Health Bill

Earl Howe Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[Earl Howe (Con)]

My Lords, the Committee will undoubtedly be grateful to the noble Lord, Lord Hunt, and the noble Baroness, Lady Tyler, for bringing forward these important amendments and for highlighting the vital contribution that unpaid carers make to our health and care system.

It is an obvious truth, but a truth worth stating, that carers are the people who know the person they care for best. They provide not only practical support but continuity, reassurance and an understanding of individual needs that can make a real difference to the quality of care. I very much welcome the recognition of the key role that carers play and the need to ensure that they are, first, identified—as many noble Lords have emphasised—and then listened to and appropriately involved in decisions about the people they support, while at the same time respecting the wishes and rights of patients themselves.

Carers are often family, friends and neighbours, and they usually do not foresee the duty happening upon them. They demonstrate the most admirable qualities in fulfilling that duty. The pressures that caring responsibilities can place on individuals and families are frequently very considerable, which is why we must never lose sight of the need to support carers’ own health and well-being, including opportunities to take a break from caring, as the noble Baroness, Lady Pidgeon, mentioned.

Amendment 21 would enshrine the right of carers to be involved in patients’ decisions, which seems eminently sensible and right. Carers, with patient consent, already have the right to be involved in discussions with clinicians. At the same time, clinicians will always need to make a judgment according to the situation, because it is just as important to go back and check the wishes of the patient and to make sure, for example, that they have privacy when they want it. Without wishing to downplay in the slightest the value of these amendments, it would be helpful to have confirmation from the Minister that a patient has the right to withhold from a carer sensitive information in their medical records that they might not want shared.

We will be debating the Government’s proposals for a national care service in a later group, but I wonder whether the Minister can give us a sense of how the Government view the position of unpaid carers in the context of those proposals. In what way do they think a national care service could or should affect the status of family carers? I ask because, with the concerns that noble Lords have raised during the debate, it seems doubly important that we do not inadvertently sideline or devalue the extraordinary contribution to society, and indeed to the economy, that unpaid carers make, or overlook the practical support and respite that carers need.

Unpaid carers are the backbone of so much of our health and social care system. Carers can be of any age. My noble friend Lord Young of Cookham rightly emphasised the role of young carers. Their contribution is immense, as are the burdens they carry, yet so often those things go unseen. Caring is a profoundly challenging role that, over time, will undoubtedly affect a person’s mental and physical health. The support for carers that noble Lords have so often called for can come in different forms: the noble Baroness, Lady Watkins, referred to the vital importance of respite and the part that care homes play in providing it. My noble friend Lady Morris has just reminded us that there are many great charities operating in this field. I wonder whether the Minister could give us a sense of what the Government’s vision is for how such support and respite should be delivered: whether they see it as primarily a role for the state or whether there is a broader palette of provision that is right and sensible to avail of.

Whatever the future structure of our care system, we must not lose sight of the people who give so much to care for others. Their voices and needs must be recognised.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, I am most grateful to my noble friend Lord Hunt and the noble Baroness, Lady Tyler, for initiating this important debate about carers, and indeed health and care partners. The points that have been made in the debate on this group were well made and well heard, and I know they are very much rooted in personal as well as professional experience. I too pay tribute to the vital work that carers, friends, families and neighbours all do to support their loved ones, often in the most challenging circumstances. I particularly note the reference to young carers by the noble Lord, Lord Young, the noble Earl, Lord Howe, and my noble friend Lord Hunt.

I turn first to Amendments 21, 214, 173 and 174, in the name of my noble friend Lord Hunt. Integrated care boards have an existing duty to promote the involvement of patients, and their carers and representatives, in decisions relating to their care or treatment. To the point the noble Earl, Lord Howe, has just raised, carers are the patient; they are the key person and they have control, as long as they are able, to make decisions about what is appropriate and what is not, as is usual. In addition on these particular amendments in this group, local authorities are required by the Care Act to have regard to the importance of people participating in decisions and being provided with information. I point out that the Health Bill also introduces a duty on integrated care boards to promote opportunities for visiting and a duty for local authorities to have due regard to the importance of individuals being able to involve other people in decisions about their care and about being able to receive visitors.

Regulation 9A already provides legal protections by placing a duty on care home, hospital and hospice providers to facilitate visits and accompaniment in a way that meets the person’s needs. As I just said, at the centre of all this are the needs of the individual. To clarify, a visit includes somebody providing physical support or companionship in person, and encompasses the support envisaged from a health and care partner.

My noble friend Lord Hunt and the noble Baroness, Lady Finlay, raised this matter in the earlier part of the discussion. The existing legislation intentionally avoids establishing a distinct term of “health and care partner”, simply because a single definition may not appropriately reflect the range of relationships that there may be and those that apply across different health and care settings. Also, the reference in Clause 57 to “other people” encompasses family, friends and carers and would already include a health and care partner.

The proposed amendments may inadvertently constrain how contact and support are provided and would inadvertently fail to provide for exceptional circumstances where offering support becomes a significant risk to the health, safety or welfare of a person using the service or on the premises. Instead, we are building on existing protections through non-legislative measures, including through the development of the NHS health and care partner policy. I hope that will meet the intentions behind these amendments.

Amendments 89, 175 and 176 tabled by the noble Baroness, Lady Tyler, relate to unpaid carers. The existing legal framework already requires the system to support carers. The Care Act 2014 places requirements on local authorities to assess and meet eligible needs. Carers are also explicitly referenced in the NHS constitution, and local authorities and NHS bodies have a duty of co-operation.

As for Amendments 175 and 176, existing legal duties establish a framework where needs assessments and subsequent care planning focus on the individual and their circumstances, rather than prescribing a particular service or solution such as respite care—something to which the noble Earl, Lord Howe, referred.

Amendment 88 tabled by the noble Baroness, Lady Tyler, raises a point that a number of other noble Lords have spoken to, including the noble Baroness, Lady Pitkeathley. It is of course important that carers are properly recorded and identified in the system. However, we do not believe that setting explicit requirements is appropriate for legislation, important though that is. We are making clear commitments in the 10-year health plan and are taking practical steps to improve identification, recording and support.

My noble friend Lady Nargund asked specifically about the single patient record. The Bill contains powers that will enable regulations to make patient information available to people other than patients on the patient’s behalf, if that is required. That can include all carers. The main point here is that we want to ensure that carers who act on behalf of those they care for can also get full benefit from the single patient record.

There is also guidance to support general practice to better identify and record which patients are unpaid carers. There is ongoing work to improve identification by promoting more consistent coding of unpaid carers by GPs.

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Moved by

[Earl Howe]

22: Clause 5, page 4, leave out lines 2 to 4 and insert—
“(1) In exercising functions in relation to the health service, the Secretary of State must act with a view to enabling patients to make choices with respect to aspects of health services provided to them, including to make choices as to the provider of those services.(2) For the purposes of subsection (1), the Secretary of State must ensure that patients who are referred for a service to be provided outside a hospital setting (“out-of-hospital services”) are offered a choice of provider of that service from among the providers available in their integrated care board area and, where relevant, in neighbouring areas, in accordance with regulations made under section 14Z45B.(3) Regulations under section 14Z45B must provide that, where an out-of-hospital service is to be provided to a patient, the integrated care board must—(a) offer the patient a meaningful choice of at least two providers capable of providing the service, which may include NHS bodies and independent sector providers approved to provide that service under arrangements with the integrated care board,(b) provide the patient with information to support an informed choice, including for each available provider—(i) indicative waiting times,(ii) the location at which the service would be provided,(iii) the quality ratings or outcomes data applicable to that provider for that service where such data is available, and(iv) whether any costs would be incurred by the patient in travelling to or receiving the service at that provider,(c) not exclude from the list of available providers any provider approved solely on grounds of commercial interest or organisational type, and(d) take all reasonable steps to give effect to the patient's choice within a clinically appropriate timeframe.(4) For the purposes of this section, “out-of-hospital services” means services—(a) provided in community, primary care or ambulatory settings rather than in a hospital inpatient or outpatient department, and(b) which the Secretary of State specifies by regulations as being within the scope of the choice obligation under subsection (2), and may include diagnostic services, audiology and hearing aid care, podiatry, dietetics and nutrition, physiotherapy, ambulatory cardiac monitoring and such other services as the Secretary of State may specify.(5) In specifying services under subsection (4)(b), the Secretary of State must have regard to—(a) the potential for the expansion of choice to reduce waiting times for the relevant service,(b) the availability of sufficient independent and NHS providers to make genuine choice meaningful, and(c) the desirability of ensuring access to choice for patients in all parts of England, including in rural and deprived areas. (6) The Secretary of State must publish, and lay before Parliament, within 12 months of the day on which the Health Act 2026 is passed, a statement setting out—(a) the out-of-hospital services for which choice obligations under subsection (2) will initially apply,(b) the timetable for extending the choice obligation to further services, and(c) the support that will be made available to patients, in particular those with limited digital access or literacy, to exercise the choices to which they are entitled under this section.(7) The Secretary of State must review and update the statement required by subsection (6) at intervals of not more than two years.”Member’s explanatory statement
This amendment strengthens the new patient choice duty inserted by Clause 5 to provide a specific right to choose between providers for out-of-hospital services.

[Earl Howe (Con)]

My Lords, in moving Amendment 22, in my name and that of my noble friend Lord Kamall, I will speak also to Amendments 24 and 68. I am also grateful to the noble Baroness, Lady Pidgeon, for tabling Amendments 23 and 67.

These amendments concern a principle which we on these Benches have long supported and which I believe ought to be central to our thinking about the future of the health service: how we can give patients greater choice over their care and make better use of the full range of healthcare services available to them.

Those services are what I would describe as a wider healthcare ecosystem—a complementary system in which the NHS works alongside independent healthcare providers, community organisations, charities and other bodies to deliver services in the way that best meets patients’ needs. The principle behind this is straightforward: many services do not necessarily need to be delivered in a hospital or by an NHS organisation, in an area where other qualified and appropriately regulated providers are capable of delivering them. These might include diagnostic services, physiotherapy, audiology, eye care or other forms of community-based treatment. Where those services can be provided safely and effectively by organisations outside the traditional hospital setting, we should surely be looking at how we can make use of that capacity.

There are several potential benefits that flow from this approach. It can allow patients to receive treatment closer to home and it can reduce unnecessary journeys to hospital. It can also provide access to services more quickly. At the same time, it can relieve some of the pressure on hospitals and specialist services, allowing them to concentrate their resources on the patients who need them most. Where services can be delivered more efficiently, they may also provide better value for the taxpayer.

I appreciate that some noble Lords may have concerns about what they might regard as encouraging the privatisation of the health service, but I want to be very clear that that is not what we are proposing. We are not suggesting that patients should be required to pay for their treatment, nor that core NHS services should be replaced by private provision. We are arguing that the NHS should have the fullest possible range of resources available when it comes to treating patients, and that patients should be able to benefit from those resources regardless of the organisational structure of the provider. The important question is whether a service is safe, clinically appropriate and accessible, and provides good value, rather than whether it happens to be delivered by one particular type of organisation.

This brings me to the question of patient choice. There is a risk in the present system that patients are not always given the opportunity to make decisions that they are well placed to make themselves; for example, a patient may be entirely happy to travel further for a particular service or may prefer to receive treatment closer to home. They may be willing to wait for one provider or prefer to be treated more quickly by another. These are reasonable choices and, wherever clinically appropriate, patients should be supported in making them. However, the watchword of “choice” means very little if patients are not told what alternatives are available or if the way that services are commissioned prevents them from accessing those alternatives in the first place.

Amendment 22 therefore seeks to strengthen the provisions in the Bill relating to patient choice, specifically in relation to out-of-hospital services. Amendments 23 and 24, meanwhile, raise an important question about what happens when a patient is referred onwards by a hospital, an NHS online service or another integrated healthcare provider. As more care is delivered through digital services and integrated pathways, we need to be certain that patients do not lose the choices that would otherwise have been available to them, had they been referred directly by their GP. Amendment 68 explores how we might extend meaningful choice into community services, which can provide an alternative to hospital-based care.

Some of the amendments in the name of the noble Baroness, Lady Pidgeon, mention optometry services. Another good example is audiology. Adult hearing loss affects 11.6 million people in the UK. It is the third leading cause of years lived with disability, and it impacts all aspects of people’s lives. Unlike most other hospital services, audiology is not consultant-led. Currently, choice over elective care applies only to consultant-led NHS secondary care services. As a result, NHS community audiology services are being commissioned in fewer than half of ICB areas. Patients often endure long waits and attend hospital when services could often be offered safely and more swiftly in the community.

The Government’s stated ambition is to move more care out of hospitals and into communities. It is a good ambition, but if we are serious about moving care closer to patients, we must also be serious about making use of the organisations, including independent providers, capable of providing that care. It would be helpful if the Minister could use this debate to tell us a little more about the Government’s plans in this area. What further steps are being taken to empower patients to exercise meaningful choice, particularly in relation to community and out-of-hospital services? I will press her, if I may, on primary care audiology provision in particular, which seems an especially salient example, given the statistics on hearing loss I have just mentioned. What is the position? Are integrated care boards being encouraged to make full use of the healthcare capacity available in their local areas, including through independent charitable and community providers? What barriers might stand in the way of this?

Much of our debate on the Bill thus far has concerned the savings that the Government hope to achieve through structural reform, but I hope we can agree that the structure of the system should not be such as to dictate or otherwise limit the choices available to patients. There is surely an opportunity both to make savings and to improve services, by looking more closely at how care is actually delivered. I look forward to the Minister’s response. I beg to move.

[Baroness Neville-Rolfe (Con)]

I thank the Minister for her helpful letter last week, answering the range of questions I had raised at Second Reading. I think that that is a symptom for a wide variety of policy issues that this important Bill raises.

I have added my name to Amendment 22, on choice, which was so persuasively and sensitively introduced by my noble friend Lord Howe. I believe that private care can complement NHS care, allow treatment nearer to home, and cut waiting times. I particularly support the “have regards” in proposed new subsection (5). I also favour the follow-up review, although there should be more focus on the value and usefulness of the independent sector in a health system that, frankly, is under so much pressure. I have had very positive experiences at Specsavers, which is contracted to do eye and audio tests in a number of NHS trusts.

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[Baroness Merron (Lab)]

I think we just have a difference of approach to and opinion about the roles of primary and secondary legislation. I respect what the noble Lord is saying and I will of course review the points that have been made, as I always do; however, the position is exactly as I have described.

[Earl Howe (Con)]

My Lords, I am most grateful to the Minister for her response and, indeed, to all noble Lords who have contributed to this debate. This has been a valuable opportunity to explore how we can give patients greater choice while making better use of the resources and expertise available across our wider healthcare system. In particular, services such as optometry and audiology have been highlighted.

I was encouraged by much of the Minister’s response, particularly her reference to the need to empower patients, not least to optimise patient outcomes. She is right that there are already several consultant-led NHS services delivered in the community. It would be helpful, though, if she could reflect on the issues I raised about audiology, which is not consultant-led. Perhaps she could consider what could be done to increase audiology provision in the community. As I said at the outset, our intention is not to undermine the NHS but to support it. Where independent charitable and community providers can deliver high-quality care closer to home and more efficiently, we should be making full use of that capacity.

My noble friend Lady Coffey rightly said that politicians of every colour all too easily make declaratory statements about choice, but that we do not do enough to bring meaningful choice to the attention of patients. I confess that I worry sometimes that the absence of choice in certain situations may, in part, not be wholly unintentional. As we heard from my noble friend Lady Neville-Rolfe, it sometimes seems to suit NHS commissioners not to bring down waiting times. The primary reason for that, I suspect, is the way commissioners channel and direct their commissioning budgets. It is important, though, to keep in mind, and perhaps remind commissioners, that out-of-hospital services can often be less expensive to provide than services delivered in hospital.

Having said that, I hope the Government will take these points away and give further consideration to how patient choice can be strengthened as this Bill progresses. For now, I beg leave to withdraw Amendment 22.

Amendment 22 withdrawn.