Health Bill

Baroness Barker Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[Baroness Grey-Thompson (CB)]

My Lords, I will speak briefly on this group of amendments because they have an impact on amendments that I have in other groups. I read with interest Amendment 45 in the name of the noble Baroness, Lady Coffey, which seeks to ensure equitable palliative care regardless of wealth or geography. I am not entirely sure whether disability would be included in this, but I am keen that disabled people are not forgotten in the Bill.

Last week I spoke to an organisation that works with wheelchair users. It was a very worrying conversation about the impact on general NHS services and specialist services from changes in spinal units and the support they give people who have had a traumatic accident, and about the lack of accessibility to a number of services that we take for granted, particularly breast cancer screening and smears. A number of disabled women have been in contact with me to say that they have been refused those basic treatments because they are disabled or because of the inaccessibility of the machines. I have had to have several mammograms over the years, and the machines are just not designed for somebody who cannot stand. Last time I had one, three nurses had to lift me up into the machine, which was not particularly easy or useful, but they managed to make it work for me. I am worried about the number of people for whom it is not made to work, who might end up in palliative care services far earlier than they need to because of the lack of treatments they are able to access. The postcode lottery is layered on top of that. I am keen that there is a real understanding of the quality of life of disabled people as part of this, to ensure that they get the right support at the right time.

It is really difficult to discuss this Bill without mentioning my recent experience of three stays in hospital since August. The first and second times, I had cellulitis. Interestingly, the papers that I took home with me when I was released the second time had my DNAR status on them. Luckily, it said “no”, but it was interesting that that was not discussed with me; I would not have expected to have that discussion, based on the condition I had, but a number of disabled people worry when their DNAR status is put on their documentation with or without a discussion.

That leads to Amendment 230 in the name of the noble Baroness, Lady Pidgeon, and the conversations it would require. Whether it is one conversation or many, it is about making sure that the right time is made available so that they are properly carried out. In this group, I am keen to focus on the specialist aspect of palliative care: it is about not just generalist education but making sure that we are absolutely able to raise the bar for the specialist palliative care that is available to everyone, to make sure they get the right support at the time they need it.

[Baroness Barker (LD)]

My Lords, like the noble Baroness, Lady Morris, I spend a lot of time sitting on the Woolsack. I did not take part in the debates on the assisted dying Bill; I could not, because I was caring for somebody who, as I said at Second Reading, died in June. I am actually very pleased that I did not take part, because I do not think that I could have done so with the composure required. I listened to a lot of the debates, and that Bill did a substantial amount of damage to this House in many ways.

One of the things it did was to damage the reputation of the House among carers’ groups, because several speeches on that Bill really denigrated carers—“some carers”, I imagine the people who made those speeches would say—leaving the impression that many in this House believe that carers can be unfeeling and mercenary, without any evidence to substantiate that. When we go on to look at what happened with that Bill, as we must, we will need to think carefully about things like that.

I say that because my experience and the experience of my wife was completely different from that. My wife was diagnosed with a condition that she knew would be terminal. At the point that that happened, she made her advance choice direction and she stuck to it; she did not want to be resuscitated. My experience and hers—she was always in charge, as far as I was concerned—was that every healthcare professional she came across asked her about that. They did not argue about it but, time and again, they asked her whether she still wanted it. She was quite clear; her statement was as clear as it could be. Yes, she would be treated for something that was treatable and could be reversed but, no, she did not want to be revived if she was dying.

--- Later in debate ---

[Baroness Gerada (CB)]

My Lords, I also welcome the amendment tabled by the noble Baroness, Lady Shawcross-Wolfson. I will speak to Amendment 253, which is in my name. Before I do, I will say that when I started in general practice in 1991, 80% of the GP workforce were men. We now have a reversal of that, so part of the issue is the feminisation of the GP workforce. Women get pregnant and care for small children and our elders. This was predictable. When I was a GP leader, I said that we needed to replace every retiring male GP with 2.4 GPs—men and women, for various reasons. Nevertheless, I digress.

I will speak on district nurses, who are our generalist practitioners in patients’ homes. I will paint a little picture. It is a wet Tuesday evening in November and somewhere in a village, town or city near any of us a district nurse is parking outside a terraced house. Inside is an elderly man with a leg ulcer that will not heal. Down the road there is a woman with diabetes who cannot manage her insulin on her own. A few streets further on a family is sitting with their mother in her final days, frightened and exhausted. The district nurse is the only one who can put up a syringe driver. This district nurse will visit them all. She will dress their wounds, check their blood, ease their pain and hold their hands. Tomorrow, she will do it again. District nurses are there every day of the year, in every corner of this country, at almost every hour of the day and night.

Successive Governments have promised to shift care out of hospitals and into the community. This Government have done the same, and I welcome that. But that shift will be extremely difficult without district nurses. They are not an optional extra; they are the linchpin. Neighbourhood health without district nurses is a building without a foundation. As the Nursing and Midwifery Council has said, district nursing is key to the achievement of the shift in healthcare that this Government seek.

I will remind your Lordships of some of the figures—we have heard a lot of figures today, so I will cut them back. According to analysis by the Nuffield Trust, in 2009 there were some 7,600 full-time equivalent district nurses in the NHS. By 2024, there were 4,322, a fall of 43%. Put simply, for every seven district nurses we had in 2009, we now have four. Over the same period, the number of adult nurses working in hospitals rose by 43%. The contrast is striking. We have said that we want care closer to home, but our workforce has continued to develop in favour of the hospital.

Some will say that this is an artefact of how we count the data because, around 2011, some community services moved to voluntary and independent providers, and some district nurses consequently stopped appearing in NHS figures. That is true, but it does not explain a decline that has continued over 15 years. The picture is even more concerning when we take population growth and ageing into account. On that basis, district nursing has fallen by 55%. The decline is continuing. The Care Quality Commission’s latest State of Care report found that the number of qualified district nurses fell by a further 5% between 2024-25 and 2025-26.

The problem is not just numbers; there is also the question of skills and experience. More than one in four of those recorded as district nurses are employed below band 6, which is the grade at which qualified district nurses would normally start. So we are losing not just numbers but the expertise on which this whole community service depends. What does this mean for patients? When district nurse teams are stretched, the first things to go are the things that matter most and are seen least: psychological support, prevention—such as looking at trip hazards and adequate lighting—and continence care. That care is now too often delivered less well, not delivered at all or pushed on to services that are already at breaking point. Investing in district nursing is not simply an investment in better care; it is an investment in preventing avoidable deterioration, unnecessary hospital attendances and expensive admissions.

The pressure is set to increase further. The Nuffield Trust estimates that the demand for district nurses could rise by 34% by 2040, based on the projected population numbers. So demand has grown but the service has contracted. This is not a failure of district nurses, who have held the line with extraordinary dedication. It is a failure of planning, as we have heard, as well as priorities and political will. That is exactly why this amendment matters. We cannot keep promising to move care into the community without first asking how many people we need to deliver it.

District nurses are indispensable. We cannot deliver neighbourhood health, safely shift care out of hospitals and provide dignified care at home without a properly trained and adequately staffed district nursing workforce. We know what happens when plans fail, and we will see the numbers of patients admitted to hospital. My question to the Minister is: will the Government commit to assessing the number of district nurses needed to meet current and projected demand, identifying the shortfall and setting out a funded plan to address it?

[Baroness Barker (LD)]

My Lords, I will add to what the noble Baroness, Lady Gerada, said. A very high percentage of our district nurses come from other countries. Therefore, what will the Minister do, talking to the Home Office, about the supply of district nurses that we will undoubtedly need in the future?

I will make one or two brief points, following on from what the noble Baroness, Lady Harding, said about planning. If any member of the Committee has spoken to anybody currently employed by an ICB, they will know that seared in their minds is the date on which they were told, about 18 months ago, that their jobs were going to go. For the last 18 months, they have continued to work under that threat. I do not know any other employer that would do that to a workforce and expect to retain it. I talked to members of staff who work for ICBs. I had the misfortune to ask them, “How are you?”, and 25 minutes later I knew how they were—it was not good. I rather suspect that the biggest demand for mental health services at the moment is coming from members of NHS staff, because they have been living with this uncertainty for 18 months.

I am not being flippant but, if the Minister cannot share great detail with us, can she at least tell us the Government’s working assumptions about the number of staff there will be in the future who are members of ICB staff now? I suspect that the attrition rate will be enormous, especially given the age profile of some members of ICB staff, in particular, who have built up specialist expertise over many years. Secondly, what working assumptions are the Government making about members of staff, particularly nursing staff, who will move out of the acute sector and into the community?

[Baroness Pidgeon (LD)]

My Lords, since taking over as our spokesperson, I have lost count of the number of times the Minister has talked about the workforce strategy that will at some point emerge from the department. I am not sure whether we will be given a season this evening, but hopefully it will be published soon.

My Amendment 253, which the noble Lord, Lord Stevens of Birmingham, and the noble Baroness, Lady Gerada, have added their names to, would require the Secretary of State, within 12 months of Royal Assent, to publish

“a health and care workforce strategy for England”.

I have included “care” on purpose because the two are so importantly linked. It must assess the staff needed to meet current and projected demands, expressly including registered nurses and primary care practitioners, and it must contain a funded plan to close staffing gaps. Annual progress reports would be laid before Parliament, keeping that issue on the agenda for us all. Putting staff in is an important marker too. We need to properly plan and invest in our workforce, both health and care, hand in hand.

The Royal College of Nursing supports this amendment, as do a number of representatives of primary care. Too often, primary care seems to be forgotten in the debate on workforce, but it is critical: GPs and district nurses—we have just heard passionately from the noble Baroness, Lady Gerada, about their role—as well as optometrists, dentists and pharmacists. As the Government look to shift services into neighbourhoods and hospitals—something I think we all support—this is really important. The early years workforce is important as well, as are health visitors.

The other amendments in this group, including that of the noble Baroness, Lady Shawcross-Wolfson, all require similar reports, perhaps on different timescales. Some are focused on really important areas such as the mental health workforce, the education and training that is needed alongside a workforce plan, and continuing professional development. Noble Lords have flagged the current vacancy rates in a number of roles, as well as skills shortages and the need for independent scrutiny of the workforce plan.

My noble friend Lord Scriven rightly stressed, using his personal family experience, the need for nurses for people with learning disabilities and the investment in that workforce, as well as the need to understand the whole workforce, looking at models in, for example, the Netherlands. The noble Lord, Lord Stevens, and the noble Baroness, Lady Gerada, talked about the complexity around primary care and the challenges with part-time workers, with perhaps more women coming into the workforce, as well as the challenges of work-life balance. Some people want to work part-time rather than full-time. These are key questions for the Government on this issue of workforce. I look forward to a comprehensive response from the Minister, and possibly a date, a season or a hint of when we might at last see that workforce strategy.