Health Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Monday 9th November 2026 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I find myself in sympathy with the noble Baroness, Lady Coffey, in her approach to Ministers’ ability to determine what happens in the National Health Service. Many of the amendments tabled, particularly when it comes to specific services, call for the intervention of the Secretary of State. That is very simple, because integrated care boards do not have any mechanisms for being locally elected, so their accountability is to the Secretary of State, and we cannot run away from that.

We have had power of direction in the health service since 1948. The Lansley Act modified it, and, although the wording has changed, we are essentially moving back to the original position. The fact is that the power of direction has been used very sparingly over the decades the health service has been in existence. It has rarely been required because in general, when Ministers or their officials are on the phone to the chair or CEO of those bodies, they understand that they need to do something—although I accept, as the noble Baroness, Lady Coffey, says, that there are some occasions when the additional powers in the Bill are probably required.

We really cannot have it both ways. If we want the NHS to be a national service, we know that the public do not accept that there should be variation. The very idea of a postcode lottery in this country is simply not accepted. It must follow that Ministers are accountable to Parliament, and therefore they must have the tools by which to determine the general way the health service is being run. There is a counterbalance. The reason why I am so pleased about the Healthwatch decision is that we need mechanisms at local level to secure some form of local input. But, ultimately, if we want a national health service, we have to accept that, in the unique way the NHS is funded and organised, Ministers need the tools to ensure that their accountability to the public is discharged effectively.

[Lord Stevens of Birmingham (CB)]

My Lords, I find myself in sympathy with the thrust of Amendments 39 and 40, but I want to draw your Lordships’ attention to some specific changes to the exceptions to the legal powers that the Secretary of State will have that are contained in the Bill. In 2022, Parliament decided that the Secretary of State should have a general power of direction over NHS England, which in turn would cascade through the system. In coming to that decision, the Government of the day rightly inserted three exceptions to the use of that power: a politician could not direct the individual treatment that a patient would get, who individually would be employed or not by the National Health Service or individual treatment availability.

For those who perhaps have not studied the text of the Bill in as much detail as I am going to now bore you with, I have to tell you that a very significant change is lurking in Clause 11, at proposed new Section 14Z62, specifying the exceptions. That is that, whereas the 2022 exception said that the Secretary of State could issue a direction about a specific medicine, treatment or diagnosis if NICE had said it should be available on the NHS, this Bill flips that and says that the Secretary of State can now direct what should or should not be available—particular treatments, particular medicines—in any situation where NICE has not opined on the topic. Given that the vast majority of treatments available on the NHS are not subject to a NICE appraisal or recommendation, that means we are giving a politician the ability to say, ex cathedra, “This treatment will not be available on the NHS; this type of diagnosis will not be available on the NHS.” This is a massive infringement on the medical autonomy and clinical judgment that we expect clinicians to be exercising across the NHS.

When one looks in the Explanatory Notes to see why the provision to amend the 2022 version has been proposed, answer comes there none. So this requires very considerable scrutiny, potentially on Report. I am not in any way detracting from the wisdom of the Secretaries of State that the health service has had in its history to date, but, as we have previously discussed, one has only to look across the Atlantic to the current US Health Secretary, RFK Jr, who has some pretty interesting personal views on vaccines. I will not list them: you can google them yourself. Were we to find ourselves with a future Secretary of State with a similar opinion set, does Parliament really want to grant that person the ability to strike out whole treatments or tests from the National Health Service? I would suggest not.

So that exception needs looking at. The other exception through which a coach and horses has been driven by this Bill is the exception that limited the Secretary of State’s power to the appointment or employment of a particular individual. Clause 37 allows the Secretary of State to fire named individual nursing directors and medical directors of foundation trusts. Again, we must ask ourselves, looking forward, whether that is something that we want or whether it is political overreach: in my opinion, it is.

[Baroness Coffey (Con)]

Can the noble Lord, Lord Stevens of Birmingham, explain to me again his interpretation of new Section 14Z62(3) and (4), to which he referred?

[Lord Stevens of Birmingham (CB)]

Certainly. The 2022 Act says that a direction

“may not be given”

by the Secretary of State

“in relation to the provision of any drug, medicine or other treatment, or the use of any diagnostic technique, unless NICE has made a recommendation or issued guidance as to its clinical and cost effectiveness and the direction is not inconsistent with that recommendation or guidance”.

NICE has to have set out its stall and, if it has, the Secretary of State can direct on the back of it. What the Bill says is that, in any case where NICE has not set out its stall, the Secretary of State has complete freedom to form a personal view about what should or should not be available on the NHS.

[Earl Howe (Con)]

My Lords, I am most grateful to the noble Lord, Lord Scriven, and other noble Lords who have tabled these amendments. They all raise important questions about the balance of powers and accountability within our health service. I listened carefully to the remarks of my noble friend Lady Coffey and will of course reflect on them appropriately. In general terms, I share the concerns that underpin these amendments, particularly around the danger of overcentralising power and what could become a distorted balance of responsibility between the Secretary of State, the Department of Health and Social Care, integrated care boards and local healthcare providers. The noble Lord, Lord Stevens of Birmingham, put his finger on some worrying features of these powers.

We have tabled amendments of our own that seek to address some of these concerns from a slightly different perspective, which we will debate in the next group. I will not therefore detain the Committee for too long, but I would like to make a few broad observations.

First, the relationship between national and local healthcare governance following the abolition of NHS England will be an enormously important one to get right. As my noble friend Lord Kamall and I emphasised at Second Reading, there is a question mark around accountability—not just the balance of accountability but the need for clarity on where accountability lies and where responsibility will ultimately lie when things go wrong. We cannot have a situation in which services are failing to meet their objectives or patients are not receiving the care they need and integrated care boards and the Secretary of State are pointing fingers at each other. If an integrated care board is expected to deliver particular services with well-defined outcomes but Ministers then exercise their powers to direct how the board exercises its functions, it is very difficult to see how anyone can be clear about where responsibility lies for the quality, accessibility or cost-effectiveness of those services.

There is also a wider tension at the heart of the Bill and a certain incoherence in how Ministers have presented the Bill as a whole. The Minister may enlighten me on this, but the Government have spoken at some length on the importance of localism and the benefits of allowing decisions about healthcare to be taken closer to the communities which those services exist to serve. I do not think anybody would argue against that as a sound principle.

Local healthcare leaders will usually be better placed to understand the needs of their populations, the pressures facing their services and the most effective ways of using the resources available to them. But if we believe that, we surely cannot simultaneously favour legislating for the kind of open-ended and all-encompassing power of direction such as that set out in Clause 11 of the Bill. Powers of direction are necessary on a limited basis as reserve powers. For example, I entirely see the case for them in a situation where an ICB may be failing to perform its legal functions or is at severe risk of doing so. I can also see the argument for a power of direction in relation to locally commissioned specialised services where unacceptable variation in provision occurs between different ICBs.

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Taken together, these amendments would establish a fairly straightforward framework. Before a direction is issued, there should be proper consideration of its necessity and consequences. When it is issued, there should be transparency about the reasons and responsibilities involved. Afterwards, there should be accountability on what it actually achieved. I do not think that is an unreasonable set of expectations; indeed, it is a highly desirable part of making the new relationship between Ministers and integrated care boards work effectively. I would be grateful if the Minister could use her response to explain a little more about how the Government envisage these arrangements operating in practice. I beg to move.

[Lord Stevens of Birmingham (CB)]

I wonder whether this might be an opportunity for the Minister to set out how the new accountability arrangements would work in practice, because the amendment from the noble Earl, Lord Howe, would rightly require that, in the event that a power of direction is used, a rationale is set forth so that it is clear why a decision was taken and where responsibility for it sits.

One illustration of this might be the situation facing maternity services in Norfolk, which the noble Baroness, Lady Coffey, mentioned. I quickly had a look at the situation there. Of the three hospitals, two had under 2,000 births a year, and the prediction is that, within a decade, two of those three hospitals will be delivering four or fewer births a day. So there is a question about the sustainability and safety of that service. If, in the interests of a political direction, these new powers are used to insist that those small maternity units with a potential safety concern remain open, even though it might be hard to staff them and to provide the level of back-up said to be required, where will accountability for the safety questions sit? Will the Care Quality Commission, when it arrives at those hospitals, do an inspection to determine whether women may be put at risk, if that is the case? Will the Care Quality Commission then issue findings against the Secretary of State—potentially with criminal proceedings in certain circumstances—or against the local provider or the ICB?

To the extent that this group is about the integrated care boards, let us not forget that, as I understand it, the proposed route for direct influence from the Secretary of State to those hospitals in Norfolk would be only partly through the ICB strategic commissioning decision. The performance management function of those hospitals, including the way in which they manage their safety, will now be routed through this new offshore special health authority, which will then route back, on some sort of new vector, directly into the hospitals concerned. Can the Minister explain, in the interests of transparency and political accountability, how will it work in a situation like that? Where will the decision-making sit? When safety concerns are front and centre, will the Secretary of State override the individual provider, and will they do so via the new special health authority or just rely on the commissioning role of the ICB?

[Lord Scriven (LD)]

My Lords, it is quite a pleasure to follow the noble Lord, Lord Stevens, who asks some important questions about the transparency of the accountability mechanism—particularly since the whole reason for abolishing NHS England was to stop it being a stand-alone body in the department. As he has pointed out, we are abolishing a quango to set up a brand new quango. I look forward to the Minister’s answers on what the accountability mechanism will be if the CQC makes findings into maternity services in Norfolk.

I thank the noble Earl, Lord Howe, for these amendments. We made our position clear in the last group. We do not think that the general power in Clause 11 should exist in its present form, and in the last group we tabled a probing amendment with an alternative based on outcomes. However, if the Government insist on this, Parliament and the public should expect at least what these three amendments offer: a reason, a test and a record of those decisions.

Under the Bill, when the Secretary of State gives a direction under Clauses 8 or 11, they must publish it as soon as “reasonably practicable”. That is all. There is no reason, no duty to consult and nothing on how long it lasts or what it costs. The department’s memorandum to the Delegated Powers and Regulatory Reform Committee confirmed that there is no parliamentary procedure. On Clause 8, the memorandum says that directions avoid taking up “valuable parliamentary time” and that, unlike with voluntary delegation, a directed ICB would be “legally obliged” to carry out that function. It also says that publication means that the power is “used transparently”. Publishing an instruction is not transparency; explaining it would be the transparency that is required.

The Bill already accepts this. Under new Section 14Z62A, the Secretary of State must publish their reasons when they intervene in a board that is failing. A board in significant failure is told why; a board doing perfectly well which is directed under the general power—we should remember that this is a new power to direct an ICB that is not in any way underperforming—is not given a reason why the Secretary of State has decided to intervene. The Government cannot say that giving reasons is impractical when they require it a few lines further on in the Bill.

First, on the reason, the amendments to Clauses 8 and 11 would require a statement within seven working days on the function concerned, the reasons, how long the direction lasts, when it will be reviewed, its financial and operational effects, its effect on the ICB’s local population and who is responsible for what, which is absolutely vital for accountability. The Clause 11 amendment goes further. When subsection (3) is used and a board is made to act without forming its own opinion, the Secretary of State would have to say what opinion they formed and why, and why the board should not be able to form its own. This also matters for money. Clause 8 says that the Secretary of State may make payments, whereas Clause 11 says nothing about funding at all. A direction with no funding moves a cost from Whitehall to local services, and those affected deserve to see that reason.

Secondly, on the test, the memorandum says that directions are needed

“to respond to emerging situations”,

which is absolutely fine, and to secure nationally consistent standards. This amendment would stop neither: proposed new subsection (3D) would let the Secretary of State act first and consult afterwards where there is an urgent risk, with a decision on the direction within 28 days.

Proposed new subsection (3A)(c) expressly counts the benefits of consistency. It simply asks whether guidance, agreement or existing oversight would do the job and whether the direction is necessary and proportionate. It would also require the ICB to be consulted. If the Minister says, as I expect she may, that Ministers intend to act in this way, there is nothing to lose by saying so in the Bill. The Health Foundation has asked Ministers to set out safeguards for how the powers will be used, but we are still waiting for those safeguards and a full explanation.

Thirdly, in relation to the record, the proposed new clause after Clause 22 would put each direction in the board’s annual report: what has changed, what it cost, what risk the ICB warned about, and where responsibility lay. Under Clause 11, an ICB can be directed and, under Clause 21, is assessed on how well it has discharged its functions. Under new Section 14Z62A, failure includes failing to act

“consistently with what the Secretary of State considers to be the interests of the health service”,

and the chief executive can be removed. A board could follow an instruction, see its performance suffer and then be held to account for the subsequent result. Clear responsibility protects the ICB and protects patients.

I will be honest about the limits. None of these amendments gives Parliament a vote. Statements would be published, not laid. The test rests on the Secretary of State being satisfied, and Clause 8 has no such test. There is also a burden: consulting every ICB on a national direction takes time. Some of the drafting needs tidying before Report, but the general principle is one to be welcomed. The Minister may well call this bureaucracy, but if the Secretary of State cannot say within seven working days why they have given a direction, how long it lasts, what it costs and who is responsible, the Secretary of State really needs to think about why that direction has been given in the first place.

I have two very quick questions for the Minister. If reasons are required for a failing board, why not for every board, including boards that are performing well? Most importantly, what happens when an ICB follows an intervention and a direction from a Secretary of State and clinical outcomes or finance get worse? What happens in those circumstances and who, ultimately, will be held responsible? A reason, a test and a record—that is not much to ask of the Secretary of State who is taking so much power. I look forward to the Minister’s replies.

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[Lord Hunt of Kings Heath (Lab)]

My Lords, I have given notice of my opposition to Clause 10 standing part of the Bill to probe exactly how the Government intend to use the clause. Reflecting on the three amendments tabled in group 1 by the noble Baroness, Lady Bennett, she was arguing for greater discretion at local level for NHS bodies; here, though, she wants to constrain them quite extensively. We are all guilty to an extent of ambiguity in this central-local relationship, which shows how hard it is to get the balance right.

I do not take an ideological approach to the use of the private sector in the health service, because we have seen some of the benefits. I think of how waiting times were virtually eradicated in the 2000s—we used the private sector quite extensively. The noble Baroness, Lady Murphy, illustrated the impact on cataract surgery as one example. However, I bitterly oppose the proposals of the noble Lord, Lord Lansley, which were enacted, for compulsory contracting out and competitive tendering. I believe that it is horses for courses. Where we think the private sector can add value to what the NHS can provide, we should use it, but there should not be an edict that you have to contract out everything or go through the mechanisms of competitive tendering and all the rest of it, which have proven to be so expensive and, in many cases, destructive.

Clause 10 is a bit of a puzzle—you can read it any way that you want. It could be used to increase the amount of private sector provision or, equally, to reduce it. In what circumstances will it be used? Will there be any guardrails around its use in the future, by which I mean in the years ahead, when we may have Governments with a different approach? The Explanatory Notes do not make clear how it would be used.

[Lord Stevens of Birmingham (CB)]

My Lords, the noble Lord, Lord Hunt of Kings Heath, has nailed it. Essentially, Clause 10 says that the Secretary of State must not do something unless the Secretary of State thinks that it is a good idea—it does not matter whether a good idea is construed as being in the interests of the health service or patients. Any Secretary of State thinks that all their ideas are good, so that is an unrestricted new power.

If the Government do not like Section 12E of the NHS Act 2006 then they would be better zapping that section rather than introducing this clause amending it, which, for the reasons that the noble Lord, Lord Hunt, has given, would be an ideologue’s charter. Under these powers, a Secretary of State could determine that all elective surgery should be done only by private hospitals, and that would be consistent. Another Secretary of State could decide the exact opposite, or they could decide that no NHS-funded terminations of pregnancy will be done by the independent sector. Since that is 81% of terminations in this country, the NHS would not be able to cope, and that would then constitute a massive restriction on terminations of pregnancy.

You can have your own ideological view on whether these are good or bad things, but that is what this clause permits. Therefore, contrary to what the noble Baroness, Lady Bennett, says, it does not lock in the status quo but produces the possibility of quite extreme swings on the part of future Governments. This Government should remember that what is sauce for the goose will be sauce for the gander.

[Baroness Coffey (Con)]

My Lords, I tabled Amendment 34 to put the focus on patients. In my short time in health, working with brilliant civil servants and great Ministers, I created Our Plan for Patients. It tried to have a very specific focus that would address some of the concerns that have been raised about what a Secretary of State could do around provision.

The noble Baroness, Lady Bennett of Manor Castle, will be on her own in thinking that the only organisations that can provide this are state-run actors. This is not how the NHS was created. Most GPs are not state-run organisations; they take on a contract. The same is true of most primary care—opticians, pharmacists, the list goes on. In my time as an MP, I used to get infuriated with the local chief executive, because they resented using private provision, despite it potentially having been better to get more patients off the waiting list, because they were frustrated at paying the same consultants who were working in one hospital in the morning and then for a different provider elsewhere in the afternoon. The patients do not care. They just want to get their hip done or whatever it is.

We have to keep reminding ourselves why the NHS exists: it is to ensure that patients get access to the healthcare that they need regardless of their means. As for provision, there are things such as BUPA, which is the largest single provider of NHS dental care in the country; it is a non-profit organisation in that regard.

There is one thing worth exploring with the Minister. Having looked at the original clause, I think this already applies, with a few exceptions. I assume that two of the exceptions are due to the fact that, in the rest of the Bill, the Secretary of State is already taking the powers from NHS England. I want to be clear why procurement regulations in particular are effectively being rolled into this new power, whereas I think they are excluded in the original Act.

More broadly, I understand where the noble Lord, Lord Stevens, is coming from, but it comes down to this: if we can keep the focus on patients, it would reduce the opportunity for the Secretary of State to be arbitrary in how they go about their view and their running of aspects of the NHS, recognising the number of constituents right around the country. Otherwise, I am concerned that there could be some ideology that starts to squeeze out private providers. Sometimes that will be for good reason. A few years ago, Circle was saying, “Put up the tariff, or we won’t do NHS work any more”. I would say, “Circle, get lost—if you can’t do it for what the NHS is doing it for, then don’t worry”. There may be a broader challenge about what is going in—I will discuss the balance of primary care and so on later—but, in terms of NHS funding overall, if we keep the focus on patients as our guiding star, then, frankly, we will have done a good job in this Bill.

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[Baroness Bennett of Manor Castle (GP)]

There is a particular issue with GP practices. My position is that I do not think there should be for-profit in healthcare. That is my long-term position.

[Lord Stevens of Birmingham (CB)]

Nuffield Health, which provides private hospital services to NHS patients, is a registered charity. To clarify, according to what the noble Baroness has just said, she would accept that it would continue to be able to be funded by the NHS but, let us say, HCA hospitals would not.

[Baroness Bennett of Manor Castle (GP)]

I am aware that there are charities and there are charities, but yes, as long as something is operating for a genuinely charitable purpose, I would exclude that from a for-profit definition.

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[Lord Evans of Rainow (Con)]

My Lords—

[Lord Stevens of Birmingham (CB)]

My Lords, I declare my interest as chair of Cancer Research UK and wholeheartedly endorse all the previous contributions on this group, which have been outstanding. The purpose of these probing amendments is simply to make sure that cancer remains very firmly on the Government’s agenda. The cancer plan, published in February, has a range of really welcome proposals, but the key thing will be putting them in place. In the cancer plan, there was a commitment to delivering the cancer waiting time standards by 2029. It would be fantastic if the Minister could confirm at the Dispatch Box that that remains the game plan the Government and the NHS have embarked on.

In doing so, can the Minister briefly comment, in the context of the three headline cancer waiting times targets, on the faster diagnosis standard for urgent referral of 28 days? We are seeing a bit of a bifurcation opening up between the faster experience that patients who do not have cancer are having—with cancer being ruled out for 79% of people, against an 80% target, which is great—and maybe only 55% of people who actually have cancer getting their diagnosis within that 28-day period. If we are interested in the outcomes improvement that will come from early diagnosis, it will be crucial to keep a beady eye on the waiting times for diagnosis for people who actually have cancer.

[Lord Tarassenko (CB)]

My Lords, I will speak very briefly in support of Amendment 250 in the name of the noble Baroness, Lady Finlay, to which I have added my name. I come to this debate as the husband of a cancer survivor. My wife was diagnosed with Hodgkin’s lymphoma 30 years ago, and I am very glad to say that she was successfully treated with radiotherapy.

I realise that, for lymphoma, the role of radiotherapy has decreased as chemotherapy has improved. But for some cancers, as we have heard, radiotherapy remains the treatment of choice. Chemoradiotherapy for cancer of the larynx cures patients while, very importantly, preserving their voice. For anal cancer, it has replaced an operation that once meant a permanent colostomy for every patient. For locally advanced cervical cancer and early lung cancer in patients too frail for surgery, it is the curative option.

Radiotherapy, of course, also works in partnership with other treatments. A study of more than half a million cancer survivors in England found that three-quarters of five-year breast cancer survivors and two-thirds of head and neck survivors had received radiotherapy. In the ProtecT trial, led by my Oxford colleague Professor Freddie Hamdy, which followed more than 1,600 men with localised prostate cancer for 15 years, radiotherapy matched surgery on survival but fewer men were left with long-term incontinence.

So, the problem is not the evidence but delivery. As the noble Baroness, Lady Finlay, has said, only four in 10 patients start radiotherapy within the 62-day standard against a target of 85%—far behind surgery and chemotherapy. More than half of cancer patients would benefit from radiotherapy, yet in England only around a third receive it. Some 60,000 patients a year miss out, and that is often because of where they live.

That is why a national delivery programme is important. First, we should think about equipment: the linear accelerators which generate the high-energy radiation of radiotherapy last around 10 years. A national programme can plan a replacement as a rolling cycle and buy at scale instead of trusts bidding for capital one machine at a time. In May 2025, the Government invested in 28 new machines, which is very welcome, but a plan is needed to go beyond one-off funding. Secondly, satellite centres such as Oxford’s, at Swindon’s Great Western Hospital, bring treatment closer to the patient’s home, but they need to be planned nationally once the gaps have been identified. Thirdly, a national programme can collect national data, including performance data, and have a co-ordinator responsible for delivery.

Radiotherapy is curative, cost effective and preserves organs. Patients deserve timely access to it wherever they live.

Health Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I take a rather different view from that of the noble Lord, Lord Patel. We need to look back at the foundation of the hospice movement—it was founded within the charitable sector. It has always been valuable that a lot of the funds to run them have been raised by hospices themselves. That has given them a certain degree of independence, which they clearly would not have if they were funded entirely by the state. It also meant that they brought innovation into palliative care in a way that directly funded services would have found difficult.

There is, however, a need now for more support from government. I acknowledge and welcome the resources the Government have put in in the last two years. I hope my noble friend can say when the framework is coming. As I understand it: one of the issues about hospice funding is that it is so hand to mouth. For some reason ICBs, and their predecessors, have seemed to be incapable of giving longer-term contracts and certainty—they always give short-term contracts and operate hand to mouth.

In a sense, this takes us to the heart of the Bill. So many of these amendments are really because we do not trust ICBs to do the job properly. Their main focus is on waiting times and financial performance. With the huge variation in the funding of palliative care, can we have any confidence that, even with the modern framework, we are actually going to get a more comprehensive package of long-term services for hospices?

Of course, there is a wider challenge of palliative care in the NHS itself, which the noble Baroness, Lady Finlay, referred to. Some reassurance on the hospice issue—that the framework, when published, will mean that ICBs have to sort this out, that they have to give long-term certainty and deal with some of the variation in funding that we see at the moment—would be welcome.

[Lord Stevens of Birmingham (CB)]

My Lords, the noble Lord, Lord Patel, spoke movingly and others spoke powerfully to make the case for palliative and end-of-life care, and I will not seek to repeat what they said. The whole of Parliament has expressed that view extensively over the last 18 months.

I will comment briefly on whether the provisions should be in the Bill or should rely on action by the Government. I anticipate that the Minister will make the case that this does not need to be specified in primary legislation; it can be done by an administrative or political act from the Department of Health and Social Care. I believe that to be the case. In principle, there is no need for new Secretary of State powers or administrative reorganisation to allocate funding to meet unmet need in palliative and end-of-life care. However, the question before the Committee is: are the Government actually going to do it? What we can do is give the Minister a bit of leverage inside the department between now and Report by perhaps sending a signal that if the modern service framework for palliative and end-of-life care has not emerged by then, it is possible that your Lordships’ House will take a more stringent view on the need for primary legislation.

The Minister told us in writing on 4 June that we will see this modern service framework for palliative and end-of-life care in the autumn—as the noble Baroness, Lady Coffey, pointed out. We are now in November: the nights are drawing in; the clocks have gone back; Guy Fawkes night is this week; and Halloween has been and gone. Is the promise of an autumn modern service framework trick or treat?

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The current statutory framework and established guidance already help deliver the intended objectives of Amendments 45, 78 and 230. The noble Lord, Lord Stevens, predicted that I would make that point, and I think he gave his support in advance for me doing so.

[Lord Stevens of Birmingham (CB)]

Conditionally.

[Baroness Merron (Lab)]

The noble Lord says “conditionally”. I would I expect it always to be conditional, but I thank him for clarifying.

To address the concerns of the noble Baroness, Lady Coffey, as we have already discussed in Committee, Section 1C of the NHS Act 2006 states:

“In exercising functions in relation to the health service, the Secretary of State must have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service”.


This is a deliberately overarching duty that applies across the whole of the health service, so we do not consider it appropriate to create separate versions of that duty for individual services. That would risk duplication and make the legislative framework overly prescriptive.

The much talked about modern service framework for palliative care and end-of-life care was referred to as a “trick or treat” test by the noble Lord, Lord Stevens —I will leave him to conclude, when I finish. I also assure the noble Baroness, Lady Coffey, that no one in this Chamber wants her to feel grumpy, and I am sure that nobody in the department wishes her to feel grumpy.

The modern service framework will focus on reducing inequalities. It will identify, measure and reduce inequalities, and reduce unwanted variation in access, experience and outcomes—I say to the noble Baroness, Lady Grey-Thompson, that that absolutely includes in respect of disability. The modern service framework is indeed anticipated in the autumn, which we remain in. I know that we are all keen to ensure that everyone can receive high-quality and personalised care in the right place at the end of life. I look forward to the modern service framework giving us the best way forward on that.

I turn to Amendment 78, also in the name of the noble Baroness, Lady Finlay. As per Clause 21, the Secretary of State is already required to undertake an annual performance assessment of each ICB in discharging its statutory functions. Again, that was spoken to by my noble friend Lord Hunt. I say to the noble Baroness, and to the noble Baroness, Lady Hollins, that the latest report for 2024-25 was published on 17 December last year. Future assessments will continue to consider how ICBs are discharging their statutory palliative care duties. I very much understand the calls from noble Lords across the Chamber and their emphasis on how important this is.

The modern service framework will indeed build on the ambitions set out in the neighbourhood health framework, which includes increasing the identification of those approaching end of life by 10% and reducing non-elective admissions and hospital bed days by 10% for those at end of life. I take the point that the noble Baroness, Lady Hollins, made about measurement and ambition in particular. On the NICE guidance in this area, in keeping with all NICE guidance, although it is not statutory or legally binding, as local healthcare professionals need autonomy to make clinically appropriate decisions in relation to their patients, there is an expectation that commissioners and service providers take it into account when they make those decisions on how to meet the reasonable needs of their populations.

On Amendment 230, tabled and spoken to by the noble Baroness, Lady Pidgeon, alongside the existing statutory framework that I have already outlined, the already published universal principles for advance care planning promote opportunities for individuals, including those with a terminal diagnosis, to discuss their wishes, their preferences and the clinical recommendations. Health and care professionals are expected to provide appropriate opportunities for individuals to engage in advance care planning. This area was spoken to by the noble Lords, Lord Kamall and Lord Patel, as well as the noble Baroness, Lady Barker.

These principles explicitly recognise the importance of involving a person’s family, carers and those who are important to them. I emphasise the point that those who are important to us do not always come neatly packaged. They are to be involved in discussions, including through the nomination of a named spokesperson. The outputs of these discussions may include one or more of the following: an advance statement —I have heard how helpful that is, along with the importance of an advance decision, where it is to refuse treatment—context-specific treatment recommendations and lasting power of attorney, where it is appropriate, in line with the Mental Capacity Act 2005.

Additionally, for those nearing the end of their life, the Government’s priority is to provide people with financial support quickly and compassionately. The noble Lord, Lord Patel, and the noble Baroness, Lady Barker, both spoke to the absolute importance of compassion being at the core of everything that is done. In a practical sense, the main way that this is done is through the special rules for end of life, which apply to five key benefits, including the personal independence payment.

I move on to the points on medicines access raised under Amendment 242, tabled by the noble Baroness, Lady Finlay. The pharmacy quality scheme forms part of the community pharmacy contractual framework. The scheme’s palliative and end-of-life care domain aims to ensure sufficient arrangements are in place so that patients, relatives, carers and healthcare professionals can obtain medicines in a timely manner—again, something spoken to very clearly by the noble Lord, Lord Patel. ICBs commission out-of-hours dispensing arrangements where there is a need for patients to access medicines outside core pharmacy hours.

Finally, I will address Amendment 26, tabled by the noble Baroness, Lady Finlay, on which we heard a number of contributions. Funding for palliative and end-of-life care is available through existing NHS funding arrangements and, as I have outlined, ICBs have statutory responsibility for commissioning. Indeed, as we have discussed on a number of occasions, local commissioners are best placed to determine how funding should be allocated according to the population need, local service provision and the best use of available resources. The ring-fenced fund proposal, which would mean establishing it in primary legislation, would, we believe, risk being overly prescriptive and would limit the flexibility of local commissioners to determine how resources are best used.

On the point about hospices and funding, I very much recognise, as have noble Lords, the absolutely vital part that voluntary sector organisations, including hospices, play when providing support to people at the end of life, but also to their loved ones. It is also worth noting that the majority of palliative and end-of-life care is provided by NHS staff and services, to whom and for which we are also most grateful. It is true that the amount of funding for each charitable hospice will vary but, by definition, that depends on the demand in local areas and on the type of palliative care provision. My noble friend Lord Hunt made the point that hospices value their operational independence—that is something that I have found in my discussions with them—and they are great innovators. I understand the point about funding, as I do in this whole area. However, when I have looked at this and spoken with hospices, that ability to operate independently is one that they really value.

The modern service framework will ensure that palliative care and end-of-life care is well within a strategic commissioning model. Importantly, there will be clear and transparent contractual arrangements, which I hope noble Lords will welcome.

--- Later in debate ---

[Baroness Coffey (Con)]

My Lords, I find it extraordinary that we might have to legislate to get what seems very sensible work done. I commend my noble friend on raising this important issue. I also say to my noble friend Lady Harding: just wait until group 45 when we have another opportunity to develop this in more detail. I look forward to leading that group in due course.

I generally support these amendments, particularly the amendment tabled by my noble friend Lady Shawcross-Wolfson. There is no doubt that trying to come up with a workforce plan for more than 1 million people, who are working either directly as employees of the NHS or as contractors, may seem overwhelming. But I put it to the Committee that it is absolutely necessary to deliver what is expected and the promises made. I am conscious that a lot of the mechanisms in the Bill are about the Secretary of State effectively taking over the functions of NHS England. Nevertheless, I think it is great. I enjoy this Bill and would like to see even more in the hands of Ministers in trying to make stuff happen. I am a great believer in the Nike model, “Just do it”. At times it was JFDI—please do not put that in Hansard. It is a case of trying to get momentum going.

Even in the short time I was in the Department of Health and Social Care as a Minister, we tried to get certain things moving. I will give an example of what may seem extraordinary and why it still seems to take an unnecessarily bureaucratic way of getting stuff to happen. I was astonished to find out that dentists in Scotland could not automatically come and practise in the NHS in England. We had to do some regulations to enable the General Dental Council to do something, then there was some other local commissioning, instead of just making the rule that anybody who is qualified to work in the NHS as a dentist in any part of the United Kingdom can also do it in England. There is no doubt that we should be thinking about how we ensure that qualifications we recognise from other parts of the world—we need to be careful—match the standards of the NHS in this country. But I would hope that we can agree it, at least among the United Kingdom, without too much effort, without regulation and without bureaucracy.

My noble friend referred to the more than 100,000 vacancies. A lot of those are filled by agency and bank, which we know is very expensive. I give credit to the Government as I think they put a lot of focus at the beginning of their administration on working with NHS England to bring that down. Undoubtedly, that huge cost should be unnecessary in a well-run organisation, particularly where management should be highly rated and world-class. Unfortunately, what we see in reality is often very different. People will leave the NHS or turn to these other forms of helping patients because of the inflexibility across the system, which is a real tragedy.

We see this in a different way when we look at the sickness rates of people who work for the NHS, particularly in secondary care. It continually surprised me that the sickness rates are a lot higher for non-clinical staff than for clinical staff. Something is not right there. I would hope that the level of detail that future Ministers will have at their fingertips to try to understand this, or at least to be able to see the analysis and ask the questions, will prompt a thorough workforce plan.

My noble friend suggested that the NAO is the right body to do this. That could be right. I often find that the NAO is great at looking backwards rather than forwards. In trying to understand some of the operational challenges, it varies. When 40% of our annual budget for day-to-day spending is consumed by the NHS—the Barnett formula makes that even higher in other parts of the United Kingdom—it is right that we have a parliamentary body through the NAO involved in scrutiny to give confidence to the scrutiny of both Houses and to give an element of independence that is not so far from reality. This is so that it can be seen as credible and not necessarily wishful thinking by the Government. Sometimes think tanks will come up with a lot of wishful thinking on what should happen.

I turn to how we get the workforce in, how we keep the workforce—I have already briefly touched on that—and what is happening with the exit. After Covid there was a huge spike—a surge—in people wanting to go to university and train as nurses. It was roughly 22,000 per year for 2022, 2023 and 2024. The sad reality is that a lot of those people who are graduating have not found jobs within the NHS as there have been recruitment freezes. Something has gone fundamentally wrong there. It should not be a surprise to us, sadly, that the attrition rate for nursing degrees is about 20% to 24%.

On the other hand, we have quite a modest number of people going through the nursing apprenticeship degrees—about 2,500 to 3,500 per year on average over the last five years. The advantage those people have is that they have a guaranteed job; they are already working in the NHS. That is concerning, such that the Government put out a nursing graduate guarantee scheme, but I do not think there is any evidence that it has had any impact whatever. I may be wrong on that, and I would be happy to hear from the Minister, but I appreciate that she has a lot to cover in her 20-minute reply. I would be grateful if she could write to me if that information is not available now.

My successor made it a degree requirement to become a paramedic, which had been pushed for by the Royal College of Paramedics and other chief executives. I am still at the stage of questioning why, over the past 15 to 20 years, there has been a massive push to require degrees for lots of public services, such as to be a police constable, whereas when we challenge the private sector and other professionals, we say it is outrageous that you must have a degree if you want to become a solicitor. We need to get our thinking caps on and work with the brightest and the best.

I commend my noble friend Lady Harding. She gave up a lot to run NHS Improvement and work alongside other people there, particularly during challenging times. This can be done. I know that the noble Lord, Lord Stevens of Birmingham, was also exemplary in his running of the NHS during his time there. Not everybody has all the skills, but together we can make it better. That is why I support something as serious as this being in the Bill. As I mentioned, it is something that I will explore in a later group.

The noble Baroness, Lady Pidgeon, has filled the missing gap regarding the care service being part of the workforce plan. That is understandable, given the ongoing work on the creation of a national care service. It was Jeremy Hunt who requested that health and social care be put together. He recognised that having these work together was part of the same desirable outcome, and that it made sense to broaden that. However, I appreciate that that risks a strategy that will cover between 3 million and 3.5 million people in England alone, which is challenging.

I appreciate that when a new Secretary of State comes in they may be in the middle of a Bill that they never dreamed of doing and must now look at the detail of the NHS 10-year workforce plan. That is why “imminent”, which normally means that the Government are waiting for a grid slot, becomes “in due course”, which means it has almost certainly been completely rewritten from word one. This will take a bit of time, but the clock is ticking. We know there was a change made on waiting lists and that we need the staff to get that done. That is why, for the benefit of patients, I support my noble friend’s amendment.

[Lord Stevens of Birmingham (CB)]

I also strongly welcome the leadership that the noble Baroness, Lady Shawcross-Wolfson, has shown in tabling her amendment, which is before the Committee. To paraphrase her speech, the proposition, in essence, is that Parliament should help save the Government from themselves. When it comes to these workforce questions, the dual pathologies of short-termism multiplied by wishful thinking equals the problem that we have. There is a need to do something better. In supporting other amendments in this group, I will briefly illustrate why that might be the case in respect of mental health and primary care.

On Amendments 92 and 232, which concern mental health, I think we can all recognise there is quite a degree of uncertainty as to what mental health services will have to address on the demand side over the course of the next decade. It is not just the review, which recently took place and has partly concluded, on the increase in self-reported mental health problems and the question around unmet need and diagnostic fluidity. Look at the NEETs problem, the huge fiscal crunch that the country faces and the spending review next year, which will be a slaughterhouse.

Solving that problem will require much greater flexibility in offering targeted services and support, rather than simply putting people on to benefits. That will require a movement from what our colleagues in Grand Committee, who are noting Fortifying the Fiscal Framework, will know as AME spending into DEL spending and translating automatic entitlement to benefits into services. Some of those services will have to be mental health services, which will require a workforce. Therefore, we need a much more forensic approach to some of the scenarios and how we will respond to this from the point of view not just of the NHS but of the fiscal sustainability of the United Kingdom. It is high stakes getting this stuff right.

Primary care is less a demand-side question and more of a supply-side conundrum. In my opinion, a lot of what is happening in the gulf between the increased population and the decreased availability of GPs has been misdiagnosed. However, a very useful quantitative analysis published by the BMJ in 17 September last year shows that part of what is going on is that a much higher proportion of GPs and consultants who come through training are choosing to work part-time, and that gap has widened over the course of the past decade. In 2015, the ratio of FTs to GP headcounts was 0.81—in other words, the typical GP in general practice was working four-fifths of the week in NHS general practice. That had fallen to about 73% by 2024, whereas, throughout that period, NHS consultants were working over 90% of their week in their hospital or in specialist care.

Health Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Wednesday 28th October 2026 Lords Chamber

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

[Lord Stevens of Birmingham (CB)]

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

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

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

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

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

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


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

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

[Lord Lansley (Con)]

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

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

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

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

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

Cancer Outcomes in the UK

Lord Stevens of Birmingham Excerpts

Tuesday 21st April 2026 Grand Committee

[Lord Stevens of Birmingham (CB)]

My Lords, I pile on to the congratulations to the noble Lord, Lord Patel, on this fantastic session. Given the excellence of the contributions that we have already heard, I will just draw out a small number of things. I will try not to be duplicative of the brilliant contributions that the Committee has heard.

I declare my interests as chair of Cancer Research UK and chair of King’s College London’s council. Cancer Research UK has a proud tradition of supporting research in the UK as well as internationally. Some eight out of 10 medicines that NHS cancer patients use were either developed by or with Cancer Research UK. CRUK has pointed out that we are indeed the beneficiaries of that research. We have seen a 29% reduction in the death rate from cancer since 1989. The Government’s very welcome new NHS cancer plan points out that five-year survival rates increased from about 50% to 60% between 2008 and 2022. Your chances of dying from cancer on an age-adjusted basis are lower now than they were five years ago, 10 years ago or 15 years ago, but for all the reasons we have heard, there are no grounds for complacency. There is an enormous opportunity in front of us, and the cancer plan is right to set that out.

As other noble Lords have pointed out, in order for it to succeed it must meet two signature commitments: that three-quarters of people get diagnosed at stage 1 or 2 by 2035 and, linked to that, the expectation that three-quarters of people will survive five years as a consequence. That makes complete sense, but we should reflect on what have been the barriers to achieving that up to now, so that we get it right over the next decade.

There is a caveat: we need to be careful that we do not just increase the proportion of stage 1 or 2 diagnoses by detecting a lot of what would otherwise have been indolent cancers that would not have gone on to cause people problems. That has got to be matched by seeing an age-standardised reduction in the number of people diagnosed at stage 3 or 4, so we really are clear that we are getting stage shift and not just expanding into a wider group for whom the diagnosis would not necessarily have been a problem.

That is significant, because our understanding of cancer biology continues to evolve. The standard assumption that individual mutations at cellular level grow, spread and develop into advanced disease or systemic diseases such as cachexia turns out to be not quite right. My colleague Professor Charlie Swanton at the Francis Crick Institute has pointed out, for example, that a typical 60 year-old will probably have 100 billion cells in their body with some form of cancer mutation. So, in a sense, the question is, why is cancer not more common, given that underlying fact?

Continuing to invest in research to understand the tumour microenvironment and the way in which oncogenes and suppressor mechanisms interact and cancer spreads is what we are going to have to achieve if we are going to make the progress needed to get to the 75% target. That cannot be achieved just by sweating the NHS assets, as it were. For important conditions—the glioblastomas, pancreatic cancers and ovarian and oesophageal cancers—we need to continue to shift the frontier of research in order to produce those benefits.

The research and life sciences environment in this country continues to be hugely important. We are a bit of an outlier as a country in that of our non-commercial cancer research, two-thirds is funded by charities and slightly less than one-third by government. That is a lower proportion than for other major conditions and a lower proportion than is seen in other countries. So it is vital that we think about the entire research infrastructure and, as the noble Baroness, Lady Bottomley, briefly alluded to, we cannot be blind to the pressures on our brilliant British universities, which have done so much. However, in order to sustain that, we are going to have to, through the broader set of approaches that the Government take, make sure that they have the resourcing to do that.

We are not going to get to the goals in the new cancer plan without further progress on some of the cancers of unmet need through the research enterprise, but it is also the case that there are several things inside the NHS that have got to work, and I suspect that my colleague the noble Baroness, Lady Gerada, will shortly talk about the pressures on primary care, given that that represents the first point of contact for most cancer patients.

It is the case, of course, that, whereas the share of NHS resources going on primary medical care increased between 2015 and 2020, it has since fallen back. I am anticipating that the Minister may say that the Government do not think that spending-share targets are a good way of measuring these things: that is certainly their position on mental health, although it appears not to be their position when it comes to pharmaceutical spending, where there is a novel commitment that we will spend an extra 0.3% of GDP on our medicines pricing, linked to the deal done with the Trump Administration. Nevertheless, for primary care and mental health, apparently that logic does not apply.

We will want to really understand how we make the primary care element of the NHS robust over the coming 10 years. We want to understand the referral thresholds. The reality is that about 22% of cancers are diagnosed in patients from a GP referral on a non-cancer referral pathway, not the urgent suspected cancer pathway, so we need to make sure that the new GP contract, which incentivises a 25% reduction in referrals, is not cutting across the referrals that we need to detect cancer early, including in the specialities that are covered by the scheme—gastroenterology, gynaecology and urology. The NICE referral pathway, NG12, needs a refresh to make sure that people are getting referred appropriately and that the filtration is not artificially stopping people from getting checked up as they should be.

The Government are to be commended on the expansion of the community diagnostic centres—that is an excellent model, and we need more of them. There is capex and other support to do it. That is good. The lung health check programme, to which the noble Baroness, Lady Ramsey, referred, has been a brilliant success. The long-term plan in 2019 gave us the rollout for that. More than 2.5 million people have been invited. As she said, it has produced the extraordinary result that 76% of people getting a lung cancer diagnosis through that lung health check do so at stage 1 or stage 2. That is the kind of stage shift we are looking for overall, achieved through that novel programme. As she also rightly said, it has, unlike most other screening programmes, produced another extraordinary result: poorer people are more likely to get an early diagnosis through that screening programme than better-off people. That is a direct impact on health inequalities that we do not see elsewhere.

Those kinds of models are hugely important. We need to see continued innovation in that area. If we pull all these pieces together—the resourcing, continued research and the focus on what has and has not worked in the NHS—I see no reason why we cannot continue to make really significant progress on cancer over the decade ahead.

Terminally Ill Adults (End of Life) Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Friday 20th March 2026 Lords Chamber

[Lord Pannick (CB)]

My Lords, it is a great pleasure to see the noble and learned Baroness, Lady Prentis of Banbury, back in her place. She has been very much missed, and I hope this is the first stage on the road to full recovery. She, like me, may have a feeling of Groundhog Day because we have made lamentably slow progress on the Bill since she was last with us. We are on day 12 in Committee and we are still on Clause 5 of 59.

As the noble Baroness, Lady Coffey, mentioned, she began our Committee proceedings on 14 November when she moved the first of her 111 amendments in relation to Wales, and here we are again. I say simply to the Committee that of course the Bill should apply to Wales. The Bill seeks to create an exception to the prohibition on assisted suicide and that is an aspect of the criminal law of England and Wales. We all agree that criminal justice is a matter reserved to Westminster. It would be bizarre were this House or Parliament to approve the Bill but not approve it in relation to Wales. There is simply no sensible reason why people living in Wales should be denied the same options as people living across the border in England.

I listened carefully to what the noble Baroness, Lady Smith, said, and she suggested that there has been some parliamentary mischief, and that the people of Wales have not been listened to. But it is the case that the people of Wales have a number of representatives in the House of Commons. My understanding is that they all voted for the Bill.

[Lord Stevens of Birmingham (CB)]

Most of the amendments in this group relate to Wales, but some of them also relate to Scotland. Notwithstanding the noble Lord’s sensation of Groundhog Day, there has been an important development since we met last Friday, which is that the Scottish Parliament, by a decisive majority of 69 to 57, has chosen against assisted dying. In that context, therefore, a number of the provisions in the Bill need a significant rethink; in particular, references to Scotland in Clause 57(2) and (3), which would extend the provisions to Scotland, surely should no longer apply.

[Baroness Whitaker (Lab)]

I thank the noble Lord for giving way. There is a substantial difference between the Bill that was not accepted in Scotland and the Bill that we are debating now. The Bill that was debated in Scotland had fewer safeguards; it is not the same Bill and therefore the noble Lord’s premise is not quite as he said.

[Lord Stevens of Birmingham (CB)]

The noble Baroness brings me neatly on to the second point I was going to make, which is that the lack of safeguards in Scotland precisely demonstrates the constitutional and practical difficulty of trying to legislate in Scotland while a number of those key safeguards are reserved matters to Westminster. Part of the reason the Royal College of Psychiatrists and the pharmacists came out decisively this week against the Scottish Bill was because it was not able to include enforceable conscience protections for health professionals that would, for example, have enabled them to refuse an instruction from their employer to participate in assisted dying. Instead, the mechanism that was forced, as it were, on the Scottish legislation was a Section 104 order, which would be subject to a future Westminster Government changing their mind.

The Scottish Parliament was being asked to legislate for assisted dying, absent any Scottish safeguards for conscience and dependent on the future decisions of a Westminster Parliament. The noble Baroness neatly illustrates the point that there is a fundamental problem when one part of the United Kingdom seeks to go its own way. It is incapable of getting the necessary protections and that is one of the reasons why the measure was defeated. Amendment 887 in this group, which would withdraw the reference to Scotland from some of the measures, clearly makes sense given that the Scottish Parliament has just decided that it will not go down this path.

[Lord Falconer of Thoroton (Lab)]

The three reasons why it extends to Scotland are so that people cannot advertise in Scotland to England and Wales, so that people in England and Wales get proper protections if they want to use the conscience clause, and so that substances are dealt with by the United Kingdom. That is why Scotland is included. Is the noble Lord saying that he wants those removed if the Bill goes through?

[Lord Stevens of Birmingham (CB)]

Can the noble and learned Lord elaborate on his second reason?

[Lord Falconer of Thoroton (Lab)]

The second reason is that if, for example, you want the protection of employment law, that employment law which extends to the whole of the United Kingdom should protect you in Scotland as much as in England. You should never be prejudiced. That is why it is included.

[Lord Stevens of Birmingham (CB)]

Is the noble and learned Lord suggesting that Scottish health professionals will be travelling south to undertake assisted dying? Is it a sort of Berwick-upon-Tweed provision?

--- Later in debate ---

[Lord Stevens of Birmingham (CB)]

It is not so much a matter of prejudice because, as I understand it, this provision was inserted in the House of Commons in the anticipation that the Scottish Parliament was going to have before it a Bill on assisted suicide, which it would at that point have passed. This was trying to do a belt and braces on a Section 104 order which everybody could see was likely to be deficient.

[Lord Falconer of Thoroton (Lab)]

No, that is not right. The reference to Scotland was included to provide protection for people in England and Wales who, under employment law, wanted to exercise the conscience clause. If I am right about that, I am sure the noble Lord would not wish it removed.

[Lord Stevens of Birmingham (CB)]

I would be interested to come back to that on Report when we have had a chance to investigate that point further.

Fundamentally, this shows that there is a great problem, a structural problem, in trying to do these types of big social changes through Private Members’ Bills, be they in Scotland or England. The reason for that is that it requires concurrent action by the Governments of both nations. We have seen time and again that when these sorts of questions have arisen and we have posed these questions, we have been told by the Front Bench, for reasons we all understand, that amendments to try to deal with these problems pose workability concerns. Then we ask, “How would you address those workability concerns?” and answer comes there none, because the Government are officially neutral on the question. Dealing with these sorts of questions cannot be left to Private Members’ Bills when you cannot get to the bottom of the workability concerns or deal with the fact that, in order for the narrowly drawn legislation to work, there are a whole set of other things that have to be in place that only the Government can provide.

I conclude on that point by noting that this past week we have seen a report from the House of Commons Public Accounts Committee, once again on hospice and palliative care. It says:

“There is an urgent need for reform to address the financial challenges that the independent adult hospice sector faces … The Department’s solution—the Modern Service Framework—is in the early stages of development, details are sketchy, and it is at least a year from being introduced. This is not good enough when so many hospices are announcing service cuts”.


The idea that we should legislate when that is the context right now seems to me utterly ridiculous.

[Lord Deben (Con)]

My Lords, as a Welsh-speaking Welshman, who has, in this House, consistently supported Plaid’s perfectly right demand that there should be fairer funding for Wales—I am not a Plaid supporter, but I support that aspect—I hope that the House will have listened carefully to the fundamental comments made by the noble Baroness, Lady Smith. If the Bill is passed, the Welsh Government will have to make arrangements for its implementation in Wales. In Wales, the provision of palliative care is not as good as it ought to be—this is widely understood. Yet we would be imposing on the Welsh Government the necessity to make particular decisions about health in Wales, when they have no powers to make those decisions for themselves.

That is a very simple issue, and I recognise the problems stated by the noble and learned Lord. But the truth is that we have an underfunded Welsh Government who spend half their money on health and know that there are real gaps in the provision. Last week, the noble Baroness, Lady Murphy, told us that assisted suicide was part of palliative care. That, of course, has solved the case—we now know that it is just part of palliative care. But those of us who do not think that it is part of palliative care recognise that, in Wales, the issue is sharper than anywhere else because of the lack of funding, which is about the misuse of the way that funding from the centre is put out.

I beg this House to take very seriously what the noble Baroness, Lady Smith, has said. If we were to ignore the amendments we are talking about here, we would be saying to the Welsh, “You just stuff it because we are going to decide”. We have had that issue before on abortion in Northern Ireland: they decided what they thought and we chose a moment when we had the power to decide they could stuff it. I believe in devolution, and I do not believe that this House should tell the Welsh people to stuff it; we should let them make their own decisions.

Finally, I will turn to what the noble Lord said. I know perfectly well—

--- Later in debate ---

[Lord Falconer of Thoroton (Lab)]

The health service could determine who it is going to make it available to free, but it could not prevent other people—for example, private providers—having different provisions in relation to it.

The next category of amendments was in relation to removing Scotland. I gave an answer to the noble Lord, Lord Stevens, in relation to that in the course of the debate.

[Lord Stevens of Birmingham (CB)]

Perhaps the noble and learned Lord will clarify the answer he gave on Scotland. I think he is saying that even though the Scottish Parliament has decided that assisted dying should not be lawful in Scotland, a Scottish hospice could nevertheless not prevent its employees doing something that would be unlawful in Scotland if they travelled across the border to perform that act in England. Is that the consequence of what he is suggesting?

[Lord Falconer of Thoroton (Lab)]

This was picked up by the noble Baroness, Lady Merron. She focused, rightly, on what would happen in the case of a doctor who lived in Scotland but worked in England. The question was: could they be prejudiced? The answer is no—employment law would apply, and employment law is right across the country. On what is not being done in relation to the Bill, it does not refer to Scotland, because in Scotland they are awaiting the Scottish Bill. It is entirely focused on the protection of people working in England. That is why it is there. It is also focused on advertising coming from Scotland into England. So it is not in any way dependent upon what might happen in Scotland.

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[Lord Rooker (Lab)]

My Lords, as usual, I came to listen and not to speak, but there are a couple of things that have been said to which I want to react. I agree entirely with my noble friend Lady Hayter, to be honest.

I will not go into the details, but I lost my first wife before the internet. There were no internet searches at all, because it was so long ago. We could work it out. It kept coming back in half the time—three years, 18 months. She was still at work—no problem there—managing a college in south London. It was coming back in half the time, so it was fairly obvious that you could measure it. We did not do it like that, and it was only later that we worked out that it came back in half the time.

When I went through it, I had no warning at all. I say to the noble Lord, Lord Moylan, that there was a consultant who had looked after me since the beginning, when I had no warning. About four years after I finished chemo—she was going off somewhere else to do research, so I was not going to see her again—she said to me, “You have to remember that the drugs deal with only half the problem”. That made me very satisfied. On the other hand, I have gone through cases involving people who were as positive or more positive than I was, but it got them in the end. That is what I remember. The drugs deal with only half the problem.

[Lord Stevens of Birmingham (CB)]

On the thrust of the argument, I agree with the noble Lord, Lord Moylan, that approaching this probabilistically, rather than with a single number, clearly makes sense. It is wonderful to hear the impact that these new immunotherapies have had in his own personal case as well as for oesophageal cancer.

Just for the record, I want to associate myself with the comments of the noble Baroness, Lady Royall, because the evidence is pretty clear that there is not an association between positive thinking and cancer survival. There may be a link with quality of life, but frankly, it is perfectly normal, having had a cancer diagnosis, for people to feel depressed or anxious.

The only reason for raising this very briefly at this point is that we need to be very sensitive. When somebody’s cancer progresses and ultimately kills them, we should not be leaving the impression that we think that is because they lacked the positive attitude that would in some way have enabled them to survive. I know that is not what the noble Lord was suggesting, but just for the record, I think that the noble Baroness, Lady Royall, was right to draw that to our attention, and we should be clear about that.

[Baroness Jay of Paddington (Lab)]

To add to what the noble Lord, Lord Stevens, said, I very much dislike the death notices, for example, which refer to people having put up a great fight or having failed to deal with the battle, or whatever expression is used, which suggests precisely what the noble Lord said—that they have somehow failed in a mortal combat.

Tobacco and Vapes Bill

Lord Stevens of Birmingham Excerpts

Report stage
Tuesday 24th February 2026 Lords Chamber

[Lord Sentamu (CB)]

My Lords, I listened to the noble Lord, Lord Pannick, and he persuaded me that, at the end of the day, we are dealing with a question of health, not choice. I will give an example. Colin Bennetts, Bishop of Coventry from 1998 to 2008, died in July 2013 after a period of illness due to cancer. His lungs were filled with deposits of smoke. He said to everybody, “I have never smoked in my life”, but as a youngster he had worked in an office where cigarettes were lit at every moment. Colin, who had not smoked, died of lung cancer. You do not have to smoke to die from it —others sitting near may get it.

I respect the noble Lord, Lord Clarke, but you cannot compare gambling on horses with smoking. Gambling on horses affects only those gambling, but secondary smoking is detrimental to anybody in a place where people are smoking. I do not think these amendments would be helpful. We should stick with the Bill as drafted, because we are trying to protect people’s lives and make them healthier.

I suffered what is called in medical terms a lung infarction, where bits of your lungs do not quite operate. I still have that illness, so every time I go into a place where there is a lot of smoking, I can barely breathe—I have to get out into the fresh air and get it in my lungs. Friends, this is about health. If we do not do this now, then when?

[Lord Stevens of Birmingham (CB)]

My Lords, I declare my interest as chair of Cancer Research UK. Given that smoking continues to be the single biggest cause of cancer, it will not be a surprise that I oppose the amendments in this group, which would substantially weaken this landmark legislation. In explaining why, I will respond to each of the six points made by the noble Lord, Lord Murray of Blidworth.

First, the noble Lord argued that we do not need more tobacco control legislation anyway because smoking rates are already coming down. That is not correct; Javed Khan has pointed out that, among the most deprived parts of the country, on current trends we will not be smoke-free until 2044. In any event, some in the tobacco industry have come to the same conclusion. I quote from an advert that Philip Morris took out in the New Statesman, no doubt designed to influence people such as us: “Here in the UK, smoking rates are not declining fast enough. None of the home nations are on course to hit their smoke-free dates, and the most deprived communities are lagging significantly behind”. The suggestion that we can just assume that the status quo will produce a benign outcome is incorrect.

The noble Lord’s second argument was that, rather than having a generational tobacco sales restriction, we should instead just move towards delaying the age at which smoking can be initiated to 21. The tobacco industry would doubtless switch its efforts to targeting twenty-somethings instead of teenagers. On the surprising claims we have heard in respect of the behaviour down the decades of Gallaher or British American Tobacco, I simply say to noble Lords: google their internal documents. They have all been disclosed as a result of international treaties and court cases, and noble Lords will see the systematic duplicity, bribery and corruption that has continued across the world in advancing big tobacco’s agenda. Those documents, the internal files, are there: noble Lords can check them out for themselves.

The noble Lord, Lord Murray of Blidworth, referred to the Republic of Ireland as an example we should perhaps be following, when it proposed to adopt the age of 21. However, the director of the tobacco industry-funded front organisation FOREST said of the effect of adopting the age of 21 as a tobacco sales restriction:

“If you’re not careful, you’re actually going to make smoking … fashionable again. You’re going to actually encourage young people to smoke”,


on the back of this proposed sales restriction to over 21 year-olds.

The third argument we heard was about the black market. For reasons that are a non sequitur, we have several times heard cited the example of Australia. The amendments in this group relate to changes to the age of sale. There has been no change in the age of sale in Australia. As far as I am aware, it is still 18 and has been for 30 years. So, whatever else is going on in Australia, it has got nothing to do with the amendments in this group in respect of age of sale. In fact, the Australian example tells us that you need rigorous enforcement. Until very recently, there was no retail licensing available for New South Wales, Victoria or Queensland, covering about 70% of the Australian population, and it has only been patchily introduced subsequently.

There is agreement that we need strong enforcement to deal with the illicit trade, but the argument that we should essentially do whatever it takes to maximise revenue for the Exchequer is a flawed one. If that were the case, as we have heard from other noble Lords, we would be legalising and licensing handguns, assault weapons, fentanyl or crack cocaine. The fact is that, when it comes to tobacco control policy, it is not the Laffer curve that we should focus on, it is the life expectancy curve.

The fourth argument has been around the impact on retailers. I accept that there are legitimate concerns, and the noble Lord, Lord Sharpe of Epsom, has rightly drawn attention to the epidemic of violence and also noted the provisions that will be in the Crime and Policing Bill as one step to attempt to tackle this. But the fact is that the progressive age of sale restrictions in the Bill are an evolutionary measure that will be phased over many years, giving retailers much opportunity to adjust. There are substitutes that they can sell, including vapes, as alternatives to smoked tobacco. Surely, nobody is suggesting that the trump argument should be that we need to sustain the margins of retailers at the expense of 80,000 people who die prematurely from smoking every year.

The fifth argument we heard was around the Windsor Framework. It is fair to say that alternative legal opinions are available. Member states are free to determine the age limit that they see as appropriate on their territory. This does not constitute a trade restriction within the meaning of the EU treaties. In any event, even if a court found that it did, it could be justified on public health grounds. Perhaps the Minister can confirm that the Bill has the support of Northern Irish Health Ministers and that legislative consent has been received from the Northern Ireland Assembly.

Lastly, we come back to the liberty argument: the freedom of unborn smokers to become addicted in decades to come. Well, those of us who take the opposite view judge that this is a proportionate response to a great harm. It is a novel piece of legislation; we will need to see how it plays out in practice. One of the government amendments that will be before us on Report will be precisely a report on its real-world effects in the coming years. In the meantime, to weaken what has the potential to be one of the most fundamental health-improving pieces of legislation this Parliament has ever enacted would in my judgment be a grave error.

[Lord Bethell (Con)]

My Lords, it is a privilege to follow the noble Lord, Lord Stevens, who gave a pretty good summary of many of the arguments against this group of amendments. I join him in all that he said. My fundamental motive is twofold. First, I would like to see the eradication of smoking in this country. That is a vision that we should embrace and be proud of. Just kicking the can and putting up the age limit, as this group of amendments seeks to do, would simply extend a very large and unfair addiction that kills two-thirds of its users and that we could all do without.

Secondly, I am very proud that my party was leading on this issue and brought about the generational ban. I remind noble Lords to have a moment of self-awareness. This is a measure that is massively supported by voters, taxpayers, smokers, Conservatives, retailers and even by the tobacco companies which, at least in this country, have a notional commitment to the eradication of smoking. You can judge whether to take that at face value, but that is at least their rhetorical position. So it seems out of date for my noble friends Lord Murray and Lord Naseby to be stalwarts for the permanent establishment of smoking in the face of such opposition.

Medical Training (Prioritisation) Bill

Lord Stevens of Birmingham Excerpts

Report stage
Monday 23rd February 2026 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare an interest as a UK graduate and as a pro-chancellor of Cardiff University, which has a very large medical school.

The ethics issues raised by the noble Lord, Lord Hunt of Kings Heath, are really important when we look at the Bill. What is our ethical role in attracting people—literally—and pulling them from places that have a terrible shortage of any medical provision whatever?

Another aspect that my noble friend Lord Patel brought out so clearly is the problem of career progression. I hope that, in summing up, the Minister will reassure us that the Bill is step one in sorting out the medical career progression for people in this country. Only this weekend, I heard of a large teaching hospital that has two consultant posts coming up, for which there were 28 appointable applicants, many of whom are already consultants. There is a real bottleneck for trainees who have gone right through their training programme and done all their exams. Broadly, there are two ways of progressing: run-through training, which provides some security, and training at a postgraduate level, where they have to reapply before they move on. The problems of geography for young people, or for parents with children who are settled, are absolutely massive.

I have been worried that the pay story hides huge problems and unhappiness, particularly in relation to the lack of teams in the way that training has been organised. I am referring not to Teams on the internet but to clinical teams where people know that they belong, where they know the person they can contact and where there is longer continuity. There has been a fault by the medical royal colleges—I hold my hand up, having been involved in some curricula in palliative medicine—in that we have overstepped different bits of experience and undervalued the importance of people coming through.

While I support these amendments from my noble friend Lord Patel, it is important to remember that some on international medical training programmes have no, or almost no, communications skills training or training in medical ethics. In fact, there are some where they have no clinical experience of any note until they pass their almost totally theoretical exams and then they have to gain all the clinical experience later. I am not passing any judgment on the quality of their medicine later on, and they may have a better scientific foundation, but we are not comparing like with like in the process.

I hope that the Minister will be able to assure us that Oriel, as an appointments and selection process, will have a much more subtle way of looking at the experience that people have and not just crude categories, because it will be important that we do not select away excellence in the name of the medical school that somebody graduated from. There is a spectrum of quality in every medical school output cohort. There are some who are superb, and there are some who, frankly, might have done better not getting into medicine in the first place—it may be a small number—but among graduates from other medical schools there will be people with superb experience and who turn out to be excellent. We see some of those in very senior positions in medicine across the UK.

The prioritisation message needs to be subtle, and it needs to look at the full employment history from graduation, including applicants’ NHS experience and the quality of their work during that. Apparently, the system can automatically calculate a lot of this, drawing on GMC data as well. There is a lot of work to be done by this system in relation to the data held by the GMC, and there is a lot of work to be done by the royal colleges.

[Lord Stevens of Birmingham (CB)]

My Lords, I declare my interest as chair of King’s College London. I think that there is a welcome consensus that the UK should aim for self-sufficiency in the production of new doctors through medical school, specialty training and into the NHS. In fairness, the last Government deserve credit for having taken the decision to expand medical school undergraduate intake to put us on that path. It was also not unreasonable, as a temporary measure, to make use of selective international recruitment while those new doctors came through the system, not least as the independent Migration Advisory Committee reported at the time that, in respect of doctors,

“there is sufficient and overwhelming evidence of a UK-wide shortage”.

Given that it takes perhaps 15 years for new medical students to come into independent clinical practice, telling patients to hang on for 15 years while that intake fed through the system would not have been good, certainly for patients.

However, the issue now is that, clearly, there needs to be better prioritisation during the transitional system. We spent a lot of time in Committee discussing the pros and cons of what that transitional prioritisation might look like, but one question that has not yet been completely resolved, which would aid the House in assessing the proposals that the noble Lord, Lord Patel, has put before us, is whether we could have a clear answer from the Minister as to what the increase in the pipeline and in the availability of specialty training places is going to be for the current year and over the next three years. As she pointed out to us in correspondence during recess last week, the NHS 10-year plan that the Government published last July talked about an additional 1,000 specialty training places over three years. However, the Secretary of State for Health and Social Care put on the table the proposition of not 1,000 but 4,000 additional specialty training places over three years, of which an additional 1,000 would become available in this coming year. That is what was put on the table in the discussion with the BMA on 10 December. Given that it is only a few months until these posts are filled, presumably the Minister must know the answer to the question: exactly how many additional specialty training places will we get for the year ahead so as to reduce the prioritisation problems with whichever criteria the Bill puts forth?

Medical Training (Prioritisation) Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Thursday 12th February 2026 Lords Chamber

[Lord Mohammed of Tinsley (LD)]

My Lords, I speak to the amendments in this group in my name—Amendments 5 and 10—and to Amendments 9, 11, 24 and 25 in the name of the noble Lord, Lord Stevens of Birmingham, which I have also signed.

I follow up the point that the noble Earl, Lord Howe, talked about in terms of the fairness for those people who went into the application process last summer. They started this process with the expectation of getting a confirmation any time now and being able to prepare. That is why my Amendment 5 proposes to postpone the implementation of this speciality training prioritisation for this year’s intake, so that those people who are applying for 2027 know that we are changing the rules, rather than telling those people who applied last summer that we have changed the rules. Let me be clear from the outset: this amendment does not seek to undermine the principle of the objectives of this Bill on medical training; rather, it seeks to ensure that these objectives are implemented fairly, coherently and without unintended harm to the very trainees upon whom our healthcare system depends.

The central issue for us here has always been timing. As the Bill currently stands, these changes would be introduced during an active application cycle. This raises serious concerns about procedural fairness and legitimate expectations. Applicants have made life-altering decisions—academic, financial and personal—based on a set of rules that existed last summer when they applied. To change these rules mid-cycle, in my opinion, is not merely inconvenient but fundamentally unjust. Like many others, I have been contacted by affected medical students who have articulated their concerns around the criteria. They noted that they had complied fully with all the requirements enforced at the time of application, only to find themselves potentially excluded by the change that has now been imposed. Without transitional protections, the Bill would disadvantage applicants who acted in good faith, followed the guidance provided and had every reasonable expectation that the rules would not be rewritten half way through the process. This is not about isolated grievance; it reflects a systematic risk inherent in rushed implementation.

Medicine is a profession that demands long-term planning, with years of study, examination, placement and significant personal sacrifice. When Parliament alters the conditions of progression without adequate notice or transition, it destabilises that planning and erodes trust in the system. My amendment therefore offers a modest but proportionate and sensible solution: a one-year delay that would allow for clarity in communications and proper preparation. It would give institutions time to adjust their process, regulators time to issue clear guidance and applicants time to make informed decisions so that people who will be applying this summer know what the criteria are. Crucially it would also align with the principles of this House, which has long upheld fairness, legal certainty and an avoidance of disadvantage. We should be especially mindful of these principles when legislating in areas that directly affect access to professional training and career progression.

There is also the practical consideration. Disruption of the current application cycle risks creating gaps, appeals and bottlenecks that could ultimately harm workforce planning in the NHS. At a time when staffing pressures are already acute, we should really be wary of reforms that may have unintended consequences and might deter capable candidates. My amendment would not delay the reforms indefinitely, but simply ensure that reforms are done properly. By supporting this amendment, we would send a clear message that, while we are committed to improving medical training pathways, we are equally committed to treating applicants fairly and honouring the rules under which they apply.

We have heard about the immigration status mentioned earlier and the criteria on which that is based. With my Amendment 10, I would like to raise with the Minister the alternative option, given that the Government are also seeking to change the rules around indefinite leave to remain. My understanding is that there is a better option. The NHS has its own recruitment platform, the Oriel system, which is able to demonstrate professional commitment to the NHS. In doing so, it shifts the focus from legal residence status to actual service, contributions and engagement with our health system.

The NHS does not run, as we heard earlier, on immigration categories. It runs on people who turn up to shifts, who trained within its system, who understand its pressures and who have committed themselves to caring for patients day in, day out. The Oriel registration is not just a symbolic tactic; it is a gateway through which NHS recruitment, training and workforce planning operates. It is a clear, objective indicator that an individual is already participating in or seeking to participate in the NHS.

Similarly, the concept of professional commitment to the NHS allows for a broader and fairer assessment of contributions. It recognises work undertaken in the NHS trust, clinical placements, foundation training, research, teaching and other forms of service that directly benefit patients and institutions. This approach reflects reality far more accurately than a single immigration milestone, which may have little bearing on an individual’s clinical engagement or future commitments or intentions.

There is also a serious risk of equality issues at stake. Many doctors who have trained in the UK, worked in NHS hospitals, paid taxes and served our communities for years do not yet hold indefinite leave to remain, due to the structures and lengths of immigration pathways. To divert these such individuals despite their proven service risks sending a deeply damaging message that contribution is secondary to paperwork. At a time when the NHS remains heavily reliant on international medical students, we should be careful not to erect barriers that discourage retention or undermine morale. These clinicians are not temporary stopgaps; they are integral members of our workforce. Many intend to build long-term careers here and many already have.

From a practical standpoint, this amendment also improves administrative clarity. Assessing our registration and documenting NHS experience is straightforward, verifiable and directly relevant to workforce needs. By contrast, tying prioritisation to immigration status risks complexity, inconsistencies and unintended exclusion. If the aim of the Bill is to strengthen medical training and to support the NHS workforce, our criteria must align with that goal. This amendment ensures that prioritisation is based on what truly matters: demonstrated commitment to the NHS and the work that it exists to do. Therefore, I urge noble Lords to support both my amendments.

[Lord Stevens of Birmingham (CB)]

My Lords, I repeat my declarations of interest from Second Reading as chair of King’s College London and chair of Cancer Research UK, and as an honorary fellow of the Royal College of Physicians and the Royal College of General Practitioners. I am going to speak to my Amendments 9, 11, 24 and 25. I am most grateful to my co-signatories: the noble Earl, Lord Howe, and the noble Lords, Lord Mohammed of Tinsley and Lord Patel.

The Government, in my opinion rightly, want to prioritise for specialty training doctors who, among other things, have significant prior experience working in the NHS. They propose in the Bill that that would be an explicit criterion to be taken into account from 2027. So the principle is clear. The practice for 2026, however, is said in the impact assessment to be such that they cannot use that criterion for the current cycle. So, instead, a series of proxies are proposed which, in the words of the impact assessment, would

“capture applicants who we believe are most likely to have NHS experience”.

This set of amendments, which should be an easy pill for the Government to swallow, would simply give them the ability to apply in 2026 the same criterion relative to work experience in the NHS that they propose from 2027 onwards. I recognise that there may still be some discussions, as we just heard from the noble Lord, Lord Mohammed of Tinsley, about the executability of that criterion, using the Oriel system or other mechanisms. These amendments would not require the Government to bring forward their 2027 approach but simply permit them to do so if, in the weeks between now and 5 March, for example, if that is the deadline for when Royal Assent is required, it becomes clear to them that the modest enabling work on the computer software, estimated at £100,000, can be put in place if that were needed.

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[Baroness Merron (Lab)]

I cannot give an exact proportion, as the noble Lord is aware, but I have noticed that the proportion has changed as the Bill has progressed. As we have approached Committee, I have certainly seen more email traffic urging a non-amended Bill rather than an amended Bill. I would imagine that that is reflected in other emails. The noble Lord is indicating that it is not. I can see differing responses, but that has certainly been my impression.

The application of prioritisation to the 2026 intake is necessary and justified. If, as I referred to earlier, we waited until 2027, competition ratios are projected to rise even further, meaning that more UK graduates would be unable to progress their careers on time, with a greater risk to the long-term sustainability of the workforce. For these reasons, another year’s delay is not an option, and we cannot accept the noble Lord’s amendment.

Amendment 10, also tabled by the noble Lord, Lord Mohammed, also seeks to change categories of people who would be prioritised for specialty training places, starting in 2026, by virtue of having significant NHS experience or by reference to their immigration status. We cannot accept this amendment on the basis that the effect would be to prioritise every individual who applied for specialty training places in 2026 because all applicants are, by necessity, already registered on Oriel. This amendment would in practice nullify prioritisation for 2026 and render the legislation ineffective. It would not address the severe and growing bottlenecks in specialty training that the Bill aims and is designed to tackle.

The proposal to prioritise those who have demonstrated a professional commitment to the NHS also presents workability problems as there is no clear or objective definition of what such a commitment looks like, nor any reliable way to assess it for tens of thousands of applicants at this stage. Attempting to do so would be unmanageable in a practical sense and would introduce inconsistency, delay and uncertainty for applicants.

[Lord Stevens of Birmingham (CB)]

One objective proposition that has been suggested is two years of NHS experience, which, it is said, would be readily trackable on Oriel. Can the Minister confirm whether that would indeed be possible?

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[Lord Stevens of Birmingham (CB)]

My Lords, I speak in support of the thrust of the amendments in this group. I start by acknowledging the concern that I think is animating the Government on this point, which is that they do not want to see a thin end of a wedge that opens up substantially with a lot of newly created international programmes that then end up further displacing UK-trained graduates and undermining the ability to effectively plan the medical workforce of the future.

Fortunately, however, none of these amendments actually constitutes the thin end of the wedge—there is no wedge. As we have just heard, these amendments grandfather the current, very modest arrangements at QMUL Malta and Newcastle University, which are so numerically small, with a couple of hundred students relative to 12,800 for the other training programmes. So those are not the programmes that have caused the problem that the Bill is seeking to address, nor should they therefore be collateral damage as the Bill progresses.

As discussed at Second Reading, particularly in respect of Malta we have a long-standing relationship, and we have a series of diplomatic and other ties of bilateral agreement that the British Government and the Maltese within the last 12 months have renewed, which are of continuing and considerable significance to us, including on defence, security and other aspects. So the Government would be well advised not to throw the baby out with the bathwater and to take seriously the concerns that these amendments represent.

[Lord Mohammed of Tinsley (LD)]

I shall speak to the Amendments 15, 16 and 19 to add my support to the amendments on the issue of Malta from the noble Baroness, Lady Gerada, as well as Amendment 17 from the noble Lord, Lord Forbes, and Amendment 20 from the noble Earl, Lord Howe.

Given that we have had a substantial discussion on Malta, particularly from the noble Baroness, Lady Gerada, and the noble Lord, Lord Clement-Jones, I shall speak more towards Newcastle, forging the northern alliance that we may have—and more importantly because my mentor, the noble Lord, Lord Shipley, who cannot be here, made a particular point of visiting my office to say, “You are going to be speaking on Newcastle on Thursday, aren’t you?” So here we go.

The amendment from the noble Lord, Lord Forbes, would ensure that graduates from overseas campuses, and United Kingdom medical schools in particular, are treated fairly and consistently. I think that the amendment is precise and proportionate. It applies three conditions: first, that the primary medical qualification is awarded by a United Kingdom medical school—in this case Newcastle, but there will be others; and, secondly, that the qualification is obtained through study at an overseas campus that existed at the point of this Act being passed. The noble Baroness talked about potential creep when we discussed this last week in terms of other institutions being able to take advantage and open that back door. With this very timely amendment from the noble Lord, Lord Forbes, it is very clear that—

[Lord Stevens of Birmingham (CB)]

Is it the noble Lord’s understanding that there would be the opportunity for creep as is currently set out in the Bill? For example, if Queen Mary University of London wished to establish a medical school in Liechtenstein, which currently lacks one, it would be able to do so with an unlimited number of places. All those new students would then be passported into the NHS.

[Lord Mohammed of Tinsley (LD)]

The noble Lord, Lord Stevens, has given people ideas. Possibly, this could happen, yes.

Thirdly, both courses and study for the convocation are approved by the GMC as being equivalent to the UK medical qualification. This is not about lowering standards or creating a new route through the back door. On the contrary, this is about recognising the standards that already exist and are regulated by the GMC. The GMC is determined that these courses are equivalent in content assessment and outcome. It is difficult to justify why we should exclude them, given the numbers that we heard about earlier.

Universities such as Newcastle—and there may be others as well—rely heavily on this partnership. These programmes have not just happened overnight. They have existed for some time. They are run by UK institutions, aligned with UK curricula and assessed identically to UK standards and subjects. Graduates receive UK-awarded degrees, not foreign substitutes. Such programmes contribute to the NHS. Only yesterday, we heard from Newcastle University that they have had up to 150 students on their Malaysian campus. As we heard earlier, some of those students have come back to the United Kingdom and, in particular, have served for many years as GPs when we have had an acute shortage. We need to take heed of that contribution and also the long-standing relationships that exist both with Newcastle and Queen Mary.

We are only asking for a very small change. We are not asking for tens of thousands of students to come here. We are asking for a small number through long-established partnerships that have existed and stood the test of time. We are asking the Minister for some flexibility. This is being heard from all sides of your Lordships’ House. We are about to go on a holiday. I hope that the Minister will take this time to reflect on our debate and come back on Report with government amendments that we can all support. I look forward to the debate that we are going to have in less than a fortnight’s time.

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[Lord Stevens of Birmingham (CB)]

I want to come in on the point about whether or not the UK Government would lack the ability to control the expansion of international places in the grandfathered campuses. Is it not the case that, in fact, the UK Government do have such a tool at their disposal, through the Office for Students? The OfS has to agree the number of undergraduate medical places that a university can operate here in the UK and can cap those, and could therefore introduce an off-setting mechanism so that any additional place created outside the UK would see a reduction in the UK authorisation. That would be incentive enough, I suspect, to ensure that universities did not behave in the way that the Minister is concerned about.

[Baroness Merron (Lab)]

The noble Lord kindly raised this with me before, and I did test it out. I am grateful that he has given thought to this, because it is an important point. However, I am advised that, unfortunately, the solution that he has come up with would not deal with all the concerns we have and would still give us difficulty. The noble Lord talked about the thin end of the wedge, and I fear that we are still in the same place. I am happy to write to the noble Lord, and to make that letter available, to explain further detail. I am grateful that he has given consideration to a solution for what is undoubtedly an issue.

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[Lord Kamall (Con)]

My Lords, in speaking for the first time in Committee, I refer to my interests as a professor of politics and international relations at St Mary’s University, Twickenham, where I teach an MBA module on healthcare policy and strategy, and where I also co-operate with the school of medicine, which will start accepting students later this year. I also work as an honorary fellow at the Vinson Centre for the Public Understanding of Economics and Entrepreneurship at the University of Buckingham, which also has a medical school but with which I have no direct connection.

I tabled Amendment 22 to facilitate a wider debate on the level of provision of medical training places and its impact on the outcomes for doctors and, by extension, patients, as well as the need for regular review. We all agree that the NHS and other health providers need highly qualified staff if they are to deliver the quality care that people expect of them, but that means that policymakers should seek to establish an education system that encourages young people to see the benefits of medicine as a career path, supports those going through medical training every step of the way and removes barriers to those who want to be doctors. As my noble friend Lord Howe said earlier, currently, too many young doctors reach the point at which they need to secure a medical specialty training place but find themselves disappointed, either because they are unable to access a training place or because the training place they are able to secure does not meet their needs.

A 2023 study by Tomas Ferreira on the career intentions of medical students found that many medical students finishing their foundation programme do not intend to take up medical specialty training places. The report says

“we report an increase in intention to not take up specialty posts immediately after the Foundation Programme, with an increase from 6.75% … of first-year students to 35.98% … of final year students. A contributing factor to this scenario could be a significant increase in competition ratios for specialty training posts, partly due to increasing medical student places and no corresponding increase in the number of training posts available”.

The lack of specialty training places to retain those medical students within the NHS is a challenge that the Government and we all face—something, I concede, we realised perhaps too late when we were in government. If the issue is not tackled, we will continue to see talented young doctors who might otherwise prefer to stay in the UK and work within the NHS, and maybe other health providers, leaving the UK to complete their training elsewhere.

The Government have announced their offer to the BMA to expand specialty training posts by 4,000, with 1,000 of them brought forward this year. That expansion in training places is welcome and necessary. I ask the Minister to confirm whether there will be any delay in their delivery and whether they will be delivered this year.

In May last year, I tabled a series of Written Questions on resident doctor medical training places, and the responses showed that very small numbers of training places are available in some regions. For example, in 2024, just one medical oncology specialist training stage 3 post was offered in the whole of the north-east region. The figure for the Wessex region was two places. For the earlier specialist training stage 1 posts in gynaecology, the Wessex region had just 11 places in 2024, while the whole of the south-west region had just 16 of those places. Can the Minister say whether those numbers are meeting the needs of those regions and whether there is a gap? What are the key factors that restrict the number of training places that can be offered in those regions?

The overall number of training places is probably the most important challenge young doctors face, but there are other considerations that affect talent retention. The geographical distribution of training places is also something that we all know needs attention. Last month, the Government announced that they will introduce new training places targeted at trusts with the biggest workforce gaps, prioritising rural and coastal areas, where patients currently struggle the most. We welcome that. That is good news. But, in designing this policy, I ask the Minister what assessment the Government have made of the number of medical students who actually want to train in these rural areas and whether that is a factor in some UK medical graduates choosing to go abroad or is irrelevant.

In response to concerns from the BMA about the challenge of doctors having to cover the upfront cost of their training, the Government have offered cost-related measures in their offer to the BMA, including reimbursement of exam fees. I ask the Minister for a little transparency and to give the Committee more detail on how reimbursement would work if the BMA were to accept that offer.

I hope that the Minister is able to answer these questions, either today or later in writing. I assure her that we look forward to working constructively with the Government as they face up to these workforce challenges. I beg to move.

[Lord Stevens of Birmingham (CB)]

My Lords, to help the Committee to assess the need for this further report that the noble Lord, Lord Kamall, just set out, it would be helpful if we could hear from the Minister when the Government will produce their replacement long-term workforce plan for the 2023 edition, which itself was deemed to be long term but ended up having a half-life of less than two years. How imminent is that and will it deal with the sorts of points that the noble Lord, Lord Kamall, rightly brings to our attention? When will we see the follow-on to the excellent Medical Training Review: Phase 1 Diagnostic Report, authored by the Chief Medical Officer and the previous National Medical Director of NHS England, published in October, which sets out these issues extremely well? The clue is in the title: it is the diagnosis. But when do we get the prescription? When does the treatment begin?

In a sense, the problem that we are dealing with through the Bill—again, as the noble Lord, Lord Kamall, just set out for us—owes its antecedents to the disconnect between the provision of NHS services and the ability to make smart, long-term workforce decisions. Unfortunately, for the period 2012 to 2022, those decisions on medical training were outwith the NHS and in effect were being controlled by the Treasury, which was constantly saying no to Health Ministers who were at the time trying to bring forward constructive solutions. Indeed, it was only when a former Secretary of State for Health became Chancellor that the situation was unblocked and we got the medical school expansion. Perhaps that is an inspiring example for the current Health Secretary—I do not know; perhaps he aspires higher. The fact is that we need that whole-government engagement on these kinds of questions to bring coherence and deal with these problems at root. Therefore, in responding to the noble Lord, Lord Kamall, any light that the Minister can shed on when precisely we will have line of sight to these sorts of questions would be, I think, of great benefit to the Committee.

[Lord Clement-Jones (LD)]

My Lords, I support Amendment 22, standing in the name of the noble Lord, Lord Kamall. He absolutely made the case but, having heard what the Minister had to say on the previous group, I have a terrible certainty about what her response will be.

I assure the Minister that many of us want to find solutions, in the way that the noble Lord, Lord Stevens, mentions. The principles of the Bill are supported across the Committee; it is some of the detail that is in contention. We must be honest that the Bill deals with the symptom—competition ratios—not the cure, which is the bottleneck of insufficient specialty training places. I go back to the phrase that the noble Lord, Lord Stevens, used at Second Reading. We are simply reshuffling the queue.

This amendment places a necessary duty on the Secretary of State to review the adequacy of training places. We have received warnings from doctors in shortage specialties such as psychiatry and general practice, who fear that the Bill will drive away the international talent that we rely on. We need to know whether this legislation will succeed in retaining UK graduates or whether it will inadvertently exacerbate shortages by signalling to the global medical community that the NHS is closed for business. We cannot manage what we do not measure.

Medical Training (Prioritisation) Bill

Lord Stevens of Birmingham Excerpts

2nd reading
Wednesday 4th February 2026 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, I declare an interest as an honorary fellow of the Royal College of Physicians and the Royal College of General Practitioners, and as chair of the council of King’s College London, which is Europe’s largest educator of health professionals. I too congratulate the noble Lord, Lord Roe, on his excellent maiden speech. Given the deteriorating physical fabric of the Palace of Westminster, it is reassuring to know that we have a firefighter in our midst.

I start by endorsing the thrust of the policy set out in the Bill. It clearly makes sense for the NHS and for British taxpayers to properly connect undergraduate medical education with access to specialist training, and then the flow-through of doctors able to contribute over the balance of their careers to the work of the NHS. All that makes total sense. Nevertheless, I echo three of the concerns we have heard already in the brilliant contributions to this debate.

The first is about the difficulties and concerns around the transition year, 2026, that the Bill proposes. For 2027 and beyond, rightly, there is the suggestion in the Bill that applications will be prioritised from doctors with NHS experience, who have made a contribution to the NHS. But because of not being able to get the computer system right, that is excluded for the 2026 transitional period.

As we heard from, I think, the noble Lord, Lord Clement-Jones, there is a range of views that suggest that that is not a correct assessment. I think the impact assessment says it is £100,000 to sort out the Oriel computer system—against a £4.3 billion taxpayer expenditure in this area. This is an area where the Minister and the Minister in the Commons, Karin Smyth, might want to give officialdom a little tap and just double-check that what they are being told is right, not least because there is a degree of oddity about this in that the Government declared their intention to introduce this new prioritisation for UK graduates seven months ago. It was in the 10-year NHS plan published on 3 July. It is not completely clear why there has been a seven-month lapse before we get this emergency Bill that has to be passed within four weeks.

There is the transitional 2026 concern and then, relatedly, there is the question of whether, by just changing the prioritisation, the Government actually have a game plan to deal with the more fundamental, underlying problem of the bottlenecks. This piece of legislation by itself does not widen the bottlenecks, it just changes who will occupy them. As the noble Earl, Lord Howe, I think, asked, it would be very useful to know, of the 1,000 additional specialty training places over three years promised in the 10-year plan, or the 4,000 put on the table in December as part of the Government’s negotiation with the BMA—of which 1,000 extra were to be in place for the coming year—what is their current assumption about the expansion in specialty training that will go alongside this reprioritisation for 2026 and 2027?

Today, we have seen the publication of the cancer plan, which, quite rightly, says that the Government

“will work with the Royal Colleges to encourage resident doctors and internal medicine trainees to specialise in clinical and medical oncology”—

where there are significant shortages—and will prioritise

“training places in trusts … where vacancy rates are higher and performance is lower”.

Can the Minister tell us whether the Government will give effect to that commitment in the cancer plan with the 2026 and 2027 increases in specialty training places, which are clearly required?

To circle back to a point that the Minister made—and, indeed, the Health and Social Care Secretary made at Second Reading in the Commons on 27 January—the Government’s estimate appears to be that even with this tighter, or reshaped, prioritisation, there will still be a ratio of two applicants to every place for specialty training. Just stand back a moment—that means we will be turning away half the doctors who would be able to fill those places. Are the Government sure that they are going pedal to the metal on the expansion in specialty training to reduce that oversubscription rate?

How does that connect with the upcoming rebadged, or refreshed, long-term workforce plan, given that the undergraduate doctors who start their training this year will be, in practice, coming out to deliver clinical care as consultants from 2040 and training their successors up to 2070? We really do need a long-term plan here, rather than the constant chopping and changing that, sadly, we have seen.

Finally, I completely endorse the comments about Malta. Three collective institutions have been awarded the George Cross—Malta and the NHS are two of them. We should sustain those relationships. The idea that we have less in common with the Maltese than with the good people of Liechtenstein—I have just had a quick look and Liechtenstein has one 35-bed hospital and a per capita GDP more than three times that of the UK—misses the point. We have to see the wood for the trees; the Department of Health and Social Care needs to raise its gaze and value these historic relationships that are so important for us.

Terminally Ill Adults (End of Life) Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Friday 30th January 2026 Lords Chamber

I hope the sponsors of this amendment might consider a redrafting that takes account of these fundamental differences, retaining access to helpful diagnostic tools while excluding a general-purpose superintelligent AI, still to be developed, from a decision-making process that properly resides in human agency.

[Lord Stevens of Birmingham (CB)]

Essentially, I agree with the right reverend Prelate the Bishop of Hereford. I could almost leave it there, but I will briefly say, in the spirit of the amendments, that the tablers are right to raise general concerns about the possibility of abuse through bias—as we heard from the noble Baroness, Lady O’Loan—and hallucination. After all, we have had the first high-profile resignation of a public sector leader in the form of the chief constable of the West Midlands praying in aid the fabrication of a non-existent football match as the reason why Parliament was misled.

In addition to bias and hallucination, there is the risk of what is called scheming. The results from some of the LLMs—published, for example, in the journal Nature in October—show some pretty disturbing examples. In the article, headed “AI Models that Lie, Cheat, and Plot Murder”, there are examples where models have attempted to write self-propagating worms, fabricate legal documentation and leave hidden notes to future instances of themselves. The punchline, essentially, is that, in regard to some of these technologies,

“the world is in a lucky period in which models are smart enough to scheme but not smart enough to escape monitoring”.

That is scary because, in five years’ time, that may no longer be true. So there are good reasons for generalised concerns about AI and wanting to circumscribe the role it might play in this legislation.

However, for the reasons that others have mentioned— I suspect the noble Baroness, Lady Coffey, herself would accept this—this probing amendment is written too broadly. It says:

“Artificial intelligence must not be used to carry out any functions in any section or schedule of this Act”.


Given that, for example, under Clauses 5(5) and 12(2), a doctor has to discuss with a person their diagnosis, their prognosis, any treatments available, the likely effects of them, and palliative, hospice and other care, it is highly likely that those will be informed by machine learning. It will interpret, for example, CT scans or MRIs, and AI tools will personalise and optimise therapies, potentially with predictive AI for better prognosis. So, were this to come back on Report, there would be a good case for ensuring greater precision in the firepower that is aimed at this particular concern.

However, all that should not in any way excuse or divert us from an equivalent worry: we must not kid ourselves that the gold standard is human expert judgment on many of the questions posed by the Bill. As we discussed, Clause 2(1)(b) requires an assessment of whether somebody with a terminal illness will live longer than six months. Unfortunately, as we have heard, that turns out to be a clinically irrelevant threshold that is very hard for expert judgment to get right.

I have just pulled the data from a large study looking at 98,000 people across London over the last decade and at prognostic accuracy, and the answer was that clinicians were able to be accurate about whether somebody was going to live for two weeks with about 74% accuracy, and they were able to be accurate about whether somebody was going to live more than a year with 83% accuracy, but, in terms of being able to predict whether somebody is going to survive for weeks or months, accuracy was only 32%. So, whatever our concerns about AI, human expert judgment, which underpins the Bill, is itself highly fallible.

[Lord Markham (Con)]

To follow on from that, as my noble friend said right at the beginning, the amendment was put down in such a blunt fashion absolutely to stimulate this sort of debate. What has been really useful in this debate is finding that there is a broad degree of consensus that AI can be valuable as an input to decision-making, but it should not be used as the output: as the final decision-maker. As mentioned, AI can detect the progression of cancers and can probably do better prognosis or improve, especially over the time that we are looking at here, so that you can get better assessments of how long someone is likely to live.

On the AI in the chat box, there are very many instances where it could be very useful in terms of detecting coercion if it is talking to someone over quite a long period of time. Therefore, in all of this we see that, with inputs to the decision-making process, AI has a valuable part to play, but I think we would also absolutely agree that the final decision-maker in terms of an output clearly has to be a human; obviously they will be armed with the inputs from AI, but the human will make the final decision. I think that is what the Bill does, if I am correct, in that it is very clear that the decision-makers, the panels, the doctors and everything are those people, but at the same time—although I guess the Bill is silent on this—obviously it enables AI as an input.

I hope this debate is useful in that it shows a degree of consensus and that in this instance we probably have the right balance, but, again, I would be interested to hear from the Bill sponsor in his response whether that is the case.