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.

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?

--- Later in debate ---

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
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.