Health Bill
(1 day, 7 hours ago)
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Baroness Coffey
“Support for helping people stay and get back into workIn the National Health Service Act 2006, after section 1C insert—“1CA Duty to support people to stay and get back into workIn exercising functions in relation to the health service, the Secretary of State must have regard to the need to offer workplace health provision support to—(a) small and medium sized employers, and(b) institutions and providers within the National Health Service, considering the need to support the workforce of—(i) small and medium sized employers, and(ii) the National Health Servicein order to tackle ill health and reduce work days lost to sickness.””
Baroness Coffey (Con)
My Lords, this amendment should be pretty topical because, according to the Government, the country is facing a NEET crisis. A lot of this is driven by people with poor mental health or a lack of mental well-being. In my time as a Cabinet Minister, looking after DWP and, for a short time, health, I long felt that if the NHS had to pay for the health benefits, a lot more attention would be given to getting people better, getting people well and recognising that it should be a duty of the Secretary of State for Health and Social Care to do what they can to help people get better.
In this probing amendment, the duty is about support to help people stay in and get back into work. I have gone into particular detail about occupational therapy or occupational health—whatever the latest term is. Apparently, nowadays it can be seen as bad to use the phrase “occupational health”, because employees may feel that this is their way to being fired. That is not the intention of good occupational health, and nor is it the outcome desired with occupational therapy.
I know that small employers struggle, and it is going to get more challenging. I think there is a duty on the NHS, and the Secretary of State—by effectively taking over all the functions of the NHS—will have an absolutely key role to play. Amid all the other duties and functions they are taking on, this one should really be at the top of their agenda.
There is no special reason why all of a sudden there is this NEET crisis. When I was Secretary of State, I had the lowest-ever youth unemployment figures, both seasonally adjusted and actual, in terms of people claiming benefits and people economically not working, so I know this can be done. It takes a lot of drive and effort. During Covid we were also helped with aspects such as getting the kick-start Bill going. By the way, I commend the current Secretary of State on managing to persuade the Treasury on the latest scheme to not have additionality as something that has to be proved. I appreciate that may not always economically be right, but sometimes the bureaucracy, as I explained to the Covid inquiry, meant that very good jobs were being set aside because of a lack of clarity or a lack of understanding.
This builds a lot on what Sir Charlie Mayfield has been doing for the Government; I appreciated the recent briefing organised by the Employment Minister, Andrew Western, at which Sir Charlie spoke. It is about how we help employers in particular to make sure that it is more straightforward for people to stay in work. As we know, it is not just about getting people back into work; it is about helping them stay in work and, once they come back in, trying to make sure that they succeed. Today is not the day to get into the whole PIP discussion—it is about how health can support this.
I have long believed—and there is no particularly easy way of saying this—that actually prescribing a job could be one of the nicest things that a doctor would ever do to somebody who is unwell in one aspect or another. As we saw in jobcentres, a lot of young people are lonely and not confident, and that spirals into a different way of doing things. Quite often, work coaches would end up being like the big brother, big sister or auntie who encourages people to stop looking at their feet and look at them, and to re-engage. That is what we are seeing in quite a lot of the challenges we have. Meanwhile—and I have some sympathy with this—healthcare professionals are saying, “We don’t want to be the gateway to benefits”. Nobody is asking them particularly for that to be their principal role; what I am sure everybody would like is a healthy society and particularly a healthy young population—but there is no doubt that small and medium-sized employers need some help on how to make that happen.
Lord Singh of Solihull (Con)
My Lords, it is a great pleasure to follow the noble Baroness, Lady Coffey, and I thank her for Amendment 48. Small employers rarely have access to occupational health and the NHS, our largest employer, loses far too many working days to sickness. Her amendment is about helping people stay in work; mine is about helping young people to get there, often for the first time. I am glad that our amendments are grouped together, because they rest on the same principle. Health and work are not competing concerns but integral parts in a single life.
I speak to Amendment 279QF in my name and refer the Committee to my interests on the register. I am an NHS consultant psychiatrist, and for the last 25 years I have devoted my life to delivering early intervention in psychosis, nationally and internationally. My amendment asks the Government to commission an independent review of the therapeutic role of work in recovery from mental illness for young people. For far too long, we have treated work as an economic question, and almost never as a clinical one.
Let me begin with a paradox. When in life we are at our most physically robust, during late adolescence and early adulthood, we are at our most vulnerable psychologically. Half of all adult mental disorders begin around the age of 14 or earlier; 75% begin before the age of 25. Therefore, mental illnesses arrive just when a life is being built: exams are being sat, jobs found, relations formed and independence discovered.
Among the many serious illnesses, the most serious are psychotic disorders such as schizophrenia. They fracture your thinking, break your networks, scatter friendships and delay your education. When I began training, our approach to psychosis was gentle management of inevitable decline. However, I vividly remember a young man I met on a psychiatric round, very early in my training. We fell into a conversation. Rather randomly, he asked me whether life was worth living, almost as if it was a joke. I said, “Life is what we make of it. We can think of each day as a blank page in a diary and, within reason, we can choose what we write on it”. We parted company and I forgot all about him. Three years later, I received a letter from him. It said that he had been diagnosed with schizophrenia while a patient in that hospital. He had been told by a doctor that he would never recover. He was considering suicide. That accidental encounter with me changed his mind. He was now at university, fully well and looking forward to a future. If a few words from a stranger can provide such comfort to someone in such deep anguish, imagine what hope engendered by trained clinicians can do for those who suffer.
Early intervention in psychosis has completely changed our view of it, from pessimism about inevitable decline to optimism about intervening early. We now know that early intervention works. The earlier we intervene, the better the outcomes. England now has the best early intervention services in the world. Most young people with early psychosis now reach remission from their symptoms, but recovery is more than absence of symptoms. Your voices may have gone but you still do not have a job. You are staying in your bedroom. You have no friends and are socially isolated. You have nothing to look forward to. The young man who is no longer hearing voices has not recovered; he is simply not acutely ill any more.
This is where IPS—individual placement and support—comes in. This is an approach to vocational rehabilitation. Traditional approaches were “train, then place”. IPS says, “Place and then train”. It helps a young person quickly to find a job that is of interest and to their preference, and then supports them, along with their employer, to stay in employment. As my noble friend Lady Coffey said, employers need support for that as well. IPS does not wait for full recovery. Nobody is turned away because they still have symptoms. You may still be hearing voices or be slightly low or anxious. Added to early intervention, IPS increases employment rates from around three in 10 to around six in 10. In a randomised trial with colleagues, we went one step further; it was published in the British Journal of Psychiatry. We randomised teams into those where clinicians were given some training, along with IPS in both teams. Among the clinicians, we tackled their ambivalence about young people returning to work. Employment rates in those teams more than doubled, from 18% to 43%.
We found that the obstacle was not the illness as much as people’s ambivalence about young people with mental illness returning to work. Clinicians had told us, “Work would be stressful and would trigger a relapse” or “This young person does not have the confidence to go to work”. These fears were well intentioned but completely wrong. As I said in my maiden speech, diagnosis should never be a prophecy.
Work is not incompatible with recovery; it is an essential part of it. There is robust evidence of the benefits of work. Those who work less have poor mental health, and those who return to work see their mental health improving. Work gives a day shape, and it gives an individual an identity and a role in society. It also builds self-esteem. We assume that confidence must come before achievement, but it is the other way around. Self-esteem is not a precondition for achievement; it comes from achieving and from facing adversity—getting back to work despite having to struggle. If young people with psychosis can return to work, and work is healing, then we should be offering similar opportunities to a much larger group of young people who are suffering from depression, anxiety or neurodevelopmental conditions such as autism and ADHD. Trials of IPS in young adults with a range of mental illnesses show that it can be effective.
Let me be clear: this is not an argument about cutting benefits or using work as a stick. A young person pushed into work that they cannot yet manage may fail, and that failure will only confirm the prophecy we are trying to break. But offered with skill and at the right time, work is therapeutic. The economic case is compelling, but the case I make for this review is also clinical, moral and humane. I hope the Minister can tell the Committee whether the Government will commission such a review within 12 months, and whether she will meet the noble Baroness and me to discuss how both our amendments can find their place in the Bill. Thanks to early intervention, we no longer think of a 16 year-old with emerging psychosis as facing inevitable decline. For young people recovering from psychosis, a job is not a reward for getting well. Very often, it is part of how they get well.
Baroness Hollins (CB)
My Lords, I support both amendments in this group. The amendment tabled by the noble Baroness, Lady Coffey, draws attention to the responsibility of the NHS not only to treat illness but to help people remain healthy enough to work, and to return to work.
As a psychiatrist, I am especially concerned about the growing impact of work-related stress, anxiety and depression, and the figures are deeply troubling. A recent Policy Exchange report estimated that sickness absence in the NHS represents the equivalent of more than 80,000 employees being absent throughout the year—enough to staff 80 hospitals—at an annual cost of some £4.6 billion. In June 2025, anxiety, stress, depression and other psychiatric illnesses accounted for almost 30% of NHS sickness absences. Behind these statistics are people whose health and confidence have been damaged, colleagues struggling to cover their work and patients waiting longer for treatment. When one clinician goes off sick with burnout, colleagues must take on additional clinics. Their workloads increase, their own well-being suffers and the risk of further sickness absence grows. This is a vicious cycle. It cannot be resolved simply by encouraging people to return to work more quickly. We must ask what made them ill in the first place.
There is also a more disturbing dimension. Suicide among healthcare professionals is a serious concern, particularly in some clinical occupations. Data from the Office for National Statistics in the 10 years up to 2020 showed that there were an average of four deaths of healthcare workers by suicide every week. While we need to be cautious about interpreting occupational suicide statistics, we cannot ignore the distress experienced by staff working under sustained pressure. The NHS has a duty of care to its workforce, just as it has to its patients. Occupational health needs to be about much more than assessing fitness to work; it needs to include early psychological support, effective supervision, manageable workloads and so on. Small employers need access to similar expertise, which many cannot afford to provide independently. I hope the Government will consider how NHS occupational health services, working with other providers, might help develop accessible support for smaller businesses without diverting resources from patient care.
The therapeutic value of good work depends on the work itself being healthy. If we want the NHS to help people remain in employment, it must demonstrate what it means to be a good employer. I added my name to the amendment by the noble Lord, Lord Singh, calling for a review of
“the therapeutic role of work in health and recovery”.
Good work can give us a reason to get up in the morning. It can provide structure, purpose, friendship and the satisfaction of knowing that our contribution matters and that we have something worthwhile to give. As a psychiatrist, psychotherapist and family carer, I believe that these ordinary human experiences deserve much more attention in our discussions about mental ill-health prevention and recovery.
Baroness Bennett of Manor Castle (GP)
My Lords, I will speak very briefly to these two amendments. It is a great pleasure to follow the noble Baroness, Lady Hollins, who made some of the points that I intended to make. We really need to give people the chance to meaningfully participate and to be part of society. Good work may be one route to that, but it may not be suitable or available to everybody.
The noble Baroness said that there is a great deal of not-good work out there, and I will point to some figures that recently came out on the loss of autonomy across the entire workplace. In 1992, 62% of people said that they had a great deal of discretion over the task they conducted and how they organised their working day. In 2024, that figure was 34%—it very nearly halved. People are not getting a sense of agency and autonomy in their workplace. That is without me getting into, as the noble Baroness did, the issues of zero-hours contracts, inadequate wages, unpaid overtime, et cetera.
Having said that, Amendment 279QF has some very good elements. I particularly applaud proposed new subsection (3)(a), which states that
“the Secretary of State must consult … young people with lived experience of mental health conditions and of being out of education, employment or training, and their families and carers”—
nothing about us without us. It is crucial that it is there, but I respectfully suggest to the noble Lord, Lord Singh, that perhaps this would be better as a “good work and meaningful participation in society” amendment or something along those lines.
I am afraid that I respectfully disagree with Amendment 48 from the noble Baroness, Lady Coffey. I will be interested to hear what the Minister says about it. A basic principle of the NHS from the very start has been that healthcare is provided on the basis of need. Giving the Secretary of State a special duty to help get people back into work would take away from that basic fundamental principle. Not making it on the basis of need and seeking to use the NHS to serve the economy would be a disturbing change in principle that needs to be highlighted and questioned.
In introducing the amendment, the noble Baroness talked about prescribing a job. That terminology would be really frightening to many people. I have met people with serious mental health conditions—we know there are significant numbers of them, including people in the NEET category—who are not applying for benefits, stepping away from the system and not getting help because it is really frightening to them. We absolutely do not want them doing that with the health service. If the health service were seen as a place of fear or compulsion then that would be dangerous to their future health and well-being and, indeed, the future health and well-being of society.
Lord Mawson (CB)
My Lords, I welcome these two amendments because they encourage us to debate a very important matter—employment. I have said before that the GPs I work with would remind us that, in the very challenging communities in which they work, getting a job does more for people’s health than anything they can do as doctors. We have done lots of work in this space over the years in east London and we are now replicating that practice around the country. It is why people like me are encouraging the health service and the public sector to learn from science and business that you innovate and learn only by doing things, not by writing clever reports or academic documents at 60,000 feet. You actually have to engage.
For example, to pick up the point from the noble Baroness, Lady Bennett, we have been running for over 15 years, with Investec, a jobs and small business programme in east London. It has been enormously successful. We have built 97 businesses, or local people have, many of them with health, mental health and other complicated conditions. When you get into the granularity of all that and you watch people’s lives, you watch what happens to their children and their family when they get a job and how things actually change, it is an extraordinary thing, that journey. It is a journey, I feel, and that is why I have been challenging the direction of travel of this legislation and this Government, because I fear we are missing a serious opportunity. If it is true what Michael Marmot and some of us saying—we come to very similar numbers that 70% to 80% of the determinants of health are social and nothing to do with doctors—then we enter this space, which is really important.
I declare my interest: I am working on a 30-acre site in Surrey at the moment, with a school that has been in very difficult circumstances. In the middle of that, there is an old primary healthcare building stuck there, disconnected from the school. There is a college behind a fence over there, which is doing what the head teacher would describe as babysitting children. Is this really about employment or is it ticking boxes? You have a large piece of land where you could bring health, education and housing together in a very interesting environment. We are looking at that opportunity. There is a real opportunity there to build what this Government call a neighbourhood health centre.
I am into all that, but neighbourhood health centres in the modern world cannot be just about bringing biomedical people together in a building—a biomedical box. That is not taking seriously what this conversation is about. We need to build multidisciplinary teams. We got into employment, health and wealth seriously over the years. We have even done projects with eight year-olds on developing their business plan. It is really interesting what happens when you do that with children. It would be interesting to have the Minister’s response on this. There is an opportunity, with neighbourhood health centres, to innovate, do something seriously and pick up the strands of this discussion.
I suggest that the way we get beyond the concerns from the noble Baroness, Lady Bennett, is to create practical learning by doing cultures on the ground, because all that theoretical stuff then falls away as irrelevant. You get into people with names and addresses, you watch what happens as you bring business, entrepreneurs, health practitioners and teachers together on the ground, and you start to build multidisciplinary teams. Innovation and something rather different happens. It absolutely relates to what the noble Lord, Lord Singh, said. I have been involved, as has he, in mental health, because mental health is a really big issue in these communities. You begin to get into the detail of that and beyond the theory into practice. When you watch a young person or an adult move away from many years of dependency and drug use—much of that drug use, by the way, at great expense from the NHS—you watch them take on life and see what happens to their children and family, my goodness it is a great inspiration. My view is that that is what these neighbourhood health centres should be about is multidisciplinary teams, learning by doing and getting into the granularity of what this discussion is about.
Lord Kamall (Con)
My Lords, I am grateful to my noble friends Lady Coffey and Lord Singh of Solihull for their amendments, and, in fact, to all noble Lords who spoke. We know that ill health is an issue not only for individuals, families and the community. At the macro level, it is a principal driver of economic inactivity, with millions of people of working age not working because of long-term sickness. Recently, my noble friend Lord Howe and I met with a GP who wanted to share his experience. He said that he was told that 93% of all notes that GPs sign are sick notes, so only 7% were to return them to work. His suggestion was that maybe the GPs in those situations should be asking for a second opinion, because there is a clear imbalance going on.
For many, work provides more than an income. It offers independence, purpose, structure and social connection, and losing that connection due to ill health has wider consequences, as the noble Baroness, Lady Hollins, and the noble Lord, Lord Mawson, said. Both my noble friends said that we should think of employment not simply as a matter for the Department for Work and Pensions but as part of someone’s well-being. That was very well illustrated by the real-world example that my noble friend Lord Singh of Solihull gave from his experience as a psychiatrist.
Baroness in Waiting/Government Whip (Baroness Hyde of Bemerton) (Lab)
My Lords, I thank the noble Lord for that warm welcome.
With permission, I will address Amendments 48 and 279QF together, which look at the very important relationship between health and work. I agree with the point made by the noble Lords, Lord Mawson and Lord Singh, and the noble Baronesses, Lady Hollins, Lady Bennett and Lady Coffey—possibly all noble Lords who have contributed today—that good work, and I say that advisedly, is good for health, which is why we are already taking action to address the relationship between work and health. I agree with the noble Lord, Lord Singh, that work and health are not competing interests. I agree with the noble Lord, Lord Kamall, that the responsibility for good health does not sit just within the DHSC.
We already have programmes that bring together health and employment support around the individual, including health and growth accelerators. We are already acting at scale. This month, WorkWell began its national rollout across every ICB in England, building on pilots that have already supported around 25,000 people. Backed by up to £259 million over three years, the expanded service could support up to 250,000 people with health conditions to stay in work—this goes to the point made by the noble Baroness, Lady Coffey—or return to work. The 10-year health plan is clear on the critical role that the health system has, alongside local partners, in addressing health-related economic inactivity, especially through prevention and early intervention, which the noble Lord, Lord Singh raised.
Sir Charlie Mayfield’s independent Keep Britain Working review, published a year ago, highlighted the scale of the problem of people falling out of work for reasons of ill health and disability, including mental health conditions, and the vital role employers can play in addressing this. Further, the Government are already taking forward the development of a better model of workplace health provision through the Keep Britain Working programme. This system is intended to improve access to support for employers of all sizes, including the small and medium-sized enterprises referred to by the noble Baroness, Lady Coffey, and will be supported by a robust, recognised BSI employer standard. We are testing reforms to the fit note process so that the system works much better for patients, employers and GPs. These are aimed at moving from administrative sickness certification to a service focused on getting people the support they need to stay in work or return sustainably.
Finally, we have commissioned the recent Fonagy review and the forthcoming independent Milburn review, given the importance that the Government place on the relationship between work and health. Alongside this, given that several noble Lords mentioned young people, the Government are investing £2.5 billion by 2029 into the youth guarantee and the growth and skills levy. This investment will support young people and create up to 500,000 opportunities to learn and earn.
We do not believe that additional statutory duties or reviews are the right approach here. We are happy to offer the noble Lord, Lord Singh, the noble Baronesses, Lady Coffey and Lady Hollins, and other contributors today a meeting with the officials working on the Keep Britain Working thread. The Government are already taking significant action in the health and work space, and I hope that noble Lords are reassured that the Government recognise the importance of this issue.
Lord Mawson (CB)
My Lords, this all sounds fine in theory, but people like me are nosy—we go and have a look under the carpet at what is happening, in detail, in the machinery. Often, this machinery means well but the structures and siloed systems prevent the kinds of relationships that need to happen in the modern world.
I will illustrate this. From 2015, for many years I led the Well North programme for Duncan Selbie, which has now evolved into a national programme. It is interesting to talk to the Well Doncaster programme, which the noble Baroness, Lady Armstrong, will be pleased to hear now has 34 staff and operates across Doncaster —it is a fantastic success story and some great things are happening there. But I was talking to one of our lead colleagues there just a few weeks ago, who was saying that, in Doncaster, the Pride in Place programme is completely disconnected from this programme. I am sharing this with the Minister because there is a desperate need to get under the carpet of these practical issues, otherwise we will say all these wonderful things but—I say this from experience—very little will change.
Baroness Hyde of Bemerton (Lab)
I thank the noble Lord for those points. I recall that I did not answer substantively his point on neighbourhood health, and the further point he has raised cuts to the heart of that. I am very optimistic, as a former lead member in a local authority and now a Minister in this place, about the opportunity of neighbourhood health. It is a great moment to get away from the model of a clinical box and viewpoint and work holistically across a wide range of services. Let us continue to look under that bonnet together, because we are driving at the same aim here: improved health for all our communities, outside the silo of DHSE.
Baroness Coffey (Con)
My Lords, I am grateful to my noble friend Lord Singh of Solihull for his amendment and for the other contributions made. I respect the noble Baroness, Lady Bennett of Manor Castle, but—it will probably be the same the other way around—I do not agree with what she has asserted today. I think work is a good thing.
I am grateful to the Minister for her reply. As I expected, sadly, the Health Minister did not contribute in this debate, which somewhat sums up the situation we have within government. It is my understanding that the noble Baroness, Lady Hyde of Bemerton, is a Government Whip—I did not know that she had a policy role in the Department of Health and Social Care.
Lord Hunt of Kings Heath (Lab)
The noble Baroness is being extremely discourteous. It is the tradition in this House that, when a Bill is going through, duties of the Government Benches are shared by Ministers and Whips, and my noble friend is doing it very well.
Baroness Coffey (Con)
I am not disputing that the noble Baroness spoke very well. I am just saying what I feel it shows about this key issue. Sir Charlie Mayfield’s review is nothing new; it is great that he agreed to do it and has the clout, but it is no different from reports that came out in the last year. It is great that Alan Milburn is engaged—I hope he will bash heads together to get something really powerful done, and he has the clout to do that. I am flagging that, sadly, the Department of Health and Social Care and the NHS more broadly tend to not really get engaged. I thank the noble Baroness, Lady Hollins, for her contribution in that regard.
The NHS has a challenging time ahead with its own employees, and so does business. That is why working together will be absolutely vital.
Finally, noble Lords have talked about friendships. There is a workforce survey used by the best companies in the world: Gallup’s Q12. The most important question is question 10: “Do you have a best friend at work?” Initially, that can be quite a difficult thing to get through. Here we are on Armistice Day; people who serve their country often do so because they have their friends and comrades and the camaraderie. That matters at work too. That is why, building on what my noble friend Lord Singh of Solihull said, we need to look at this carefully. I hope the Department of Health gets far more engaged than simply the DWP programmes we have heard about today, which I still hope will continue to do well. With that, I beg leave to withdraw my amendment.
Baroness Coffey
“Promoting access to dentistry equitablyIn the National Health Service Act 2006, after section 1C insert—“1CA Duty to promote access to dentistry equitablyIn exercising functions in relation to the health service, the Secretary of State must have regard to the need to ensure provision of dentistry across England accessible to all regardless of wealth or geography.””
Baroness Coffey (Con)
My Lords, I have tabled an amendment about dentistry. With the agreement of others, I degrouped it so that we could have a short but focused debate on what is a key part of healthcare but one where access is so variable across the country that it is really struggling.
I appreciate that the Government have made some changes to the dental health contract. Three years ago, when extra UDAs—units of dental activity—were offered around the country, only one dentist in my own county of Suffolk took up the opportunity. That dentist was in Lowestoft. A couple of years ago, an adult could get added on and get routine NHS dental care at seven dentists within a mile of this place. At that time in Suffolk, you had to go about 35 miles to be able to access that if you were not already registered with a dentist. At the same time, we saw a lot of the dental providers for which people pay insurance pulling out of many rural areas. That is why I have been careful to put “access … equitably” in the amendment. Later amendments, tabled by the noble Baroness, Lady Pidgeon, refer to the “dental deserts” of which I am well aware.
I am pleased to announce some progress. In Suffolk, you now have to go only 12 miles to get to two dentists where you can see an NHS dentist. After that, it is another 23 miles to potentially see three more. Meanwhile, here in London, near the House of Lords, where no dentist is taking anybody on unless they are eligible for free dental care within a mile, you can find 14 dentists within two miles. That difference is happening not solely in Suffolk or London but right across the country.
A lack of dental provision has many significant impacts. It is not quite the same as not being able to get an operation. Things can be done in different ways, urgent care may well be available, and it does not necessarily stop people working. But it impacts their daily lives. As I said, I appreciate that the Government have done more, but I am not convinced that they have gone into the level of detail to make sure that the National Health Service is happening nationally when it comes to dentistry.
I would like to understand more from the Government on what they are doing on the measurement of access and on UDA distribution across the country. I appreciate that if you live in a rural area, you are not necessarily going to have 15 dentists within two miles of where you live. I get that. But it feels very focused on our major cities, where there is availability right now but it is very difficult to access, especially when providers are also withdrawing their private practices for people who pay insurance.
I will be interested to hear from the noble Lord, Lord Hunt of Kings Heath, about his “state of dentistry” report, which is definitely worth doing. I encourage the Government to do that even if they do not want to put it in this Bill. I am very conscious of dental deserts. With that, I beg to move.
Lord Hunt of Kings Heath (Lab)
My Lords, I have Amendment 213 in this group. What is interesting in relation to dentistry is that on the one hand we know that many people are finding it difficult to get access to NHS dentistry, but on the other hand we rarely debate dental matters in Parliament. This is a welcome opportunity to allow the Government to say some more about what they have been doing and to discuss ways in which we might see future improvements.
There is no question that since Covid there has been a sharp drop-off in the number of adults who have seen an NHS dentist in the previous two years. It was never good—it has always hovered around 50%—but, as I understand it, it has dropped to 40%. Behind that is the fact that there are areas where it is very difficult to get a dentist. We know that some people have had to go abroad, particularly where expensive treatment is concerned, because they cannot get it on the NHS. In some situations we have seen reports of people doing DIY dentistry, which, frankly, takes us back many decades.
The Government have done a lot. One must acknowledge the phased introduction of the new contract, the commitment to providing an additional 700,000 urgent and emergency NHS dental appointments each year, rolling out supervised toothbrushing programmes for children and supporting the expansion of water fluoridation schemes. These are all making a big difference and I commend the Government for them, but clearly there are some fundamental underlying issues which still need to be tackled, including workforce issues, such as whether we have the right contract to provide preventive dentistry. I agree with the BDA that the units of dental activity do not meet the modern needs of oral health in this country and we have to start to move away from that.
My amendment is about ensuring that we get, on a regular basis, an assessment of the state of dentistry services in this country, alongside a more general analysis of oral health challenges to enable us as a country and as a Parliament to have a regular update of where we are going, what the problems are and how we can solve them. This is a very long amendment, which I plead guilty to drafting, but I hope the Government will understand the principle behind it and the need for us to try to prioritise dentistry in a way that has perhaps not been done over the last few years.
Lord Patel of Bradford (Non-Afl)
My Lords, I support the aims of all three amendments in this group. At Second Reading I raised the stark health inequalities facing people living in our coastal communities, and I thank the noble Lord, Lord Hunt, and the noble Baroness, Lady Tyler, for introducing my amendments while I was not here. I particularly thank the Minister for agreeing to meet us to discuss coastal and rural health inequalities. For clarity, when I am talking about coastal communities, I normally think of small towns of 10,000, 20,000 or 50,000 people. Collectively, we are talking about 10.4 million people, which is nearly a fifth of the population.
I declare my interest as chair of the Coastal Navigators Network, a community interest company originally founded by NHS England. It brings together more than 20 coastal towns and locations to put into practice the recommendations of Sir Chris Whitty’s 2021 report, Health in Coastal Communities. Several of those areas are working to improve oral health and access to NHS dentistry through prevention, local workforce training, and community-based services. Their experience can help us understand where people are struggling to get care, and what needs to change locally.
Sir Chris Whitty’s latest report, Health in Rural Areas and Small Towns, was published just last week. It highlights a national framework for improving oral health in rural and coastal areas. This has been developed by the office of the Chief Dental Officer, working together with the Coastal Navigators Network. The work is led by Jason Wong, the Chief Dental Officer for England, and his team. Our contribution has been to bring practical experience and case studies from our coastal communities.
I was going to give two examples, but I will only give one, because one was about Lowestoft, which the noble Baroness, Lady Coffey, has already mentioned. The other example is Dorset, where the report says that only 35% of adults currently access NHS dental care, and no practices are accepting new adult NHS patients. In response, Health Sciences University, based in Bournemouth, and NHS Dorset are developing a proposed oral health institute, bringing together care, prevention and local workforce training. It is intended to support more than 30,000 clinical patient contacts a year. That is an amazing, potentially promising, answer, but they need the premises and facilities to deliver the care, and train the workforce.
The latest business case still shows a funding gap of around £10.25 million, mostly in capital funding. Without that capital investment, there is a real risk that this work will be delayed, or that the institute will not go ahead at all. The Dorset example shows why identifying unmet need must lead to practical action. Commissioning more NHS dental care will take us only so far if the facilities to provide it are not there. We need capital investment alongside commissioning, so communities can develop services and train the people who will deliver them.
The geographical problem is substantial, and perhaps the noble Baroness, Lady Pidgeon, will talk about this. A study published in the British Dental Journal in August estimated that around 2.3 million people in England live in neighbourhoods with a centre that is more than 5 kilometres from the nearest NHS dental practice. But distance is only part of the problem. Is the practice accepting NHS patients, and can someone without a car get there? For coastal communities, transport difficulties, travel costs and a shortage of NHS appointments can put all the care out of reach. That is why I welcome Amendment 213, tabled by the noble Lord, Lord Hunt, and the noble Baroness, Lady Pidgeon, with its emphasis on unmet need, workforce distribution and geographical inequalities. National and ICB averages must not hide communities where access is particularly poor.
I also welcome the focus of Amendment 216 on practical action, including emergency access, contract reform and workforce planning. There is, however, an important question about how we identify a dental desert. Amendment 216 counts practices: excellent. The British Dental Journal measures distances from one place, a home, to a dental practice. Both are useful, but we also need to know whether those practices have any NHS appointments available, and whether people can reach them.
I would welcome the Minister’s response on a couple of practical points. Will the Minister ensure that reporting shows whether people in coastal communities can actually get NHS dental appointments, and include the barriers caused by workforce shortages and difficulties with travel? Where that reporting identifies unmet need and dental deserts, how will the Government ensure that commissioning and investment follow? Will that include capital funding, where the premises and facilities are simply not there, when they are needed to provide care that is missing? Without that commitment to act, we risk describing the problem again and again, without helping people get the care that they need. More widely, will the Government use the national framework developed by the Chief Dental Officer’s team to help other rural and coastal communities facing similar problems?
Finally, I would appreciate it if the Minister could ask officials to work with the Dorset partners to explore how the proposed oral health institute can move forward so we do not lose such an invaluable option.
Lord Young of Cookham (Con)
My Lords, I shall intervene briefly in this debate on a subject on which I have interrogated the Minister from time to time. I shall make three points.
First, when I asked an Oral Question last year, 2.2 million people needed urgent dental treatment, as we have heard from the noble Lord, Lord Hunt. Since then, we have had 700,000 additional appointments, which I welcome. Can the Minister tell me whether the figure of 2.2 million needing urgent care has now been reduced?
Secondly, each year 30,000 children have rotten teeth extracted under anaesthetic. That is a terrible statistic. Has any progress been made in reducing that appalling figure?
The third point, which is related to the second one, was also touched on by the noble Lord, Lord Hunt: progress with fluoridation. I asked the Minister about this last year and she said:
“On water fluoridation, as the noble Lord said, an extra 1.6 million people across the north-east will benefit from a water fluoridation scheme following quite a lengthy process and that will start in 2027-28”.—[Official Report, 19/3/25; col. 1228.]
Why is there such a lengthy process? And are any other areas following up this very welcome initiative in the north-east? I look forward to the Minister’s reply.
Baroness Finlay of Llandaff (CB)
My Lords, the noble Lord, Lord Young, has highlighted the problem specifically for children. I shall expand on that slightly, because this is a major public health problem. Prevention is essential. Children who have had their teeth extracted may do fine if they are fit and well, but there is another group of children who are already ill, who may have a malignancy or may be on chemotherapy, or who have learning difficulties. There is a need for even more prevention measures for those children because, at every stage where they get tooth decay, their risks of things such as septicaemia and so on go up.
It is also a public health issue. In schools, children are now being taught to brush their teeth, which is excellent. The fluoridation programme is to be commended, and some of us would like to see it rolled out even faster. However, the other area is fizzy drinks, sweets, babies being given sugary dummy things to suck, and so on. Children are being brought up to have tooth decay, sometimes from the age when they are weaned.
These are all big public health initiatives, but the health service is being left to pick up the tab. I found it rather worrying that the cost of these decay-linked dental extractions in young people is over £50 million a year. This is not insignificant, and it really needs to be tackled.
Baroness Bennett of Manor Castle (GP)
My Lords, I will speak very briefly. I begin with an apology to the British Dental Association, because I told it I had signed Amendments 213 and 216 but then found the email stuck in my outbox this morning.
I shall make just two points. First, the arguments for action, at least in those two amendments, have already been powerfully made, even though we have not yet heard from the noble Baroness, Lady Pidgeon. I had a meeting with my honourable friend Adrian Ramsay in the other place with a great organisation, the beautifully named Toothless in Suffolk, which is now Toothless in England. It is great to see people getting out, campaigning and doing politics, but they should not have to campaign to get basic dental services. To pick up on the figure mentioned by the noble Lord, Lord Hunt, six in 10 adults have not seen an NHS dentist in the last 10 years.
Secondly, following on from the point that has just been made about children’s health, we also need to consider dentistry at the other, older end of life. There is increasing evidence of the effects of a systemic inflammatory burden on heart disease and diabetes, and there is very good evidence that it makes managing blood sugar more difficult. There are increasing links to pneumonia, exacerbation of COPD, and, potentially, joint inflammation and Alzheimer’s. We tend to think of dentistry as being one thing and health another, but actually we need to join all this up and see dentistry as requiring the same focus and attention—as part of the whole general health of our society, rather than as a separate thing.
Lord Lansley (Con)
My Lords, I want to intervene in this debate to talk about dentistry, particularly for the reasons set out by the noble Lord, Lord Hunt of Kings Heath. We do not debate dentistry much, and insofar as this Bill is not changing but simply restating the commissioning obligations of the NHS, we should take the opportunity to say, as we will in a number of other respects as we go through the Bill, that there is room for reform. That reform may not necessarily require primary legislative change, but that does not mean we should not take the opportunity to make those points.
To follow up on what noble Lord, Lord Hunt of Kings Heath, said about the need to move on from units of dental activity being the basis, my noble friend Lord Howe and I fully agreed with that thought 15 years ago. That was why we entered into the now tedious process of trialling, piloting and then prototyping how a new dental contract would work. Its purpose would be to pay practices on a capitation basis, with a focus on preventive work and the maintenance of good oral health, rather than remuneration by reference to units of dental activity and what is regarded as the treatment treadmill on which dentists had worked. Notwithstanding the Government’s view in 2023 that these prototypes were a failure, the principles remain right. Therefore, we should say to the Government: do not let it drop.
First, the capitation was based essentially on existing populations, and the whole point of the system would be to establish the initial oral health status of a given population to a degree of granularity that enables it to be a serious measure of what needs to be done. That would be really important, taking the point made by the noble Lord, Lord Patel of Bradford, in places where there are serious deficiencies in present oral health status. It would allow us better to modulate dental resources to the places where the need is greatest. The first thing is therefore to get that capitation—that basis—right, and there is going to have to be an initial investment to establish the oral health status of the population in relation to dental practices before we start down the process of remunerating practices for the work they have to do.
Secondly, the structure of payment to dental practices needs to move away from treatment towards prevention and the maintenance of the oral health of the population. Once we have a good measure at the start, we can assess how well practices are doing. That means that we have to introduce for dentists a quality and outcomes framework with similar incentive effects to the framework for GP practices; it should adopt a similar approach. In addition, we must be clear that the purpose of this is to maintain and increase good oral health, and therefore to reduce the number of treatments. Indeed, the prototypes of the new dental contract took various forms, but it did lead to a significant reduction in the number of treatments. However, because the incentives were not aligned properly, dental practices were not then incentivised to increase access. The whole point is to reduce the number of treatments and to increase patient access to NHS dentistry.
We should aim to arrive in the long run at a point where not only children but most adults assume that they can access NHS dentistry. We will have to be open to combining NHS entitlements in the maintenance of good oral health with the ability to use private dental care.
Finally, the Treasury had a hand in all this, and some 10%—or in some cases maybe more—of the patient income did not materialise in these prototypes because the patients were not paying for the treatments. We received about £860 million a year by way of dental charging, and losing £100 million or thereabouts was not something the Treasury was very keen on. But that just means we should have dental charging that is not linked to treatments. The logic says that if we are aiming for a dental contract which prioritises access, good oral health and preventive work, then so should the charging regime; all these incentives have to be aligned.
I hope that, notwithstanding the unhappy experiences that many would say the dental contract reform process has suffered up to now, we do not give up. We should go back to it. We should look at it and say we have learnt a lot. That means that we have to go back into this process, reasserting the principles and aligning the incentives with those principles.
Lord Kakkar (CB)
My Lords, I support Amendment 213 in the name of the noble Lord, Lord Hunt of Kings Heath, and the noble Baroness, Lady Pidgeon. I wonder whether the Minister might comment on the fact that while chronic gum disease in itself is a bad thing, resulting from a lack of access to primary dental services, it is associated with a profound impact on systemic health and, in particular, chronic diseases such as cardiovascular disease. Those with gum disease are at far higher risk of heart attacks, stroke and narrowing of the blood vessels—atherosclerosis.
In establishing the principles and the mechanism for the delivery of a regular state of NHS dentistry report, with the capacity now to federate across different datasets in the NHS, we would have the opportunity to start understanding the relationship between the failure to provide primary dental services and the prevalence of other chronic diseases, in particular cardiovascular diseases. That might well help further improve the mapping of services and local investment not only in dental services but in services for other, potentially fatal diseases.
I wonder whether the Minister and indeed the department have considered how this report might be the stimulus for bringing together other datasets and understanding the impact of the failure in dentistry provision on the broader health of the nation.
Baroness Pidgeon (LD)
My Lords, we have had a really good debate on this group of amendments. My Amendment 216 addresses one of the most persistent inequalities in our healthcare system: the growing number of communities that simply cannot access an NHS dentist. For too many people, finding an NHS dental appointment has become an impossible task, with entire areas effectively becoming dental deserts. Other amendments in this group are very much in the same place.
Amendment 216 would require the Secretary of State to establish a scheme specifically designed to tackle that problem, ensuring that integrated care boards can guarantee emergency access to NHS dentistry and provide free dental check-ups to children, mothers within one year of having given birth, pregnant women and low-income households. The amendment recognises the current state of access to NHS dentistry across the country, and that preventive care is better for patients and more cost-effective for the NHS than treating advanced dental disease later.
However, my amendment would go further by recognising the critical importance of dental health for patients facing serious medical treatment and guaranteeing dental appointments for those about to start chemotherapy or undergo transplant procedures. It would help ensure that necessary treatment was not delayed because of untreated dental problems and would support those patients at a time of great need.
In this debate, we have heard of how dentists are remunerated. My amendment would require the publication of a reformed dental contract before the scheme was introduced, because the current contractual arrangements have contributed significantly to the workforce shortages and access problems that we see today.
My amendment is practical and targeted at ending dental deserts, improving access to dental care and ensuring that NHS dentistry is once again available to the people who depend on it. The noble Lord, Lord Patel, and the noble Baroness, Lady Coffey, have given clear examples of the different needs of coastal and rural communities and the importance of access to transport for access to services, which too often gets forgotten in these debates.
The amendment from the noble Lord, Lord Hunt, to which I have added my name, would ensure the publication of an important, regular report on the state of NHS dentistry and a debate in Parliament, which would keep a focus on this issue. There is so much going on in the health space that this can easily get lost, which in some ways has led to the situation we are in today.
We mentioned children in our debate. More than for any other reason, children attend A&E because of tooth decay. That is extraordinary. We can talk, and we have talked, about how we are tackling the issue—we have programmes teaching children how to brush their teeth properly—but what are we doing in nurseries and other early care settings? Only 10 years or so ago, my son was in nursery. That nursery had an NHS dentist who came in every six months and did check-ups with the children, and you got a note sent home. Why are we not looking at some of that preventive work? This report would allow the wider debate that we have started today, as well as discussion of some of the other important points and links to other health issues. I hope the Minister will respond positively and pick up the issue of that regular report.
Lord Mawson (CB)
My Lords, I support the amendment from the noble Lord, Lord Hunt. I will share a practical experience. In Tower Hamlets, a large proportion of the residents are Bengali and eat betel nut, which produces all the symptoms and serious health impacts that the noble Lord, Lord Kakkar, has well described. I have previously mentioned the street we rebuilt following some very difficult health circumstances. We ended up building a health centre, a school, 600 homes, and now a primary school, and we joined it all up with a multidisciplinary team. When you bring the headteacher, the GP, the pharmacist and the housing practitioners together, you start to learn things about the community in which you are based, and we began to discover this serious health implication among the Bengali community.
Because we had a very good working relationship with Queen Mary University, which is up the road and which became a partner in this development, there was an opportunity to bring a dental school, with a brilliant professor of dentistry, on to the street. We could then connect it to the pharmacy, the school and the science programme—which we have been running for 14 years with Professor Brian Cox—and create a whole joined-up situation that would not only improve the dental health of people but, if we connected it properly into the school, might well produce more dentists. It would mean that, instead of the health centre being overwhelmed by these issues, the dentists could start to deal with patients and the detail of all this. My point is that, if we began to think of neighbourhood health centres not as a box but as a street and a campus, and of the connections between these things, it would begin to throw up interesting innovations and solutions to issues that arise particularly in places such as Tower Hamlets, which are very much to do with dentistry.
I have to say that this was one of our health failures, because all that was coming together; everyone was in favour of it, and the professor of dental health was brilliant, but it sadly fell because of the politics going on in the medical school. I am illustrating it because, if we create a culture on the ground in neighbourhoods and build the relationships, these kinds of innovations around these very serious issues, which deal with the very serious medical conditions that the noble Lord, Lord Kakkar, rightly described, can start to happen.
Lord Evans of Rainow (Con)
My Lords, perhaps I may start by warmly welcoming the noble Baroness to the Dispatch Box. We wish her well.
This has been a valuable debate on an issue that affects millions of people across the country. While the amendments before us take different approaches, they are united by a common concern that access to NHS dentistry remains increasingly difficult to secure. I particularly wish to speak in support of the amendment in the name of my noble friend Lady Coffey. At its heart lies a simple but important principle: access to dentistry should not depend on where a person lives or what they can afford. Few would disagree that oral health is an integral part of overall health, yet for too many patients access to NHS dental services has become a postcode lottery.
The duty proposed by my noble friend would place equity at the centre of decision-making. That is a principle which this House has supported on many other occasions in many other areas of healthcare. It is surely no less important when it comes to dentistry.
The amendment from the noble Lord, Lord Hunt, and the noble Baroness, Lady Pidgeon, also raises an important issue. One frustration for Parliament and for the public is that discussions about NHS dentistry are too often conducted in the absence of clear, comprehensive and consistent information. Regular reporting on workforce pressures, access, inequalities and unmet need would provide a valuable evidence base against which future progress could be measured and Governments held to account.
The amendment from the noble Baroness, Lady Pidgeon, addresses perhaps the most visible manifestation of the current problem: so-called dental deserts. Finding an NHS dentist has become extraordinarily difficult, if not impossible, in many parts of the country. Today, three in five adults are not accessing NHS dentistry. That is not a marginal problem; it is a challenge affecting communities across the kingdom. We now have areas of the country where fewer than four in 10 adults have seen an NHS dentist in the past two years. That should concern us all. It speaks not merely of pressures within the service but to growing inequalities in access to care.
Patients are travelling significant distances for routine treatment; being forced into the private sector, despite financial pressures; or presenting at GP surgeries, walk-in centres and A&E departments because they have nowhere else to turn. These are symptoms of a system that, despite the dedication and professionalism of the dental workforce, is struggling to meet public demand.
Improving NHS dentistry requires more than warm words. Good oral health is not a luxury; it affects children’s development, educational attainment and well-being. It affects people’s ability to work, to communicate with confidence and to maintain their dignity. Increasingly, we understand its connection to wider physical health and quality of life. At a time when we are rightly focused on prevention, reducing health inequalities and delivering care closer to home, dentistry must be part of that conversation. We cannot continue to accept a situation in which access to NHS dental services depends so heavily on geography, workforce shortages or the ability to pay. These amendments offer thoughtful and constructive ways of advancing that object.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I am very pleased to respond to this group, following on from these Benches from my noble friend Lady Hyde, who I am delighted to be working with on this Bill. I am very glad that she made her debut on group 1 today. We look forward to hearing more.
I am in absolutely no doubt of the challenge when it comes to dental services and dentistry. I am also deeply conscious of the situation that we started from. I will refer to some of the points about improvements and the need for further improvements, but let me turn first predominantly to the amendments before us.
On Amendment 49 from the noble Baroness, Lady Coffey, I understand the good intention behind this amendment but do not believe that it is necessary, because under Section 1 of the National Health Service Act 2006, the Secretary of State will continue to have a duty to promote a comprehensive health service in England and that includes NHS dental services.
In addition, Clause 4 strengthens the statutory framework by amending the Secretary of State’s existing duties so that they must have regard to the need to reduce inequalities in access to health services across England. As the noble Lord, Lord Patel of Bradford, rightly said, that includes coastal communities as well as others. The duty that I referred to provides a clear statutory basis for considering geographical and other inequalities in access. A dentistry-specific duty would therefore duplicate the deliberately broader framework that the Bill establishes.
I can reassure the noble Baronesses, Lady Coffey and Lady Pidgeon—because the comments that I am about to make also relate to Amendment 216 in the name of the noble Baroness, Lady Pidgeon—that we are taking practical action to tackle dental deserts. I was grateful for the comments of the noble Lord, Lord Patel of Bradford, who made the point that the definition of a dental desert is rather more complex than just miles, or indeed numbers, and that is indeed the case. The practical actions that we are taking include introducing a package of reforms to address some of the most pressing issues that dentists and dental teams have been experiencing, and therefore the knock-on effect to patients. These reforms prioritise those with the greatest need and shift care away from clinically unnecessary check-ups.
On the matter of addressing dental deserts, we have, supported by some £11 million, brought in some 50 additional dental school places on top of the existing 809. It is interesting to note that the University of Porstmouth and the University of East Anglia are where these will be provided; we are going to train more dentists in the areas that need more dentists. As we know, throughout the medical professions, when you train in an area you are more likely to stay. I add that all NHS regions now have a dental school. We also have the golden hello recruitment incentive scheme, with payments to dentists of £20,000 to work for three years in areas that need them the most. As of July this year, 159 dentists had started working in the areas that needed their services the most.
Referring back to Amendment 216 in the name of the noble Baroness, Lady Pidgeon, I make the point to a number of the comments made that since July 2024 we have sought to rebuild NHS dentistry while being in no doubt of the challenge. In 2025-26, just under 3 million additional NHS treatments were delivered compared with the previous year, and around half of those benefited children. I very much share the concerns that noble Lords have described. It is totally unacceptable that the primary reason for emergency care for children is their very poor dental health. Children’s access now exceeds pre-pandemic levels, more adults are being seen and more dentists practise in the NHS, if we compare it with 2019-20.
I absolutely agree with the noble Baronesses, Lady Finlay and Lady Pidgeon, and other noble Lords, about the key role of prevention. That is exactly why, as the noble Baroness, Lady Finlay, said, we have brought in a toothbrushing scheme for young children, as well as fluoridation. We are seeking to tackle—if noble Lords will forgive the pun—the root causes. I cannot think of another word, but perhaps noble Lords will enjoy that anyway. It is important that we prevent as well as treat, for sure.
I turn to Amendment 213, tabled by noble friend Lord Hunt. We agree that transparency and accountability are essential to a properly functioning NHS dental system. However, the amendment risks duplicating existing arrangements. For example, the annual dental statistics help to identify problems and inform policy development, and I know that nobody present would wish to divert resources away from patient services. The whole focus of the Bill is on increasing Ministers’ accountability to Parliament, so I have no doubt of that happening.
I will pick up on some of the other points that were made, in more general terms. The noble Baroness, Lady Coffey, the noble Lord, Lord Lansley, and my noble friend Lord Hunt spoke about the dental contract and expressed concerns about the focus on units of dental activity, which I understand. I agree that reforming the dental contract is a key lever, and that is why we are working with the British Dental Association and other representative bodies to do just that. In addition to that contract, we are looking at how we can better use technology and boost the number of NHS dentists, as well as all the other areas that I have spoken to.
The noble Lord, Lord Patel of Bradford, asked about funding. I can confirm that the dental budget is worth around £4 billion, net of patient charges. The Government want to ensure that the ring-fenced dental budget is spent on the patients who need it most, and we need to maximise treatments for taxpayers’ money. I am pleased to say that we reduced the NHS dentistry underspend, which was standing at £392 million in 2023-24, to £36 million in 2024-25. That will make a major change to the provision of dental services. On the question from the noble Lord, Lord Patel, about the dental framework being developed by the Chief Dental Officer, I will be pleased to write with more detail on that.
I will pick up a few points in response to the noble Lord, Lord Young; where I cannot do so at the moment, I will be pleased to write to him. As I have mentioned, 4 million urgent appointments were delivered in 2025-26; that is 8.4% more than in 2024-25, and more than in any previous year under the current contract. We have now required high street dentists to deliver a minimum amount of urgent treatment as part of their contract. On the point about fluoridation, which the noble Baroness, Lady Finlay, also spoke to in terms of prevention, we are investing £136 million over five years to maintain existing schemes across England and fund the expansion to which the noble Lord referred across the north-east of England. Some 6 million people are already benefiting from fluoridated water, and this latest intervention is expected to reach an additional 1.6 million, to reduce tooth decay and inequalities in dental health.
The noble Lord, Lord Kakkar, talked about bringing together datasets to understand the impact of dentistry on broader health, which is a point I take. I will be pleased to look into that and write to him.
Lord Patel of Bradford (Non-Afl)
I thank the Minister very much for that detailed response. When she writes to noble Lords, can she specifically pick up the issue of capital funding? Lots of the places that I am looking at have a population with enough people to have complex problems, but not big enough to have infrastructure. We really struggle without some capital investment. As the noble Lord, Lord Lansley, said, we need some capital funds to set up some of these physical services to actually do the workforce training.
Baroness Merron (Lab)
Yes, I will be very pleased to include reference to that. I would probably use the word more broadly—the infrastructure that is necessary to support the dental activity—but I take the point and I will do my best to assist.
Baroness Coffey (Con)
My Lords, I thank the Minister for her comprehensive response. There is something in what she said about a dental team. Many noble Lords have talked about children. Dental therapists are unsung heroes and heroines who are perfectly qualified to undertake a lot of the work that has been mentioned today, particularly when dealing with children. The challenge is that too many dentists will not allow dental therapists to practise. I have asked them for reasons why, and there are certain things they cannot and are not allowed to do with NHS paperwork. Dentists also talk about liability, in terms of insurance.
We need to open this up much more widely. I encourage the Minister to speak to the Minister for Health Innovation, who I believe is responsible for dentistry, to see what more could be done. Too many children’s teeth, never mind older people’s, are just being ruined when they do not need to be. It does not need to be a dentist who goes into a nursery to look at these things; there are perfectly well-qualified people who can undertake that.
I will likely return to the issue of dentistry on Report, but, with that, I beg leave to withdraw my amendment.
Baroness Coffey
“Promoting access to ambulance services equitablyIn the National Health Service Act 2006, after section 1C insert—“1CA Duty to promote access to ambulance services equitablyIn exercising functions in relation to the health service, the Secretary of State must have regard to the need to ensure provision of ambulance services across England accessible to all regardless of wealth or geography.””
Baroness Coffey (Con)
My Lords, we have got a Holy Trinity now. We have dealt with how we encourage people to get into and stay in work, we have talked about dentistry, and now we are going to talk about more things to do with urgent care.
This amendment is about promoting equitable access to ambulance services. I feel passionately about this: it was something I dedicated a lot of my time to as an MP, trying to improve access at local level. It was when I learned about how often, on a regional basis, we would see actual manipulation of where ambulances were placed in order to make sure targets were hit—but it did not mean that patients were served well.
There are a number of issues in regard to ambulances, and I pay tribute to many first responders. In the statistics, recorded nationally, a volunteer responder turning up is the same as having a paramedic arrive. In the East of England Ambulance Service, which had started to show improvement but is now really struggling —again—ambulances are quite regularly sent without any qualified paramedics in them.
I come back to the point that this situation can be very serious. Quite often, outside our major cities, for example in the east of England, if you have a stroke or a serious heart issue, you have to go to Cambridge for the best treatment. Stuff has happened along the way to try to make sure that you can stop en route, in places such as Ipswich and Norwich, in order to get something along the way. A stroke is something that causes the greatest harm, in terms of people having a good quality of life later. Of course, having a wide range of first responders across the country is a very useful way to help people who have had either a cardiac arrest or a heart attack, to keep them alive. But the difference in your quality of life depends on how quickly you get treatment when you have had a stroke; it is a real life changer.
One of the things I am conscious of is that we have many rural areas around the country. Something more needs to be done to help rural communities. It also happens to be the case—particularly thinking of coastal areas—that a lot of tourists rely on emergency services when they are on holiday. That is not taken into account in some of the funding measures, as far as I am aware.
I am pleased that we have seen an increase in the number of paramedics, but, reflecting on the point referred to earlier by the noble Baroness, Lady Hollins, on clinical staff in the NHS, it is paramedics who have the highest sickness rates. I think it is more than double —perhaps even treble—how often an average hospital doctor or consultant sadly ends up being off ill. It is not the Cinderella of the NHS, but it is certainly a part of the service that has been forced into mergers over the years, and there is huge reluctance among NHS leaders to break them apart in a way that would perhaps help patients. Indeed, we are effectively seeing many more mergers happening around England, which is going to be a real struggle, particularly for rural communities.
I am grateful to the Minister for sending the letter today about what will be happening. ICBs are taking on dentistry as part of their statutory duties, but there was no reference to what would be happening with ambulance services. I know it is common practice that one ICB tends to do the commissioning on behalf of all ICBs in that area, because they are currently constrained by the fact that they do not have any choice in where they get their ambulance service. I am not suggesting that we go for some free-market approach. We need a sensible, well-connected way of dealing with these emergencies. It would be useful to hear what the Secretary of State’s plans are for the next phase of NHS provision across the country.
I share the concerns, reflected in other amendments in this group, about people suffering corridor care. I look forward to trying to better understand the amendment from the noble Baroness, Lady Pidgeon, regarding 12-hour admissions to A&E. It has become terrible how patients are not being seen, especially when that can be a matter of life and death. I hope that we will have some further useful discussions on this important blue-light service and recognise the contributions made by paramedics and community first responders right across our country. I beg to move.
Lord Scriven (LD)
I know the noble Baroness likes to be absolutely correct. She said that the highest rate of NHS staff sickness was among ambulance paramedics. It is actually ambulance support staff, which does not include paramedics. I am sure she would like to correct the record.
Baroness Coffey (Con)
I am grateful to the noble Lord for doing that. That is not in the information that I have, but I completely accept what he has said. It is unusual in the NHS that the average number of sickness days lost to non-clinical staff is more than double that to clinical staff, but I completely understand the noble Lord’s point.
Lord Patel of Bradford (Non-Afl)
My Lords, Amendment 72, in my name, addresses a straightforward concern: patients being made to wait for assessment or treatment because of an administrative or financial rule when clinically appropriate care could be provided sooner. My amendment would prohibit minimum waiting times imposed across the NHS in England for administrative, financial or capacity-management reasons. It would apply to both commissioners and providers, including through contracts and activity plans. It would protect clinical decisions about when an assessment, investigation or treatment should take place. A patient may need to wait for a clinical reason, but they should not be made to wait because a commissioner has imposed a minimum waiting period to manage budgets or activity.
That is already happening. An investigation published by the British Medical Journal on 9 September found that nearly half of England’s integrated care boards had introduced some form of minimum waiting time. It reported minimum waits of 16 weeks for routine procedures in Shropshire, Telford and Wrekin, and West Yorkshire, and for cataract treatment in south-east London. Can the Minister confirm whether these policies remain in place and whether the Government consider them acceptable when clinically appropriate care can be provided sooner?
The situation is even starker for ADHD and autism assessments. For example, published information from West Yorkshire’s ICB confirms a minimum wait of two years from referral for assessments with independent providers. The ICB says that this is intended to make waiting times fairer and to manage financial pressures, but the central question remains: why require someone to wait two years if an appropriate assessment could be provided sooner? An assessment can help someone understand their difficulties and get appropriate support. A two-year delay can have consequences for their education, employment and family life.
The ICB allows urgent assessments where certain specified clinical criteria are met. Those urgent exceptions are important, but what happens when the criteria are so restrictive that they exclude patients whom clinicians believe are at serious risk? I present this point from a practical perspective. I heard only last week about a concern in another ICB area. Clinicians there identify patients whom they believe are at risk of serious harm, including self-harm and suicide, yet those patients appear to fall outside that ICB’s tightly drawn criteria for urgent assessment. When clinicians raised these concerns, the responses reported include directing patients to NHS 111 and suggesting that referrals could be returned to their GP if the provider is concerned about managing the clinical risks while they wait. Of course, NHS 111 and GPs have important roles in helping patients access urgent support, but that does not answer the clinicians’ concern that these patients need an earlier specialist assessment.
This concerns the restrictions on funded activity rather than a fixed minimum wait time, but it raises a serious question: are urgent criteria being drawn around the available budget rather than the clinical needs of the patient? Surely there must be a prompt clinical review and a clear, funded route to appropriate care for patients whose clinicians identify serious risk, even when they fall outside the ICB’s specified categories.
I recognise that commissioners face very difficult financial choices, but making patients wait when appropriate care is available does not remove their need for care. Their condition may worsen and they may need more help from other services while they wait. I have three concerns about policies that impose these minimum waits: harm to patients, fairness and transparency.
First, on harm to patients, someone waiting for a hip replacement, cataract surgery or diagnostic test may be living with pain, unable to work or drive, or losing their independence. Their life does not go on hold because a waiting time clock has started. If their condition worsens, they may need more help from their GP, social care or emergency services. Meanwhile, capacity that could have been used to treat them sooner may grow unused. How is that a sensible use of NHS resources? In responding to the BMJ investigation, the Royal College of Surgeons warned about deliberately delaying patients who are ready for treatment. The Royal College of General Practitioners also questioned blanket minimum waits while patients could be treated sooner.
Secondly, on fairness, access to care should depend on clinical need, yet a patient in one ICB area may be required to wait at least 16 weeks while someone with the same needs in a neighbouring ICB area faces no such rule. Surely that is the definition of a postcode lottery. What does “patient choice” mean if someone chooses an appropriate provider who could see them sooner but a commissioning rule prevents it?
Thirdly, there is transparency. In Written Answers to Dr Luke Evans MP on 22 June, the Government said there was
“no formal national policy supporting minimum waits”,
but they confirmed that the NHS standard contract allowed local commissioners to set what they called “activity planning assumptions”. Whatever the label we use, if a contractual rule stops a patient receiving care sooner, its effect must surely be open to scrutiny. Yet the Government also said that NHS England did not collect information on which ICBs impose minimum waits, which services were affected or their impact. How can the Government judge these policies without that information? Patients should know why they are waiting and be able to challenge a rule that unnecessarily delays their care.
Baroness Finlay of Llandaff (CB)
My Lords, I shall address Amendments 219 and 229, tabled by the noble Baroness, Lady Pidgeon. I have already had a brief discussion with her, because I would have liked to have signed Amendment 229, except for a bit of the wording. She is absolutely right that corridor care is one of the scandals of our time. In fact, it was on the news at lunchtime today, with patients being filmed in corridors still. We also still have social care problems arriving in emergency departments. These are people who really need to be looked after; they cannot just be sent out.
One thing about emergency departments is that people arrive, attend and then, after they are assessed, there is a decision about whether they are to be admitted. There is a clear line in the way that the figures are collected. That becomes important because roughly 25% of the people who attend are actually admitted. We have to be really careful that there is no gaming around these figures, which can happen by managers if targets are put in that become difficult to reach for one reason or another.
There are terribly long trolley waits at the moment. In each of the past three years, over half a million patients have been waiting on trolleys. As we touched on at Oral Questions yesterday, the flow through hospitals is a problem, with very high bed occupancies. We have far fewer beds in our NHS than the average across the EU—we have below half of that average. Also, the countries that have lower bed numbers often have other services in place. For example, in the Netherlands, the numbers of beds in hospitals are not that high but it has the discipline of nursing home medicine, with a large number of beds and staff trained to a very high level.
One problem that we face is the flow through hospitals —in, through and out of them. In simply addressing the front door, we are not addressing the problem properly, because there are a number of patients who are deemed to be medically fit for discharge but remain in hospital. That number is estimated at nearly 13,000 patients a day, which is huge. These patients are deemed to have been medically optimised but no longer need to remain in the hospital.
The design of our emergency departments does not help in relation to corridor care or other care. I had the privilege of spending some time in Groningen in the north of the Netherlands and was astounded at its emergency department, which was superbly laid out. There were two direct resus rooms from the ambulance bay, fully equipped so that they could be turned into emergency operating theatres for very major trauma, with CT scanners in them. They had moved from the open front door, which we have, to being able to move major trauma and other problems straight into much more appropriate environments than we have been providing.
I commend the Government for taking on the problem of modernisation, but I hope that we look at the whole issue of patient experience and patient flow and recognise that, unless we do something about our emergency departments, the more than 90% of staff who feel that they cannot cope in the longer term will be on their knees and we will have more problems going forward.
Baroness Pidgeon (LD)
My Amendment 219 addresses the deeply concerning and increasingly common practice of corridor care. No patient should be left receiving treatment, assessment or prolonged care in a corridor simply because there is nowhere else for them to go. A friend of mine only a couple of weekends ago showed me a picture of a relative in hospital, who was in a corridor. This is absolutely unacceptable. As we heard from the noble Baroness, Lady Finlay, it was on the news again today. Corridor care undermines patient dignity, compromises privacy, increases clinical risk and places additional strain on hard-working NHS staff who are trying to deliver safe care in environments that were never designed for that purpose.
We all recognise the immense pressures our hospitals are facing, from rising demand to workforce shortages and delayed discharge, but corridor care must never become normalised, as I fear it has, as an acceptable feature of our health service. Dr Ian Higginson, president of the Royal College of Emergency Medicine, has described corridor care as
“dangerous, undignified, and a source of national shame”.
Survey data published by the royal college only on 20 July shows that 61% of clinical leads in England said that their trusts did not even capture corridor care accurately, with many saying that patients who were on chairs and in waiting rooms waiting for admission were not counted towards their corridor care figure.
There is significant variation in reporting between hospitals and emergency departments. Consultants are concerned about patients who wait on chairs in waiting rooms, off-the-clock assessment units and the repurposing of space as “non-corridor” places, where they put chairs so that patients can wait and not be counted. I have even been told of somebody being sat on a chair in a cupboard because that would not count towards corridor care figures. This is also not counting patients waiting in ambulances or on corridors on the way into departments. It is simply unacceptable. This amendment would help shine a light on the true scale of the problem and support genuine efforts to ensure that patients are treated in appropriate clinical settings with the dignity, safety and respect that every person deserves when they turn up to their hospital in their time of need. We need this to lead to the end of this practice.
My Amendment 229 seeks to address another visible symptom of the pressures that our National Health Service faces: the growing difficulty in securing timely admission from accident and emergency departments into appropriate hospital beds. When patients have been assessed and a clinical decision has been made that they require admission, prolonged waits in A&E not only are frustrating but can lead to poorer outcomes, increased risk to patient safety and greater distress for patients and their families. These delays also contribute to serious overcrowding in emergency departments, making it harder for clinicians to deliver care to all those who come through their doors. While we know that the causes are complex—bed capacity, workforce shortages, which we talked about earlier, and the difficulty of discharging medically fit patients into the community and social care settings, as we heard from the noble Baroness, Lady Finlay—we should be clear that long waits for admission are just not acceptable.
This amendment would provide greater transparency and accountability and help ensure that the health system focuses on reducing delays and delivering the safe, timely and dignified care that patients have every right to receive. Putting this right in the NHS constitution would focus efforts and make sure that we address this serious issue. We do not want patients avoiding A&E because they fear endless hours of waiting. We know that is happening; we hear about it. Sorting out admissions and ending corridor care would transform the patient experience and, most importantly, patient outcomes.
The amendment tabled by the noble Lord, Lord Patel of Bradford, on prohibiting minimum waiting times is important. We discussed this in a group only last week. We need to see waiting times minimised and patients receive the diagnostics and treatment that they need in a timely manner—one that is led clinically rather than by budget rationing, which we see too often today. The amendment from the noble Baroness, Lady Coffey, talks about ambulance services. I commend the recent work by the Public Services Committee, which looked at the response and reaction between ambulance services and emergency departments, but it only scratched the surface of that issue. A lot more could be done with that workforce and those teams to ensure that patients get to the right door for further clinical care. I look forward to the Minister’s response to this important group, as this is really on the minds of the public today.
Earl Howe (Con)
My Lords, I shall speak only briefly on this group of amendments, not because I am in any way lukewarm about their content—quite the opposite—but for the practical reason that, as a Committee, we are being urged to make faster progress, bearing in mind the number of debating hours allocated to us. Let me say how impressed I was by the speeches from the noble Baroness, Lady Finlay of Llandaff, and the noble Lord, Lord Patel of Bradford. I hope the Minister will take their very powerful points back to officials in the department. I also agree fully with all that the noble Baroness, Lady Pidgeon, said about the unacceptability of corridor care.
I will make a couple of points on my noble friend Lady Coffey’s amendment on equitably available ambulance services. This is a tremendously important issue. As she will remember, I had to grapple with it as a Health Minister, not least as regards services in her then constituency. It is sadly the case that the category 1 response target of seven minutes has not been met nationally since April 2021. The Government have made big investments in emergency response services since coming to office; that is excellent, but since July 2024 the dial on category 1 and category 2 response times has not moved appreciably, if at all. That is not meant as a criticism but simply as another indication of how difficult a challenge this is.
Baroness Merron (Lab)
My Lords, I am most grateful to noble Lords for their contributions. Indeed, we all share a determination to ensure that patients receive safe, timely care in the right place. I am grateful to the noble Earl, Lord Howe, for his brevity; I will also seek to focus on amendments, and I hope noble Lords will appreciate that the reason for that is so we can deal with the content of the Bill.
Amendment 50 in the name of the noble Baroness, Lady Coffey, raises the important issue of rural access to ambulance services. I confirm that ICBs already have a statutory duty to meet the needs of their local population and to have regard to the need to reduce health inequalities, with respect to both ability to access health services and outcomes. I can assure your Lordships’ Committee that the funding that ICBs receive for commissioning ambulance services is based on factors such as age and deprivation and is adjusted to reduce health inequalities. To the point on rural areas, this includes adjustments for longer emergency ambulance journeys. We have heard some statistics, but I confirm that the category 2 mean ambulance response time is, as of July of this year, three minutes and 35 seconds faster than in July 2024. That is not the end of the story; I am simply indicating progress that is being made. I recognise, as always, the challenge of the situation that we are dealing with.
On Amendment 229, tabled by the noble Baroness, Lady Pidgeon, I certainly share her determination to reduce long waits in A&E. Trusts are already expected year on year to improve four-hour performance and to reduce waits of 12 hours or more from arrival. There is no complacency about what we have to do to improve performance, which is why the Secretary of State recently announced £140 million of investment in urgent and emergency care schemes across England, including urgent treatment centres, same-day emergency care, emergency department upgrades and additional ambulance capacity.
We are also taking action across the urgent and emergency care pathway to reduce excessive waits and to improve patient safety and flow through hospitals, which the noble Baroness, Lady Finlay, spoke to. I assure your Lordships’ Committee that this will continue following the abolition of NHS England. It is our view that a legal time limit in itself would not address the underlying pressures on capacity and patient flow that contribute to long waits, and establishing a new statutory scheme would risk distracting from the crucial work that is already under way.
On Amendment 219, also tabled by the noble Baroness, Lady Pidgeon, I could not agree more that corridor care must not—not even should not, but must not—be normalised. I am reiterating some of the points that I made in a recent Oral Question, which I believe was from the noble Baroness, on this very important point. Our priority is sustained action to address the causes by improving patient flow and discharge, expanding urgent care capacity and supporting the most challenged hospitals. We have introduced a consistent national definition and reporting arrangements, and we have improved transparency and enabled support to be focused where it is most needed.
The Secretary of State has also asked NHS England to bring forward urgent plans aimed at eliminating corridor care for children. I can say that one in six trusts consistently reported no corridor care across their emergency departments or the wider hospital over the summer. I particularly make the point about the summer because of the extreme pressure due to the weather—not something we usually say, but we are increasingly seeing it. The pressures were immense, and that was their report to us.
The noble Baroness, Lady Finlay, made the strongest case for exactly what we are doing with the neighbourhood health service, which is about moving the focus from hospital to community. I spoke earlier this week in the Chamber about the movement of savings accruing from timely discharge that can be directed to neighbourhood health. We are trialling that, because it is a very clear and practical way to make the move that the noble Baroness rightly identifies.
Baroness Pidgeon (LD)
My Lords, may I tease something out that the Minister was saying about corridor care? She quickly moved on to another thing, and I wanted to come back in.
Yes, this is similar to a discussion we had only last week or the week before in answer to a Question I had tabled, but two-thirds of medics working in emergency departments are saying that their trusts are not accurately reporting the data on corridor care. The Minister keeps saying that we have this new definition or whatever; it was decades ago that I worked in the NHS, but we had a way to make sure that people were not counted as being on a trolley: you took the wheels off and it became a bed. Trusts are very creative at finding ways around to meet their definitions. If two-thirds of those surveyed by the Royal College of Emergency Medicine are reporting that their trusts are not accurately calculating this, what are the Government doing to try to get under the data, to make sure that the Minister and the department are getting accurate data to be able to deal with this serious problem?
Baroness Merron (Lab)
I feel quite sure that the noble Baroness herself never did such a thing.
Baroness Merron (Lab)
I take very seriously the point that the noble Baroness made. I am sure it is already being looked into, but I will personally make sure that that is the case.
On corridor care and children, one example of the practical action taken is our recent announcement that the NHS is rolling out a standardised system to spot when a child’s health is deteriorating, so that early warning signs are caught earlier and there is faster action. The paediatric early warning system will be introduced in all emergency departments by the end of 2027-28, with an ambition to also roll this out in ambulance and community settings in the future. This is broader than just corridor care, but I know that that is a particular concern, as I said, when it comes to children. I cannot confirm often enough that we remain committed to fully eliminating corridor care before the end of this Parliament.
Finally, on Amendment 72, in the name of the noble Lord, Lord Patel of Bradford, I can give the reassurance that there is no national policy supporting blanket minimum waits. Indeed, patient safety always comes first. If a commissioner puts capacity measures in place, urgent referrals must be excluded, minimum waits must not be set above 18 weeks and providers must continue to triage patients according to clinical priority.
At the start of the year, it is important and expected that commissioners plan to balance service delivery with their yearly budgets while prioritising patient safety and clinical need. I remind your Lordships’ House that it is due to our approach to financial planning that the NHS stayed in line with its budget in 2025-26 while also cutting waiting lists by over 250,000 between July 2024 and August 2026. Removing the use of tools to support planning could drive unplanned activity and overspending, which would of course undesirably divert resources from other patients.
On the points made by the noble Lord, Lord Patel, about autism and ADHD assessment, expectations have already been set out for ICBs and providers to reduce those long waits and to improve experience, quality and productivity in ADHD services over the next three years. We are moving to a needs-led support model that means earlier access to information and support and appropriate interventions that are individually based, without and before a diagnosis.
On the question about ICBs imposing minimum waits and whether we will publish which ICBs are doing this, there are no plans to publish this information. The data is held locally and that is right, because these are decisions for local areas. To restate what I said before, commissioning decisions are for ICBs to make.
Lord Scriven (LD)
The Minister just made a very important point. Can she clarify? Is she saying that there is a requirement for ICBs to statutorily report that they have implemented a minimum wait standard, or not?
Baroness Merron (Lab)
The question from Lord Patel was about whether there were plans to publish this information, and I was explaining that there are no plans and the reasons why.
Lord Patel of Bradford (Non-Afl)
Going back to the analogy of taking the wheels off the beds, it feels as if ICBs have certain budgets they want to spend on certain things and they are creating criteria that exclude vulnerable people. This is really important. All I am asking is, are the Government not looking at the more than 50% of ICBs that have put in minimum waiting times without assessments? If they are not assessing that information or looking at the data, how do they know what ICBs are up to? It is not about publishing it—okay, I suggested that we should publish it; it is about examining what these ICBs are doing and what the potential dangers are. I heard the conversation that said, “These are our criteria”. While our clinicians are saying that these people are at risk of suicide, they are saying, “These are our criteria”.
Baroness Merron (Lab)
I am glad that the noble Lord understands the reason why the Government are not seeking to publish, which was the question I was being asked about. For me, this is a question about the accountability of ICBs, currently held accountable by NHS England. But the whole purpose of the Bill is to improve the quality of accountability after the abolition of NHS England.
Lord Patel of Bradford (Non-Afl)
I just have one last point, and I am conscious that people have said that we do not want to take this too far. Will the Minister reflect on the issue and the principle that somebody who requires treatment or assessment should not have to wait for purely financial or administrative reasons, even though there is a clinical need?
Baroness Merron (Lab)
I have already made reference to what the priorities are: need and patient safety. I assure the noble Lord that I reflect on everything noble Lords say, and I certainly believe that I have already given that assurance.
Baroness Coffey (Con)
My Lords, this group of amendments has been informative, as have noble Lords’ contributions. I think that the noble Lord, Lord Patel of Bradford, may be referring to situations where a minimum is being deployed for people who have expressed their view that they would like to use an independent provider to tackle the issues, and I think that something is not quite right there. But we also have to be realistic. NHS England and all the trusts have to live within their means and not every area can be bailed out, as continues to happen at the Nottingham University Hospitals Trust and the Liverpool University Hospitals NHS Foundation Trust, which is in the recently published figures.
Obviously, whether it is about an ambulance or going to an urgent treatment centre or SDEC, I am conscious that the philosophy in the NHS up until fairly recently was that it was very proud that it had far fewer beds per person on average compared to other parts of Europe, on the basis that people would often get their operation, be dealt with and go home safely that same day. Thus, the thinking was that not quite so many beds were needed.
I welcome the reference to Sir Chris Whitty’s report, particularly in the context of rural communities. But without further ado, I beg leave to withdraw my amendment.
Baroness Hayman
“Duties as to climate change etcIn the National Health Service Act 2006, after section 1CC (inserted by section 6 of this Act) insert—“1CD Duties as to climate change etc(1) In exercising functions in relation to the health service, the Secretary of State must have regard to the need to—(a) contribute towards compliance with—(i) section 1 of the Climate Change Act 2008 (UK net zero emissions target), and(ii) section 5 of the Environment Act 2021 (environmental targets: effects), and(b) adapt to any current or predicted impacts of climate change identified in the most recent report under section 56 of the Climate Change Act 2008.(2) The Secretary of State may publish guidance about the discharge of— (a) the duty imposed on the Secretary of State by subsection (1) of this section;(b) the duty imposed on integrated care boards by section 14Z44 (duties as to climate change etc);(c) the duty imposed on NHS trusts by section 26B (duties in relation to climate change etc);(d) the duty imposed on NHS foundation trusts by section 63B (duties in relation to climate change etc).(3) In discharging their duty under section 14Z44, integrated care boards must have regard to guidance published under subsection (2). (4) In discharging the duty under subsection (1), the Secretary of State must have regard to guidance published under subsection (2).””
Baroness Hayman (CB)
My Lords, I am grateful for the support for my Amendment 52 from the noble Baronesses, Lady Sheehan and Lady Ritchie of Downpatrick, and the noble Lord, Lord Crisp. I shall listen with interest to the debate on, and particularly the Minister’s response to, Amendment 248, tabled by the noble Baroness, Lady Boycott, which is a very practical way forward.
I did not take part in Second Reading on the Bill. Actually, I had a self-denying ordinance. I decided, having had my first involvement with the NHS in 1980, having seen so many reorganisations and, I am afraid, having become a little jaundiced about the effectiveness of those reorganisations in transforming patient care rather than changing administrative structures, that I would not say anything. My mother always said that if you cannot say something nice, do not say anything at all. However, here I am, and I am here because of the recent history of legislation on the NHS, in particular, the NHS Health and Care Act 2022.
I was involved in the debate on issues relating to climate in that Bill. After cross-party pressure on the issue, the Conservative Government of the time tabled amendments which became part of the Act, and which are mirrored in Amendment 52 in my name today. They were described thus by the then Minister, the noble Baroness, Lady Penn:
“They place a duty on NHS trusts, foundation trusts, ICBs and NHS England to have regard to the Government’s key ambitions on climate change and the natural environment in everything they do. This could mean preparing thousands of NHS buildings to adapt to climate impacts, protecting and enhancing biodiversity across 25 million square metres of trust estate, or decarbonising the millions of kilowatts of energy used by trusts every year”.—[Official Report, 1/3/22; col. 729.]
That, of course, saves money for the trusts involved. The amendments were warmly welcomed by the then Opposition, with the noble Baroness, Lady Wheeler, saying:
“I thank the Minister and welcome these government amendments in response to the key concerns raised in Committee about the crucial importance of including the NHS’s duties on climate change and working towards net-zero emissions in the Bill”.—[Official Report, 1/3/22; col. 733.]
My amendments, which mirror those amendments, are trying to maintain the status quo. They are essentially Conservative in the sense that it was a Conservative Government who introduced them.
Therefore, I ask the Minister to help me understand why, when NHS England’s functions transfer to the Secretary of State along with responsibilities to consider the impacts of climate change on our health services and public health and the significant role the NHS has to play in helping the UK to meet its national climate and environmental targets and to provide leadership—we saw that at COP 28 in Glasgow, with other countries’ health services actually responding—the Bill before us omits the NHSE’s statutory duty to publish guidance on what it regards as the best way for ICBs and the organisation itself to meet those duties and how it is fulfilling them, along with an established framework for reporting details of progress on reducing emissions in its annual report and accounts. There is no in-kind replacement for these requirements on the Health Secretary, meaning that without legislative change and amendments of this sort, there will be no obligation on DHSC to continue driving progress, specifically on the health service’s carbon emissions reduction work.
Ministers may say that they will have powers to issue fresh guidance if they choose to, but whether it is issued and how robust its contents are will be contingent on the priorities of the Government of the day, and we have an example before us of how those can change. That outcome does not bring the same level of certainty or direction that the NHS needs to maintain regular accountability and long-term national momentum towards its targets. I hope that the Government will not try to argue that, because the Climate Change Act 2008 applies to all government departments, this amendment is unnecessary. It is clear that the powers that were put in the 2022 Act are much more specific to the NHS and the health system and essentially provide accountability and transparency. The NHS itself says that the duties supported the health service’s own ambition to become the world’s first health system to embed net zero in legislation. The 2022 Act requires commissioners and providers of NHS services specifically to address the UK net-zero emissions target and environmental targets and to adapt to any current or predicted impacts of climate change identified within the Climate Change Act 2008. We saw quite a few of those this summer and quite a few of the effects on the health service.
The Bill before us does not require the Health Secretary, when making decisions about the NHS, to consider how the organisation is contributing to carbon targets, to regularly report on its performance or to prepare it for the climate risks it faces. That is what we risk losing if we do not amend the Bill. I know the Government are trying to clear provisions and responsibilities out of the way and do not want to put extra bureaucratic requirements on the NHS, but my amendment recognises this. Because it is already in the 2022 Act, it does not widen the requirements in any way. It is simply trying to restore the status of the existing duties. The need to co-ordinate and steer responses to climate change and nature loss at the national level ought not to be treated as unnecessary paperwork. These duties have been quietly working as intended in the face of rising climate challenges. NHSE appears to have been getting on with them and setting emissions reductions targets that now have a statutory basis. It reports that direct emissions were reduced by 14% in the years 2020-25 and that the NHS is on track to meet its 2032 and 2040 goals.
Within the last four years, the evidence points to climate change increasingly becoming a major challenge for health and health services. The Parliamentarians’ Guide to Health and Climate Change, developed by Peers for the Planet—in which I declare a past interest—and the Wellcome Trust is insightful reading and shows why climate change is already a UK public health issue. A number of organisations, such as the Wellcome Trust and the UK Health Alliance on Climate Change, have expressed concerns that failing to replace these obligations once NHSE functions are transferred to the Secretary of State will mean that there is no obligation for Ministers to report annually on progress towards NHS net-zero commitments, to publish sustainability guidance or to account to Parliament for this work. This will leave future transparency and oversight reliant to an unacceptably large degree on ministerial discretion, and it will undermine co-ordination of national objectives. I hope the Minister will be able to tell us how, if these duties for the DHSC are not replaced, we can ensure that our national health services have appropriate regard to the challenges of climate change. I beg to move.
Baroness Boycott (CB)
I will speak to Amendment 248, but first I want to say that that was a terrific introduction by the noble Baroness, Lady Hayman, who is such a long-term, amazing campaigner for climate change. I would be horrifically surprised if the Minister does not reply completely in the affirmative towards this amendment, because, especially following the summer we have had, I do not see how anyone could continue to have their head in the sand about this risk. Climate change is not a hypothetical threat. There were 2,877 health-related deaths in May and June alone in the heatwaves—and this is not going to get better. This is not a one-off thing. In the climate emergency film there is a memorable line which says, “This is the best weather you are going to get in your lifetime”. That is truly scary. It may not happen next year, but it sure as hell will happen within the next two or three years.
The effects of this heat are not spread evenly over the population. It affects vulnerable people, children, the elderly, people living with chronic conditions, those in poor-quality housing and pregnant women. The noble Baroness, Lady Hayman, mentioned our work with the Wellcome Trust. I am vice-chair of Peers for the Planet. We have examined the effects of heat on pregnancy and maternal health, and it is not about being somewhere super-hot, which is what I have always thought. It is about being somewhere where your normal temperature condition changes. You are just as vulnerable if you are in Bristol as if you are in a field in southern India. It is about temperature change rather than extremes of temperature. It is important that we understand that, because that is going to hurt us. The climate and environmental impacts are also adding strain, as we have heard, to a service under pressure. The NHS said that this summer’s heatwaves piled pressure on its services and the NHS showed that A&E bore the brunt. We have just heard the amendments from the noble Baroness, Lady Coffey, and the other amendments about the emergency services. This is just going to make it worse.
Heat-related A&E attendances already account for 6% of average daily total attendances across the UK on extreme heat days, and the impact is estimated to cost £538 million a year. This cost could rise by 144% by the 2030s. That is almost tomorrow, really, when you come to thinking about putting a new building together. It is welcome that the NHS trusts will retain their current “have regards” to climate change, but we really need to do more. We are not ramping up enough. The climate itself is not standing still. The Climate Change Committee warned that our health service remains chronically underprepared to deal with the risks, and there remains a lack of resilience for the physical NHS estate to cope with extreme weather.
Lord Crisp (CB)
My Lords, I am delighted to have put my name to both amendments, and to have heard them argued for so powerfully and cogently by my noble friends Lady Hayman and Lady Boycott. I want to emphasise one or two points, and add one slightly new point, because so much has been covered very quickly.
It seem odd that, in this year of all years, we decide to get rid of a power that used to be there, to reduce the emphasis on climate change and not to make it clear that the duties of NHS England need to be transferred in their detail. This was the point that my noble friend Lady Hayman was making. It is not just the general point that the Secretary of State has a responsibility as part of government policy to ensure that climate change is tackled; the detail of it needs to be there. Requiring NHS institutions to create and publish detailed resilience plans—the sort of plans that you can recognise in practical detail—would not only be useful for them but, frankly, give the public confidence, because there is a public confidence issue here.
I will not emphasise the Wellcome report on climate change. I hope that noble Lords and the Minister have had a chance to look at a report that is specifically focused on climate change and health. As I recall—sorry, this sounds like an advert—it has nine chapters that detail the impact from the latest research that is available globally. It is a powerful report; I declare an interest.
The NHS is interesting in this regard, because the NHS is both affected by climate change and a cause of it, and between them these two amendments deal with that. When I was chief executive of the NHS, there was some extraordinary figure that something like 3% or 5% of traffic in London was caused by the NHS and by people going back and forth to appointments. There is a lot on that side in terms of the impact on the climate from what the NHS does. A lot has been done in the last 20 years, but there is more to do.
The second amendment, proposed by my noble friend Lady Boycott, is about helping the NHS to be resilient. This is the big point that I want to emphasise. It was in my noble friend’s speech, but I would like to make it even clearer: many people in your Lordships’ Chamber have been involved with the NHS, and I guess we all know that everything in the NHS is a priority to someone. That is why it is so difficult to deal with, and one has to think of it in that way—but there are some overarching priorities. Frankly, this is an overarching priority. It is not about a discrete issue; it is about something that is going to affect all the services we have talked about earlier today, and other services as well. I hope that the Government are going to give this a high priority in their future thinking. I suspect that the public expect them to do so, and one can only imagine the consequences if the NHS does not get this right. I hope the Minister will accept these amendments. As my noble friend Lady Boycott said, the case is compelling and we are looking for an affirmative.
Baroness Bennett of Manor Castle (GP)
My Lords, it is a pleasure to take part on this group and to utterly applaud the three speeches we have already heard. I have not signed any of these amendments, because I wanted to leave space for others. Speaking as an old newspaper editor, “Green signs amendment about climate and environment” is a bit like “Dog bites man”, so I wanted to ensure that we had the maximum impact from other signatures. We have already heard the case made powerfully for this, but I want to make a couple of additional points and to follow on from what the noble Lord, Lord Crisp, said about priorities.
I have encountered many individuals in the NHS who are doing spectacular work in reducing the NHS’s carbon emissions. The Minister is not currently in her place, but I will say to another Minister that I encourage her to visit County Durham and Darlington NHS Foundation Trust, where tremendous work is being done, particularly on reducing the impact of acute care. Sometimes with acute care there is a feeling that we have to do the emergency stuff and we cannot do anything here. Actually, what we have seen is that in looking at where the use of intravenous drugs can be reduced and tablets used instead, clinical outcomes are improved and the amount of plastic use is significantly reduced. When you really start to look at what you are doing and how you can do it better, you can improve both clinical and environmental outcomes. That is just one example that I happen to know about.
It is important that the people who are doing this know that they have support from the centre and that this is an NHS priority, because they are putting time, energy and attention into this. Unless we see support from the centre by saying that this is a priority, it is hard for them to get the resources and support they need to make change happen. We know that any large organisation has a large sense of inertia, and delivering change needs support right through the organisation. As the noble Lord, Lord Crisp, said, the climate emergency is a health emergency as well, and there are so many ways in which these two factors interact.
On the amendment from the noble Baroness, Lady Boycott, looking at resilience to climate and environmental degradation risks, I want to cross-reference it to the joint intelligence chiefs’ report on the impact of environmental degradation on our food security. Are we thinking about the food security of the NHS? We have to be able to feed the patients, but there is also a great deal of feeding of staff that has to happen in the NHS. How much have NHS institutions looked at how secure their food supply is? That is something that the joint intelligence chiefs, not known as radical green activists, have said is really an issue. I note in passing that we still have not seen the publication of that full report, which is very disappointing.
There is another issue that I think everyone is very aware of after this summer. I note that my honourable friend in the other place, Hannah Spencer, has a Private Member’s Bill about working conditions and having a maximum working temperature, which, whatever that might be, has been exceeded in many of our NHS institutions over the past summer. We have seen staff collapsing as a result of the heat in their workspace. That has to be considered unacceptable, but what is it doing to patients if staff are collapsing from heat?
Baroness Coffey (Con)
My Lords, this is another interesting group. I want to follow on from the initial amendment from the noble Baroness, Lady Hayman. I have more of an interest in thinking of the Environment Act and the targets there and reducing waste. This is a story about how much single-use plastic is used in the NHS.
I spent a month in hospital a few years ago and, for me to have a shower every day, a nurse used to get a bin bag or two and then strap them around my arm, basically because I could not get water on a particular cannula. I was a bit surprised by that, because you could just buy from Amazon a whole bunch of sleeves that can be dried and reused. I am sure there is some clinical reason that they could cite—I was struggling to find out why—just because I was in hospital. I did exactly what I have just mentioned when I went into recuperation at home. Instead of just thinking about straws or plastic cups, the NHS has a real opportunity to do a lot more thinking about what it uses, what needs to be thrown away and what could go back to somewhere else. I am not suggesting that people reuse syringes and the like, but the NHS could think more carefully, instead of this single-use culture.
Building on that, the amendment tabled by the noble Baroness, Lady Boycott, is also highly relevant. I am very conscious that we did not make much progress in getting hospitals built, sadly. Some of this was, frankly, due to an argument going on between local hospitals, the NHS, the Treasury and so on about what was going to be built. The purpose of moving to a modular basis of building is to have something that is scalable and that should be a lot more resilient in the future. The reason I mention that is that we still have the challenge of hospitals that have a RAAC risk and the unfortunate delay in their construction being replaced. I think there are five around the country—it so happens that three of them are in East Anglia—that will not now be happening until, I think, 2033.
One of the simpler things that we can learn from the continent, where we have seen extreme weather—indeed, we have been experiencing it more regularly ourselves—is design, thinking about heat, as has been mentioned. Indeed, that month I spent in hospital happened to be during a particularly hot summer, and I bought my own fan so I could try to keep cool. It was regularly removed because it had not gone through the electricity checking system and therefore obviously had a dodgy plug that was going to blow up the entire hospital. There are areas like that where intelligent design, thinking through not only the use of materials but the design of hospitals in future, is going to be vital.
I appreciate that this is not just about hospitals. Quite rightly, noble Lords have referred to what is happening in terms of quality of housing. This Bill can play a role in trying to get embedded, right across the country in our NHS settings but also at home, that real change and transition. Whether it is about having more shutters, making that much easier to operate and, if you have them at scale, much cheaper to deploy, or whether it is about thinking carefully about design and whether every NHS building has to be BREEAM Excellent —my personal view is the answer to that is no—it would certainly reduce a lot of cost. By and large, BREEAM Excellent tends to prefer air conditioning to aspects of simpler design. I am very pro air conditioning, but that does not mean it is needed quite everywhere.
Lord Hunt of Kings Heath (Lab)
To follow on from the noble Baroness, Lady Coffey, we should acknowledge that the NHS has done an awful lot in its environmental and climate change policies, and we should pay tribute to the people who have led that. One of their problems is that some proposals—maybe to do with heating or lighting—that will not only reduce carbon usage but reduce costs long term need some up-front investment, but we still do not seem to have found a way to allow for the NHS to borrow against a fund for it to be repaid over the years ahead. I hope that we might think about this, particularly in relation to sustainability and climate change.
I was looking at advice issued by the CQC in the light of the 2022 legislation that the noble Baroness quoted from. It says:
“Trusts and ICBs meet this new duty”—
that was placed in the 2022 Act—
“through the delivery of their localised Green Plans. Every trust and ICB in the country now has a board-level lead for net zero and sustainability”.
Perhaps my noble friend the Minister might want to write to me about whether, despite the changes in legislation, that responsibility still lies with local NHS services. Will the CQC guidance still stand post the passage of the Bill?
Baroness Pidgeon (LD)
My Lords, I am grateful to the noble Baronesses, Lady Hayman and Lady Boycott, and all noble Lords who have put their names to these amendments, including my noble friend Lady Sheehan.
The central question is straightforward: as the Bill proposes changes to the organisation of the health service, how do we ensure that its responsibilities for climate change, environmental protection and—from all that—patient safety are strengthened rather than simply diminished and reduced?
We absolutely support Amendment 52. As the noble Baroness, Lady Hayman, has clearly set out, in 2022 the House established climate and environmental duties for NHS England integrated care boards and trusts but not for the Secretary of State. As functions move into the department, responsibilities for this must not disappear. The amendment is modest; it talks about “have regard” to the duty. It would not prevent the Minister balancing competing priorities but would make sure climate change was absolutely on the agenda.
Can the Minister explain who will report progress to Parliament once NHS England’s annual reporting responsibilities are lost? How will Parliament be able to scrutinise this in future? Just because there is an organisational change—and we see that a lot in the NHS—it should not then lead to a huge accountability gap and a potential reduction in work in this area.
We also support Amendment 248 and its requirement for each NHS trust and foundation trust to publish an assessment of climate risks to its premises, workforce and services, together with plans to address them. This is a practical and proportionate requirement; we should not wait until wards are overheating or hospitals flood before asking whether there was a plan and doing something about it. Adaptation is about patient safety, as we have heard, and, given the extreme weather that we are now living through, it is essential. It is about resilience, as the noble Lord, Lord Crisp, said.
The final point made by the noble Lord, Lord Hunt, was important: this is about investing to save in terms of tackling sustainability issues. That is spot on. Years ago, there was an “invest to save” fund. We need to look at that if we are going to be able to make savings in the future to invest in the capital works that are needed. I hope the Minister will be able to respond positively to this group.
Earl Howe (Con)
My Lords, again, if the Committee will forgive me, I will speak only briefly. I start by expressing my support for the remarks made by the noble Baroness, Lady Hayman, in speaking to her Amendment 52. It seems impossible to argue that the Secretary of State for Health and Social Care should be exempt from a duty to be mindful of the climate change agenda in everything they do, especially as we remember that the Secretary of State for Health and Social Care presides over an organisation with a very large carbon footprint. It was very much with that in view that Section 9 of the Health and Care Act 2022 included duties on NHS England to have regard, in the exercise of its functions, to the Climate Change Act 2008. Therefore, the noble Baroness was entirely right that the duties that apply currently to NHS England in this area should now logically apply to the Secretary of State.
Having said that, I would be surprised if the Minister did not respond by saying that the first part of Amendment 52 is unnecessary, for the very dull reason that Section 15 of the Climate Change Act 2008 already places a duty on “the Secretary of State”, in exercising his or her functions, to have regard to
“the need for UK domestic action on climate change”;
the section spells out what that means in practice. It has long been drummed into me that an Act of Parliament conferring duties on “the Secretary of State” should be read in law as applying to any Secretary of State. That is a very legalistic point, and I do not think that it constitutes a sufficient reason for the Minister to resist this amendment, for all the reasons set out so well by the noble Lord, Lord Crisp.
Personally, I feel the need for something declaratory and specific in this area. The duty to issue detailed guidance seems a very definite omission from the Bill. As we heard the Minister say in response to the previous group of amendments, climate change is becoming a highly relevant factor for ICBs and trusts in the planning of service delivery. As the noble Baroness, Lady Boycott, was right to emphasise, it is equally relevant in the public health context and to the design of buildings, including hospitals. With all that in mind, I hope that the Minister will feel able to give the noble Baroness’s amendment a positive response.
Baroness Hyde of Bemerton (Lab)
My Lords, I thank all noble Lords who took part in the debate on this important group of amendments. I will address Amendments 52 and 248 together.
I turn first to Amendment 52, tabled by the noble Baroness, Lady Hayman. The Government remain committed to tackling climate change and ensuring that the NHS continues to play its part. I agree with the noble Lord, Lord Crisp, that this is an overarching priority. However, we do not believe that this amendment is necessary. I am indeed going to say that the climate change target and environmental targets referred to in the amendment already apply to the Secretary of State through the Climate Change Act and the Environment Act. The 10-year health plan was clear that we will continue to support the NHS’s climate ambitions. The reforms in this Bill do not remove or weaken that commitment.
The amendment also provides for guidance on the discharge of climate duties. However, the Bill already enables the Secretary of State to issue such guidance to integrated care boards, alongside transferring NHS England’s existing guidance powers for NHS trusts and foundation trusts to the Secretary of State. Importantly, integrated care boards, NHS trusts and foundation trusts will retain their existing statutory climate duties. We will continue to support the aims of the NHS’s climate ambitions in a way that improves delivery of care, returns savings to front-line services and drives wider economic growth. I say to the noble Baronesses, Lady Coffey and Lady Bennett, that I look forward to debating in full the use of single-use plastics in the NHS in the group of amendments on medicines and medical devices beginning with Amendment 111, but I will not pre-empt a fulsome discussion of that by delving into that content here, so we can all look forward to that.
I turn to Amendment 248, in the name of the noble Baroness, Lady Boycott. NHS trusts and foundation trusts have to consider the need to adapt to the current and predicted impacts of climate change. All trusts and foundation trusts are already required to have green plans in place. In reply to the noble Baroness’s point about how we will ensure that this happens, following the abolition of NHS England, the Secretary of State will issue guidance to support the system in discharging their duties, building on the existing Green Plan Guidance published by NHS England. There are statutory guidance-making powers in the NHS Act 2006 for ICBs, trusts and foundation trusts, under which the Secretary of State expects to issue guidance to support that system in discharging its duties.
As many noble Lords raised, including the noble Baroness, Lady Hayman, we know that the impacts of climate change are already being felt across the NHS, including disruption from heat in particular, flooding and other types of extreme weather. That is why the 10-year capital plan committed to renew that focus on climate resilience. We have strengthened adaptation planning with green plans to prepare for severe weather events and improve climate resilience of local sites and services, and plan to conduct an adverse weather emergency response exercise in every NHS region by 2030, so strengthening that whole system preparedness for extreme heat through UKHSA-led planning, co-ordinated alerts and mandatory local response arrangements across the NHS.
All trusts are required to have adverse weather plans to ensure service continuity during major events, such as heatwaves. Beyond planning for acute incidents, trusts also undertake climate change risk assessments to identify and reduce overheating risks and their potential impacts. There is already, therefore, a clear framework for trusts to plan and respond to climate risks. I humbly suggest that the Government do not have their head in the sand but that our focus should be on delivering against these existing duties and plans. The 10-year health plan also committed to supporting the NHS’s existing net-zero targets and climate objectives as set out in Delivering a “Net Zero” National Health Service, published in 2020. I am sure noble Lords are aware that, since the publication of that strategy, NHS carbon footprint emissions have indeed fallen by 17%.
To address the point raised by the noble Lord, Lord Hunt, I have covered some of the local duties points. The CQC guidance will remain, but I will write in full laying that out. On the point from the noble Baroness, Lady Pidgeon, about how this will be reported to Parliament, information on annual NHS emissions will continue to be published in the DHSC’s annual report and accounts, which are also laid before Parliament annually. That will ensure that Parliament continues to receive that regular information on the NHS’s progress towards those environmental objectives. I hope that this reassures noble Lords that the Government recognise the importance and, as many noble Lords have raised, ongoing salience of this issue.
Baroness Bennett of Manor Castle (GP)
I think this was probably before the noble Baroness came into the House, so I will not ask her whether she remembers the Financial Services and Markets Bill, on which we had a very similar debate. The Government eventually made a concession that was introduced directly into the Bill and did not say that we had to rely on the overarching Environment Act, et cetera. Will she have a look at the debate on the Financial Services and Market Bill, in particular Third Reading, when the Government explained why they had given way on that Bill?
Baroness Hyde of Bemerton (Lab)
I believe I was in the House; it was after the King’s Speech. I will absolutely go away and review that debate and take it back.
Baroness Coffey (Con)
I have just looked at the other amendments and can find “plastic” referred to only in terms of infant feeding material, so I just wanted to get a sense of which amendment we are talking about. I did not quite catch which one the Minister referred to.
Baroness Hyde of Bemerton (Lab)
There is a group of amendments beginning with Amendment 111, which includes an amendment with a reference to single-use plastic. It is grouped in the medicines and medical devices section. I believe it was de-grouped; it was originally in this group and now is in the group beginning with Amendment 111. I know nothing will stop noble Lords discussing the things they want to in that group, irrespective of the content of the amendments.
Baroness Hayman (CB)
My Lords, I am extremely grateful to everyone who has taken part in the debate, perhaps particularly to the noble Baroness, Lady Coffey, because she quite rightly pointed out that the amendment deals with Environment Act duties as well as the climate change ones, and that is extremely important.
I was very grateful for the support, generally for—I think it was the noble Earl, Lord Howe, who said it—the declaratory nature of what is needed in this Bill. There is a very powerful case to say that there are gaps between the previous legislation and what we have now. There will be some very interesting governance arrangements within the NHS; we have been talking about new special health authorities, for example. There are lots of different ways in which we have to make sure that we are secure in having an overarching commitment.
On the essentially legalistic position which I think the Government are taking on this, the noble Baroness, Lady Bennett, is quite right to cite the Financial Services and Markets Bill. The Chancellor did not say then, “The Chancellor has a responsibility under the Climate Change Act, so you cannot put anything in at all”. The Minister was here for that Bill, but she was not here for a couple of other examples I could put forward to her. It would be very helpful if Ministers were willing to continue to discuss how we can bring this to a resolution, because I am encouraged by the amount of support for the current amendment around the Committee. I beg leave to withdraw the amendment.
Lord Tarassenko
“Duty as to UK suppliers and sovereign capabilityIn the National Health Service Act 2006, after section 1CC (inserted by section 6 of this Act) insert—“1CD Duty as to UK suppliers and sovereign capability(1) The Secretary of State must take into account the matters mentioned in subsection (2)—(a) in setting the award criteria for a relevant contract under section 23 of the Procurement Act 2023, so far as those matters relate to the subject matter of the contract, and(b) in having regard, under section 12(1)(a) of that Act, to the importance of delivering value for money in connection with the award of a relevant contract.(2) The matters are—(a) the extent to which the data, control and support of the system concerned will remain within the jurisdiction of the United Kingdom,(b) the risks to the security and resilience of the health service arising from any respect in which they will not, including the risk that access to NHS patient data could be compelled under the law of a country or territory outside the United Kingdom, and(c) so far as consistent with the international obligations of the United Kingdom, the contribution of the contract to developing and maintaining capability within the United Kingdom to design, deliver and support technology and information systems which handle NHS patient data.(3) Subsections (4) and (5) apply to a material relevant contract under which—(a) the data, control or support of the system concerned will not remain wholly within the jurisdiction of the United Kingdom, or(b) the supplier, or any subcontractor with access to NHS patient data, is subject to the law of a country or territory outside the United Kingdom under which access to such data could be compelled,(a “jurisdiction-risk contract”).(4) Before entering into a jurisdiction-risk contract, the Secretary of State must consult—(a) the National Cyber Security Centre,(b) persons representing the interests of patients, and(c) trade unions representing health service staff,on the proposed contract, and must, before, or as soon as reasonably practicable after, entering into the contract, lay before Parliament a report on that consultation.(5) As soon as reasonably practicable after entering into a jurisdiction-risk contract, the Secretary of State must lay before Parliament a statement setting out—(a) the reasons for the award, including how the matters in subsection (2) were taken into account, and(b) whether the Government is taking, or is planning to take, steps to develop or support long-term domestic alternatives to the systems provided under the contract. (6) The Secretary of State must, at least once in every period of 12 months, lay before Parliament a report setting out—(a) the number and total value of relevant contracts entered into during that period, the proportion of each awarded to UK suppliers, and the number and total value of jurisdiction-risk contracts entered into during that period; and (b) how the award of those contracts has contributed to the objectives of any NHS Digital Sovereignty Strategy published under section (NHS Digital Sovereignty Strategy) of the Health Act 2026 (NHS Digital Sovereignty Strategy).(7) A report or statement under this section may omit information the publication of which would be reasonably likely to prejudice national security or the commercial interests of any person, but must state that information has been omitted.(8) This section is without prejudice to the national security exemption under paragraph 25 of Schedule 2 to the Procurement Act 2023.(9) In this section—“material relevant contract” means a relevant contract with an estimated value, determined in accordance with Schedule 3 to the Procurement Act 2023, of more than the threshold amount that applies under Schedule 1 to that Act to a contract of that kind awarded by a central government authority, including a contract awarded under a framework and a renewal or extension of a relevant contract;“NHS patient data” means patient information (within the meaning given in section 250E(7)) relating to persons who have received health care or social care in England;“relevant contract” means a contract entered into by the Secretary of State for the provision of technology or information systems which—(a) form part of the single patient record, or hold or process patient information for its purposes, or(b) are provided for use across the health service in England as national systems and hold, process or provide access to NHS patient data;“the single patient record” means the system for making patient information available referred to in section 250E(1), whether or not established by regulations under that section;“UK supplier” means a company incorporated in the United Kingdom which either has no parent undertaking or each of whose parent undertakings (within the meaning of section 1162 of the Companies Act 2006) is incorporated, and has its head office, in the United Kingdom.””Member's explanatory statement
This new clause would require procurement of the single patient record and national systems handling NHS patient data to weigh UK jurisdiction over data, control and support, and UK capability, with consultation and statements to Parliament for higher-value contracts outside UK jurisdiction, and an annual report on the UK share.
Lord Tarassenko (CB)
My Lords, I shall also speak to Amendments 171 and 289, all in my name and that of the noble Baroness, Lady Kidron, who I thank for her support. I remind the Committee of my interests: I hold an honorary contract with Oxford University Hospitals NHS Foundation Trust, which is in the process of being renewed, and I am a director of LIO Health, a UK company which contracts with mental health NHS trusts.
The NHS holds health data no other country can match, namely longitudinal records for the whole population of England: primary care data, electronic patient records—EPRs—in hospitals and patient outcomes in multiple national registries. The single patient record, SPR, has the potential to bring primary care and secondary care records together for the first time and, in time, to link them to outcome data. That is a national asset of extraordinary value, not only for direct care but for research that will improve patient outcomes. It provides a unique opportunity for the UK companies that could build the systems which hold and process the SPR data.
The Government have told us that the SPR will indeed be delivered through contracts with multiple suppliers, with no single supplier dominating. Those contracts will be awarded over the next two years. These amendments ask a simple question: which companies are likely to win these contracts? Today, the US company Epic supplies the EPR in close to 20 NHS acute trusts. This year alone, four trusts in Somerset and Dorset have signed a £222 million 10-year contract with Epic, and Lewisham and Greenwich a £52 million contract. In general practice, EMIS, a company founded in Leeds, was sold to United Health in 2023 for £1.2 billion, and then on to another American company, a private equity firm, TPG, this year, so a large share of our GP records now sits with a US-owned supplier.
UK capability, although patchy, is still there. TPP, still UK-owned, supplies SystmOne across general practice and community services. Nervecentre, a British company founded in 2010, now has some 15 trusts committed to its cloud-native EPR, including a 10-year, £53-million contract with Liverpool University Hospitals, signed this spring. As I said at Second Reading, Kynos, a FTSE-250 company, won the contract in open competition to build UK Biobank’s output-checking system. UK companies can win and do win when procurement gives them a fair chance.
The contracts awarded for the single patient record in the next two years will typically run for 10 years and will define the health software market until the mid-2030s, the end of the NHS 10-year plan. If UK companies do not win a significant proportion of these contracts, the gap between US and UK suppliers will not stay where it is now. It will widen with every contract award, as revenue, engineering talent and know-how about NHS data build up on one side of the Atlantic. In 10 years’ time, that gap will be insurmountable. We will have lost the ability to build and support the core digital infrastructure of our own health service, and we will not get it back; the window to act is now.
Amendment 53 makes sure that UK jurisdiction and UK capability are taken into account when they matter: at the point of contract award. It requires the Secretary of State to take three matters into account when setting award criteria under Section 23 of the Procurement Act 2023 and when weighing value for money under Section 12(1)(a) for contracts for the single patient record and for national systems handling NHS patient data: first, the extent to which the data control and support of the system will remain within UK jurisdiction; secondly, the risk to the security and resilience of the NHS where they do not, including the risk that access to NHS patient data could be compelled under the law of another country, the US CLOUD Act being the obvious example; and, thirdly, consistent with our international obligations, the contribution the contract makes to building and maintaining UK capability.
Value for money is not simply the lowest price of a contract term. It must include the cost of dependency, the cost of exit and the value of the capability we keep. For larger contracts where data control or support will not remain entirely in the UK, the Secretary of State must consult the National Cyber Security Centre, patient representatives and NHS trade unions, and lay a Statement before Parliament explaining the award and whether domestic alternatives will be developed. Every year, the Secretary of State must report the number and total value of the contracts and the proportion awarded to UK suppliers, defined as UK companies with no foreign parent.
Amendment 53 deals with individual contracts and Amendment 171 provides a strategy. It requires the Secretary of State within 12 months of Royal Assent to publish an NHS digital sovereignty strategy. That strategy must cover four topics: first, treating NHS patient data as a sovereign data asset, including where it is stored and from where it may be accessed; secondly, assessing the risks across hardware, software, supply chains, and procurement, including reliance on foreign technology; thirdly, building domestic capability, including options to prioritise UK technologies; and, finally, research access to pseudonymised data in a way that keeps public trust. A sovereign data asset held in the UK under UK control with the benefits flowing back to the NHS is the best guarantee of that trust.
For research access, the NHS digital sovereignty strategy must set out the hierarchy: UK universities, medical research charities and the NHS itself, including the NIHR, will come first; UK suppliers second; and everyone else third. The strategy must also address how the NHS will share in the value created, with returns reinvested in the health service. Data must be accessed only within a trusted research environment in the UK, with outputs checked before release. Amendment 289 would bring both new clauses into force on Royal Assent, when the 12-month clock for the strategy would start, and the procurement duty in Amendment 53 would apply to the SPR contracts now being prepared.
All the amendments in this group share one concern: who controls the digital foundations of the NHS? I look forward to hearing from the noble Lords who have tabled them.
I support Amendment 277, from the noble Baroness, Lady Neville-Rolfe, which would require the Secretary of State to report on how NHS procurement supports patient care, value for money, resilient supply chains and economic activity in the UK. I also support Amendment 160, from the noble Lord, Lord Clement-Jones, which would require the Secretary of State to establish through regulations a governance framework for NHS IT and data contracts.
Several amendments in this group are concerned specifically with the Palantir contract for the NHS federated data platform. After the Secretary of State’s appearance in front of the Commons Health and Social Care Committee last week, when she refused to be drawn on whether the Palantir contract would be extended, I look forward to hearing what the Minister might have to say about the topic. I have two questions that I hope the Minister will answer in full. First, how will the value-for-money assessment of the SPR contracts take account of UK jurisdiction and resilience? Secondly, will the Government commit to publishing an NHS digital sovereignty strategy, whether or not they accept the wording of Amendment 171? After all, last week the Secretary of State said:
“We want … sovereignty. That has to include sovereignty for UK data”.
This country has world-class health data science and a health tech sector that should be given the opportunity to grow. The single patient record contracts are the biggest opportunity that the sector will see in the next 10 years. We must not spend the next decade buying back our own capability at a premium. I beg to move.
Lord Clement-Jones (LD)
My Lords, it is a pleasure to follow the noble Lord, Lord Tarassenko. I will speak to Amendments 144, 147, 158 to 160, and 172E in my name, and I give our strong support to Amendment 53 on the digital sovereignty package, spoken to so convincingly by the noble Lord, Lord Tarassenko. We are very much singing from the same hymn sheet on these Benches.
I was unable to take part at Second Reading, but, over the years, as the noble Lord, Lord Kamall, will know from his time as a Minister, I have taken a strong interest in the access to, use and destination of NHS data for all purposes. Digital technology and data analytics hold transformative potential for our NHS, but technology is as effective only as the governance that underpins it, and health data platforms can succeed only if they command absolute public and clinical trust. If the NHS hands over its core data architecture to closed, proprietary vendors without retaining public ownership of software connectors or enforcing open API standards or clear parliamentary oversight, we risk locking our health service into perpetual vendor dependency.
In speaking to these amendments, I am building directly on the outstanding work of my Liberal Democrat colleagues in the Commons. I pay tribute to my honourable friend Martin Wrigley, who led the charge on vendor lock-in; my honourable friend Helen Morgan, who tabled a new clause on a sovereign health data trust; and my honourable friend Dr Danny Chambers, who tabled a new clause establishing the framework for an NHS digital sovereignty strategy.
On these Benches, we believe three principles should apply: NHS patient data is a sovereign public asset, exactly in the way that the noble Lord, Lord Tarassenko, described; data infrastructure must adhere to open, FAIR—findable, accessible, interoperable and reuseable—standards; and commercial suppliers must operate under strict public benefit conditions, with the NHS retaining full legal ownership of software interfaces and data pipelines.
Baroness Bennett of Manor Castle (GP)
My Lords, it is a great pleasure to follow two of your Lordships’ House’s real experts in this area, and I look forward to hearing from a third shortly. To extend the metaphor of the noble Lord, Lord Clement-Jones, we are singing from the same hymn sheet, but just different parts. That is what this group of amendments is doing.
I will start with my Amendments 168, 169 and 172B, and I will deal with Amendment 268 at the end, which is somewhat different. These three amendments address different parts of the same problem. Who has access to NHS patient data? Who controls the infrastructure holding that data? Should the NHS should continue to rely on Palantir to provide that infrastructure?
I will start with the principle behind all three: NHS patient data belongs to a public health service under public control. It should not be accessible to commercial companies simply because the NHS has entered into a contract with them to provide the technology. The Government will no doubt say that patient data remains under NHS control and that Palantir acts as a data processor and cannot use the information for its own commercial purposes. Those are important contractual assurances, but they do not, as the other amendments in this group highlight, answer the issues that are raised. There is a difference between owning the data and having control over the systems through which that data is accessed, processed and managed. There is also a difference between a contractual promise and having the practical ability to guarantee that sensitive information remains beyond the reach of commercial contractors. In fact, we know that that is exactly what is happening.
NHS England has confirmed that three Palantir engineers have administrative-level access to the national data integration tenant, part of the federated data platform. A further 12 Palantir engineers have had more limited project-specific access for particular data sets and tasks. Now, this is not an allegation that Palantir employees are routinely browsing individual patient records, but administrative-level access to a system holding identifiable patient information is a serious responsibility. It raises huge questions about the boundary between public control and commercial access. I note that the National Data Guardian herself has questioned this. She said that the information about external contractors having access to identifiable patient data appeared to be inconsistent with the data protection impact assessment she had previously reviewed and she sought clarification from NHS England on this.
Amendment 168 addresses this directly. It would stop commercial entities and their employees, officers and subcontractors from accessing identifiable NHS patient data. That includes not just direct access to patient records but administrative and privileged access to databases, as well as access through software, support, maintenance and testing. We need this because we cannot allow the distinction between accessing patient records and administering the systems that contain them to become a loophole in the protection of confidential information. Commercial suppliers can still provide technical services. The amendment does not prevent the NHS from buying software or obtaining technical support, but it requires those services to be delivered using anonymised records. The NHS should be able to benefit from technical expertise without giving commercial companies access to identifiable patient information.
We come to the specific issue of Palantir, which is covered by both amendments. Palantir, as has already been alluded to, is not an ordinary technology supplier with no wider controversies. Its work with the Israeli military has drawn serious criticism from human rights organisations, including Amnesty International, which has documented the company’s links to Israel’s military activities in Gaza. It is also important to look at the ownership and the philosophy of this company. In March, Alex Karp said he believes AI will shift power away from
“highly educated, often female voters who vote mostly Democrat”
and towards working-class men.
I asked the Library to have a look at the ownership and control structures of Palantir. I thank it for its very detailed research, to which I am not going to subject noble Lords in detail. The key point is that Alex Karp, to whom I have just referred, co-founder Stephen Cohen, and chairman Peter Thiel have between them 49.99% of voting power because of the stock structure of the company. I note that the major institutional shareholders are Vanguard Group and BlackRock, Inc. They are not known for being companies that stand up for human rights, the rule of law or the public good. They have very distinct financial interests.
In particular, the company’s chairman, Peter Thiel, is known for his controversial views. At the Oxford Union in 2023, he said that the NHS makes people ill and should be privatised. I note also, in a broader context, that he is on the record as framing politics as an existential struggle against the Antichrist. Mr Thiel has named possible suspects for the Antichrist, including Representative Alexandria Ocasio-Cortez, Greta Thunberg and people who are critics of artificial intelligence. Now, that is quite disturbing. I would also note the fact that he was asked, in a video available online under the headline “Peter Thiel and the Antichrist”, whether he preferred the human race to endure. The interviewer said:
“You’re hesitating”.
Peter Thiel said:
“Well, I don’t know. I would … There are so many questions around this”.
The interviewer repeated:
“Should the human race survive?”
After 18 seconds, Mr Thiel said, “Yes”.
I have some questions to put to the Minister within the framework of the fact that the UN guiding principles on business and human rights make it clear that businesses have a responsibility to respect human rights. Have the Government properly considered those responsibilities when awarding and continuing this contract? Have they assessed Palantir’s links to breaches in international human rights law? Will the Government explain what human rights due diligence was undertaken?
I will jump to Amendment 172B. I stress that it does not say that we have to switch off Palantir immediately. It is a proposal for a transition away from Palantir, with patient care and data security protected throughout. The Government may point to the benefits that they say the federated data platform is already delivering. Of course, better use of data can help hospitals to manage waiting lists and make better use of resources, but none of that requires the NHS to surrender its control.
Lord Austin of Dudley (Non-Afl)
My Lords, I will speak to Amendment 279A in my name and comment on the potential impact of the amendments tabled by the noble Baroness, Lady Bennett of Manor Castle.
My amendment would require the Secretary of State to report annually to Parliament on NHS and social care procurement of medical devices, consumables and services in England, assessing its performance against the objectives in Section 12(1) of the Procurement Act 2023, and would confine the report to those objectives. Noble Lords scrutinised the Act carefully, including the objectives that authorities must have regard to when carrying out procurement: delivering value for money; maximising public benefit; sharing information so that suppliers and others can understand procurement policies and decisions; and acting, and being seen to act, with integrity. Those duties are already established in law. My amendment would provide Parliament with a focused, regular account of how they are being applied in an area of considerable importance to patients and taxpayers.
In the NHS, as we heard earlier, value for money cannot simply mean the lowest purchase price. An MRI scanner that costs less to buy may prove more expensive over its working life through maintenance, breakdowns or additional training requirements. Reliability and clinical effectiveness matter, as do the consequences for patients when equipment is unavailable. An annual report would help Parliament to examine whether those considerations are being weighed properly. The Act does not require each objective to receive equal weight in every procurement, so the report should explain how they have been applied in practice.
Proposed new subsection (2) would keep the report focused on those established objectives; other applicable legal duties would continue to apply. Proposed new subsection (3) would exclude procurement still governed by the previous regulations under the transitional arrangements. The reporting arrangements should be proportionate, drawing wherever possible on information already collected. I hope the Minister can explain how the department intends to account to Parliament for the application of these objectives, and whether the Government would consider the focused annual reporting duty proposed in this amendment.
Amendment 172B raises serious legal and procedural problems. In singling out one company, it raises the question of whether it would make this Bill a hybrid Bill. It also risks breaching the United Kingdom’s obligations under the WTO Agreement on Government Procurement. The Ministerial Code expressly requires Ministers to comply with international law and treaty obligations. Will the Minister explain how this amendment could be implemented consistently with those duties? Your Lordships’ House spent many hours scrutinising the Procurement Act; this was serious work to protect public money, secure good services and ensure that suppliers are treated fairly. This amendment could completely undermine that work.
The amendment singles out one company by name, even though many tech companies provide services to the NHS. It seeks to end its contract at the first opportunity and exclude it from the replacement. It asks us to substitute a subjective political judgment for the outcome of a competition in which bids were assessed against objective published criteria. If its supporters believe that different standards should apply, they should explain what those standards are and apply them consistently; they should not ask Parliament to settle the outcome for one company in advance. What opportunity would the company have to demonstrate that it could meet the requirements? It would have none. However effective its technology and however competitive its price, the amendment would already have decided the answer. That is an extraordinary approach to spending public money. The precedent would extend well beyond this contract. We should be particularly careful about singling out a supplier by a political test that no elected body has defined.
Why should a company spend time and money competing for a public contract if the published rules can be set aside after it has won? The risks are clear: there would be fewer companies willing to bid, weaker competition and higher prices for taxpayers. While politicians argued about which suppliers they approved of, public services would wait longer for the technology they needed. If there is evidence that a supplier threatens national security, there are statutory powers for dealing with that. Serious allegations should be examined against the evidence, through the proper processes. Patients and taxpayers are entitled to ask what they would gain from this proposal. Would it mean shorter waits, safer care or lower costs? What would replacing the system cost? How would services be protected during the change? Where is the evidence that this amendment would deliver better care or better value?
We have already seen the consequences of the dispute over technology procurement. This is a different subject, but the principles still apply. When the Met was facing substantial financial pressures, the commissioner wanted to use technology to reduce administrative work and protect front-line services. He also said that it could help the police catch people who threaten the public
“at a pace that simply isn’t possible without”
the enabling technology. Yet the proposed contract was blocked and the commissioner warned that between 500 and 700 officers and staff posts delivering services to Londoners could be affected, which would make the city and its residents less safe. The mayor’s office said its concerns were about procurement and value for money. Those questions deserve proper examination, of course, but why were Londoners originally told suppliers should
“share the values of our city”?
Procurement requires evidence and a proper assessment of the consequences. It cannot become a test of whether politicians approve of a company’s so-called values. The same principle applies to the NHS. I think this amendment is a political boycott dressed up as procurement policy. It seeks to exclude a company from serving the NHS because of its relationship with Israel—but Israel, as the only liberal democracy in the Middle East, is deeply integrated into the world’s technology and medical industries. Major companies operate there, invest there and work with Israeli institutions. Palantir is one of many tech firms working in Israel. Perhaps its offence is that it is not embarrassed about it. Oracle came second in the bid process for the federated data platform; it has supplied software to the Israeli military. IBM came third; it has contracted to build data centres for the Israeli military. Microsoft has supplied the Israeli military with cloud technology. Nobody complains about Parliament using Microsoft Word and Outlook to conduct our business. If every corporate association is now a test of political purity and individual politicians’ values, there will be much more boycotting to be done in future.
This amendment singles out one company. It offers no consistent standard against which every supplier would be judged. Doing business with Israel should not disqualify a company from serving the NHS. Contracts should be awarded in line with the rules and on the basis of whether they can fulfil the contract, the quality of their work and value for money—open, free and fair competition which increases quality and reduces costs to the taxpayer.
The standards for technology in our health service should be demanding. Suppliers must demonstrate that their systems work, protect patient information and provide value for money. They must show how their technology helps doctors and nurses deliver better patient care. Every supplier should face those tests, because patients should come first. A patient waiting for cancer treatment gains nothing from a political boycott. If technology can help bring an operation forward, we should establish whether it works and can be used safely. Procurement decisions must not be turned into an instrument of somebody else’s foreign policy. If a system can help get someone treated sooner, I want the NHS to be able to use it. There should be fair rules, applied consistently, with patients and taxpayers coming first. Those are the principles that I ask the Minister to uphold.
Baroness Kidron (CB)
My Lords, I will speak to Amendments 53, 171 and 289 in the name of my noble friend Lord Tarassenko, and Amendment 160 in the name of the noble Lord, Lord Clement-Jones, all of which I added my name to. I have my own amendment on NHS data as a sovereign data asset in a later group, which is remarkably poor organising on my part, but it does give the Minister two shots at saying we are right.
The primary difference between the amendments in this group and those in the later group is that these amendments focus largely on the use of NHS data by companies contracted and procured to provide services to the NHS, rather than primarily on how the benefits from technology trained on NHS data are retained in the UK. However, both sets of amendments cover the key elements and, whichever approach is finally taken, determining who has access to UK health data, and on what terms, is an extremely urgent issue.
During debates on the Data (Use and Access) Bill last year, I tabled an amendment on sovereign data assets, of which the NHS’s data was a key example but not the only one. At the heart of that debate, which I urge officials to look at, was a warning that has become only more urgent. The speed at which the Government are giving access to our data is swifter than the plans they have to protect its financial or societal value. We are nearly two years on and there is still no published strategy or government policy to maintain British control over valuable data assets. We do not have a clear plan for how our data or the systems that host it will be resilient to foreign interference. We do not have a clear strategy for building technological capability within the NHS for its data or ensuring that all the healthcare and economic value that comes from our data will indeed come back to the UK as a benefit.
Amendment 53 offers a road map for the conditions for access to NHS contracts, with a focus on control of data, building sovereign capability for data handling and reducing the dependencies and risks from foreign firms. This is not government data; it is data held in trust for the British public and they are being poorly served.
Amendment 160 looks at how contracts are awarded and ownership of the architecture that supplies services to the NHS. It singles out the way in which free or low-cost services are used to gain access, create dependency and result in vendor lock-in, which a number of noble Lords have already described well.
Amendments 171 and 289 would require the Secretary of State to publish a digital sovereignty strategy for the NHS, including control of systems that host data, control over the data itself, avoiding vendor lock-in and capitalising on our data to build technological capability and commercial value. It is an exhaustive checklist, but it mirrors those issues I laid in the Data (Use and Access) Bill and the Cyber Security and Resilience Bill, and in the debate on digital sovereignty in July. It also aligns with multiple recommendations by committees of both Houses, including—I will try to say this very quickly—the Commons Science, Innovation and Technology Committee’s report, Rewiring the State; the Commons BIST Committee’s report, Investing in the UK Economy, the Joint Committee on the National Security Strategy’s report on undersea cables; and the Lords Science and Technology Committee’s inquiry into financing and scaling UK science and technology. The Lords committee also has an open inquiry on innovation in the NHS and personalised medicine. How many times do we have to make the same recommendation? This is a flashing warning light.
Baroness Hyde of Bemerton (Lab)
My Lords, as agreed by the usual channels, we need to move to consider dinner-break business. While unusual, I therefore propose that the debate on this amendment be adjourned and that we return to it after dinner.