ill-judged measure. To oppose it is in no way to condone the crime or the criminal, but it is to acknowledge the appalling conditions in many of our prisons, which are giving rise to discontent and the offences that are being committed, as we just heard graphically described by the noble and learned Lord, Lord Garnier.
Given that the majority of the prison population consists of people with numerous problems, disadvantages and frustrations—many of whom would have been much better and more successfully dealt with outside the prison system—clashes with authority within are inevitable, and the conditions they now are serving in make that only worse. The potential doubling of penalties under these rule changes risks dramatically damaging the mental health of the recipients, but I will concentrate my remarks on their potential to add to the chances of prison leavers being homeless.
People leaving prison regularly walk out straight into homelessness. In the year to March, the number averaged 300 a week. Is it any wonder that, for some, reoffending seems the easiest way to find accommodation and a degree of security? These ill-thought-through measures are likely only to add to that problem.
Many prisoners have family relationships that are, at best, fragile. Visits from relations can at least preserve those flimsy relationships—they might even nurture them. They could be crucial in ensuring that, on release, the prisoner has a home to go to. Damaging those relationships by forbidding visits seems a dangerously short-sighted move. All the evidence is that strong relationships on the outside can be pivotal in allowing a prisoner to rebuild his life after release. Having friends or family prepared to provide immediate accommodation may be the crucial factor in preventing the individual reoffending. Governors should never jeopardise that chance.
As a society, we surely should not tolerate people being released from incarceration by the state into a life on the streets. Last month, it was alleged that, on release, some prisoners were being issued with tents. The Government’s response to that was simply: “It is not government policy”. To underline why I believe it is so vital that governors should not endanger any chance of prisoners leaving into proper accommodation, I ask the Minister for a simple yes or no. Under this Government, have prisoners been issued with sleeping bags and tents on their release?
Baroness Porter of Fulwood (Con)
My Lords, reducing reoffending is widely recognised as the central purpose of our prison system. This was true when I worked in the Ministry of Justice 10 years ago and remains so today. Yet these rules, allowing social visits to be removed or restricted as a punishment, potentially undermine one of the very things that can help reduce reoffending.
We know that our prisons are full to bursting. We cannot carry on as we have been. We also know what helps reduce reoffending: education and training, drug and alcohol treatment, preparation for employment, stable accommodation on release and, where needed, mental health support. Provision remains inadequate. HM Inspectorate of Prisons reported last year that 94 of the 104 closed prisons it had inspected were rated poor or not sufficiently good for purposeful activity. At a time when public finances are stretched and difficult trade-offs are having to be made about what to prioritise, many of these areas are not being adequately resourced.
There is one area, though, which the state does not need to fund and which will save money over the long term, if it leverages it: developing strong social networks around offenders. I pay tribute to my noble friend Lord Farmer and Dr Samantha Callan for their important work in this area over many years. The Farmer review makes a compelling case for maintaining family ties during imprisonment. It cites Ministry of Justice research showing that for a prisoner who receives visits from a family member the odds of reoffending are 39% lower than for one who does not.
Removing visits risks undermining precisely the relationships that can help prevent reoffending after release—a point that has been made many times already. Family relationships should not be treated as a luxury item for those who behave well. Ensuring an ordered and disciplined environment is the foundation for a well-run prison. The irony here is that these rules risk undermining one of the building blocks that can help create the very behaviour and stability that prison discipline seeks to achieve. If we are serious about reducing reoffending, we need to be asking how we can strengthen family ties, not treating them as a special treat that can be removed as punishment. That governors have themselves expressed hesitancy over these changes and that their likely impacts have not been assessed mean that we should surely proceed with caution.
Ultimately, prison discipline should support a prison system that protects the public, and this must mean reducing reoffending. We should not risk undermining that objective without a clear understanding of the consequences.
Lord Foster of Bath (LD)
My Lords, on these Benches, we support the broad thrust of the Government’s proposals, but, like many others, we are concerned by the proposal to withdraw family visits as a punishment in the cases covered by the SI. That is why we support the regret Motion in the name of the noble Lord, Lord Farmer. Few have done more than he has to demonstrate the importance of family relationships in reducing reoffending and helping prisoners rebuild their lives.
I chair your Lordships’ Justice and Home Affairs Select Committee. In our report on prisons last year, we argued that the prisoners’ punishment is the loss of liberty, and that the job of prisons is to reduce reoffending through education, purposeful activity, tackling addiction and mental health problems, and preparing people for release. That also means, as so many people have said, maintaining family relationships. As the noble Lord, Lord Farmer, has rightly described, family ties are the golden thread in reducing reoffending. Evidence shows that family contact improves prison behaviour, supports mental health, reduces self-harm and, importantly, reduces reoffending.
Against that backdrop, I find it extraordinary that the Government should introduce rules allowing family visits to be withdrawn as a disciplinary punishment. Of course, effective sanctions are needed, but why introduce a punishment which undermines the very thing that makes prisons and the public safer?
There are three fundamental objections. First, as the noble Baroness, Lady Fox, said, it is counterproductive. Family contact provides hope, emotional stability and an incentive to behave responsibly; removing it risks increasing isolation, frustration and resentment.
Secondly, as the noble and learned Lord, Lord Stewart, said, it punishes innocent people. Partners, parents, adult children and other relatives have committed no offence, yet lose contact with someone they love. The exemption for children under 18 is, of course, welcome, but what about everybody else?
Thirdly, as the noble Baroness, Lady Wheatcroft, said, it damages relationships essential for successful resettlement. Families often provide accommodation, practical help and emotional support on release. Why weaken those relationships?
Disciplinary sanctions may be necessary, but they should address a prisoner’s behaviour without damaging relationships that will help to prevent future crime. We should strengthen relationships that help prisoners to turn their lives around, not take them away. The consequences will be felt by prisoners, innocent families and, ultimately, by the communities to which prisoners return. If we are serious about fewer victims, safer communities and less crime, we must stop treating family contact as a privilege that can be withdrawn and instead recognise it as essential to reducing reoffending and protecting the public. I hope that the Government will think again.
Lord Keen of Elie (Con)
My Lords, we appreciate and acknowledge the extensive work and experience of my noble friend Lord Farmer in this area and therefore understand what has prompted him to table this regret Motion. However, we cannot offer him support on this occasion.
This statutory instrument will increase the powers that are available to governors and independent adjudicators in relation to disciplinary breaches. Given the rising levels of violence and disciplinary issues in prisons, it is important for prison governors to have these additional powers available to them, to manage those prisoners who repeatedly break the rules.
An obvious concern with the instrument is the failure of the Government to provide a considered impact assessment. That would include a consideration of the impact on prison capacity, with the increased 84-day limit on the number of days that can be added to a sentence. We would like to hear from the Minister the expected impact of this extension on prison capacity.
The Ministry of Justice recently published a rapid evidence assessment on safety in prisons, written by Professor James McGuire. It looked into violence in prisons and sought to explore the factors that impact the level of violence. It noted:
“Higher staff numbers, a stable staff cohort, and a minimal level of vacancies were associated with lower levels of violence”.
There is hardly any surprise there. The most recent quarterly data for the Prison and Probation Service, for the quarter ending June 2026, showed that the number of prison officers in post had actually reduced over the last two years by more than 1,500. What steps are the Government going to take to support prison officers in reducing violence by increasing recruitment and retention?
In conclusion, while conscious of the concerns that have been expressed about the potential impact of these proposals, we are broadly supportive of the need to give prison governors greater powers to deal with indiscipline. Accordingly, we will not seek to oppose.
Baroness in Waiting/Government Whip (Baroness Hyde of Bemerton) (Lab)
My Lords, I thank the noble Lord, Lord Farmer, for securing this important debate, and all noble Lords who have contributed. I recognise the work that the noble Lord has done over many years to make sure that family relationships are taken seriously within our prison system. He has been a consistent and powerful voice on the importance of those relationships in helping people to turn their lives around. I thank the noble Lord for his reviews on prisoner family ties in 2017 and 2019, which many noble Lords have referenced today.
The noble Lord’s Motion focuses particularly on the introduction of new restrictions on social visits. I understand why he has raised concerns about potential consequences for prisoners and their families and for rehabilitation. I will lay out why the Government believe that these changes are needed, what safeguards have been put in place and how they strike a reasonable balance. I make it clear from the outset that I do not see prison order, safety and rehabilitation as competing priorities—quite the opposite. They all depend on each other. A prison that is not safe cannot properly rehabilitate and a prison that does not rehabilitate properly cannot fulfil its duty to protect the prisoners within it and the public. It is not about being unnecessarily punitive, or appearing as such.
On the point made by the noble Baroness, Lady Jones, the Government are absolutely committed to prisoner safety. We are focused on supporting safety and rehabilitation, working with partners across government and at a local level to improve outcomes for people in custody and on release through better access to treatment and recovery services, prison education, employment and stable accommodation.
On the point raised by several noble Lords, including the noble and learned Lord, Lord Garnier, and the noble Baroness, Lady Wheatcroft, about the more general state of our prisons and the contribution of that to prison indiscipline, I will take the opportunity to point out that this Labour Government inherited, in 2024, a prison system that was on the brink of collapse after 14 years of Conservative mismanagement, with fewer than 100 spaces left in the prison estate.
Lord Garnier (Con)
There really is no point in saying, “We inherited this”. Every Government could come in and say that. I said the same things in 2010. It makes no difference. We have to deal with what is going on right now under her watch.
Baroness Hyde of Bemerton (Lab)
I will move on to those comments, but it is only fair and right that I lay out the territory, as the noble and learned Lord would expect me to, including referencing the work of his colleague, the noble Lord, Lord Farmer, in my opening comments when I have 10 minutes to speak.
As I was saying, this Labour Government have spent over £40 million on physical infrastructure across 34 prison sites. We have introduced specialist staff and equipment to stop the smuggling of contraband into prisons, which can contribute to violence and instability. We are modernising prison education and creating that joined-up system so that basic literacy and numeracy are in place, supporting people into employment and higher education. There is much discussion in this of carrots and sticks, and incentives and sanctions, so I flag that the Government have expanded incentivised substance-free living units, where prisoners who agree to regular drug testing can access enhanced opportunities. This will be increased by a further 12 prisons by the end of 2027-28.
As I am sure all noble Lords who are contributing to this debate know, we have launched the independent review of the prison system, led by the right honourable Amber Rudd and supported by a panel of experts. That is to provide that strategic, risk-based assessment of the current risks and opportunities facing the system, to identify the reforms that will enable us to build that prison system fit for the future. That is due to report back next month and I am sure all noble Lords would welcome that.
The purpose of this instrument is to strengthen the range of measures available to governors and independent adjudicators. As noted by the noble and learned Lord, Lord Keen of Elie, this is for when serious or persistent rule-breaking occurs, to provide a fair, proportionate response that is sensitive to the circumstances of each individual prisoner.
It is really important to be clear about why the measure has been introduced in this way. The new social visit sanction forms part of the wider measure in the Victims and Courts Act which, once enforced, will give Crown Court judges the power to impose prison sanctions where an offender aged 18 or over refuses, without reasonable excuse, to attend their sentence hearing where a court has ordered them to do so. Parliament has long considered secondary legislation the most appropriate for matters concerning the management of prisoners, via the Prison Rules, as it allows flexibility to amend the regulations. To enable Crown Court judges to restrict social visits, the sanction must be contained within the Prison Rules, making it also available as an option for prison governors or independent adjudicators to use in limited circumstances.
It is impossible to include a sanction for non-attendance at a sentence hearing that only judges can impose without an amendment to Section 41B of the Sentencing Act 2020. This is because the Act specifies that the power of judges to give sanctions for non-attendance at sentencing hearings is limited to sanctions that correspond to the ones governors can give in the Prison Rules. The affirmative statutory instrument specifying sanctions available to Crown Court judges will be debated and the timings for that will be announced imminently. Therefore, I will try to keep the focus of my response to the subject of the Motion in the name of the noble Lord, Lord Farmer.
The Government recognise the importance of family contact, as referenced by the noble and learned Lord, Lord Stewart, the noble Baronesses, Lady Fox of Buckley and Lady Porter of Fulwood, and the noble Lord, Lord Foster of Bath, among other noble Lords. First, and really importantly, children are exempt from this sanction, so they can continue to visit their parents. I reassure the noble Baroness, Lady D’Souza, of that. That reflects the Government’s commitment to protecting that relationship between children and parents in prison, wherever that is safe, appropriate and in the best interests of the child.
Secondly, this measure should be used only as a last resort. The prison discipline policy framework said that it
“should only be used exceptionally for very serious breaches of the Rules … in cases of severe and persistent rule breaking for which other interventions or punishments have not proved effective”.
Adjudicators will have to set out the reasons why they consider the sanction appropriate.
Thirdly, those under the age of 21 when the offence was committed must not be given forfeiture or restriction of social visits. This is to reflect the separate policy approach for young offenders and children in custody.
Fourthly, individual circumstances will be taken into account. Some prisoners face serious mental health difficulties or are vulnerable, and losing social contact could make their situation worse. The Government expect those circumstances to be considered carefully before any restriction is imposed. This is about giving governors and independent adjudicators an additional option where other measures have failed—a measure of last resort.
A number of family circumstances should be taken into consideration by the governor where social visit sanction would cause disproportionate or unintended harm. This includes where a prisoner’s family is going through a key transitional period, such as a separation or other period of instability.
I understand the concerns of the noble Lord, Lord Farmer, about the effect of restricting social visits, and I take them seriously. As other noble Lords pointed out, having someone on the outside who cares about you, encourages you and gives you a reason to keep going can make an enormous difference. As your Lordships know, rehabilitation that genuinely cuts crime is central to this Government’s approach. The Ministry of Justice is supporting this by updating the strengthening family and relationship ties policy framework and reviewing the current social visits policy to promote child-friendly practice, safeguarding, and consistency across prisons.
The Government have not lost sight of the importance of family relationships and recognise that there will be times where serious or repeated misconduct requires a different response. When a small number of people are violent, threatening or potentially disruptive, they make life harder for those trying to use their time in prison positively. Those trying to get an education, learn a trade or deal with an addiction should be able to do so in safety.
The noble Lord, Lord Farmer, raised the question about whether these new sanctions will improve things for those in prison. As the noble and learned Lord, Lord Thomas, said, it is crucial to get to the heart of what causes prison indiscipline. Prison order should not depend upon sanctions alone, which is why governors can use rehabilitative adjudications alongside or instead of traditional sanctions, helping to increase accountability and encourage behaviour change. This includes unpaid rehabilitative or reparative projects.
In the interests of time, I will write to the noble Baroness, Lady Wheatcroft, to answer her question. However, it is completely unacceptable that people are leaving prisons with tents. That is not the Government’s position, but I will write to her to outline that more fully.
To conclude—at speed—this debate has been valuable and I am grateful to all noble Lords who contributed for their scrutiny and insight. I hope that I have addressed the principal points raised. I am aware that I need to write to a few noble Lords.
If the noble Lord, Lord Farmer, would be happy to meet me and perhaps my noble friend Lord Lemos to discuss further the detailed proposal he outlined in his opening speech, we can arrange for that to happen. I reiterate my thanks to the noble Lord for tabling this Motion.
I take this opportunity to pay tribute to all those who work to make prisons places of rehabilitation and to keep prisons safe. Therefore, this instrument should be supported. The Government do not believe that the instrument should be regarded as a matter for regret. Therefore, I hope that the noble Lord, having heard the assurances the Government have given today, will feel able to withdraw his Motion.
Lord Farmer (Con)
My Lords, I thank all those who contributed so powerfully to this debate. I think that all noble Lords, apart from the noble Baroness, Lady Gill, supported the argument against these sanctions being available to every governor to punish any prisoner for any crime. It is all very well to say that there will be advice and that governors will take things into account, but we have 110 prisons with 110 different prison governors. If the sanctions are there, they will be used differently.
I hear the Minister when she says that she will be happy to talk to me. However, I am aware of the mood of the House. I am also aware of the whipping on the other side and my own party’s lack of support, but this is, frankly, a very important matter and I wish to test the opinion of the House.
Health Bill
(1 day, 9 hours ago)
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The Deputy Chairman of Committees (Baroness Garden of Frognal) (LD)
My Lords, we start with Amendment 29. The noble Lord, Lord Shinkwin, will be taking part remotely in this debate. I remind the Committee that unless Members are leading a group, remote speakers speak first, after the mover of the lead amendment in a group. They may therefore speak to other amendments in the group ahead of Members who tabled them.
Clause 7: Education and training
Amendment 29
Baroness Gerada
“(1A) In discharging the duty in subsection (1), the Secretary of State must ensure that education and training for persons employed in the health service in England includes training on recognising, preventing and responding to antisemitism and other forms of racism.”Member's explanatory statement
This amendment seeks to ensure that the workforce education and training duty transferred from NHS England will include training on antisemitism and racism, as recommended by the Lord Mann review (recommendations 32 to 36).
Baroness Gerada (CB)
My Lords, in moving Amendment 29 in my name I will also speak to Amendments 79, 258 and 259. I thank the noble Lords, Lord Hunt of Kings Heath and Lord Austin of Dudley, for adding their names. I also thank the noble Lord, Lord Mann, for his review of antisemitism and other forms of racism in the NHS, and the Government for accepting all 36 of its recommendations. These amendments do not seek to reopen that decision; they aim to ensure its implementation.
According to the 2025 NHS staff survey, as reported in the review of the noble Lord, Lord Mann, 13% of Jewish staff reported discrimination from managers or colleagues, compared to 11% from patients or the public. Jewish staff are the only group for whom discrimination from within the workforce exceeds that from patients. The review heard evidence that staff no longer wish to work in the NHS. This is unacceptable and must never be accepted as normal. The review also found that some Jewish patients are putting off the care they need. A consultation works only if a patient can tell their doctor about themselves without fear. When that trust goes, it is a question not only of equality but of patient safety.
For many years, I led the NHS’s Practitioner Health service, to which over 40,000 doctors, dentists and other healthcare staff turned for help with their mental health problems. My work has taught me that doctors who do not feel they belong become unwell, and doctors who become unwell leave—and we cannot afford to lose them. These findings concern Jewish staff and patients, but the principle at stake is far broader. A health service that makes any group of patients hesitate to seek care, or any group of staff feel unsafe at work, fails us all. That is why these amendments address antisemitism alongside every other form of racism.
Why bring them to this Bill? Much of the work required to deliver the review rests on guidance, contracts and programmes already owned by NHS England, even if the Bill transfers its functions elsewhere. Commitments that exist only in guidance can be quietly lost when the body that wrote them is wound down. These amendments will place the essentials in statute.
The Deputy Chairman of Committees (Lord Russell of Liverpool) (CB)
My Lords, I now call the noble Lord, Lord Shinkwin, to make a remote contribution.
Lord Shinkwin (Con) [R]
My Lords, I support Amendment 29 and other amendments in this group. I would like to say that it is a pleasure to follow the noble Baroness, Lady Gerada, but it is a mixed one. That is not a reflection on the noble Baroness but a reflection of my disbelief that we are even having to raise this crucial issue. But raise it we must. I thank the noble Baroness, and the noble Lords, Lord Hunt of Kings Heath and Lord Austin of Dudley, for giving your Lordships’ Committee the opportunity to consider it.
I say “disbelief” because I cannot imagine that those noble Lords who helped pass Labour’s Race Relations Act could ever have envisaged that, 61 years later, we should be debating whether it is necessary for the Government to take measures to counter the shocking anti-Jewish racism that scars our NHS, a founding principle of which is surely equality. As a lifelong patient who owes so much to the NHS, I would say that, for such a treasured institution to apply that principle in practice, the provision of healthcare must be made in an environment in which all feel safe and mutually respected, patients and staff alike. The reason why I believe this amendment is essential is that, sadly, some feel neither, on account of their Jewish identity.
I would hope that it is generally recognised that racism is wrong. What I am less sure about is that antisemitism is recognised as racism. Adolf Hitler was very clear: his virulent hatred of Jewish people was racist. Indeed, he was so passionate about his racism that he made it a central tenet of the Nazi creed, which, sadly, as we all know, underpinned and informed the Holocaust. Jews were to be murdered for the crime of being Jewish. It therefore strikes me as bizarre that anyone could either delude themselves or seek to delude someone else—on social media, for example—that antisemitism or anti-Zionism is somehow not racist. This is simply factually incorrect, which is why the recommendations made in the review of the noble Lord, Lord Mann, and the amendments in this group, are so important.
I wonder whether the Minister, in her response, can assure the Committee that the third aspect of training mentioned in the amendment—that of responding to antisemitism—will include reference to historical facts, such as: the fact that the Jewish people have a historical claim to the land of Israel; that Israel has a long, if broken, history; that biblical records about, for example, the construction of the temple of Solomon in Jerusalem, which is believed to have existed between the 10th and 6th centuries BC, bear testimony to this; that the Jews were dispersed from their homeland by the Romans almost 2,000 years ago; that perhaps no other race has been subjected to such extreme prejudice and barbaric persecution in the history of humanity; and that, given the history of how the Jewish people have been treated, Israel has learned that there is only one country on which it can rely to defend its interests—most recently in the face of the egregious fabrication that the tragedy of Gaza is a genocide—and that is Israel. In short, can the Minister assure the Committee that any training on the need to respond, and on how to respond, to antisemitism and other forms of racism will be informed by, not divorced from, factual historical context?
In conclusion, there is another reason why I support this group of amendments. I discovered only after he had passed away that my childhood orthopaedic consultant, who played such a vital part in optimising my life chances, fled for his life on the last Kindertransport to leave Prague before the Nazis closed the borders in June 1939. Records show that the family members he left behind were murdered at Auschwitz only 82 years ago—within the lifetime of some Members of your Lordships’ House. Hanuš Weisl lived with that memory for the rest of his life. I am not Jewish, but for me his memory will always be a blessing. It is in recognition of the debt I owe to him, and indeed that I believe many of us owe to members of our wonderful Jewish community—particularly those who have dedicated their skills and their lives to the NHS—that I support this important group of amendments. I hope the Government will give it the careful consideration it deserves.
Lord Blencathra (Con)
My Lords, the proposed new clause in my Amendment 279C would require statutory regulators of health and care professions to remove from their professional registers any practitioner found to have engaged in antisemitic behaviour or speech, as defined in my amendment. It would also make clear that removal from the register is a mandatory sanction and cannot be replaced by a lesser penalty.
The amendment is founded upon a simple principle: medicine depends upon trust. Every day, patients place themselves in the hands of doctors, nurses and other healthcare professionals. They disclose intimate details of their lives. They place themselves in vulnerable situations. They trust that they will be treated fairly, equally and without prejudice, regardless of their race, religion, ethnicity, nationality or beliefs.
That trust is not optional; it is fundamental to the practice of medicine. If patients lose confidence that they will be treated impartially, the doctor-patient relationship is damaged. If an entire community begins to doubt that healthcare professionals regard it as deserving of equal dignity and respect, confidence in the healthcare system itself is undermined. That is why racism has no place in medicine. That is why antisemitism has no place in medicine. That is why this amendment is necessary.
Lord Hunt of Kings Heath (Lab)
My Lords, following the review by the noble Lord, Lord Mann, I certainly hope that the regulators toughen up their act, and in accepting its recommendations the Government certainly expect them to. I agree with the thrust of where the noble Lord, Lord Blencathra, is coming from. Whether all discretion should be taken away from the regulators, I very much doubt, but it will be interesting to hear what my noble friend has to say on that.
In supporting the amendment tabled by the noble Baroness, Lady Gerada, I want to reflect on two points. First, I repeat what the noble Baroness said, which was striking, arising from the report of the noble Lord, Lord Mann. Drawing on the NHS staff survey, Jewish staff are the only religious group where discrimination from managers and colleagues exceeds discrimination from patients. This is a very serious indication of the stress and pressure on Jewish staff within the NHS.
I am afraid that, so far, the response from management has been pretty poor. We have seen that in relation to what we might call uniform policy. As the noble Lord, Lord Mann, described it:
“Examples such as the brandishing of badges, the display of uniforms on political marches or the co-branding of the NHS by staff or others with third parties has made it unclear what patients can expect from the NHS”.
Patients are entitled to be treated without seeing staff display any political leanings whatever or support for campaigns. Teachers are simply not allowed to do this. One has to ask, what is with NHS employers that they have failed to put across to their staff the behaviour that is expected of them?
The noble Lord, Lord Mann, clearly called for NHS England to review what we might call its uniform policy. It is not the standardised uniform, but what people wear and how they display it. My understanding is that that work is being undertaken, subject to consultation. I hope that, when it comes out, it is not going to be wiffly-waffly, leaving too much discretion to local employers. Now that the Government are taking this over—because I doubt it will be finished before 1 April next year—they should make it abundantly clear to NHS employers what should and should not be expected.
I know that Manchester has been cited as a very good example. As the noble Lord, Lord Mann, said, some trusts do not permit the wearing of political badges, of any item of clothing with a political message or of a uniform to political rallies. We need to see something firm about this so that employers are implementing what is required of them from the centre. For employers, this would be much easier than going through the agony of developing local policies that are subject to consultation and lead to variation. Patients and staff are entitled to be in an environment where somebody else’s political views are not displayed in a way which causes huge upset and concern.
Baroness Manzoor (Con)
My Lords, I understand and support the aims and sentiment behind this group of amendments—particularly Amendment 29 and 258. Any form of discrimination or racism is abhorrent. How one identifies oneself should not be a problem. Antisemitism is not acceptable.
It may be helpful to remind ourselves of some figures as, sadly, racism and discrimination remain embedded challenges within the NHS, affecting both staff and patients, as acknowledged by the noble Baroness, Lady Gerada. It is worth noting that 28.6% of NHS staff in 2024 were from ethnic-minority backgrounds. That was around 450,000 people, yet only 12.7% of senior managers came from those backgrounds. The 2025 NHS staff survey found that ethnic-minority staff were more likely to experience discrimination from managers and colleagues: that is 13.9% of ethnic-minority staff compared with 6.51% of white staff. Some 29.16% of ethnic-minority staff experienced harassment, bullying or abuse by patients and by the public, compared with 23.54% of white staff. It is important to further strengthen legislation as there are gaps.
The Equality Act 2010 prohibits racial discrimination, harassment and victimisation. However, significant weaknesses remain. The public sector equality duty requires organisations to “have due regard to” equality but does not guarantee measurable improvements. The NHS equality standards lack sufficient enforcement and meaningful consequences for persistent institutional discrimination. Will the Minister consider how the Government can strengthen this further, particularly as reporting, investigating and addressing racism remains inconsistent, with inadequate protections and support for whistleblowers? How will the Government address this? There is no sufficiently robust uniform accountability framework ensuring that perpetrators and senior leaders face consequences, as the noble Baroness, Lady Gerada, stated. Will the Government consider developing such a framework on all forms of discrimination? This would also support the 2026 review by the noble Lord, Lord Mann, which reinforces the need for stronger investigations, transparency and organisational accountability.
Lord Patel of Bradford (Non-Afl)
My Lords, I strongly support the intentions behind these amendments. Two practical issues are leadership and accountability, and the protection of those who speak out.
Tackling antisemitism and racism must be a clear responsibility of NHS leadership. These issues should be included in the performance objectives of every chief executive in the NHS—I have done this in the past. The boards would be required to monitor them and hold the executives and themselves to account. I am sure the CQC could incorporate this into its well-led reviews and make sure it happens. It is not enough to have policies and training programmes; we need to know whether they are making a difference and who is responsible when they are not.
Secondly, we must protect those who report racism or antisemitism. Too often, staff are reluctant to speak out because they fear the consequences for their careers or their relationships with colleagues. We need clear reporting arrangements, protection against victimisation and retaliation, and independent routes to raise concerns if senior managers themselves are involved. I hope the Minister agrees that we should hold boards and NHS chief executives to account and properly protect those who call this out.
Lord Scriven (LD)
My Lords, I just have a very quick practical suggestion to deal with some of the issues the noble Lord, Lord Blencathra, and others raised about staff neutrality, because that is what we are talking about. Would it not be wise, rather than going through a long process, to make it part of the NHS constitution that staff have to be neutral in how they deal with fellow staff and patients with whom they come into contact? I ask the Minister to consider that seriously when she reports back not just today but on Report. It is just a practical suggestion.
Baroness Finlay of Llandaff (CB)
I will be very brief in supporting that suggestion from the noble Lord, Lord Scriven. When I was listening to the debate, I was thinking about people who have told me about feeling discriminated against. They often do not declare their racial, religious or whatever view, because they are terrified of being further labelled and discriminated against. The noble Lord, Lord Shinkwin, spoke about the history of this for the Jewish people; there were lists of who was Jewish, particularly in the Netherlands, which were rapidly exploited to round them up with speed and persecute them further. That is a very deep-seated fear in a lot of these people.
The other fear is that, if they disclose that they have been discriminated against, they will be undermined in other forms that make their lives even harder. I can again think of other specific examples that have been brought to my attention. I commend this solution as a way forward.
Baroness Pidgeon (LD)
My Lords, this group of amendments is incredibly important. I thank the noble Baroness, Lady Gerada, for tabling most of them and for her powerful words about Jewish staff and patients, and their experiences in the data that she also presented. In different ways, all these amendments are trying to ensure that all parts of the NHS stamp out antisemitism and racism, and provide the right training on it, as recommended by the review from the noble Lord, Lord Mann.
I completely agree with the neutrality point that the noble Lord, Lord Hunt, raised about the uniform that staff wear. I recall that, several years ago, the Metropolitan Police had a huge issue with badges that officers started to wear as part of their support for charities such as Help for Heroes. That was ruled out of order, and they were not allowed to wear them. I think this is a similar thing, and there has been a sort of creep in uniforms over the years in what is acceptable or not. We need to make sure that all staff are seen to be neutral and behave neutrally.
The amendment on assessing the performance of ICBs is important in ensuring that trusts have a duty to prevent this and respond to it; it would ensure that that is integral to these organisations. The noble Lord raised a point about leadership. We on these Benches fully support the Mann review and the implementation of its recommendations, and my noble friend Lord Scriven’s practical suggestion about the NHS constitution is certainly a good idea worthy of consideration by the Minister. I hope the Government will look at how best to implement these amendments—as worded or in a different way—and I look forward to the Minister’s response.
Baroness Cash (Con)
My Lords, this looked like a very serious group of amendments on paper but, until we had this debate, quite how grave the current gaps are in the NHS did not really emerge. I thank the noble Baroness, Lady Gerada, for tabling her amendments and the noble Lords who spoke to them. I also pay tribute to the noble Lord, Lord Mann, for his review and to the Government for accepting the recommendations that Members from all Benches in the House appear to accept unreservedly.
I sympathise with and support the intent of every amendment in the group. I particularly support Amendments 79, 258 and 259, given the gaps they highlight and the urgent need to close them. Even in light of what the Government have accepted, it is quite apparent that shocking levels of antisemitism are continuing, and there need to be some urgent interventions to stop that.
I spoke quite recently in this House on Sir David Bell’s review of the levels of antisemitism in schools. It is really quite sad, and a shame for this country, that the review by the noble Lord, Lord Mann, shows the same pattern in the NHS. There is clearly a major problem and it is racism, plain and simple, directed at Jews. Too many institutions are tolerating it in a way they would never tolerate against any other group.
The facts are devastating. Community Security Trust recorded 3,700 antisemitic incidents in 2025—the second-highest total ever recorded. In the 2025 NHS staff survey, as we have heard, 13% of Jewish staff recorded discrimination from their own managers or colleagues. That is intolerable in your workplace. How can anyone possibly feel safe going about their day-to-day interactions? We have heard from a number of noble Lords this evening that Jewish people are the only religious group, the only ethnic group, for whom discrimination from colleagues is more common than discrimination from patients. The hostility is coming from inside the institution, and it is therefore beholden on us, debating this Bill, not to miss the opportunities to address this and close the gaps.
The Commission on Antisemitism found Jewish patients considering whether they should remove their religious symbols before treatment. Imagine feeling so unsafe in a healthcare setting, when you are at your most vulnerable, that you may have to consider concealing that about your identity. Patients who feel they have to hide who they are to be treated have lost trust in the NHS; they have lost faith that their doctors will do no harm—the first and basic premise of healthcare—and they have lost confidence that they will be safe.
The regulator has not done its job, which is why I support these amendments, even though the Government have actions in progress and even though they have accepted the recommendations of the review by the noble Lord, Lord Mann. Around 70% of completed appeals by the GMC against tribunals have succeeded, and we know that if the regulators are succeeding seven times out of 10, there is something fundamentally wrong in the disciplinary decisions.
I will not repeat what has been said by noble Lords in support of their amendments, but we should give serious consideration to the proposal from the noble Lord, Lord Scriven, so that we can address the fundamental issue here: a loss of neutrality and an overt willingness to attack colleagues and patients on the basis of their Jewish identity. My noble friend Lord Blencathra goes even further in his Amendment 279C, and I look forward to hearing the Minister’s response to that. He outlined the very serious reasons why he has asked for that, and those reasons and facts need to be addressed.
On Amendment 29 and training, I support the recommendation of the noble Lord, Lord Mann, that it is needed, but he was very specific in what he asked for. He called for the mandatory module, used by 1.5 million staff already, to be updated with quality assured content on antisemitism and anti-Muslim hostility. He added that subject experts should be consulted and that the training be monitored and reported on publicly to ensure it has the desired impact, but I have real reservations about the training that would be possible under Amendment 29, because as drafted it does not contain any of the noble Lord’s safeguards. That does not mean we should not consider or expedite the training that is needed.
The record of equality training in the public sector gives a good reason for us to take care. In 2020, the Government phased out unconscious bias training in the Civil Service after a review found no evidence that it changed behaviour, and some NHS anti-racism training has left out antisemitism entirely. Moorfields Eye Hospital’s compulsory anti-racism seminar was reported last year to have made no mention of Jews at all. Training built on theories of privilege has too often placed Jews among the privileged and therefore outside the protection it claims to offer. So, there are lots of types of training that will make the problem a lot worse. I would like to hear from the Minister what types of training and suppliers will be used, and what accountability and monitoring there will be for anything currently being developed.
It is very important to note that the noble Lord, Lord Mann, recommended mandatory training for the chairs and chief executives of NHS trusts within six months of his review, but the Government’s same statement in response to his review said that senior leaders would be invited to complete it by March 2027. I hope that the Minister will explain to noble Lords why a recommendation for mandatory training became an invitation to train, and when that training will be completed by all chairs and CEOs of NHS trusts, as recommended.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I am most grateful to noble Lords across the House for their sensitive consideration of something that is very insensitive: antisemitism and other forms of racism. I know that the words spoken today—the sentiments and the commitments—will resonate across communities in a way that will make a difference, and I personally am most grateful for that. I also am grateful to my noble friend Lord Mann for his review and, indeed, to the former Secretary of State, Wes Streeting, for listening to the voices of those for whom the situation they have to live with day in, day out, is quite intolerable, and for commissioning that review. That set the tone.
As the noble Baroness, Lady Gerada, observed from the outset, we have accepted in full the recommendation of my noble friend’s review, and we are taking action to deliver. As was referred to, we provided our latest update last month. This work is continuing, and I understand that noble Lords are asking for more to be done. Indeed, there is no let-up, but we want to get this right, of course.
I will address Amendments 29, 79, 258, 259 and 279C together. We have all said this, but it always bears saying: there is no place for discrimination, antisemitism or racism in our NHS. As noble Lords have said, patients and staff and those associated with them must be free from all forms of racism and religious hatred—and, indeed, from the fear of that, as well as the actuality. That is at the core of these amendments and this debate.
I say to the noble Lord, Lord Shinkwin, that Ministers have asked all NHS bodies to adopt the IHRA definition of antisemitism. We are receiving a good response and will continue on that.
Lord Scriven (LD)
My point about the important value of neutrality is this, and let me give an example. You might not be discriminatory: you have somebody who is Jewish, somebody who is Muslim, somebody who is Christian and somebody of no faith, and you treat them all equally, but you might have something on your body which is not neutral to two of them. You are therefore possibly treating that person differently, from their perspective. If neutrality and fairness is such an important value for the NHS, can the Minister go away and look seriously at making it a key component in the NHS constitution, because it is not there at the moment?
Baroness Merron (Lab)
I take that point and I certainly accept the spirit in which the noble Lord suggests it. I will take all the points that have been discussed away to see whether there is any way that we can work with it, rather than extending a debate on what neutrality means, because I know what the noble Lord is getting at. It is helpful that he has given thought to that.
On Amendment 258, NHS bodies are already subject to clear legal duties to prevent and address discrimination and racial harassment, alongside established responsibilities to tackle extremism and safeguard patients and staff. In a technical fashion, I certainly caution against adding further legal duties here because it would risk confusion about what we expect ICBs and trusts to do. I know that is not something that any of us would wish to do.
On Amendment 259, we have accepted the recommendation from the noble Lord, Lord Mann, to consider amending the performers lists regulations, which would enable conditions to be imposed on suitability grounds. We intend to amend the regulations, subject to consultation. The amendment is unnecessary as the Government are already taking forward the substance of it. It would also impose a six-month statutory deadline before the necessary consultation and consideration have taken place, whereas we have to allow sufficient time to make sure that any changes are legally robust, proportionate and workable. Nor would we wish to pre-empt consultation by committing in this moment to how particular forms of conduct should be addressed in the regulations.
On Amendment 279C, under NHS staff standards—which, as I referred to on the comments from the noble Baroness, Lady Manzoor, were launched on 6 July—employers must take sustained and meaningful action to prevent and root out racism. NHS organisations will be measured on this through the national oversight framework. In addition, I say to the noble Lord, Lord Blencathra, that regulatory processes are already in place to which all registered healthcare professionals are subject. Regulatory fitness to practise processes allow concerns about misconduct to be investigated. They allow evidence to be considered and the appropriate regulatory action, which could indeed include removal from the register, to be determined in each case. The Professional Standards Authority for Health and Social Care acts as an independent body in this regard to make sure that regulators apply the right sanctions. Where it considers that a decision does not provide sufficient public protection, it has the powers to refer the decision to the courts for consideration.
In drawing this together, I assure the noble Baroness, Lady Gerada, the noble Lord, Lord Patel of Bradford, and your Lordships’ Committee that we are ensuring that ICBs and providers are fulfilling their duties. The key means to do that is through performance assessments. I gently caution against adding additional criteria to the current approach, because it is important that assessments have sufficient flexibility to adapt to the evolving role of ICBs as strategic commissioners, which, after all, is at the heart of the Bill.
Baroness Barker (LD)
I thank the noble Baroness, Lady Merron, for that very detailed and thorough answer. Can I just check that, in the midst of what she said, she made it clear that NHS staff and NHS providers are under a legal obligation to ensure that all the protected characteristics under the Equality Act are treated properly and with respect?
Baroness Merron (Lab)
They should absolutely have regard to the law in respect of protected characteristics. That is the fullest answer I can give at this moment.
Baroness Gerada (CB)
My Lords, I am grateful to noble Lords who have spoken and to the Minister for her assurances. I just want to make a few very brief comments, because I am aware of the time.
I was struck by the noble Lord, Lord Shinkwin. If I heard him correctly, his orthopaedic surgeon was on the last Kindertransport out of Prague. Our own noble Lord, Lord Dubs, was also on the last Kindertransport from Prague, as was my father-in-law. Such are the coincidences that happen in this life.
I am not Jewish, but I have been subject to antisemitism. I suspect that is because people assume I am Jewish. I have been left fearful, hurt and angry, with all those emotions and not knowing where to take them. If I experience that, I can see that my Jewish colleagues experience it in spades. I work in the NHS, and I can tell noble Lords that antisemitism has become normalised. Although the figures we have seen—13% and 11%—are pretty awful, I suspect it is considerably higher than that. It has become almost de facto that one can abuse Jewish colleagues, although not necessarily Jewish patients because you are subject to greater regulatory forces. Certainly, in the last 12 to 18 months Jewish staff have been subjected to quite appalling behaviour from colleagues with whom they work. Antisemitism has been normalised and almost accepted.
Nevertheless, I thank the Minister. I hope that the training does not become a tick-box exercise and includes the issues that we heard about from the noble Lord, Lord Shinkwin. I may wish to return to this issue on Report, but at this stage I beg leave to withdraw the amendment.