Health Bill

Earl Howe Excerpts

Committee stage
Monday 9th November 2026 Lords Chamber

[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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Moved by

[Earl Howe]

32: Clause 8, page 5, leave out lines 19 to 24 and insert—
“(5) Where the Secretary of State has given a direction under subsection (1) the Secretary of State must publish a statement before the end of the period of seven working days beginning with the day on which the direction is given.(6) A statement published under subsection (5) must set out—(a) the statutory function in respect of which the direction is given,(b) the reasons for giving the direction,(c) the period for which the direction is to have effect,(d) the date by which the operation of the direction is to be reviewed,(e) any payment which the Secretary of State has made, or intends to make, to an integrated care board under subsection (4) in connection with the direction,(f) the Secretary of State’s assessment of the financial and operational effects of the direction on each integrated care board to which it applies,(g) the Secretary of State’s assessment of the effect of the direction on the ability of each integrated care board to meet the needs and priorities of its local population, and(h) the respective responsibilities of the Secretary of State and each integrated care board to which the direction applies for the exercise of the function and for any outcomes arising from its exercise.(7) If the Secretary of State varies or revokes a direction under this section, the Secretary of State must publish—(a) the variation or revocation before the end of the period of seven days beginning with the day on which a direction is made, and(b) a statement setting out the reasons for the variation or revocation and its expected financial and operational effects.”Member’s explanatory statement
This amendment would require a direction to an integrated care board to exercise a function of the Secretary of State to be set out in a statement published within seven working days.

[Earl Howe (Con)]

My Lords, in moving Amendment 32 in my name and that of my noble friend Lord Kamall, I will also speak to Amendments 37, 38 and 86.

These amendments, like those in the preceding group, concern the relationship between the Secretary of State and integrated care boards and, in particular, the powers of direction that the Government propose to introduce through the Bill. I hope the Committee will forgive me for having separated these four amendments out from those of the noble Lord, Lord Scriven, but I have done so because I felt it would be useful to debate these provisions from a slightly different angle from the one that he adopted, albeit persuasively, in some of his earlier amendments.

I have already set out my concerns about the mixed messages that the Bill sends out regarding where accountability for decision-making in the health service should lie, and the inherent contradiction of legislating for open-ended ministerial powers of direction over ICBs against the background of an explicit government policy that recognises the benefits of devolving decision-making to a local level. I will not repeat the points that I have already made on that theme.

I was reassured by the Minister’s statement in response to the last group that there is no intention to micromanage the NHS. Nevertheless, I underline the point that the powers as drafted would not protect decisions that ICBs may choose to make in some very important areas: which services to provide, how to allocate budgets across a population, and whether and how services should be reconfigured. I took the point made by the noble Lord, Lord Hunt, about service reconfiguration, and I will say more about that in a second. But, armed with the powers in the Bill, the Secretary of State would be able to interfere with all those things. That is the backdrop. Let me instead focus on the specific provisions of these amendments, which have one guiding purpose: to propose a set of basic, overarching principles that should govern the exercise of the powers of direction in any given set of circumstances.

Amendment 37 is perhaps the most substantive. It would require the Secretary of State to be satisfied that a direction is necessary and proportionate, and that its objectives would not reasonably be achieved through guidance, agreement with the integrated care board, existing oversight arrangements or some other less restrictive means. In other words, I am suggesting that the power of ministerial direction should essentially be a power of last resort, and not, as it could be read as being, a ready option available to Ministers whenever they happen to disagree with a local decision or the direction of travel taken by local decision-makers. The amendment would also require the Secretary of State to consult the relevant integrated care board and consider the potential consequences of a direction for the ICB’s finances, its operations and its ability to take decisions in the best interests of patients.

There are two important principles at play here. First, if we believe that local healthcare leaders are best placed to understand the needs of their communities and to commission in their best interests, their views ought to carry considerable weight before Ministers decide to override their judgment by insisting on something else. The other principle is that of local autonomy and the value we should attach to it. The moment that local leaders in the health service believe there is no point trying to do things in an innovative way to improve the delivery of services, for fear that they will be told by the powers that be to direct their energies elsewhere, we will breed a set of leaders who are leaders only in name. The best leaders are those who are motivated to take new ideas forward and to excel.

I am proposing this amendment as a basic constraint on the unfettered use of the ministerial power. As the Minister said in response to the previous group, there may be urgent and unexpected circumstances in which consultation cannot reasonably take place beforehand, and the amendment makes provision for that. Outside those circumstances, it is entirely reasonable to expect Ministers to explain why intervention is necessary and why other options would not be sufficient.

Amendments 32 and 38 are about another principle, that of transparency. They each seek to ensure that, where directions are issued, there is a clear and publicly available record of what has been decided and why. They would require the Secretary of State to publish a statement within seven working days of a direction, setting out the reasons for the direction, its intended duration, its expected financial and operational consequences and the resources available to the integrated care board to comply with it.

Crucially, they would also require an explanation of how the direction might affect the board’s ability to meet the needs and priorities of its local population. That is particularly important. A ministerial direction is no small step to take. Take service reconfiguration as an example. If a Minister directs an integrated care board to pursue a particular course, and doing so requires the board to divert resources away from another area of activity previously deemed a local priority, then everybody—Parliament, patients and the public—should be able to understand that. They should know who made the decision, why it was made, what alternatives were considered and what the consequences are expected to be. If the direction results in poorer performance elsewhere, there should be a clear record of whether that was the consequence of a local decision or of a requirement imposed by the Secretary of State.

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[Baroness Merron (Lab)]

I will always make available as much information as possible. Some of the core of our discussion is around what is appropriate to be in the Bill and what is not. It would be unusual to have the detail of an operational model in the Bill—which the noble Lord is not quite suggesting. However, I can certainly undertake to give as much information as possible.

[Earl Howe (Con)]

My Lords, I am grateful to all noble Lords who have taken part in the debate on this group of amendments and for their insightful contributions. I am particularly grateful to the noble Lord, Lord Scriven, for his very helpful comments. As I mentioned in my opening speech, these amendments are intended to press the Government to address the key distinction between ministerial direction and local direction that the Bill has yet clearly to define, and to tease out more on the operational model, as we have just heard.

I thank the Minister for her reply, but I shall need to reflect carefully on her assertion that no explicit threshold on the use of the powers is appropriate or necessary. The noble Lord, Lord Stevens, set out a good hypothetical example of what could happen if amendments along the lines of those I have proposed are not adopted, especially Amendments 32 and 38 on transparency. The key questions are the ones so well expressed by the noble Lord, Lord Scriven, and, like him, I think that these are issues we shall wish to return to on Report. I am grateful for the briefing later this week to which the Minister has just referred, but I hope she will be open to working with us on these issues as we go forward. For now, I beg leave to withdraw the amendment.

Amendment 32 withdrawn.

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[Baroness Pidgeon (LD)]

My Lords, getting primary care right is absolutely crucial for our health service to work for patients and to ensure that neighbourhood health really delivers. Amendment 61 in my name would ensure that access to NHS sight tests remains nationally protected and is not subject to local variation once integrated care boards take on the commissioning of primary ophthalmic services. The national sight testing service remains the foundation of eyecare across the country and is one of the most effective public health services in the NHS. Primary eyecare in England provides more than 23.6 million appointments every year, covering sight tests, enhanced eyecare services and contact lens care.

Protecting vision means supporting people’s independence and safety, including from falls and accidents, and enables people to live well and work well. It is important, as raised by my noble friend Lord Scriven, for the needs of people with a learning disability. The national contract model is the most cost-efficient way of commissioning the service for the NHS. This is because the funding offered by the NHS, as we have already heard, does not come close to covering the cost of an eye test, and it is feared that any fragmentation of the commissioning route will only add more bureaucratic costs. This is a probing amendment, and I would be grateful if the Minister could confirm whether the national NHS sight testing service provided through this cost-effective national contract model will remain in place under the Bill. I also fully support Amendment 61A from the noble Baroness, Lady Gerada, on access to community-based, urgent and minor eyecare.

Amendment 218 in this group would give patients a new right in the NHS constitution to receive a GP appointment. Patients should be able to access primary care when they need it, and too many people across the country are forced to wait weeks for a GP appointment, only to see their condition deteriorate, which does ultimately place greater pressure on emergency departments and hospital services.

That is why these Benches are proposing a new right in the NHS constitution for patients to receive a GP appointment within seven days or within 24 hours if their need is urgent. This is not merely a target but a commitment to restore confidence in GP services and to ensure that timely access to primary care is recognised as a fundamental patient right.

General practice remains the front door to the NHS. Ensuring prompt access to a GP can lead to earlier diagnosis, more effective treatment and better management of long-term conditions, as we heard from the noble Baroness, Lady Gerada. Ultimately, it can reduce demand on overstretched hospitals. The amendment on continuity of care from the noble Baroness, Lady Neville-Rolfe, and supported by the noble Baroness, Lady Gerada, is really important to consider as part of the Bill.

My noble friend Lady Janke’s amendments on ensuring that community pharmacies are supported is important. Her challenge on the cost of medicines and how pharmacists are reimbursed is an important issue that was raised when the Public Services Committee looked at medicines security. I was quite astonished that pharmacies often provide medication at a loss; it is no wonder so many are going under. This group is really important, so I hope the Minister can assure the Committee.

[Earl Howe (Con)]

My Lords, this has been an illuminating discussion that has elicited some valuable contributions from across the Committee. I do not intend to add much to what other noble Lords have already argued so well, but I will underline how much I agree with my noble friend Lady Neville-Rolfe on all that she said about continuity of care. Continuity of care is something on which patients place enormous value, whether in primary care, in community settings or in hospital. My noble friend’s amendment rightly prompted a wider discussion about how we can strengthen those relationships across the health service.

At a time when many patients feel that their care is fragmented and impersonal, it is worth our looking closely at how the NHS can better support relationships between patients and the professionals who care for them. Continuity of care is not simply about patient satisfaction; as has been said, it undoubtedly contributes to better outcomes, often through earlier intervention and a more personalised experience of healthcare.

I have no doubt that the single patient record, when it is eventually rolled out, will be of huge benefit to the efforts of primary and secondary care clinicians to deliver seamless care to patients. However, the noble Baroness, Lady Gerada, was quite right: seamlessness of care is not the same as continuity of care. I agree with her and with my noble friend that, in this context, the more immediate focus for the NHS is that of primary care. More than 90% of patients’ direct experience of the health service is through primary care and, at the moment, many patients experience an NHS under increasing pressure.

The number of trained GPs has gone up over the last decade but, as we noted in an earlier debate, the number of full-time equivalent GPs has fallen. At the same time, despite GP practices employing more nurses, pharmacists and other healthcare professionals, the rise in patient demand has been unrelenting, especially in areas of the country that could fairly be described as underdoctored. These pressures make continuity of care particularly difficult to achieve within general practice. That is not to say that some GP practices do not still achieve it, but the demand curve does not look likely to flatten in the short or even medium term.