Health Bill

Baroness Coffey Excerpts

Committee stage
Tuesday 3rd November 2026 Lords Chamber

[Baroness Manzoor (Con)]

My Lords, I support the amendments in the group, particularly Amendments 22 and 24, in the names of my noble friends Lord Kamall and Lord Howe. I say to the Minister that patient choice needs to be significantly strengthened, particularly in three important areas.

Currently, there is choice, but we need to make choice much more meaningful, rather than simply theoretical, by giving patients greater control over access to services and their care pathways and ensuring that choice is available across the whole of the NHS and the health ecosystem, not just elective hospital treatment, as was clearly outlined by my noble friend Lord Howe. Patients are not always aware that they can choose which hospital or provider they attend. In practice, patients may simply accept the hospital suggested by their GP or referral system, without being told about alternatives.

How do we improve this? I passionately believe that GPs should have a duty to routinely explain patients’ rights to choose, and patients should be offered a meaningful range of clinically appropriate providers. They should be provided information about waiting times, quality, outcomes and location, as Amendment 22 suggests. Patients should be supported to make informed decisions, rather than being directed towards a single provider. The NHS England guidance recommends currently that referrers should shortlist an average of five provider choices where it is practical, clinically appropriate and preferred by the patient.

Choice is particularly relevant in relation to NHS 111 and A&E attendance. Patients contacting NHS 111 are often given a recommended pathway, but their ability to access alternative services may be limited. For example, a patient might be advised to contact their GP, attend an urgent treatment centre, access a community pharmacy, receive a telephone or face-to-face clinical assessment, or attend A&E if clinically necessary. The problem is that a recommendation is not necessarily a genuine choice if the alternative service is unavailable.

Improvement is needed. There needs to be better access to same-day GP appointments, wider choice in the NHS and wider health ecosystem, more accessible urgent treatment centres, greater availability of evening and weekend services, better integration between NHS 111 and local urgent care providers, and much greater transparency about where patients can receive treatment. The key principle should be that patients are given practical alternatives, not simply redirected from one service to another—audiology has already been mentioned. Amendments 22, 23 and 24 would enable this. I know that this can happen, because, back when we had regions, we had the ability to refer patients to other providers where waiting times could be reduced, and it worked very well. Of course, we must not allow cherry-picking, which is a danger, and we must clearly define what outcomes are to be expected.

[Baroness Coffey (Con)]

My Lords, I agree with the amendments. The original duty included by the Government feels a bit lightweight and almost declaratory, rather than anything of substance. That it is why it is proving a useful debate, through the variety of amendments, to look at putting more substance to this.

In the real world of the NHS, in my experience as a patient and previously as an advocate, what is convenient for the NHS is more important. We will come to this in a broader sense later in the Bill, but it is vital that we try to help patients, as with the earlier duty in the clause that is not being changed, to have more involvement in their healthcare. As my noble friend Lady Manzoor just said, patients are often not aware of the availability of other services. It would be useful to get an understanding of how the Secretary of State intends, through this clause, to make patients more aware.

At the same time, as my noble friend Lady Neville-Rolfe points out, in effect, probably due to budget constraints, rationing has started by not allowing patients to take advantage of provision in the interests of trying to manage budgets. I am not saying that the NHS is a bottomless pit—it is not—but we have to come back to what the NHS is there for. The constitution is quite clear that patient choice is a key element. That is reasonable in order to try to make sure that we have a healthier society. As my noble friend pointed to, quite a lot of illnesses are stopping people working, or working to their full potential. That is no good. A lot of illnesses mean children are not allowed to reach their full potential and are spending time out of school.

We need to consider such factors when carefully considering the amendments tabled by my Front Bench and that of the Liberal Democrats to beef up what it means to ensure that other provision can be readily accessed to have a healthier society. I hope that my noble friends will bring this back on Report if we do not have any satisfaction today.

[Lord Patel of Bradford (Non-Afl)]

My Lords, I support the aims of Amendments 22 and 24 and welcome the intentions of Amendments 67 and 68 in this group.

I want to concentrate on what these proposals would mean in practice for patients and families. The question is whether choice is meaningful, accessible and protected throughout their care. For patients, the questions are straightforward: where can I receive appropriate care, how long will I wait and how will I get there? Amendment 22 rightly draws attention to the information that is needed to make those decisions, including waiting times, location, quality and travel costs. Simply presenting someone with a list of providers does not necessarily give them a meaningful choice. A service offering an earlier appointment may be difficult to reach, while a nearby service may involve a much longer wait. Patients need help to understand those options and decide what works for them.

Does the Minister accept the case for strengthening patient choice in services outside of hospital? Whether she accepts Amendment 22 or not, how will the Government ensure that patients receive the information and practical support that is needed to exercise choice, particularly those patients who cannot readily use digital services, have communication needs or require help with transport?

Amendments 23 and 24 raise an equally important question about onward referrals. A patient’s ability to choose should not depend on which door they entered through, or which organisation happens to make the next referral. As services become more integrated and virtual services play a greater role, we must ensure that patients are told about the choices that are available to them. Integration should make their journey easier, while preserving access to suitable providers beyond the organisation arranging their care. Can the Minister explain how patients will be protected from being directed automatically to a closed list of preferred providers without being offered the choice to which they are entitled?

Amendments 67 and 68 raise a related issue about choice in community services, including eye care and audiology, very eloquently expressed by the noble Baroness and the noble Earl, Lord Howe. Moving care closer to home should bring benefits to patients. We should ensure that a change in the setting or organisation of care does not unnecessarily narrow their options. For a family seeking an ADHD or autism assessment, choice can also have very practical consequences. Where choice rights apply and an eligible provider can offer appropriate care sooner, families need to know that this option exists and understand what the service includes. They should also have the confidence that their choice will be respected as referral pathways change.

As the noble Earl said, choice must operate within appropriate clinical criteria, with providers meeting the required standards and regarding the sustainability of local services. It must also be available fairly, rather than depending on a patient’s confidence or ability to navigate the system. Can the Minister explain how existing choice rights will be protected as services are reorganised, how compliance will be monitored and what remedy a patient will have if available choice is denied? The practical test is whether patients can reach appropriate care sooner, with clear information and continuity of treatment. I hope that the Minister will respond to the concerns behind these amendments and explain what the Government will do to make meaningful patient choice a reality.

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[Baroness Coffey (Con)]

My Lords, I tabled Amendment 45, which refers to “Promoting palliative care equitably”. In particular, it refers to the need to be

“accessible to all regardless of wealth or geography”.

I am very fond of the Minister. Nobody can get grumpy with the Minister, but I am getting grumpy with the Department of Health and Social Care, and other Ministers, because we still do not have the modern service framework for end-of-life and palliative health care, which has been going on for some time. I think the latest Written Answer, published in September, said that it would be published in the autumn. To be generous to the Government, that normally means right up until Christmas Eve, but I hope we will see this framework; it is a long time coming. The stories that we hear, such as that which we just heard from the noble Baroness, Lady Finlay of Llandaff, illustrate that access to palliative care often seems to be a postcode lottery.

When I first moved to Suffolk, I became aware of the Halesworth Community Nursing Care Fund—it no longer exists, having been absorbed into the Pear Tree Fund, which is still in Halesworth. The local people, frankly, got fed up of waiting for a hospice, and there are still valiant efforts to try to have a building. I appreciate that hospice at home is a key element of the modern hospice service. Nevertheless, it was felt that, unless there were people with deep pockets or those who run marathons around the country, or take part in other ways of raising funding, too often either that nearby hospice would never open or its continuing support would collapse. That is why I welcome the proposals and ongoing targets—I think aimed at 2029—regarding this in the neighbourhood health plans, but we still need the substance. Living in a rural community, I am very conscious that not everything will be on hand, but that does not mean that it should be so far away that it more or less becomes irrelevant. I would like to understand more about how the Government will consider the provision of such care in rural settings.

Amendment 230, tabled by the noble Baroness, Lady Pidgeon, would, as I understand it, require a conversation about end-of-life care once a terminal illness has been diagnosed. The amendment as drafted provides that such a conversation would need to be offered but the person would not necessarily have to take it up. However, another provision in the proposed new clause suggests that, where the person does not or cannot take up the offer, the family must be offered it instead.

I appreciate that having conversations about the end of life can be very tricky. We should bear in mind what happened in the not-too-distant history to people who were nearing the end of their lives. I think of the heinous Liverpool care pathway, where people were, in effect, starved and not allowed water. That was horrific. I was pleased when the recommendations of the review by the noble Baroness, Lady Neuberger—it is good to see her here—were followed by the Government, and that was cast to history.

There is also the wide-ranging element of do not resuscitate, and here I will share a personal anecdote. I recall that, when my mother broke her hip, they constantly tried to get her to do a DNR but then told her that the consultant could do it anyway. It is not very encouraging. When she was finally, sadly, diagnosed in hospital, they did not know exactly what was wrong with her but told her that she had less than a month to live—which was true; that is what happened. It was very clear that, for my mother, her patient choice was that she was desperate to die at home. To be fair, a particular nurse tried everything and was successful, but there was argy-bargy to get it done. For a woman who was dying, I was prepared to shove her in my car and drive home, although eventually we got the agreement for an ambulance to take her home. Even then, all of a sudden, as we were ready to leave, the DNR was there, and I knew my mother did not want it. They went and found her; she was not speaking very much by then, but she shook her head to show that she did not want it. It involves an element of trust, and, frankly, I do not know how many people necessarily have confidence that end-of-life care will be provided.

My mother was a woman of faith, and a priest from the local Catholic church, Father Joseph Welch, happened to be on duty. He came in, and that conversation, more than anything, helped a woman of faith who was scared of dying to effectively be reconciled. It is important, in a different way, to recognise that this is not just about the NHS saying, “Let’s have a chat about the end of your life”, because I am afraid that there is still nervousness about where that will end up.

I am conscious that, when debating another Bill in this House, we spent a lot of time on the fact that people are scared, towards the end of their lives, and that there may be pressure to take a particular pathway. We need to be careful, and how we get that judgment right is important. That is why, although I understand the sentiment behind Amendment 230, I would be pretty nervous about putting it in the Bill and about how delivering it could be done in a way that is absolutely right for everybody. Can we get the quality and a real understanding that this would work to the benefit of the patient, albeit perhaps in their final weeks?

[Baroness Hollins (CB)]

My Lords, I thank my noble friend Lady Finlay for making the strong economic case for specialist palliative care and for these thoughtful amendments. I have added my name to several of them.

On Amendment 78, ICBs already have responsibility for commissioning palliative care. That came about following amendments to the 2022 health Act, which my noble friend Lady Finlay introduced, but there is insufficient accountability for whether and how they are meeting the needs of their local populations. The House of Commons Health and Social Care Committee’s recent inquiry found no clear standards or reporting requirements for ICBs for the provision of palliative and end-of-life care.

Geographic inequality is striking. In 2023, the proportion of people dying in hospital varied from 36% to 52% between ICB areas, and the proportion dying at home varied from 26% to 33%. Why are there so many differences between different areas? We cannot improve what we do not properly measure, and palliative care at the end of life is an essential component of healthcare, not an optional extra. This amendment would require annual performance assessments regarding the standard of palliative and end-of-life care provided.

Amendment 26 would require urgent investment in palliative care through a transformational fund. The Health and Social Care Committee considered the specialist palliative care workforce to be in a critical situation. It described 78 consultant vacancies and around 40% of hospitals not providing a seven-day face-to-face specialist palliative care service. More funding would support the Government’s intended move towards more care in the community and help to avoid needless prolonged hospital admissions.

Amendment 242 would ensure that NHS and hospice services can work together effectively, with timely information sharing and the access to beds, medicines, equipment and appropriately trained staff that patients need and deserve. At the moment, it is so fragmented; it is very hard for people trying to co-ordinate and manage their own end-of-life care at home, as I know only too well after my husband died last year.

The scale of the voluntary sector’s contribution is considerable. In 2024-25, hospices across the UK provided palliative and end-of-life care to 310,000 people, alongside direct support to 89,000 family members, friends and carers. But the financial pressures they face are significant, and of course they rely heavily on charitable donations and fundraising. However, voluntary sector providers are not peripheral to our health and care system; they are essential partners.

The Public Accounts Committee in the House of Commons has estimated that 300 hospice in-patient beds have been lost due to lack of funding. It would be very timely to agree all these amendments and I give my wholehearted support to them.

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The amendment is about patient safety. It is about maintaining confidence in professional regulation, supporting victims who have the courage to come forward and recognising that sexual misconduct by a healthcare professional is not simply another disciplinary offence; it is a fundamental violation of the trust that underpins healthcare itself. When that trust has been abused in such a serious way, the privilege of professional registration should be lost permanently. I look forward to the Minister’s response, and I hope she will look favourably on this amendment or tell me it is not necessary because the Government are already going to do it.

[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.