Health Bill

Debate between Lord Stevens of Birmingham and Baroness Coffey

Committee stage
Monday 9th November 2026 Lords Chamber

[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.

--- Later in debate ---

[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.

Health Bill

Debate between Lord Stevens of Birmingham and Baroness Coffey

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[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.

Terminally Ill Adults (End of Life) Bill

Debate between Lord Stevens of Birmingham and Baroness Coffey

Committee stage
Friday 27th February 2026 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, contrary to Amendment 129, I think that the Bill gets it right in requiring, at Clause 4(3), that the voluntary assisted dying commissioner must hold or have held office as a judge of the High Court, the Court of Appeal or the Supreme Court. This is quite clearly not a medical role. Its principal functions are to ensure that the statutory processes and safeguards that Parliament would have established are being adhered to.

However, we have to accept that a postholder having been a judge does not automatically mean that they will not come with personal views about the scope of the law that Parliament has passed. Therefore, the debate that the Committee has just had on how to make sure that there is transparency about the views that such an individual might hold before their appointment is ratified has merit.

For example, I was very struck by an important interview that the noble and learned Baroness, Lady Hale of Richmond, the former President of the Supreme Court, gave in Prospect magazine in December 2024. She recorded that, in the case, for example, of Tony Nicklinson back in 2014, who wanted it to be declared that it was lawful for people to assist him to take his own life because he had a disabling illness but was not terminally ill, two Justices of the Supreme Court

“would have been prepared to make a declaration that the current law on assisting suicide was incompatible with the Human Rights Convention”.

She went on to say:

“There were nine of us on the court. Of that, five of us took the view that when the time was right, the court might make such a declaration of incompatibility. But three of those five thought the time was not yet right”.


I infer from that that—at that particular point in time, anyway—five Justices of the Supreme Court would have taken the view that the Bill before us, if passed by Parliament, would fall foul of their reading of the European convention.

It is helpful to think about the mechanisms by which Parliament could know the views of such judges, were they to be put forward for appointment as the voluntary assisted dying commissioner. The thrust of Amendment 127 in the name of the noble Lord, Lord Beith, therefore has merit. It would require, for example, pre-appointment hearings by one or more Select Committees in the House of Commons, which would give us an opportunity to probe these questions and make sure that a nominee was going to stick to the faithful implementation of the legislation that Parliament, after such careful deliberation, would have produced, rather than, for example, interpreting the role of the voluntary assisted dying commissioner as in some way akin to that of the Children’s Commissioner, which is clearly an advocacy role for the rights of children.

[Baroness Coffey (Con)]

My Lords, this is a really important clause and a really important schedule. This is the one time when a judge, whether they are current or retired, will be involved in any of this process after the Commons chose to strip judges away from the original proposal. I have tabled stand part notices opposing Clause 1 and Schedule 4 because I would prefer a judge-led process; I have a lot of sympathy with what the noble Lord, Lord Carlile, articulated several weeks ago.

Let me say at the start that I disagree completely with the idea from the noble Baroness, Lady Cass, that this role should start to become like that of the Children’s Commissioner, the Victims’ Commissioner or similar. That is simply not the case, and not only because the legal powers in the Bill—in Clause 18, in particular— are where they must make judgments on whether there have been errors of law in the panellists’ determination. I am very keen, which is why I have tabled Amendment 913ZD, for us to get this back in focus, particularly in terms of the commissioner’s role, and to think about this person being a judge, not the Secretary of State.

I agree that it should be the Lord Chancellor so, to some extent, I agree with the noble Lord, Lord Beith, that Select Committees of Parliament should be able to go through this process as well; it should be the Ministry of Justice and the relevant committee in the Commons. There is precedent here. I think it was the noble Lord, Lord Tyrie, who managed to get a determination role for the Treasury Committee so that it had, in law, a power of veto on the appointment of the chair of a body; I think it was the CMA, but I cannot quite recall it right now. So there is a precedent in this regard.

I agree with what the noble Lord, Lord Stevens, just said. The Bill is right, in that it should be a retired judge. There are a lot of views and a variety of opinions on this. So far, only one retired judge, as far as I have been able to ascertain, has come out publicly against the Bill. Those who have expressed views are, as has just been articulated, very much in favour of the Bill; in fact, they think it should go a lot further. So some sensitivity will be required by whoever gets to make the decision on who the commissioner should be.

My noble and learned friend Lord Garnier would like this role to be done by His Majesty. There is a certain irony there. It is good to see so many Lords Spiritual here. I did try to see whether I could table an amendment to strip out, at the very beginning of the Bill,

“with the advice and consent of the Lords Spiritual and Temporal”,

but the Lords Spiritual have already been very clear that they do not, and will not, consent to the Bill. Why, then, should we put the onus to make this appointment on the Supreme Governor of the Church of England? I appreciate that there have been some difficulties with the current Prime Minister and his appointments recently, but I would be surprised if anything quite so careless happened again with future appointments concerning this or other approaches. More broadly, I support their proposals to get this into the public appointments process.

On Amendment 134, I support my noble friend Lord Moylan completely in trying to prevent mission creep. That is a risk, which is why I have tabled Amendments 913ZA to 913ZD and 914A to 914C as probing amendments. Schedule 1 to the Bill says that, basically, the Secretary of State will hand over as much money as they see fit. They will decide on pay and pension arrangements and will give people offices—all the things one might expect of a sole corporation. As far as I can tell, none of the employees will be civil servants, unless they are seconded civil servants.