Health Bill - Second Reading

House of Lords, 13 October 2026.

Lord Kennedy of Southwark (Labour)

My Lords, before we move on to the Second Reading of the Health Bill, I want to stress the importance of all noble Lords speaking to be here for the majority of the debate. Equally important is that noble Lords who speak must return at the end of the debate to hear the Front-Bench responses. The advisory speaking time is five minutes.

During this debate, the noble Baroness, Lady Campbell of Surbiton, will address the House using an AI-generated voice. This is a first in a British Parliament. As it is a first, I have advised the Whips that some leeway in the advisory time for the noble Baroness should be allowed as this is the first use of this technology. I am sure the House will agree with me.

Baroness Merron (Labour)

My Lords, the NHS matters deeply to people across our country; it profoundly touches all our lives. Every one of us will have our own experience of the National Health Service and our appreciation of the care it provides, and we will all have hopes for its future. As the needs of patients are evolving, so must the National Health Service. Our job is twofold: first, getting the NHS treating patients on time again; and, secondly, reforming the health service so it is fit for the future. These ambitions run throughout the core of the Bill.

Modernisation does not mean change simply for its own sake, but making considered changes that drive real and tangible benefits to patients, who are at the heart of all we do. It means making better use of technology, empowering local leaders to meet patient needs, and taking a clear view of what needs to be done nationally so that more funding and resource reach the front line.

Before turning to the substance of the legislation, I will make a few points of gratitude and note: first, to all Peers who have engaged constructively with the development and scrutiny of the Bill, and who I know will continue to do so. I also want to appreciate the work of my ministerial colleague, the Minister of State for Health, Karin Smyth MP, who led the Bill through the other place, where there was considered debate of more than 400 amendments in Committee, Report and Third Reading. The Bill was approved at both Second and Third Reading without dividing, which is a sign of the broad consensus on its central aims.

On a number of issues, the Government have listened to concerns and amended the Bill. We remain committed to working with both noble Lords and the other place as the Bill continues its passage. I am confident that this House will take a characteristically constructive approach to its important role of scrutinising every line of the Bill. I thank all noble Lords who have already discussed the Bill with me and who attended the information session after First Reading; I look forward to further discussions in the days and weeks ahead.

I am sure noble Lords would also want me to congratulate no fewer than five noble Lords—which I understand is a most unusual number, in a good way—on the occasion of their maiden speeches. I thank them for choosing this Bill in which to make their own introduction to this House. I look forward to hearing from them and I warmly welcome them to your Lordships’ House. As the Chief Whip said, we have a world-first today. I am most grateful to the noble Baroness, Lady Campbell, for making this happen, and for making AI help her make her speech. I am grateful not just to the noble Baroness for choosing this Bill in which to do this, but to the parliamentary authorities for making this possible and ensuring that accessibility prevails in this House.

I turn first to what I believe is one of the most important reforms in the Bill: the single patient record. For many years, patients, carers, clinicians and campaigners have spoken to the shortcomings of fragmented information systems. Too often, information follows institutions rather than individuals; too often, patients and carers repeat the same story over and over again to different professionals; and all too often, healthcare staff make decisions without a complete picture of a patient’s needs. When records are incomplete or inaccessible, opportunities for mistakes increase and continuity of care can be compromised; at worst, these consequences can be deadly. A report on maternal deaths published in 2025 found that failures to share critical information between providers were a significant factor in nearly half of the cases examined; this could have been avoided.

The Bill establishes the legal foundations for the single patient record to create a single, secure and authoritative account of patient information. It will bring together health and social care records so that those providing care can access the information that they need, when they need it. It will empower patients to make informed decisions about their health, while supporting clinicians to provide safer, more joined-up care.

Public support, I am glad to say, is strong. Independent public deliberations show that 76% of participants supported the principle of a single patient record. The benefits are real, including every year: 20,000 fewer A&E attendances, 6,000 fewer hospital admissions, more than £20 million in medicines savings and the release of around half a million hours of doctors’ time. This surely is a prize worth having.

I am grateful to noble Lords who attended the single patient record round table. I recognise the concerns that were expressed about privacy, confidentiality and public trust, so I can assure your Lordships’ House that the single patient record will operate with strict safeguards, strong cybersecurity measures, clear controls over access, robust oversight arrangements and full compliance with existing legal protections. The Bill is about safer care, not weaker protections. It is about empowering patients; it is not about diminishing their rights.

I turn to the abolition of NHS England and the guiding principle of the democratic accountability of our health system. Since NHS England was established, the number of staff working across NHS England and the Department of Health and Social Care has increased substantially. I have experienced the overlapping responsibilities and convoluted processes that slow up decision-making and divert attention away from patient care—something that I know none of us wants. This Bill will return the functions of NHS England to government and the wider NHS system where appropriate. In doing so, it will provide greater clarity for the system. It will restore democratic accountability and free up resources to be reinvested on the front line, where we want to see them. There will also be greater clarity about where responsibility lies, ensuring that Ministers are accountable for national decisions while devolving more power to local NHS organisations.

On that point, let me turn to the matter of devolution and local leadership. This Government believe that a more devolved NHS will be a more effective NHS. Those closest to patients are best placed to understand their needs. That is why the Bill devolves decision-making, empowers integrated care boards, strengthens strategic commissioning and provides greater flexibility for local leaders. Having said all that, I also recognise concerns around local representation and expertise. We listened carefully to those concerns during the passage of the Bill in the other place. As a result, the Government amended the Bill to restore the requirement that every ICB includes a local authority member, jointly nominated by relevant upper-tier local authorities. I believe that this amendment strengthens the Bill. It ensures that important expertise on social care and public health continues to inform decision-making and helps to lay the ground for future social care reform.

Looking ahead, integrated care boards will act increasingly as strategic commissioners of local health services, with responsibility for a broader range of services and resources, while holding that responsibility in their own right rather than as duties delegated to them by others. We want decisions to be made as close to communities as is feasible, with the ICBs providing strategic leadership while working closely with local authorities and other local partners. Neighbourhood health will be at the very heart of this approach.

I know that patient safety is a concern shared by noble Lords across the House. Before turning to that issue, I extend my congratulations to the noble Baroness, Lady Neuberger, on her appointment as chair of the Care Quality Commission. I look forward to working with her and I am sure we all wish her well.

No Government should ever pretend that things do not go wrong in the NHS. When they do, patients, families and the public must have confidence that lessons will be learned and acted upon. The independent review, led by Dr Penny Dash, identified a patient safety landscape that has become cluttered and confusing. The sheer number of recommendations to health bodies in this landscape—over 1,400 in the last 30 years—can make it very difficult for them to focus on doing the right thing. The Bill streamlines that landscape. It transfers the functions of the Health Services Safety Investigations Body to the Care Quality Commission, helping to create a clearer connection between learning from failures and improving care. At the same time, we will ensure that vital safe space protections remain in place.

The Government also recognise the importance of ensuring that the CQC is ready to take on these functions, and that is why we are taking a carefully managed approach to implementation and have been working closely with the CQC to monitor its operational readiness. This transfer will happen only when the CQC is ready. I want to assure your Lordships’ House how seriously we take consideration of patient safety. We will listen to noble Lords’ concerns and keep them updated on any and all progress in this important area.

The Dash review also spelled out how to simplify the arrangements for the patient voice. The Bill abolishes Healthwatch England and local Healthwatch, placing responsibility for listening and responding to patients and the public with the organisations that plan and commission services: ICBs and local authorities. Again, I recognise that noble Lords have raised concerns about these reforms, and I am grateful to my noble friend Lord Hunt for meeting me to discuss them. I look forward to continuing discussions with noble Lords as part of our review of these measures.

Let me take a moment to remind the House of the additional amendments that the Government have made during the passage of the Bill thus far. They relate to pharmacy regulations, visiting in health and care settings and reforms relating to medicines and medical devices. Together, these changes support patient well-being and access to high-quality care and innovation.

In bringing my remarks to a close, I wish to highlight one further commitment relating to a statutory maternity and neonatal commissioner. The Government accepted the recommendation of my noble friend Lady Amos, and I thank her and her team for all their hard work in delivering the national maternity and neonatal investigation. The Secretary of State has made it a priority to bring forward an amendment to establish a statutory maternity and neonatal commissioner to provide independent leadership, oversight and accountability for maternity and neonatal care in England. This is an important opportunity to strengthen accountability and champion the interests of women, babies and families throughout the system. I thank noble Lords for the questions and points they have raised about the role, and I look forward to working with them on this important development.

The Bill will not solve every challenge facing the NHS, but it will be a significant and necessary step towards a modern, accountable and patient-centred health service. It will help information to follow patients rather than institutions. It will reduce bureaucracy and strengthen accountability. It will give local leaders greater freedom to deliver for their communities, and it will place the patient voice closer to decision-making. I, for one, welcome all of that, and I beg to move.

Earl Howe (Conservative)

My Lords, it is a pleasure for me to open our first discussion on this significant Bill, and I thank the Minister for introducing it in her customary clear way. I do not think she would disagree with me if I described the Bill as a landmark measure, proposing as it does a range of major changes to the way healthcare in England is organised, commissioned and delivered.

It is, therefore, I confess, a somewhat surreal feeling for me to lead off this debate for the Opposition, being the person responsible 14 years ago for steering through your Lordships’ House a number of the measures that this Bill now seeks to unwind. For a good many of us here, I suspect, the difficult parliamentary process that we had to go through in 2011-12 is seared on the memory—notwithstanding the fact that a large element of what we sought to achieve through the underlying policy, let us remind ourselves, commanded widespread support.

What were we seeking to achieve? There were two principal policy aims. One was to bring decision-making around the design of health services much closer to clinical leaders and, simultaneously, to redefine the role of Ministers as that of setting the broad strategic direction for the health service. Empowering clinicians and local managers was seen as a way of bringing to fulfilment the work of the noble Lord, Lord Darzi, when he was a Health Minister, which was to enable the system to commission for quality; in other words, to commission for patient outcomes whose quality could be measured by reference to defined national standards. That was the first policy aim.

The other main aim was to give public health a place at the table that it had not had for many years. With the creation of Public Health England as a discrete body within the National Health Service, Government Ministers were made directly and unambiguously responsible for population-based health policy and delivery. In the round, therefore, the intention was to make the system more responsive to people’s needs and, in so doing, to improve patient care and better protect the health of the nation. The upheaval arising from the reorganisation of NHS structures—I do not deny that it was an upheaval—was the price that we thought worth paying to achieve those desired ends.

My point in recalling all this is not to rehearse the Health and Social Care Act 2012; it is simply to point out that there was a purpose behind the Act that reflected an explicit intention and desire to benefit patients. The White Paper published by the Government in advance of that Bill was called Liberating the NHS, and the creation of NHS England as the national body accountable to Ministers for the delivery of NHS services was one of the principal measures designed to achieve that liberation.

The Bill before us proposes a step that is, I suggest, every bit as momentous, complex and time-consuming as the creation of NHS England: it is to take NHS England apart and abolish it. I do not doubt that Ministers are convinced of the need to take such a step, despite what will undoubtedly be a painful process for many committed and skilled men and women in the NHS who have lost or face losing their jobs. Let us not forget them and, equally, let us not forget NHS patients. The labyrinthine process of reabsorbing roles and responsibilities into the Department of Health and Social Care and parcelling out other roles and responsibilities to ICBs—bodies that are themselves undergoing restructuring—will, as sure as night follows day, eat up large slices of leadership capacity that would otherwise be devoted to service improvement.

That dilution of leadership bandwidth, with all the costs associated with it, is a big price. For that reason, I strongly suggest that we need to hear rather more from the Minister than we have hitherto about how she believes the abolition of NHS England will benefit those whom the NHS is there to serve—not how it will benefit the system, not how it will benefit the spending review, but how it will benefit patients, for that is surely the prime test against which the entire Bill should be judged.

As regards patients, the Government have repeatedly stated that their intention is to devolve greater responsibility to integrated care boards to allow decisions to be taken closer to the communities whose needs those boards are intended to understand. The Bill accordingly places a much greater proportion of commissioning responsibility directly with ICBs, including formal responsibility for primary care and other services which they currently commission under delegated arrangements.

However, at the same time, the Bill transfers to the Secretary of State extensive powers of oversight and direction. It creates a new general power to direct ICBs as to the exercise of their functions; it allows the Secretary of State to require ICBs to exercise health service functions on his or her behalf; and it transfers to the Secretary of State NHS England’s existing responsibilities for ICB resource allocation, financial directions, appointments and oversight.

The forces created by the Bill therefore pull in two opposing directions: one which devolves responsibility for commissioning and the other which centralises significant powers over the way that that responsibility is exercised. That is not merely a source of tension; it promises to be a source of confusion. If NHS England is to cease to exist, the arrangements that replace it, to be effective, must make authority and accountability completely clear.

That clarity matters on three levels. Those working within the health service need to know who is empowered to take a decision; patients and the public need to know who is responsible for what; and Parliament needs to know whom it should hold to account when services improve, and crucially, when they do not. We surely cannot have a situation in which, let us say, services at a local level deteriorate, and fingers of blame are then pointed in multiple directions. As a bare minimum, what we should be looking for with ministerial powers of direction is transparency in their use, what the reasons are for using them and what their financial and practical consequences are expected to be. More importantly, perhaps, we will need to examine at later stages whether the broad powers of direction granted to the Secretary of State should be circumscribed in order to ensure that NHS organisations enjoy sufficient autonomy, both to innovate and to be accountable for their own performance to the communities they serve.

What matters to those communities is the health service in their local area. As we speak, the NHS is undergoing upheaval and change. At a time when powers and roles are being shifted to the centre, and ICBs are being told to reorganise themselves on to different footprints, the risk of service disruption becomes that much greater. In a situation of this kind, it is surely all the more important that we have systems in place that can sound the alarm should any risks to service quality appear to be emerging. Yet, Clauses 70 and 71 of the Bill, together with Schedules 10 and 11, would abolish both Healthwatch England and all local Healthwatch arrangements—the very organisations that are there to meet that need.

I state here and now my grave concerns about this proposal. The value of Healthwatch is not simply the feedback it sends to commissioners and providers: it is a route independent of the wider system through which patients and service users can gain a voice. It is a way for them to highlight inequalities of access or of outcomes, and in doing so help to eliminate them. It is a means by which any worrying patterns of service provision can be identified in a timely fashion. The insights provided by Healthwatch are often very local and so not ones that necessarily become visible through published performance data. If we are to abolish these arrangements, we need to put something equally effective, equally accessible and equally trusted in their place. However, what this Bill proposes as a substitute for Healthwatch is not, in my view, likely to tick any of those boxes. My noble friend Lord Kamall will say more on this subject when he comes to speak later on. Healthwatch recommends itself as a model for patients and public involvement because it is trusted by the ordinary citizen. We risk squandering that trust at our peril.

It was put to me recently that trust is a commodity that arrives on a tortoise and leaves on the back of a racehorse. The same maxim can be applied to the proposals for HSSIB, the Health Services Safety Investigations Body, which, under the Bill, as the noble Baroness explained, is to be abolished as a separate organisation, its functions being transferred to the CQC. I have not yet heard a convincing argument in favour of that idea. The CQC is a regulator and inspector. HSSIB performs a deliberately different function. Its purpose is to investigate systemic patient safety failures in order to understand what went wrong, and for that reason it relies on people being willing to speak frankly about a serious safety event with a guarantee of anonymity. Whatever Chinese walls may be put in place within the CQC to keep the two functions separate, it is the way it looks. Once contributors fear or suspect that the information they supply is going to be fed through to a regulatory body, their confidence to speak up will evaporate.

Where does all this leave us? The Government’s case for abolishing NHS England rests in significant part on the proposition that doing so will remove duplication between NHS England and the department, reduce bureaucracy and release resources for frontline care. Ministers have said that the reforms are intended to save about £1 billion a year by the end of the Parliament. Against that, the Government now estimate that paid exits and redundancies across the department, NHS England, ICBs and commissioning support units will cost approximately £1 billion to £1.3 billion. On top of that, there is the cost of establishing the new commissioning arrangements. It would therefore be most helpful if the Minister could tell the House what assessment the Government have made of the net financial effect of the reorganisation. When does the department expect the cumulative savings generated by the new structure to exceed the costs of implementing it? What mechanisms will Parliament have to assess whether those savings have actually been realised?

There is a legitimate case for asking whether the present architecture of the NHS is too complex, whether responsibilities are sufficiently clear and whether resources currently devoted to bureaucracy could be used more effectively elsewhere. But any reform should make things better. Responsibilities should be clear. Accountability should be identifiable. Savings should be demonstrable, rather than assumed. Operational risks should be understood before functions are transferred, and reforms intended to simplify the system should not, in practice, create new ambiguity elsewhere. Above all, patients and the ordinary citizen should not be forgotten.

The NHS review of the noble Lord, Lord Darzi, which was commissioned by the Government in 2024, contained conclusions and recommendations which were warmly welcomed by Ministers. But the noble Lord ended up saying that

“a top-down reorganisation of NHS England and Integrated Care Boards is neither necessary nor desirable … Constant reorganisations are costly and distracting”.

Was the noble Lord right or was he wrong? I hope and trust that our further debates will come up with the answer.

Baroness Tyler of Enfield (Liberal Democrat)

My Lords, it is an absolute pleasure and privilege to follow the first two speakers and to directly follow the noble Earl, Lord Howe, a veteran of the 2012 Bill; and I am very much looking forward to no fewer than five maiden speeches.

As we have heard, the Bill introduces significant structural changes to the NHS —although some of them feel contradictory—and of course the development of a single patient record, but these must be viewed within the wider context of the state of health and care in this country. According to the Health Foundation, while we have seen some welcome improvements, the big picture is that health inequalities are widening—particularly the life expectancy of the richest and of the poorest—healthy life expectancy is falling, declining working-age health is costing the economy dear, and waiting times remain unacceptably high.

The big question for me is whether this Bill provides a legislative framework to enable the three “big shifts” set out in the 10-year plan, because there is a clear consensus that we need to move to a more preventive community-based health system. The obvious concern is that these structural reforms will simply serve as a distraction from much-needed improvements in patient care, service design, workforce planning and productivity gains. I will touch briefly on four key issues. Other very important issues, including structures, a single patient record and patient safety, will be covered by my noble friend.

The Bill transfers to the Secretary of State a duty to consider inequalities in access to health services and outcomes achieved. Although welcome, that is not nearly strong enough. The Bill should place a clear duty on the Secretary of State to act to reduce health inequalities, a call supported by many external organisations. This needs to be accompanied by co-ordinated action across government to tackle the wider social determinants of health, along with transparent reporting on progress. There is a golden opportunity in this Bill to put tackling health inequalities on a statutory footing, and I look forward to working with other noble Peers to get the Bill substantially strengthened.

On patient voice, in the debate on the King’s Speech I expressed my serious concerns about the proposal to abolish Healthwatch England and local Healthwatch. At Report in the other place, following strong concerns about removing trusted and independent channels for people to make their voices heard, the Government committed to review the Healthwatch provisions. I welcome this and very much hope that the Government will think again.

The Bill as drafted unhelpfully separates public voice functions concerning the NHS from those related to social care and public health. It does not put an equivalent independent national and local patient voice function on a statutory footing. I know that many noble Lords, like me, want the Government’s review to deliver a system which both preserves independence and has sufficient authority to secure action when concerns are raised. At the risk of stating the obvious, the most cost-effective route would be to stick with the current arrangements, particularly the trusted local relationships built up by local Healthwatch over 13 years. So I ask the Minister: what is the scope of and timescale for this review, and who will be consulted?

I now turn to unpaid carers. I pay tribute to the 4.7 million unpaid carers in England, whose contribution is vital to our health and care system. The value of the care they provide is estimated at £152 billion a year in England—roughly equivalent to the NHS budget—and unpaid carers outnumber NHS staff by around 3:1. Despite this, carers can too often feel invisible and unsupported by the NHS. This Bill provides an important opportunity to ensure that carers are recognised by the NHS and can rely on support such as respite breaks actually being available. So I intend to bring forward an amendment to introduce a new duty on ICBs to identify unpaid carers and to match what already happens within local authorities, along with an amendment to strengthen provision for breaks for unpaid carers.

I want to talk briefly about what I call the forgotten areas. Adult social care is largely absent from the Bill. That is a real missed opportunity for integration. The Prime Minister has brought forward the publication of the Casey commission’s final report to next summer and has committed to setting out plans for a national care service before the next general election, but I do not think that we can wait that long. Significant challenges remain in the short term. Pressure on providers, workforce shortages and unmet need continue to pose major challenges to both social care and the NHS, meaning that urgent action to stabilise the sector is vital while longer-term reforms are developed.

There are other things that I would like to have said on children’s and young people’s health and mental health services, but time prevents me doing so. In my view, those areas are very much overlooked in the Bill, so I intend to return to them in Committee. I would very much welcome further discussion with the Minister and her team on the issues that I have raised. I look forward to working with her, along with other noble Lords on all Benches.

Baroness Campbell of Surbiton (Crossbench)

My Lords, before I contribute to this debate, I would like to thank the Procedure Committee for allowing me to bring my AI-generated voice into the Chamber, and the technical department and the other members of the House of Lords staff who have made this possible. This is cutting-edge technology that will enable me to contribute to debates in my own, once-clear voice before it begins to deteriorate due to my disability. I hope that your Lordships will agree with me that this is an exciting development for the House of Lords, showcasing to the world inclusion in democracy at its best. With that, may I introduce noble Lords to Baroness Campbell mark 2?

I welcome the Bill and share much of its vision. The Government’s commitment to integrated, personalised care and support is long overdue. If implemented correctly, it could transform thousands of lives. However, I also feel compelled to deliver a warning against the potential re-emergence of an institutional medical model. For decades, the disabled people’s Independent Living Movement has fought clinical paternalism, which defines us by our medical condition. We are individuals with the right to control our lives, choosing what we do and who supports us.

NHS personal health budgets—PHBs—were designed to give individuals support to lead ordinary lives on their own terms, however complex their medical needs. The 2019 guidance promised greater choice and control and enhanced independent living. Direct payments enable people to employ personal assistants, or PAs, and to decide how and when they are supported, so I am nervous when I hear the Prime Minister speaking of healthcare and social care staff as one workforce. We must not replace personal control with a one-size-fits-all service. Notional personal health budgets in a national care service could squeeze out direct payments in favour of standardised care packages. Where a PHB is a direct payment, individuals have greater control over NHS funding, and it offers better value, with average savings of 12% to 16% compared with conventional services.

Some ICBs are showing creeping rigidity over the use of PHBs. As I recently highlighted in the Guardian, individuals have been prevented using budgets to enable their PA/carer to support them when they are away from home. Lucinda Ritchie was forced into residential care from hospital against her will, rather than returning to her adapted bungalow and her experienced PA team. Only after we raised the alarm and involved the BBC did her ICB change its mind. This will not do.

In July, the Minister and I discussed my proposal for an inquiry into ICB practices to address these issues. Perhaps she could update me on this, and on whether the Government remain committed to PHBs for 1 million people by 2030 and for anyone who would benefit from them by 2035. Sadly, evidence from the Coalition for Personalised Care tells a different story. Since the restructure, hardly any ICBs have a named lead for PHB expansion. Without the dedicated NHS England team, PHBs have declined from 188,489 in 2023-24.

An NHS-funded PA/carer provides essential support for people with complex needs. I am here today contributing equally with your Lordships as a result of a PHB. I am fortunate. Denying portability effectively institutionalises a person at home. When systems dictate that people cannot travel or place rigid rules around support, they treat the home like a hospital ward, flying in the face of Article 19 of the Convention on the Rights of Persons with Disabilities, ratified by the UK in 2009. I will therefore be scrutinising the Bill to ensure that integration and devolution to ICBs does not weaken PHB protections and freedoms. Choice must be safeguarded through stronger guidance, including a right to portability and flexibility. ICBs must not use residential care or budget withdrawal to coerce individuals.

Let us ensure that the medical model does not swallow decades of progress on disability rights and independent living. I am not a medical diagnosis but a wife, grandparent and working member of the House of Lords. ICBs would do well to reflect on that.

Bishop of Newcastle (Bishop)

My Lords, it is an honour to follow the noble Baroness, Lady Campbell of Surbiton. I note the historic nature of her excellent speech. I congratulate noble Lords who are making their maiden speeches and welcome the wisdom and experience that they will bring to your Lordships’ House.

I welcome this Bill’s ambition to improve care and make better use of resources. I want to highlight three interlinked issues: trust, health inequalities and the relationships on which good care depends.

First, trust matters between government and the workforce, between national and local institutions, and between communities and those providing care. Transferring NHS England’s responsibilities must bring clear accountability while sustaining local decision-making. Restructuring must support staff and protect their capacity to deliver care. The proposed abolition of Healthwatch sharpens these concerns. Independent local organisations give people somewhere trusted and accessible to speak, including where services have failed them. Their independence enables them to challenge decisions and bring forward experiences that might otherwise remain unheard. I therefore welcome the Government’s commitment to reconsider these provisions. Whatever arrangements emerge, independent scrutiny and established local relationships should be protected. Patient voice should influence decisions, particularly where people struggle to navigate the system. Trust takes time to build and can be quickly lost, as we have heard from other noble Lords.

Secondly, reform must narrow health inequalities. In the north-east, healthy life expectancy is around 57 years for both men and women, the lowest of any English region. Behind that figure are people whose working lives, family responsibilities and opportunities are constrained by illness, often alongside poverty and insecurity. In Newcastle and across Northumberland, access to care is shaped by transport, distance and available support. Greater patient choice means little if someone cannot afford the journey. Digital access and a single patient record offer opportunities, but those without connectivity, competence or someone to help must benefit too. Faith communities and voluntary organisations bring trusted relationships and local knowledge. They should be partners in shaping services.

Thirdly, integration must strengthen the relationships that sustain care. Social care must be a full partner in neighbourhood services and shared records, with safeguards for privacy. Duties to commission palliative care must translate into dependable access, wherever people live.

John’s Campaign, with which I have had a long-standing connection, expresses the importance of relationships powerfully. Founded following the experience of John Gerrard, who had dementia, it champions people’s needs to have someone they trust alongside them whenever they receive care. For someone with dementia, a familiar person may help them communicate, eat, understand what is happening and feel safe. They may recognise pain or distress that would otherwise go unnoticed. Their presence is integral to safe and compassionate care. With that, I welcome the Bill’s provisions for promoting visiting and accompaniment. Essential personal support must, however, be distinguished from general visiting, and I will seek to support amendments that will be tabled by the noble Lord, Lord Hunt of Kings Heath, who follows me, on recognising and protecting that distinction.

Children’s needs also need attention. I support ensuring that adopted children’s health records remain safely connected, with confidentiality protected, so that fragmented information does not compromise care. I note that children’s distinct needs receive too little explicit attention in this Bill.

Structural reform must strengthen human relationships, protect patient voice and improve access for those whose needs are greatest. These are the principles against which I will continue to consider the Bill as it proceeds.

Lord Hunt of Kings Heath (Labour)

My Lords, I am very grateful to the right reverend Prelate for supporting amendments around the rights of carers. We look forward to debating that in Committee.

Overall, I welcome the Bill. I see it as removing the last vestiges of the 2012 changes introduced by the noble Lord, Lord Lansley; it places Ministers at the heart of decision-making and improves patient outcomes through the single patient record.

I listened with great interest to the noble Earl, Lord Howe. We have been debating NHS structures for far too long. He looked back of course to the 2011 debates that we had on that Bill. In your Lordships’ House in October 2011, we had two days of Second Reading debate with over 100 speakers, such was the concern about the Bill. My noble friend Lady Thornton played a leading role in that. The noble Earl said that the upheaval then was a price worth paying, but I put to him that it was a hugely unpopular, hugely expensive and damaging restructuring. I looked at his Second Reading speech then, and he anticipated that to an extent. But he argued, in essence, and he said it today, that the aim of the proposals from the noble Lord, Lord Lansley, whom we will hear from very soon on this, was to make the service patient-centred and to give greater autonomy to clinicians. But that did not really end well, did it? Because the reality was anything but.

In essence, GPs were not prepared to take on the task of commissioning services; NHS England never established full independence; and Ministers refused to take responsibility for large aspects of the running of the service. What is so tragic, looking back, is that the coalition Government inherited the NHS in the best condition it had ever been. Waiting lists had been virtually eradicated with the 18-week wait for elective surgery and the four-hour wait in A&E; 100 new hospitals had been built or were in the process of being built; and there were new services such as NHS Direct, which was far better than the current service that we have, because qualified nurses were the people who took the calls.

In 2010, the British Social Attitude Survey showed public satisfaction with the NHS at an all-time high of 70%: by 2024 it had fallen to 20%. During the years following those changes, there has been a continuous stripping away of that blueprint, but the framework lingered and undoubtedly contributed to NHS performance deterioration. That is why I welcome direct ministerial control and the resulting enhanced accountability to Parliament.

My noble friend stressed devolved decision-making. I agree with that. What I would say to her is that it has to be balanced out by strengthening mechanisms of local accountability and scrutiny as well. That is why I very much welcome the review in relation to Healthwatch. My hope is that a strong, independent public voice at local level will be maintained. I also hope and urge my noble friend to re-look at the proposals to abolish councils of governors for foundation trusts. They play a really effective role. Local people get involved in the running of their hospital by electing governors. The governors hold the board to account. They are a vital safeguard, being the eyes and ears of local people in their local institutions. They can broaden the trust connection with local communities. Numerous visits to patient areas provide valuable feedback. The National Lead Governors’ Association has shown in its briefings to us that it can be a statutory, independent warning system, escalating front-line safety concerns to non-executive directors. So, I hope the Government will look again at these proposals.

My noble friend rightly pinpointed the single patient record as the most important aspect of this Bill. I agree with her. She will be asked questions about the confidentiality of patient information. She will have seen, I think, the recent HSJ and Sky News survey that showed most NHS trusts are ill prepared to protect patient information. She will have seen the prosecution of staff in some cases, and certainly disciplinary action against staff who have looked inappropriately at patient records. Clearly, that will be a matter for debate. Overall, I very much welcome this Bill and look forward to our debates in Committee.

Lord Lansley (Conservative)

My Lords, I am glad to have the opportunity to contribute, not least coming straight after the noble Lord, Lord Hunt of Kings Heath. Having listened to my noble friend Earl Howe on the Front Bench, noble Lords will be aware of how lucky I always was to have him on the health team and speaking on behalf of the team in this House. It means I do not have to revisit all those issues; I thought he explained perfectly well what the intentions of the 2012 Act were.

I will add just a single point: the 2012 Act was not implemented. Clinical leadership on the part of general practitioners was stifled, pretty much at birth, by the way in which the management systems in the NHS told them they could live with the deficits or they could have autonomy; they could not have both. And NHS England was not created by the 2012 Act; it was the accretion of subsequent responsibilities. What was created was the NHS Commissioning Board, and the focus on commissioning and clinical leadership is what we should continue to have at the forefront of our mind. If there was duplication with the department, it was largely because the department never let go. Ministers did not understand that they had to let go; they had to give the NHS autonomy, otherwise inevitably there would be confusion and duplication.

I read the Bill looking for the positive purpose, and all I find is abolition: abolition of NHS England, abolition of Healthwatch, abolition of the HSSIB, and abolition of foundation trusts. What I wanted to find in the Bill was positive purpose. I follow not least the noble Baronesses, Lady Tyler of Enfield and Lady Campbell of Surbiton, in saying there is much we can do now to deliver on a government manifesto commitment. None of these things in the Bill are manifesto commitments. What there is, is a commitment to a national care service. We should use this Bill and the debates around it to help to fashion that by, as the noble Baroness, Lady Campbell, said, strengthening the existing statutory provisions for personal budgets that combine health and social entitlements; by strengthening joint commissioning between ICBs and local authorities through devolution; by implementing the cap on care costs in the Care Act 2014, which has been in legislation for 12 years and no subsequent executive has seen fit to implement Parliament’s intentions.

I listened with interest and approval to what the Prime Minister said about the difficulty of people with severe dementia not accessing NHS Continuing Care in circumstances where somebody with cancer would. We can deal with that and I will bring forward an amendment that should, if it works, enable more people with severe dementia to access NHS Continuing Care. We can do positive things with this Bill and I hope we shall.

When it comes to abolishing NHS England, I just say to the Minister that she should be careful what she wishes for because every issue will land on the Minister’s desk. At the moment, Ministers are still wandering around saying they have cut the waiting list by half a million. Good grief, when I left the department, the waiting list was 2.64 million; it is now 7.37 million. The numbers have been going up, not going down, in the past three months. She says that patients should be treated on time. When I left, 162,000 patients were waiting more than 18 weeks; it is now two and a quarter million. There is a very long way to go. If she thinks running everything from the Department of Health is going to solve the problems, she might like to talk to her former colleagues in Cardiff, because running things from Cardiff did not sort the problems of the NHS in Wales. I think she might like to think again about whether this will solve her problems.

I do not need to repeat what my noble friend said from the Front Bench about the importance of the independence of the HSSIB in relation to its investigations and the patient voice through Healthwatch, and I hope this House will be robust in defending them. I hope that the single patient record will work. I am scarred from trying to manage the results of introducing new technology in the NHS, but I think this time we have to crack it. It is important to have the statutory provision and the implementation very firmly in our debates. Finally, I will just say this: my noble friend was right that commissioning and clinical leadership in the NHS are exactly where we should focus our efforts and make sure that we give clinical leaders in the NHS the autonomy to make that happen.

Lord Stevens of Birmingham (Crossbench)

My Lords, it is almost as if we are intruding on private grief as this debate unfolds, but what a pleasure it is to join so many distinguished former colleagues from across the National Health Service. Frankly, there is much to welcome in this Bill, but at its heart is yet another top-down administrative reorganisation of the NHS. Folding NHS England into a government department and converting operational managers into Whitehall civil servants clearly corresponds to the current zeitgeist, but as we legislate, I suggest that we should be clear-eyed about both the potential benefits and the inherent risks.

The strongest argument in favour of folding NHS England into the department is clearly that it offers the opportunity to reduce duplication—fewer checkers and more doers. In fairness, I think it is also the case that the Secretary of State could have achieved the same result with a more explicit division of labour between NHS England and the Department of Health and Social Care, which is what the Government’s impact statement says—namely, that headcount reductions could have been made by the Department of Health and Social Care without legislation.

Picking up on the point made by the noble Earl, Lord Howe, I think it is surprising that a year and a half after the announcement was made about the abolition of NHS England, when describing the so-called full economic assessment of what the costs and the benefits will be in the impact assessment, all the cells where there should be pound notes are blank. The costs are described as not available and the benefits are described as not available. All we have is the press release that was issued at the time of the original Budget.

As to the philosophical argument about the need to promote more democracy, let us be clear: this is not a binary. It is not about control or no control by the Secretary of State; it is matters of degree. Our Health Secretary sets the NHS budget, sets its priorities and oversees its performance. Although we have cast our mind back to 2012, let us not forget that, in 2022, Parliament set up the arrangements that we are now about to disband. Since the 2022 Act, the Secretary of State has also had a legal general power of direction, and this Bill proposes even more of that.

Particularly striking are measures that would allow political appointments throughout the NHS locally. Turning the clock back 25 years, Schedule 3 gives the Health Secretary the power to appoint political place people to every hospital board in the country. Even more surprisingly, Clause 37 allows the Secretary of State to fire individual named executive directors of foundation trusts, and Clause 11, in effect, means that for the first time ever in the history of the National Health Service, local health board chief executives serve at the pleasure of the Secretary of State, whose subjective opinion determines their hiring and firing.

However sanguine we may be about the way in which those powers would be exercised by the current Government, one has only to look across the Atlantic to envisage a future in which that could be a cause of considerable and deep-seated concern. So, yes, removing duplication; a debate about what democracy really means in this context; but the third “D” is, of course, the risk of disruption. Frankly, the NHS is feeling the effect of that at the moment.

The new Secretary of State, Yvette Cooper, has reportedly and rightly been asking how all this administrative turbulence is affecting the big patient care challenges facing the NHS. Waiting lists remain stubbornly over 7 million, despite heroic efforts across the service to get them down. Cancer waiting times are off track by up to three years. In maternity and early years, Yvette Cooper has again rightly focused on the need for further attention. Parliament has just had a divisive debate on assisted dying, but one thing we all agreed on was the need for better palliative and end-of-life care. The modern service framework is currently missing in action. All of this runs the risk of distracting from the things that would genuinely make a difference to patients.

Instead, 18 months on from the original announcement, we still do not have the operating model which the NHS is supposed to be putting into place from April next year. We have unclear resourcing for ICBs, which will not even know their boundaries, apparently, until at least 2028, and the role of the regions, not mentioned in the Bill, as yet undefined. As the old adage says, only two things will survive a nuclear war, cockroaches and the regional tier of the National Health Service. It would be good to hear a little more on that front.

The practical test for this Bill, therefore, is: will the changes actually improve patient care? Will they drive value for taxpayers? Many believe that this is, as we progress, the triumph of hope over experience. Our job at the amending stage of this legislation is to try and improve the chances of success.

Baroness Jay of Paddington (Labour)

My Lords, I am very glad to follow the noble Lord, Lord Stevens, with whom, as another old colleague, I have had many discussions on many issues on the health service, not always in agreement. I congratulate the Government on introducing this Bill to modernise the service, with its explicit emphasis—and I emphasise explicit—on patient experience. The plan to place patient experience alongside clinical outcomes as a key measure of care quality is enormously important and, I would say to the noble Lord, Lord Lansley, a very positive purpose of this particular legislation. Some of these proposals, as he will know too well, have been in the pipeline a long time, and it is very welcome that they will now be properly enacted.

In the interests of time, I will mention just some of the improving changes which have particularly occurred to me and then raise a couple of questions about delivery. First, I am extremely pleased that every integrated care board will have members representing local authorities, and that, as the Minister has said, Commons amendments have already strengthened this membership. I am certain from previous experience on district health authorities that including some of the people from neighbourhood services, such as housing and transport, will improve public health and indirectly reduce inequalities.

A major change which will directly benefit patients is one which other speakers have mentioned: the final arrival—and it is a final arrival—of the single patient record. It seems extraordinary to me that it was 25 years ago that I was the Minister responsible for trying to streamline patient records in this way. After a lot of effort, that proposal was bogged down in many objections about shared technology and confidentiality. I am sure the details about the new electronic patient record will be rightly closely examined in Committee, because there are in fact, in this new digital age, some justifiable concerns, some of them from across the Atlantic, about who is ultimately handling and indeed owning the confidential patient data.

To me, it is reassuring that in future, overall responsibility for patient experiences will be integrated into a new directorate with responsibility at ministerial level. I welcome the fact that it may be possible to revive the original Nye Bevan commitment to answer all questions about the health service at the Dispatch Box. However, in spite of the new directorate, I have some questions about how public involvement and patient voices are to be effectively organised.

I do not think it can be stressed too often, as speakers have done before me, that a successful system must be independent, easy to access and have clear lines of accountability. Anyone wanting to express an opinion about their care or raise a complaint about treatment should be sure that this can be done in a straightforward way to an independent authority, and that, if necessary, quick action will be taken.

My main concern about patient voices is, as has been mentioned, the abolition of the Healthwatch structure, particularly at a local level. I can understand completely the laudable ambition to bring patient voices directly to the boards that commission and organise their services, but I am afraid that this can appear a more daunting official channel than the informal and, to many people, safer neighbourhood space of Healthwatch. I was frankly alarmed to learn that the figures show that, in 2024, over half of those who experienced what they described as “bad care” said they did not report it because they feared that doing so might jeopardise any future treatment. We need to be certain that any new system does not deter any service user from coming forward, especially, for example, if they are particularly vulnerable in some way or may be put off by complicated IT systems.

The Minister has already helpfully said that the Government are committed to reconsidering some of these proposals in this House. I also note that at Third Reading in the Commons, the Secretary of State spoke of “some previous arrangements”. May I ask the Minister and her colleagues to look again at the record of community health councils, which were abolished in 2003? I think they still hold some valuable ideas for the development of patient empowerment in 2026. I look forward to further proceedings on this important modernising Bill.

Lord Young of Cookham (Conservative)

My Lords, it is a pleasure to follow the noble Baroness with her ministerial experience. My view is that this Bill should be judged against the three priorities that the Government set for the NHS two years ago: from analogue to digital, from hospital to community, and from sickness to prevention.

First, on analogue to digital and the single patient record, we do not actually have a National Health Service. We have a series of local health services—medical centres, pharmacies and district general hospitals, held together by a network that is often not fit for purpose. Quite often, it is not the individual treatments or consultations that go astray but the communications between them. Hence the need for a single patient record.

A recent personal experience confirmed this. At a routine annual check-up, the consultant recommended a precautionary jab for shingles and said that she would notify my GP. Two weeks later, nothing had happened, so I contacted my GP. I quote from her subsequent reply to the consultant:

“The letter we have received includes an attachment PDF but we are unable to open this link in the format that you have sent this letter. Please could you send us the PDF document as an opened document to action”.

This was an NHS GP communicating with an NHS consultant within the same foundation trust about a treatment. Technology has transformed a doctor’s instruction from one that was illegible to one that is inaccessible. In my case, it did not matter, but it shows how the professionalism of those working for the NHS can be let down. Hopefully, a single patient record will remedy this.

I note that GPs have expressed some reservations. I know from my experience as a Health Minister over 40 years ago that GPs can defend their corner with vigour. At that time, the BMA negotiators were their chairman, Sir Anthony Grabham, and their future vice-president, David Bolt. When it came to negotiating resources for the GP contract, “Grabham and Bolt” is exactly what happened.

On the second priority—from hospital to community —the ICB will have more commissioning powers to focus on primary care and community services. I very much welcome that, but I fear the major shift from hospital to community has been kicked into the long grass by the Government’s approach to adult care, as mentioned by the noble Baroness, Lady Tyler. This is the fifth Parliament since 1997 with a healthy government majority to duck that issue. Every day, there are 13,000 people in hospital who do not need to be there because of the absence of reform of social care. The dish that was oven-ready in 2019 is still waiting for a recipe. If the noble Baroness, Lady Casey, had been instructed to report within two years, we could have had her report by now and legislated in the next Session. This unforgivable procrastination will make achieving the targets in the 10-year plan more difficult.

Finally, on sickness to prevention, I very much welcome the Tobacco and Vapes Act and its generational ban on selling cigarettes, as well as the record investment in smoking cessation services. However, funding that was previously ring-fenced at ICB level is now going to be part of a baseline budget and under threat. Research from ASH has found that the removal of this ring-fence has already led to services being decommissioned, and some 83% of services said that they face an uncertain future because of a lack of secure funding. When it comes to funding prevention, we have the mechanism for raising £5 billion over five years through a “polluter pays” levy on tobacco manufacturers, for which the noble Lord, Lord Rennard, and I have been advocating for many years and which the Minister supported in opposition. With the Chancellor searching for cash, we could both begin by recommending that to him.

Lord Patel (Crossbench)

My Lords, I say to the noble Lord, Lord Young of Cookham, that I could always read my writing, most of the time. I have accused the noble Earl, Lord Howe, previously of being a class act and I repeat that today. With his usual silken charm, he demonstrated how wonderful the 2012 Bill that he took through this House was. He succeeded partly because he had the ironclad majority of a coalition Government. Despite hundreds of amendments, he was successful in not giving quarter on any of them. However, I compliment him and accept that Healthwatch England, the public health measures that were put into the Bill and the safety arrangements were part of his doing in this House, which he conceded to not through amendment but his own charm.

This is the second Bill in a 30-year history of major reorganisation of every part of the NHS. Research by think tanks shows that they often end up not achieving what they set out to do, as the 2012 Bill proved. Some say the Bill is not necessary. Certainly, some parts of it are probably not. But it should be judged not simply on the organisational reforms it introduces but on whether it strengthens the NHS’s ability to deliver on the Government’s wider agenda to improve the health and health outcomes of the most disadvantaged.

The Bill will abolish NHS England and transfer its powers to the Secretary of State. Additional powers extend far beyond this. While the powers of the Secretary of State are far-ranging, there is nothing in the Bill on powers to improve the health of the nation, tackle variations in care and reduce the inequalities of healthy life expectancy and outcomes. I hope through amendments to try to have discussions about improving the health of the nation and reducing inequality.

Healthwatch has been mentioned several times. I agree that abolishing Healthwatch, the only independent voice of the patient, is probably not necessary. Annexing Healthwatch England and local Healthwatch with ICBs will weaken the independence and the voice of patients, particularly those of the marginalised and the frail. The NHS as a whole is poor at listening to the voice of patients. It is often patronising, as evidenced by the reports of many inquiries, from the Francis inquiry on Mid Staffs to the recent maternity services inquiries. All of them reported that patients’ voices were not listened to.

Structural changes will not lead to making the voice of the patient stronger. While there is some variation in local Healthwatch, we have been mostly successful in bringing together communities, social care and other public services. Equally, abolishing the HSSIB is unnecessary and we should restore it. In fact, we should give it more powers to establish a process for the reporting of incidents. In my view, Clause 65 is therefore not necessary.

I welcome the single patient record strategy, which has much to offer, but how it is to be implemented will be in secondary legislation. There are serious issues relating to transparency, confidentiality, control of access to data and, importantly, public trust that need to be addressed, as the Minister mentioned. How is information that patients do not want to share, such as in maternity and mental health, to be handled?

I have concerns about the lifting of the common law of confidentiality, abiding to which is a promise that all health professionals make through taking an oath and is never to be broken. I intend to amend Clause 52 to reinstate the common law of confidentiality so that it applies to all those who share patient data. At the same time, it will help public trust. I hope the House will find common cause with that amendment. Implemented with care, the SPR has the potential to improve patient and population health and drive innovation.

It is disappointing that the Government did not take the opportunity with this Bill to address some of the commitments already made, such as in rare cancers, neonatal care, mental health and, importantly, end-of-life care, which is espoused by the Prime Minister. I look forward to our discussions. I will enthusiastically support any amendments that improve the Bill, and I hope my amendments will also do so.

Lord Jabbar (Labour)

My Lords, it is with great humility and a profound sense of privilege that I rise to make my maiden speech and to follow the noble Lord, Lord Patel.

I express my sincere gratitude for the very warm welcome that I have received from all sides of the House since my introduction several weeks ago. I am particularly grateful to Black Rod, the doorkeepers, the clerks of Parliament and all other staff of the House for their generous patience and guidance. As a new Member, I have quickly come to appreciate how much this House relies on their professionalism, knowledge and efficiency.

As all here today will know, new Members must learn very quickly the rules, practices and conventions that are unique to this special place. As I came into the Palace one afternoon recently, greeting the House staff with “Good afternoon”, I was informed by one of the doorkeepers—most politely, I must add—that, irrespective of the time on the Clock, it remains the morning until the House begins its proceedings. As a newcomer, I of course accepted this without question. Indeed, such is my eagerness to learn and my deference to any and all advice received within the House that in my current state of mind my fear is that if anyone were to inform me today that the world is flat, my inclination would be to take a detailed note rather than challenge it.

I want also to express my gratitude to my supporters, my noble friend Lady Kennedy of The Shaws and my noble and learned friend Lord Hermer. Their commitment to justice and the rule of law is a source of inspiration. Having worked closely with them throughout my career, I was honoured that they agreed to support my introduction to your Lordships’ House.

As the son of immigrants seeking opportunity and a better future for their children. I count myself very fortunate to have benefited from the possibilities that this country has provided. I grew up in Manchester and attended a local comprehensive. My parents’ belief in education and hard work shaped my life profoundly. It is only sad that they are not alive now to have joined me for my introduction, but it is their values that make my standing here today in this Chamber deeply meaningful.

Before joining your Lordships’ House, I have worked for more than three decades in the field of international human rights and criminal justice as co-executive director of the Death Penalty Project, an international legal action organisation seeking criminal justice reform and the abolition of capital punishment around the world. Through this work, I have engaged with foreign Governments, policymakers, the judiciary, civil society and others, across the Commonwealth in particular, seeking to strengthen criminal justice systems, protect fair trial rights and advocate for reform.

I think it is fair and right to say that all sides of this House have consistently shown leadership in this area, rejecting the idea that state-sanctioned killing is a policy that we should support—I have worked with many people across this House, for which I am very grateful. The reporting of a botched execution and statements around public executions in the United States in the past few days are a reminder that this subject is far from remote for anyone interested—but perhaps that is a speech for another debate.

I hope to bring to this House the experience I have gained in the areas of criminal justice, constitutionalism and the rule of law. This work has taught me the importance of evidence-based policy-making and strong institutions to ensure that policy remains anchored in the experience of those it is intended to serve and that any change is grounded as far as possible by building consensus through diplomacy, perseverance and understanding.

The Bill before us concerns the organisation and delivery of healthcare. It will abolish NHS England and establish a single patient record to make data directly available to patients across healthcare settings. While health is not my area of expertise, for me, and I am sure for others, it can speak to personal concerns and experiences. A few years before my mother’s death, she suffered a severe stroke that left her paralysed and unable to speak. While she remained brave and stoic in the face of her adversity, our family experienced first hand the challenges of dealing with the healthcare system to ensure she received the treatment, care and dignity she deserved. Like many other families facing similar circumstances, we came to understand that organisational structures are not abstract matters; they directly impact both access to treatment and how families must navigate this process during immense vulnerability and uncertainty. This experience taught me that healthcare is not only about treating illness but about preserving dignity for all. Throughout my professional life working in the area of judicial administration, I have seen that institutions command trust when they seek to combine effectiveness with accountability.

I join this House mindful of the distinction of its Members and the importance of the work it undertakes. I look forward to hearing from noble Lords across the House and hope that, in the years ahead, I can contribute to the thoughtful scrutiny and debate for which it is rightly recognised. It is an honour to make my first contribution in this debate, and I thank the House for its indulgence.

Lord Bradley (Labour)

My Lords, I congratulate my noble friend Lord Jabbar on his excellent maiden speech; it was a wonderful contribution to our deliberations, full of warmth, humility and humour. I am particularly pleased to welcome a fellow Mancunian to your Lordships’ House, since my noble friend lived and was educated in my former constituency—although I take absolutely no credit for his future eminent career. Again, I offer him many congratulations on his speech; we all look forward to many more in the future.

I turn to my own brief contribution to the Second Reading of the Health Bill. I carefully listened to my noble friend the Minister’s opening of the debate, but I have to say that I am still rather perplexed. It is still not clear whether the Bill is a key part of the Government’s drive for devolution, via the transfer of power to local communities to determine how they tackle huge local health inequalities, the development of neighbourhood care centres and the moving of services from acute hospitals to primary and community settings; or whether it is a centralising Bill, with the Secretary of State for Health and Social Care taking back huge powers to determine the priorities for healthcare across the country. I accept that these are not binary positions, but clarity of purpose, responsibility and accountability is essential. Throughout our deliberations on the Bill, we will be seeking such clarifications.

For example, we will seek clarity on how the public’s voice and, crucially, the patient’s voice will be heard loud and clear, and independently, at local level following the proposed abolition of Healthwatch and the councils of governors on hospital trusts; and clarity on exactly when NHS England will be abolished. Is that in 2027, 2028 or beyond? There is still confusion among the staff in both NHS England and the Department of Health about exactly when these things will happen, and these are costs that are building up within the health service.

We need clarity on the role and accountability of regional NHS offices, particularly in relation to commissioning—this is from my particular interest in the commissioning of health and justice—and the relationship of elected mayors with a direct appointment to ICBs with the strategy for local healthcare. We also need an assurance from the Minister, which I hope she will be able to give me today, that the provision in the Health and Social Care Act 2012 that every ICB should include a non-executive director to have specific oversight of mental health services in local areas is maintained.

I will say a brief further word on specialist commissioning currently undertaken by NHS England, again in respect of health and justice, because under the new commissioning plan such services will be devolved to ICBs. Will the Minister confirm that all resources will be transferred from specialist commissioning at NHS England to ICBs and, in future, will the Department of Health have oversight and accountability for the continued development of health and justice services?

Next, I will make a brief comment on the single patient record, which I greatly support. I thank my noble friend the Minister for her letter last week attempting to clarify the Government’s position regarding the criminal justice system. The letter states that relevant healthcare professionals providing direct care in criminal justice settings will be able to access the single patient record information, but this would not give the police, courts and other criminal justice personnel general access to the single patient record. Will the Minister provide a clear definition of “direct care” and confirm that liaison and diversion healthcare staff, especially mental health nurses who provide crucial healthcare support in police stations, courts, prisons and street triage, will have access to these records?

I have two quick final points. The first is to advocate again for allied health professionals and, noting my own interest here in the register, including speech and language therapists, so that they will be afforded appropriate prescribing rights to facilitate the development and efficiency of neighbourhood healthcare.

Secondly, the Government have confirmed today that they will bring forward an amendment in this House to establish a maternity commissioner, which I fully support. However, I find it strange that when I and many other noble Lords advocated for a mental health commissioner during our recent Mental Health Bill deliberations, that was vigorously resisted by the Minister. She argued that the then Government were opposed to the establishment of commissioners and that the CQC was the appropriate body, as the regulator, to have oversight of such mental health services. Have the Government now changed their mind and is it now the intention that further commissioners can be established? I suspect this may be further debated during the passage of the Bill.

Lord Black of Brentwood (Conservative)

My Lords, I join the noble Lord in congratulating the noble Lord, Lord Jabbar, on his excellent maiden speech, and look forward to the others today.

I welcome the opportunity that the Health Bill gives us to discuss significant public health issues, and the Minister will not be surprised that what I want primarily to address is fracture prevention—this is our second outing today. More than 3 million people in England live with osteoporosis; many do not know it, with damaging consequences for their health, ability to work and quality of life. Half of women and one in five men will break a bone because of it, and the end result of untreated osteoporosis—a hip fracture—is the second largest cause of unplanned NHS bed days. An horrendous postcode lottery means that people from deprived areas are at a 25% higher risk of fractures. The Prime Minister wants good growth in every postcode, and I hope that he will start here, as good health is crucial to good growth.

Much pain and suffering are avoidable: we have safe and effective medicines and a proven model—the fracture liaison service—which picks up people after that first fracture and makes sure that they are diagnosed and treated. It will pay for itself in two years. Filling in the gaps in coverage would save health and social care services more than £600 million over five years.

None of this is in dispute, and I know that the Minister, who has been stalwart in her support of this cause, understands that. It was fantastic that the Government committed to a national rollout of FLS to every part of England before the election, but progress has been achingly slow. We still have no confirmed funding, rollout plan, implementation timetable or clinical leadership. That is where this Bill comes in.

In 2024, the Government inherited a position where FLSs served half of NHS trusts. Ministers pledged to roll out these services in every part of the country by 2030. So far, 50-plus additional FLSs are required to fulfil that commitment, but since the election, as we heard from the Minister earlier, only five have been established, all the result of local initiatives by determined doctors.

Over that period, the message from Ministers has been consistent—“The rollout will happen, the deadline is 2030, we have time”—that is, until this summer, because now Minister Karin Smyth in the other place has taken to relying on ICB-level coverage figures to make the perhaps dubious claim that the rollout is 92% complete. These figures are irrelevant because the reconfigured ICBs are enormous. Within them, the service footprint has hardly changed: 94% of the services Ministers are counting are the ones they inherited in 2024. At the current rate of progress, fulfilment of the Government’s commitment will take 38 years.

Where government fails to fulfil a pledge, it is up to this House to do something about it. I expect an amendment to be tabled to require a clear implementation plan for fracture prevention, along the lines of the one tabled in the other place with support from Government and Opposition MPs. To be clear, its aim will not be to create a new policy, simply to ensure that existing commitments are adhered to.

There are a couple of issues in the Bill which relate to people living with HIV. I declare my interest as a trustee of the Terrence Higgins Trust. First, the Bill will legally transfer commissioning of specialised services, including HIV care, to ICBs. There is a danger that as a result HIV care will be deprioritised. Commissioning of HIV care was delegated from NHS England to ICBs from April 2024, and THT and other HIV charities warned that NHS England was giving up a key lever for ending new HIV transmissions. As of June 2025, only 21% of ICBs referenced HIV in their joint forward plan. This makes the development of local HIV action plans and clear reporting against national care standards essential. Will the Minister please set out how the Government will ensure that transferring HIV commissioning to ICBs does not lead to HIV being deprioritised?

Secondly, there are concerns around the welcome introduction of the single patient record, which will be particularly important for the two-thirds of people living with HIV who also have comorbidities. There is a danger in how patient confidentiality will be safeguarded. As HIV remains highly stigmatised in some areas, 10% of people living with HIV have not shared their HIV status with their GP. It is vital that confidentiality is central to the development of this record, and that the development of the single record includes consultation directly with people living with HIV. I look forward to the Minister’s response on these points and to engaging constructively on this and other matters in Committee.

Baroness Hollins (Crossbench)

My Lords, I applaud the speech by my noble friend Lady Campbell. I agreed with every word, and I will not repeat any of her aspirations.

The success of the Government’s ambition to improve the delivery of healthcare and to promote more integrated services closer to people’s homes will partly depend on clinical leadership and commissioning. Patients—people —view success according to the relevance, quality and speed of care and support that they receive, not on the statistical findings that are reported. Clinicians need to agree the best possible outcomes with each patient, given their own history and preference. Operationalising care pathways must never lose sight of the individual patient.

The noble Baroness, Lady Tyler, reminded us of the importance of the social determinants of health. Health also requires a joined-up financial partnership with other policy areas, including education, social care, housing and criminal justice, if population health is to improve and evidence-based prevention is to be as effective as it could be.

My own expertise and interest are in people with mental illness, people with learning disabilities and autistic people, whose voices are too often unheard. It is through this lens that I will raise a few concerns.

The Royal College of Psychiatrists has rightly argued that workforce planning must be central to the success of this Bill, but this must include retaining the staff we currently have. We know that among NHS staff there are a lot of stresses and illness across the whole service, so attending to the mental health needs of staff will be important. There is no health without mental health. Going back to the 2012 Act, the one thing that I fought for was parity of esteem for mental health. There is still a huge amount of work to do, and the integration that this Bill seeks to promote must include the integration of psychiatric expertise across the wider health and care system.

The Health Bill seeks to strengthen the duty on the Secretary of State to reduce inequalities. People with learning disabilities arguably face the greatest inequalities of all. The latest LeDeR report tells us that adults with a learning disability still die, on average, 19 years younger than the general population. Some 39% of deaths reviewed were avoidable, with failures to provide adequate care not being “isolated errors” but described as “systemic” failures. Concerningly, the future of the LeDeR programme is in doubt, despite it being described as imperative that we commit to continue to identify and reduce these health inequalities.

I recently met people with learning disabilities, family carers, academics, charities and professionals to precisely discuss this problem. There was considerable agreement that we need a new national learning disability strategy, co-produced with people with learning disabilities and their families, bringing together what we already know works and identifying where further evidence and work are needed. Short-term crisis management and a rationing approach to community support are contributing significantly to poorer health outcomes for people and greater cost to the public purse over time. This has been so well documented in many reviews over decades. Will His Majesty’s Government consider developing such a strategy, with measurable objectives for reducing these extraordinary inequalities in both health and social care?

We could create a health and social care system that works for everyone. To make this a reality, people with learning disabilities and their families cannot be an afterthought but must be at the forefront of co-producing the new national care service, which really ought to be part of this Bill.

I welcome the single patient record, provided that it is a summary that is not overinclusive of confidential personal information. For people with learning or other communication disabilities, having key information that is relevant, up to date, and available across all areas of health and care could help to integrate care, avoid duplication of effort and error, and highlight areas of unmet need. As ICBs take on new commissioning functions, we need to be confident that there is effective national oversight and consistency and that, where there are smaller patient groups with quieter voices, they are not just forgotten about. Healthwatch is a vital service to enable people to have a voice.

Lord Winston (Labour)

It is a pleasure to follow the noble Baroness, Lady Hollins, with her excellent expertise.

I want to focus not on the main issues of the Bill—a really useful Bill, with huge value—but on other issues which are not fully mentioned in the Bill, one of which is whether the whole financing of the NHS is appropriate. We do not have enough transparency around that. Ever since we have had the internal market, there has been a big problem with competition, which raises issues around not understanding what procedures actually cost—how much they cost us as taxpayers and how much they cost in different areas of the country. When you have localisation, as we intend, that makes it rather more difficult.

The other issue is that of compassion, which the Bill does not describe. It is a great Bill in what it actually says, but the way it is expressed is difficult to read and it does not help us very much in thinking about what we are actually doing with patients in hospital or in general practice.

I have a colleague—a cleaner—who I do not know well, who went into hospital, vomiting, some months ago. She had blood in her vomit and pain in her abdomen. It was a very short history. She lay in hospital for two or three days and she was never examined physically, which is not untypical. A physical examination is, in my view, the essential way of getting to understand the patient, and we are not providing that. At the moment, people are not being examined at any stage in their initial treatment, and what follows is an inadequate history of the patient’s illness. Finally, on the fourth day, I spoke to her on the phone and she told me that a doctor had walked past her, looked at her notes and said, “Oh, you’ve got stomach cancer”, and then walked on. That was her first idea that she might have something seriously wrong. That is really happening, and I have seen it again and again. We are not communicating.

A lot later, I complained to the chief executive of the hospital. It was difficult to find him and difficult to find his phone number. I had to use a rather nasty way of doing it, by phoning the press department of the hospital to say that I was writing a letter to one of the newspapers and that before I sent it I wondered whether the chief executive perhaps wanted to see it. I still did not get a response, but, the following day, I went to visit my friend in hospital, and my telephone rang. It was the chief executive, who said, “Is that Robert Winston?” I said yes. I did not say where I had come from. He said, “Where are you? Can I speak to you sometime?” I said that of course he could and that I was actually in his hospital at the moment. He asked me where, and I told him I was in the huge ward upstairs. He came straight up. This chief executive did something quite remarkable. He got down on his knees, in his trousers, on the floor—the patient was lying in bed—put his face right up against hers and said the right things to her.

We have the ability, but we are not doing it nearly enough. It should not take a chief executive—it should be a doctor or a nurse. But all the doctors in that hospital, when I saw them when I was there as a patient, are operating computers outside of the wards most of the time, and are not actually with the patients. In fact, the last time I was in hospital with my leg, for 11 days, I never knew who in fact was running the ward. I never saw what we would now call the chief nurse—I did not know who that was. Most of the nurses I saw were not very well qualified at all. Indeed, one of the nurses who was dressing my leg at one point—who had plenty of time to talk because it was late at night—said that he had 10 nurses he was trying to train, who were all very good young women, but, of the 10, if he was lucky, only three might stay in Britain because they were so disenchanted.

We cannot have that happening in our health service. We have to understand that so much part of that service is not this dry language we need to use in the Bill, but in fact the warmth we have in actual communication and listening to patients. We have to have people who are listening and facing a patient, not facing a computer. We talk about personalised medicine— I have said this before—but the medicine we are practising now is impersonal unless we actually make certain that we are touching the patient and listening to the patient.

Baroness Leaman (Liberal Democrat)

My Lords, this Bill is wide-ranging and touches all parts of the structures of our NHS, but I am going to use this Second Reading to focus specifically on its impact on people with autism and ADHD. Last Friday, the Government published their own independent review of ADHD and autism services. They found more than 500,000 open referrals for ADHD and more than 250,000 people waiting for an autism assessment. I thank the Minister for her introduction, and I add my congratulations to the noble Lord, Lord Jabbar, on his maiden speech. I am very much looking forward to the four maiden speeches still to come.

This Bill does not mention autism or ADHD, but it changes who runs three things those patients rely on: the national programmes, the data and the patient voice. I want to ask the Minister about each of these, so that these patients are not lost in the move. I turn first to the programmes. Professor Fonagy’s review and the ADHD taskforce before it point the same way. Both want more of the routine, ongoing care for adults with ADHD to be provided by GPs rather than specialist clinics. The taskforce had no power to act on its own findings. That job fell to NHS England, which this Bill, of course, abolishes.

I asked ADHD UK what this means for the people it represents. Its chief executive, Henry Shelford, told me it was hard-fought to find anyone in NHS England with responsibility for ADHD at all. His fear is that ADHD will now be lost again. He also asked me a very simple question: when do the reports end and the action begin? The Government have said they will respond to the review in a mental health strategy in the coming months, and I welcome that, but could the Minister tell the House who in the department will lead this work once NHS England has gone? When can people waiting today expect to see a difference? The same question applies to autism. NHS England runs the national programme for autistic people and people with a learning disability. Can the Minister tell us where it will sit next year, and who will run it?

The second issue is data, and two kinds matter here. The first tells us how many people are waiting: NHS England publishes those figures regularly. The second tells us how many people are autistic or have ADHD in the first place. Here, the review found very little. There is no recent England-wide study of autism in children, and the best ADHD figure dates from 2017. My own Written Questions have confirmed that the Government do not centrally assess whether there are enough assessment services, so the waiting figures are the best evidence we have.

This Bill moves the teams who produce those figures into the department. ADHD UK warns that, if that work is split up, the national ADHD data dashboard will lose the figures it depends on. Can the Minister reassure us that they will still be published on the same schedule, and in a form we can compare with today’s? Will the Government commission the regular surveys the review recommends?

The third consideration is the patient voice. Locally, Healthwatch is often where a parent turns when the school, the GP and the hospital each say it is someone else’s job. My Liberal Democrat colleague Helen Morgan pressed hard on this in the Commons, and I welcome the Minister’s commitment to review the plans for local Healthwatch. Her letter to Peers says that the new patient experience directorate will focus on seldom-heard groups. Many autistic people and people with ADHD will never fill in an online survey or sit through a public meeting, so how does the department intend to reach them?

As many noble Lords have said, there is one part of the Bill I warmly welcome: the single patient record. An adult is diagnosed with ADHD by a specialist; the GP is asked to take over prescribing, and the GP declines due to lack of funding. The specialist has already discharged them, and the patient runs out of medication. A shared record could help to prevent that. It could also help at age 18, when too many young people have to start again with adult services.

I understand the Government’s aim of a simpler NHS. I hope the Minister can reassure the House that simpler will not mean that these patients become easier to overlook. There are more than 500,000 open referrals for ADHD and more than 250,000 people are waiting for an autism assessment. Each of them deserves to know who will answer for their care once NHS England is gone.

Baroness Coffey (Conservative)

My Lords, I congratulate those making their maiden speeches today. I must admit that I am particularly looking forward to hearing the noble Lord, Lord Wormald, who was my Permanent Secretary, albeit for a short time. He is a brilliant civil servant and I am sure we will learn a lot from him. I also look forward to hearing from my noble friend Lord Singh of Solihull, who, with his expertise in psychiatry, I am sure will add to many of the comments that have already been made.

Real culture difficulties cannot be addressed by legislation, only by standards and leadership. However, the Bill puts back in the control of the Government, the Minister and the Secretary of State when things go fundamentally wrong in the NHS. Because of the direct level of accountability that an elected Government have, and when we consider that 40% of day-to-day spending is spent on the NHS, it is absolutely right that elected politicians and the Government have the levers to pull.

One of the things I point out to the House is that, for example, I remember challenging the NHS chief executive about the culture of basically almost saying “The NHS can do no wrong” or, “We’ll make sure it gets better”, and saying it really would make a difference if they were to remove the foundation trust licences of some of the worst-performing hospitals in the country. But they would not do it, because that is not the NHS culture.

So I hope the Bill gets strengthened, but I hope it does not get watered down, and I say that in a number of ways. I would like it to go further in the link between decision-makers and accountable representation. I welcome the amendment that was made to reinstate local government on to ICB boards in the House of Commons. But, on what I have heard about the patient voice, I am really sorry to say that Healthwatch has never really delivered properly the patient voice, either locally or nationally, and nor has the investigation board. Look at the outcomes it has produced: not very much. Meanwhile, there are MPs, local councillors and people involved in patient participation groups, and there is the formal structure of PALS within hospitals that tries to get things fixed. However, too often patients are scared to make a complaint, particularly when they are in hospital, in case all of a sudden, because of their concern about culture, their treatment will get worse, not better. It takes some bravery to stand up against it, but you can be braver once you are out of the hospital doors and back home.

This is the element that builds on what the noble Lord, Lord Winston, talked about: how patients get treated has to be key to this. Albeit I was a Secretary of State for a short time, but one of the things I am proud of is that we put together the starting point with the plan for patients. The Prime Minister today, who was a Health Secretary in the past, used to mainly talk about staff and systems and very rarely used the word “patients”. I know that the Minister that we have today will certainly not go down that track, and I very much encourage her not to.

As regards thinking about where potentially there could be some improvements to the Bill, we have an environment plan, which is long term, so I wonder whether we could have a health improvement plan that statutorily needs to be updated every so many years. Personally, I think we should look more at the role of health visitors and think how that can be delivered locally in terms of the local NHS, not just for children but for pensioners. Could we do something here in the Bill about palliative care and about transparency? My noble friends on the Front Bench have already said how, if we are taking away certain things, we need to increase the amount of transparency. I fully agree with that. That applies not only potentially to ministerial directions but more broadly.

Wes Streeting mocked me when I had set a target of somebody being able to meet their GP within two weeks. It is still government policy today, by the way. That was designed to open up how patients were able to access their GPs and what was happening in their surgeries. It was on the grounds that not everybody needs to be treated within 48 or 24 hours; it was about people who have discovered a bit of a lump and are feeling uncomfortable and then just keep putting it off because it is not urgent. That is how we miss cancer and other health conditions, and that is why making sure that we have patients at the heart of what we do will be critical to the outcome of making sure that the Bill is a success. The SPR will help it, but I hope the patient owns it—not the doctors or the NHS. It is the patient’s property.

Lord Kakkar (Crossbench)

My Lords, it is a pleasure to follow the noble Baroness, Lady Coffey. In so doing, I add my own thanks and congratulations to the Minister on the very thoughtful way in which she introduced the Bill and laid out the arguments for bringing it to your Lordships’ House. I also declare my interests as the chairman of the King’s Fund and King’s Health Partners.

We need to look at the arrival of this particular Health Bill in your Lordships’ House in the broader fiscal context. Over the past 60 or so years, we have seen an increase in expenditure on healthcare from 2.8% of national income in the mid-1950s to 7.3% by 2020. At the same time, expenditure on defence has fallen from 7.8% of national income to 1.9%. So there has been a substantial shift in the priorities of the state over that period of time, which has allowed substantial additional investment in the provision of healthcare and the development of the NHS. Indeed, if one looks over the 40-year period prior to Covid, in only two of those 40 years was the budget that had been agreed for expenditure in the NHS in the previous year actually delivered; more often than not, it was overspent by, on average, some 1.3%.

The question that we have to ask ourselves, in considering the provisions laid out in the Bill, is: are we now moving into a fiscal situation where it may be impossible for future Governments to provide, year on year, increased expenditure to support the delivery of healthcare in our country? The Bill therefore represents a substantial opportunity to address questions on whether the structures are indeed correct and whether those structures will provide us with the opportunity to address not only clinical, organisational and workforce challenges but fiscal challenges, where it will not necessarily be possible to provide as much as has been provided by repeated Administrations over many decades.

In that context, one has to try to understand the lens through which any of the provisions of the Bill—and, indeed, scrutiny by your Lordships—should be conducted. Of course, we have heard that, ultimately, the purpose of the health service is to ensure that the best clinical outcomes are delivered for every patient compassionately and sensitively; to secure the safety of all those engaging in health services; and to ensure that the service is delivered with maximum efficiency, ensuring that the valuable taxpayer contribution is delivered for the greatest benefit.

In addition, it is vital that any measures your Lordships decide to adopt are also able to ensure the adoption of innovation at scale and pace because, ultimately, that is the only way in which the substantial amounts of public expenditure committed to the delivery of the NHS might be distributed more broadly to ensure that we can start to address a prevention agenda; large amounts of additional expenditure will probably not be necessary.

We have heard, rightly, that many areas of the Bill should be scrutinised. I completely agree that there needs to be clarity of understanding around the distribution of responsibility, powers and accountability between those being drawn back into the Department of Health, to be exercised by the Secretary of State, and how that sits with a broader devolution agenda, ensuring that integrated care boards have the capacity to deliver what needs to be done at a local level; this should fundamentally determine how the health service is delivered. It is critical that we ensure that legislative measures are able to secure the social licence and public confidence that will allow for the delivery of the single patient record, which will ultimately be transformational in how care can be delivered safely, effectively and in a cost-effective fashion.

The patient voice is critical. If we go to other jurisdictions around the world that have put a lot of effort into gathering the experiences and views of patients in real time, we see substantial improvements in clinical outcomes and safety in those institutions. These are vital matters, all of which are to be considered in the broader context of the challenges now facing our country if we are going to provide what we must: adequate scrutiny and the delivery of vital reforms to the delivery of healthcare.

Baroness Lowe of Armley (Labour)

My Lords, thank you so much for the welcome you have given thus far to this Leeds lass. I thank the whole House, Members and staff, for your kindness to me since joining, and I say thank you, too, to my noble friends Lady Taylor of Bolton and Lady Blake of Leeds for so generously introducing me in September. Finally, I thank Black Rod and especially the doorkeepers, who have been so helpful in explaining the right procedures to follow and in rescuing me when I have been wandering the corridors, lost for the umpteenth time.

To say that I was surprised to be among you all would be an understatement. On the day it was announced that I was to become a Member of this House, my daddy would have been 91, 70 years after he arrived on these shores as a member of the Windrush generation. A proud Yorkshireman, despite his Kittitian roots, my daddy loved this country and was a passionate supporter of all its institutions—especially “his Queen”, Elizabeth II. His daughter’s elevation to the House of Lords would have been beyond his wildest imaginings, yet I am here because of him and the values that he and my mum instilled in me, for which I will always be grateful.

I had the privilege of serving the Labour Party for 29 years as a Leeds City councillor for the wonderful ward of Armley, hence my chosen name. I am currently the deputy mayor for policing and crime in West Yorkshire, working for our mayor, Tracy Brabin, to hold policing to account for the public of our wonderful county.

Today, I will speak on the Health Bill. As a former chief executive of Touchstone for 17 years—Touchstone is a mental health charity based in Leeds—I believe that I have some insight to share. In 2013, Touchstone was commissioned to provide Leeds’s first-ever local Healthwatch, which is the statutory, locally-rooted infrastructure organisation for gathering and representing people’s experiences across both the NHS and social care services. Now a stand-alone CIC, Healthwatch Leeds has been hugely successful. It is adept at gathering data and insights to support health and social care service reviews and improvements for the people of Leeds, particularly those who are marginalised, underserved or seldom heard. It has also been a strong independent voice, challenging those same systems when they get it wrong.

When NHS 111 became the primary route to access mental health crisis support across Leeds and West Yorkshire in 2024, Healthwatch Leeds responded on behalf of the thousands who were adversely impacted. It conducted in-depth research with hundreds of affected people, including unpaid carers. As a result, 371 people were engaged and multiple system-level changes were delivered in real time. A text crisis service is currently being developed, and the research is being used to inform the 2026 recommissioning of this service.

Healthwatch can work, despite the reservations of some, and I am pleased to hear the Minister agree to think again about the plans for its abolition. Although reform is required, criticism about variation in visibility, influence, consistency and resourcing is fair. The foundations remain strong, though, and should be retained and built upon for the future, as evidenced by the example of Leeds and many other local Healthwatch organisations. I look forward to Healthwatch becoming a bigger and better voice for the public.

Baroness Thornton (Labour)

My Lords, it gives me enormous pleasure to follow my noble friend Lady Lowe, a fellow Yorkshirewoman. It is true that I am from Bradford and she is from Leeds, and there are historic issues there. None the less, Alison brings wonderful experience and knowledge to this House, as she has amply illustrated in her maiden speech.

The themes which run through her life are public service in Leeds, race equality and mental health. She mentioned being CEO of Touchstone and serving her time on Leeds City Council. What she did not say was that she was the first black woman elected to Leeds City Council. She was also my youngest sister’s councillor for all that time. My sister testifies that she was very effective indeed. She stopped being a councillor in 2019 and went on to be an alderman in the city. She then became our deputy mayor in West Yorkshire, a position that she still holds today. I want to welcome this Yorkshirewoman to our Chamber. I know that she has a great contribution to make to our work.

I thank my noble friend the Minister for her excellent introduction to this Bill and for the many meetings that she has had. There have also been many maiden speeches of such excellence and quality so far. We are blessed.

In this short time, I want to raise three points and questions. Like many other noble Lords today, I feel a veteran of NHS reorganisations during the 28 years I have been here. It feels slightly like “Back to the Future Part II” with this Bill. That is a great film, so it is not a criticism and is no bad thing. My noble friend the Minister and I were Ministers when the NHS was run from the department, and it will be again. I thank many organisations and the Library for the briefings that we have received. Many make it clear that there is work to be done. I am still the relatively new chair of the Social Care Institute for Excellence. The noble Baroness, Lady Campbell, was its first chair when the institute was created by my Government in 2001. How inspired I am by the speech that she made today and the method by which she made it.

My first question concerns social care. With both the Prime Minister and the noble Baroness, Lady Casey, focusing on its future, it is now way up the public agenda and a focus for both lived experience and inequality, which need to be tackled. Will this Bill help that process in the local systems that it is proposing? Not having local authorities on ICBs in the first draft did not augur well for me. How will integrated preventive neighbourhood health be delivered if there is not true co-operation on an equal basis between the NHS, social care, local councils and communities in commissioning local services? One representative on an ICB is not enough. In my ICB, that will be one representative representing nine councils.

Linked to this is the question of the single patient record. How will that interface with social care records and data so that patients accessing social care do not have to repeat over and again the same information? There is also the question of confidentiality. My noble friend Lord Hunt will be exploring this and I will join him in that debate.

The third point concerns the patient voice, which many noble Lords have mentioned. I am a veteran of community health councils—I served in Bloomsbury about 40 years ago and was in your Lordships’ House—possibly as the Minister—when we abolished community health councils and introduced Healthwatch. I think my noble friend and the Bill team will by now have realised that the abolition of Healthwatch is not welcome. The NHS marking its own homework is not a good idea and may be very risky, as we know. Just being permissive in the Bill about the patient voice at a local level is not sufficient. This needs to be nationally funded, with national powers to deliver proper patient voice at a local level.

I welcome this Bill. I see the importance of streamlining the NHS as it has done. The noble Earl, Lord Howe, and I swapped places several times over 15 years as Minister and shadow Minister. I agree with my noble friend Lord Hunt that he is the person who delivered that Bill, the Lansley Bill, through his expertise in handling it in your Lordships’ House. However, that did not make it a right Bill. It has probably cost the NHS billions in bureaucracy that was unnecessary. I welcome this Bill on the basis that accountability will be put back where it should be—in the department—and that that will lead to a much more effective NHS.

Baroness Neville-Rolfe (Conservative)

My Lords, as a Peer who normally speaks on the economy, I am conscious that health is the largest recipient of public spending, with £203 billion spent in England alone in the current year. This is significant, not only in terms of personal welfare but economically. A healthier population, not stuck at home on waiting lists or with chronic conditions, would aid growth.

Health is a subject dominated by experts, but many of us have experience of the strength and weaknesses of very large organisations. Standing back, it is clear to me that the NHS is much too big and complex, with too much bureaucracy and too many managers overlapping with one another. Accordingly, I support the abolition of NHS England. I have become increasingly sceptical of the value of such stand-alone government bodies unless they are small and expert. They lack day-to-day contact with Ministers. They have become self-promoting with PR, HR and higher pay than Civil Service equivalents. It is a recipe for expenditure growth and poor value for money. And it may not be good for consumers—patients in this case—who need to be looked after, as we have heard from the noble Lord, Lord Winston, and my noble friend Lady Coffey.

Historically, hospitals and specialist care were run by doctors—very clever people who really understand their work. Now they are run by managers, who are often paid more, and there are several layers, with bureaucracy making work for each other and for the medical staff. Can the Minister say how many management layers there are in the DHSC directorate overseeing the NHS and how many within the NHS itself? Is there a plan for cutting out layers and generating savings from the reduction in duplication that the Bill promises? What are the salient numbers? These are questions in addition to the good questions asked by my noble friend Lord Howe about the costs and the benefits.

I experienced the limitations of the present arrangements when I was a Minister in the Cabinet Office trying to speed up hospital-building. The truth is that the differences and arguments between the health department and the NHS were a major cause of delay. When modern hospitals are built, such as Chase Farm Hospital in Enfield, they are transformational for patients and staff. How long have the last five new NHS hospitals taken to complete? How much of that time is taken in the approval process as opposed to actual construction? By how much will the reforms in the Bill reduce the delays?

The best way to improve healthcare would probably be to restore the effectiveness of the GP service, which is taking a reducing share of resources. A weakness of the present service is the lack of continuity of care, an issue that I will return to in Committee. It is very difficult to see or talk to the same doctor regularly. GPs constantly need to familiarise themselves with the basic facts. What a waste.

I support the single patient record, the NHS app and interconnectivity across the NHS. If, for example, you attend A&E, a great deal of time and cost could be saved on tests and analysis. However, there is a huge gap which I would ask the Minister to investigate: the recording of care provided by the private sector. Many people are lucky enough to have employee schemes, and yet the test results hardly ever seem to get on to the NHS record.

I believe in the value of outsourcing appropriate services. Advances have been made, for example, in audiology and optometry. However, there is a worrying shift in culture under this Government. I have an example in eye health clinics, which I ask the Minister to investigate. I am told that they have to operate to an indicative activity plan; that they cannot exceed a monthly quota of operations; and that they are obliged to operate a minimum waiting time decided by reference to the NHS offering; and that if the NHS providers slow down, they have to slow down too, even if they have spare capacity. If half of this is true, it represents a poor state of affairs.

Whether the objectives of today’s legislation are achieved, including the clarity of authority and accountability sought by the noble Earl, Lord Howe, depend on the implementation of all that is replacing them. We need to know a lot more.

Lord Patel of Bradford (Non-affiliated)

My Lords, first, let me congratulate all the Peers making their maiden speeches. Nobody will be surprised that I am particularly pleased that another person from Yorkshire is part of this House now.

There is much to welcome in this Bill. For example, a single patient record could improve continuity, consistency and safety, particularly for people with complex needs. However, sensitive information, including mental health records, needs robust protection. Patients must understand how their information is used, and those unable to access digital services must not be excluded.

In the time available, I will touch briefly on five areas where I will seek further debate and scrutiny and will pursue or support amendments. First, on patient voice, I believe that abolishing Healthwatch and removing the statutory foundation trust governance model risks weakening independent challenge, particularly for people whose voices are least heard. As a former chair of a teaching hospital foundation trust, I know the value of governors as a bridge between communities and hospital leadership. Among their many valuable roles, they appoint the chair and the non-executive directors, approve the chief executive’s appointment and hold non-executive directors to account for the board’s performance. These are substantial powers of public accountability, which should not be lost without an effective replacement. We know Healthwatch’s effectiveness varies across the country, partly, I would argue, because of unequal funding. The answer should be to strengthen its resources, independence and influence. If Ministers nevertheless proceed with abolition, which I hope they do not, a credible replacement must be ready before long-established and trusted local relationships are dismantled and lost for ever.

Secondly, in respect of independent patient safety investigation, Clause 65 would abolish HSSIB and transfer its functions to CQC. In July 2024, the then Secretary of State, Wes Streeting, described CQC as “not fit for purpose”. Of course, its new leadership deserves support and time to put its house in order, but rebuilding CQC will take considerable time and resources—hardly an ideal context for a complex merger. I know that Ministers have stated that transfer will happen only when CQC is ready, but what timetable do they envisage? How will staffing expertise from ongoing investigations be protected meanwhile? It is crucial, therefore, that Parliament requires published tests of readiness and assurances of continuity. The Bill thankfully retains safe space protections, but how will investigations remain operationally independent of regulation and enforcement? I will pursue or support safeguards that give staff and families confidence to speak candidly.

Thirdly, on mental health, the Minister, having steered the Mental Health Bill through the House last year, knows very well how far we still have to go to achieve parity of esteem. This Bill must protect mental health’s priority and funding. The Commons Health and Social Care Committee recommended making compliance with the mental health investment standard a statutory requirement. That deserves serious consideration.

Fourthly, in respect of ministerial powers, Clause 10 permits variation in the balance of provider types where the Secretary of State considers it in the interests of the health service. Clause 11 adds a broad power to direct integrated care boards. These powers need clear limits and transparent justification. Patients should not wait longer because suitable capacity to treat NHS patients, including in the independent sector, is disregarded solely because of who provides it.

Finally, I argue that efforts to reduce health inequalities must address geography. Nearly one in five people in England—that is 20%—live in coastal communities. Professor Chris Whitty’s report in 2021, Health in Coastal Communities, highlighted their heavy burden of physical and mental ill-health. In some coastal communities, male life expectancy is as much as 10 years below that in inland areas, and suicide rates are more than 50% above the England average. These inequalities remain stark and unacceptable. How will the Minister ensure that commissioning, prevention and workforce plans address coastal disadvantage? Poorer health outcomes in coastal communities will continue to hold back national progress. Even where national averages improve, they can mask persistent inequalities in communities that are left behind.

I want this Bill to succeed. Ministers must therefore report transparently on reorganisation costs and benefits so that Parliament can judge whether these changes deliver better care. Success must mean better care, a stronger patient voice and healthier lives.

Baroness Pitkeathley (Labour)

My Lords, it is a privilege to speak in this debate and especially to be present for so many maiden speakers.

In almost 30 years in your Lordships’ House, I have lost track of the number of health Bills in which I have participated. However, I can be sure of one thing. In each health Bill, I would have begun my Second Reading speech with a plea, indeed a rant, to Ministers that it was of no use bringing about any reforms in healthcare without including social care, since the two are inextricably entwined. They are entwined not only in how they are delivered but in the minds of patients and families, who understandably have no ability to distinguish between a medical bath and a social bath. There are a few of us in your Lordships’ House who have been saying this for a very long time; indeed, I have often referred to them as the usual suspects.

Imagine, then, how I and others feel as we contemplate this Health Bill. The atmosphere has changed completely, even since the Bill was introduced into the other place. Social care is at the top of the agenda now, where it should be, and where we have been hoping it would be, some of us for more years than we care to admit. The Bill provides the legal basis for the largest NHS reorganisation in a decade, but let us never forget that structural reform rarely of itself improves care for patients and their families. It is the practical changes which follow that deliver better care.

I welcome the Bill’s ambition to modernise the way health information is shared, particularly the development of a single patient record. This could be genuinely transformative for unpaid carers. At present, carers can spend an enormous amount of time repeating information, navigating different parts of the NHS and trying to make sure that professionals understand the circumstances of the person they care for. A more joined-up record could reduce that burden and, with the appropriate permissions and safeguards, make it much easier for carers to be properly involved in managing someone’s care. There have been debates about this in the other place, and I am hopeful that carers may be included in the regulations as people who can have access to the single patient record with the right safeguards. I would be grateful if the Minister could confirm that carers will be explicitly recognised in those regulations.

However, information sharing is only part of the picture. We also need to make sure that the NHS actually recognises who its carers are and understands what they need. There is strong evidence of underidentification, particularly in primary care, and carers do not feel consulted or asked about whether they are able or willing to provide care at hospital discharge in spite of legislation to the contrary.

Identification is important because carers need information and advice to carry out their role. They may be administering medication, using healthcare equipment or helping someone to move safely, yet there is not always a clear point of contact within the NHS for making sure that they receive the information they need. A Labour Government introduced the first systematic identification of unpaid carers through the GP contract, which sadly has been stopped by later Governments. There is potential in the Bill to do more to ensure that carers are better identified by the NHS and consistently supported. We need to ask whether the system is delivering what carers actually need. I hope the Government will continue to work with carers and their organisations to ensure that they are supported to sustain their vital role.

The more we focus on social care, the more we must ensure that the relationship between health services and local authorities is strong and productive. If we are to make the shift to community-based services from hospital services a reality, we have to ensure that the two services are equally valued and equally understood. The influence of local government at ICB level is crucial for supporting people at home, preventing crises before they arrive, and improving the well-being of communities. Thankfully, the original proposal to remove the statutory local authority seat has been revisited, but we still have to consider whether at least one board member from local authorities is adequate.

When it comes to the patient voice—for me that includes the voice of carers and families—the issue is not so much the structures but the outcomes. At a time of significant change for both health and social care, we must ensure that the patient voice is at its strongest. I am glad that carers are also to be recognised by local bodies. What seems to be missing is an independent national voice. I hope the Minister will confirm that we all have responsibility to ensure that the patient voice is strengthened and not weakened by whatever provisions finally emerge.

Baroness Murphy (Crossbench)

Recently, at a meeting about this Bill, the noble Baroness, Lady Gerada, remarked to me that she had been through at least 15 major reorganisations of the National Health Service. Well, I can beat her. I have endured at least 22. I joined the NHS in 1966 as an auxiliary nurse—what healthcare assistants were called then—for three months before going up to medical school in Manchester. I worked on the John Player Ward at Nottingham General Hospital. We were very near the Player factory, and one of my jobs was polishing the brass ashtrays. I kid your Lordships not. Perhaps some things do change. I take heart from that.

The Minister will understand if there is a somewhat jaundiced view among old hands at this game. We fear very little will change substantially for patients’ experience of the NHS or the outcomes of care. On almost every measure, the NHS now compares very badly with other OECD countries, including most of Europe. The weaknesses of the delivery structures of health and social care are evident. Of course, modest improvements happen when another bung of money is provided, and hard-pressed and talented staff are grateful for that. But the NHS is slow to adopt innovations, unable to drive increased productivity, cut waste, use data effectively or reduce variations in care or outcomes related to inequality and deprivation. Everyone is so absorbed in struggling with day-to-day troubles, the future can go hang.

It would have been nice to have a Health Bill that recognised that some aspects of the current system seriously neglect some groups. Perhaps the largest of all the neglected groups is those with dementia. There is no ambition here to make the NHS social care services work for them, or indeed the other groups that have been mentioned by many people around this House—although, of course, we are grateful for the recent investment of research monies.

We need radical service transformations—a change that involves a more sophisticated model of primary care, properly resourced, providing continuity of care, as mentioned by the noble Baroness, Lady Neville-Rolfe, and one that is able to deliver on diagnostics. So much more is carried out by GPs and their associated staff in the community in other countries, in Europe and in Canada and Australia. I will not get started tonight on mental health services, as I fear I will not be able to stop.

So we are chucking out NHS England. I supported its creation. I thought the Department of Health was consumed by NHS acute hospitals to the exclusion of everything else, and the idea was to create a body that would focus on the NHS machinery and nothing else, removing the NHS from political interference and leaving the department to pursue all its other responsibilities, including public health and social care. But it did not work, partly because the Bill of the noble Lord, Lord Lansley, was not implemented, as he said himself. It was only half implemented. So now we have a Government who want to bring all these key arm’s-length bodies back in-house. It will be the same stuff as usual—just different titles. Absolutely nothing will change, except there will be a resumption of ministerial meddling. As always, there will be a hope of saving money—but fat chance, I fear.

I turn to other provisions of the Bill. On ditching governors of trusts—well, I hold no particular torch for governors; we wait to see whether the alternatives work. The department will appoint chairs of trusts now, guaranteeing further political meddling there too. As for abolishing Healthwatch, some are doing great work, as we have heard; others are not. I would like to know how the Minister thinks local patients’ voices are going to be heard in reality. It is very vague indeed.

The one positive about the Bill that we have all mentioned is the single patient record, if we can get it to work without spending billions—if we do, that will be a real miracle. Watching the presentations, I was thinking back to visiting acutely mentally disturbed people creating mayhem in the community in south-east London, and wondering whether I would have access to a user-friendly single patient record on my phone. Well, I hope so. I am an optimistic soul.

Sixty years on from my first job in the NHS, it is time to hold on to the principles and find a better way of delivering them. It is not cheap any more. People are voting with their feet, if they have the money. Of course, that does not help the vast majority of people who we need to provide for. We are all being failed by the unwillingness of successive Governments to grasp the challenge to create a better system, which so many other countries now have done.

Baroness Morgan of Drefelin (Crossbench)

My Lords, I start by congratulating the Government on their commitment to improving outcomes for patients. I particularly congratulate the maiden speakers on their absolutely wonderful contributions. I look forward to hearing the others to come.

I welcome wholeheartedly the proposal for a single patient record. Many people with cancer, particularly those who have faced lengthy diagnostic journeys, will benefit from no longer having to repeat and explain their history again and again to different professionals. Many patients believe that we have one already—or cannot believe, in this day and age, that we have not. We need to tackle the safeguards, but we really need to crack on with this.

Following the 2012 reforms, I was incredibly disappointed to see the disbanding of the cancer networks. Those were a collection of bodies that were set up to deliver the first NHS cancer plan, which was published in 2000. They became very strong. I will focus on three issues relating to the Bill that are of great importance to cancer patients.

First, we need to protect cancer services during the transition; we need to ensure that cancer outcomes remain a national priority; and we must continue to work on unlocking faster clinical trials. As the members of the One Cancer Voice charity coalition have argued, it is essential that the functions required to deliver the recently agreed and widely welcomed cancer plan are protected through this transition. The plan is extremely ambitious. There are more than 100 recommendations, and its success depends on effective national leadership, accountability and strong delivery. This matters, particularly to people with rare and less common cancers, where progress has often been slower.

Key functions and delivery that must be protected include, for example, the collection of robust data around metastatic cancers, research infrastructure, national oversight programmes such as for screening, and the capacity to commission vital highly specialised services. There is a tension—and we have to be realistic about this—between neighbourhood health services and the need for cancer patients to access extremely specialist services. There must be full integration so that patients can continue to receive the expert support they need. I hope the Minister can assure me and the House that cancer services, specialist commissioning, screening programmes and research infrastructure will be protected through this Bill.

I would like to ask about the future of the measure in the Health and Care Act 2022 where the mandate was established. As part of the mandate, there was a commitment to focus on monitoring cancer outcomes. The mandate will disappear and we do not know what will happen or what will replace it. I am concerned to know what will replace the mandate and how cancer outcomes will be expressed in that process.

The last thing I want to talk about, very quickly, is the importance of research in the NHS. For example, we know that clinical research has transformed outcomes for cancer patients over recent years. We have seen improvements in survival and quality of life. A thriving clinical trial environment is vital to this, to our life sciences sector and to improving outcomes for patients as we go forward. The Government’s ambition to reduce clinical trials set-up times needs to be carefully thought through here. Can we ensure that that ambition is applied to non-commercial trials as well as to commercial trials, where there appears to be much progress being made? Some 95% of participants in clinical trials are in trials being led by charities and the NHS, which are non-commercial.

I look for these reassurances from the Minister: that the cancer plan will remain on track, that we will see how improving outcomes will be maintained within whatever the replacement for the mandate will be, and that patients will continue to see faster improvement in access to clinical trials and innovation, including those for less common cancers.

Lord Blencathra (Conservative)

My Lords, I, too, congratulate the superb maiden speakers we have heard so far. I am sure that those yet to come will be equally excellent.

I wish to address a matter that ought not to be controversial in any civilised society: the right of women to privacy, dignity and safety in NHS services. For years, there has been a deliberate erosion of the rights of biological sex women across all parts of the health service, as men claiming to be women have occupied spaces specifically created for biological sex women. Different trusts have adopted different policies. Professional bodies have issued conflicting guidance. Many of them have stated that men calling themselves women but who have full male genitalia should have full access to women-only spaces. Women and NHS staff alike have often been left uncertain about their rights and responsibilities.

However, the legal position is now crystal clear. The Supreme Court has clarified the meaning of sex in law, and the Equality and Human Rights Commission’s statutory code has now come into force. The question before us is no longer what the law means; the question is whether the NHS intends to implement it or will continue to obfuscate. Despite the clarity provided by the courts and the statutory code, the NHS appears to be moving at a glacial pace. Guidance promised months ago has yet to provide the certainty that women and healthcare staff deserve. Trusts remain uncertain, patients remain uncertain and the risk of inconsistency remains widespread, as well as hostile action being taken against women who request single-sex provision.

Women should not have to argue for rights that Parliament has already recognised and the courts have already clarified. A woman of biological sex admitted to hospital should have confidence that a women’s ward is exactly that: a ward for women of biological sex. A woman receiving intimate care should be entitled, wherever reasonably practical, to request a female clinician or chaperone without being made to feel awkward, unreasonable or discriminatory. A woman who asks for female-only provision should never be criticised, stigmatised or treated as though she has committed a hate crime for daring to ask. Indeed, the evidence we have all seen in the past few years shows repeated cases where women and female NHS staff have suffered detriment, harassment or disparagement when raising concerns about sex-based facilities. That is wholly unacceptable in a modern health care system.

This is not about hostility towards any other group, since every citizen should be treated with dignity and respect, but rights based on gender identity cannot be allowed to erase rights based on biological sex. Parliament created single-sex exceptions for good reasons: for privacy, dignity, safety, cultural needs, religious needs and the protection of vulnerable patients. Those protections matter most when people are at their most vulnerable: ill, frightened, recovering from surgery, receiving intimate treatment or coping with trauma.

I therefore ask the Minister three straightforward questions. First, when will the Government publish definitive NHS guidelines implementing the laws clarified by the Supreme Court and reflected in the new EHRC code? Secondly, will that guidance make it clear that women are entitled to single-sex accommodation based on biological sex and that requests for female clinicians or chaperones should be respected wherever reasonably practicable? Thirdly, will the Government ensure that no woman and no NHS employee is subject to disadvantage, disciplinary action or accusations of prejudice simply for seeking or defending lawful single-sex provision? The time for consultation, delay and equivocation is over. The NHS now needs clear instructions, clear leadership and clear accountability to ensure that single-sex provision exists not merely in theory but in practice. The courts have spoken, the law has been clarified and women have waited long enough. The NHS must now obey the law.

Finally, a word about the Quality Care Commission mentioned in the Bill. In my experience, it is a useless waste of space, as the Public Services Committee pointed out a few years ago in our inquiry into home delivery of medicines. It has brought only about 100 criminal prosecutions in its history, and the overwhelming majority have been against private care homes and smaller providers, yet some of the greatest scandals in modern NHS history, involving hundreds of deaths, emerged without any prior criminal prosecution by the regulator. When a resident falls in a care home, the CQC rushes in to take action, but when systemic failure occurs across major NHS hospital trusts, the CQC arrives after the scandal rather than before it. In my opinion, it cannot be trusted to investigate NHS scandals unless it is beefed up in this Bill. There seems to be a cosy consensus between the health watchdog and the Department of Health never to investigate the NHS, almost like an old boys’ club in the past.

I look forward to the Minister’s reply on my points about single-sex provision and on my latter comments on the CQC.

Baroness Rafferty (Labour)

My Lords, I, too, congratulate noble colleagues on the excellence and inspiring nature of their maiden speeches and look forward to those to come.

I commend the Minister for introducing this Bill and promising a form of joined-up care on a scale that has eluded successive Governments. However, integration is not achieved by structural change alone. It is achieved when there are enough staff on the ground, with communities having a meaningful say in how that care is designed.

I speak today as a district nurse and a former governor of a large NHS foundation trust. That is why I want to focus on two connected points: what the Bill’s changes to integrated care boards could mean for community nursing and what we risk losing when foundation trust governors are abolished.

The Bill strengthens ICBs as strategic commissioners, and that ambition matters profoundly to community nursing. District nurses, specialist community nurses, health visitors—my colleague the noble Baroness, Lady Coffey, also flagged their importance—public health nurses and practice nurses care for people with complex needs in their own homes, care homes, schools and local clinics. They help people manage long-term conditions, recover from hospital, avoid unnecessary admissions and receive palliative care near the people and places that matter to them.

According to the Nuffield Trust, the health think tank, district nurse numbers fell by 43% in full-time equivalent terms over the past 15 years from more than 7,500 to just under 4,500 in 2023-24, with a patient to population ratio of 1:14,000. When we talk about moving care from hospital to community, that shift needs enough skilled staff with enough time for visits, reliable access to equipment, clinical support, safe caseloads and proper investment. If hospital activity moves into the community without the workforce and resources moving with it, the result will be not integration but rather unmet needs transferred to patients, families and overstretched nurses.

The Association of District Nurse & Community Nurse Educators has also registered its concern that the proposed reprocurement of community nursing education programmes may reduce the number of providers even further. The transfer of powers to the Secretary of State outlined in Clause 7 for education and training sets out a duty to ensure that there are sufficient people with appropriate education and training specifically to meet the workforce needs of the health service. It also requires that there is an effective system in place for the planning and delivery of education and training of people to meet those needs. In the light of this, can the Minister confirm that attention will be given to community nursing services as a matter of priority to stem the dwindling numbers and boost much-needed capacity?

This brings me to the public voice. I will not reiterate the excellent points made by my noble friend Lord Hunt of Kings Heath, the noble Lord, Lord Patel, and others, but I just flag the value of volunteers as members or governors of foundation trusts. In my trust, there were over 1,000 volunteers, and they did excellent work and provided an invaluable source of soft intelligence for the board. Might the Minister be willing to reconsider the abolition of governors and undertake an evaluation of best practice case studies, so that expertise will not be lost in translation for the new arrangements which might eventuate? I hope these points will prove constructive in supporting the progress of the Bill and I look forward to working with the Minister to achieve that.

Baroness Browning (Conservative)

My Lords, it is always a pleasure to follow the noble Baroness, and I add my congratulations on the maiden speeches that we have enjoyed and are going to enjoy today. I thank the Minister for the time she has spent in organising briefings for us on this Bill, which is very long, large and quite complex, but I support it in general.

The single patient record is urgently needed, but I suspect will not be urgently delivered, so will the Minister, in the course of our deliberations, set out some sort of timetable? My anxiety—she is probably already aware of this—is that I can think of very few large government computer systems that have been an absolute joy to behold. I just wonder what she and her department are doing to make sure that the single patient record will be commissioned in such a way that we can all have confidence that, when it is available, it will work properly.

We have heard already in this debate from the noble Baronesses, Lady Leaman and Lady Hollins, about the impact of this Bill in particular on people with learning disabilities and autism. The single patient record will be so important for anybody with a vulnerability. I hope that the Minister will countenance adding to the single patient record not just the key medical requirements that need to be on it, but also some of the other pieces of information that make all the difference to somebody with autism, for example. Many of them already have hospital passports which they take into hospital with them. We know that these are not just simple bits of trivial information. We know from reports from organisations such as Mencap that failure within hospitals in particular—not in mental health hospitals but on general wards—to fully understand how an individual with autism functions has led to deaths of very fit and able people who should never have died on a ward. I see the single patient record as a good step forward.

I have some concerns about ICBs, because they are in a state of reorganisation at the moment. I worry about their ability to commission for areas that are particularly large; for example, if they contain large rural areas and some urban areas, the rural areas may get missed out in terms of the demography of their needs. I am particularly concerned because commissioning for end-of-life hospice care lies with the ICBs, and we know that hospices are under huge pressure at the moment.

I was at a meeting earlier today on this very subject and was horrified to find that there are several hospices around the country with quite large numbers of empty beds—not because there are not patients for them, but because they cannot afford to fill those beds at the moment. We realise there is already a serious problem but, surely, if commissioning for a local community is the responsibility of these ICBs, we can at least get end-of-life care right—certainly at the very end of life, when palliative care and possibly hospice care are needed. At the moment, that does not seem to be working as it should. We know that very many people die on busy, noisy hospital wards when the reason they are still there at the point of death is that there have been no alternative arrangements for them.

Death can come quite quickly. I am thinking of people with dementia and Alzheimer’s. You know that a diagnosis of Alzheimer’s is of a terminal illness, but very often the decline in the final weeks can be quite rapid. If that happens, very often that person is not in the right place to be cared for in the final weeks, sometimes days, and there is not time to move them. I hope that, as we progress with this Bill, we will have time to talk about these individual situations, because although this is the minutiae of the Bill, the devil is always in the detail.

Baroness Janke (Liberal Democrat)

My Lords, it is a great privilege to speak in this Second Reading debate. I congratulate noble Lords who have made their maiden speeches on their very eloquent remarks and look forward to hearing those that are still to come.

Health services are a top priority across the nation, so I hope, as many noble Lords have said, that we can address our fellow citizens’ concerns through the progress of this Bill. Most people judge the quality of service on their own experience of front-line care, yet many have extreme difficulty even getting a timely doctor’s appointment. Anxiety and fear are the facts of life, particularly for elderly and vulnerable patients, who worry that they will not have proper access to healthcare when they need it. This is so much so that A&E has become the default destination for desperate patients who are unable to find timely care or advice from their local surgery.

Analysis from the Health Foundation shows that, over the decade to 2022-24, healthy life expectancy in the UK fell by about two years, to 60.7 for males and 60.9 for females. Of 21 high-income nations analysed, the UK had the second-steepest decline. As other noble Lords have said, health inequalities are worsening. The gulf in healthy life expectancy between the most and least deprived parts of England is now 19.4 years for males and 20.3 years for females. Cuts to local authority services over more than a decade have severely limited public health services and their ability to effectively deliver policies that prevent sickness. Squeezed school budgets and staff cuts have led to less effective health education, while cuts to community healthcare professionals such as health visitors, school nurses, district nurses, dentists and optometrists have whittled away at community healthcare, with devastating effects. The proportion of young people reporting a health condition that limits their ability to work increased from 26% in 2015 to 44% in 2025. Local pharmacies, which have been the pillars of community health, are in widespread decline due to a £2 billion funding gap, with 45% relying on personal savings or remortgaging their homes just to keep their doors open to the public.

We on this side welcome the focus on primary health care in the 10-year plan and the Prime Minister’s plans for devolution, but this Bill does not reflect these principles. It is a driver of greater centralisation and unprecedented powers to Ministers, as many noble Lords have said, at the expense of local involvement and accountability.

To abolish Healthwatch is to lose the voice of patients and local communities, the very areas that need to be strengthened. No good reason has been given for this, and the abolition of the HSSIB, with transfer of its functions to the CQC, is not justified in the light of the well-documented shortcomings of the CQC.

The vision of a well-resourced, community-based health service is very powerful, and what our residents want and need, but it is hard to see how the Bill before us will deliver the Government’s 10-year plan to shift from sickness to prevention and from hospital to communities with the current crisis in community and primary care. Where are all these devolved functions that we have been promised in the Cabinet statement Rewiring the State? We on this side will press the Government to address these fundamental problems throughout the progress of the Bill, including through more resourcing into primary care through a primary care investment standard.

The King’s Fund echoes the thoughts of many people looking at this Bill from the point of view of the patients. For those on the outside looking in, these technocratic restructures might look like rearranging the deckchairs on the Titanic while many core problems around the nation’s health remain unresolved. Every minute spent navigating reorganisation is a minute not spent planning and delivering high-quality healthcare, which is what we all want.

Baroness Sugg (Conservative)

My Lords, I am grateful to the Minister for setting out the Government’s approach to the Bill, and to other noble Lords who have shared their significant wisdom and experience, be that through long-term careers in the health service or their lived experience of previous health Bills and NHS reorganisation. I particularly welcome the maiden speeches we have heard and those to come.

I am sure that all noble Lords share the desire to ensure that the modernisation and reform of healthcare leads to better outcomes for patients and a more productive, efficient and accountable NHS, and improves value for taxpayers’ money.

In the time available, I will focus on three issues relating to women’s health; I know that, in her role as Women’s Health Minister, the Minister has a clear focus on this. I turn first to the Government’s commitment to introduce an amendment to the Bill to appoint a maternity and neonatal commissioner. As the Minister stated, this was a recommendation from the final report of the national maternity and neonatal review, led by the noble Baroness, Lady Amos.

The Minister will be well aware of the many reports identifying systemic failures in maternity care, alongside repeated recommendations that have yet to be implemented. It is therefore unsurprising that the latest survey from Savanta, published last weekend, found that 75% of adults are concerned about standards of maternity care in NHS hospitals. The maternity and neonatal commissioner must have the power and resources needed to deliver the national action plan, which we expect in December, and which the Government say will

“overhaul services and drive long-term change”.

Can the Minister tell us when the amendment on the commissioner is likely to be tabled, to ensure that your Lordships have sufficient time to scrutinise it properly in Committee?

The second issue I will focus on is the single patient record. As the King’s Fund has observed, the single patient record presents a significant opportunity to improve people’s experiences of health and care by bringing together fragmented information and giving patients full access to their records. I am grateful to the Minister and her department for the helpful meetings and briefings provided ahead of this debate. However, much of the detail will be set out in secondary legislation. There are understandable concerns around privacy, public trust, access, data governance and NHS interoperability. Until greater detail is available, questions will remain for patients and healthcare professionals. The Minister acknowledged this in her opening speech, and I was interested in the idea of the noble Lord, Lord Patel, on this issue.

I have a particular interest in privacy, especially around sexual and reproductive healthcare and other sensitive treatments, such as for mental health, addiction and, as we have heard from my noble friend Lord Black, HIV. The SPR could significantly improve patient experience and eligibility decisions by reducing reliance on patients recounting complex medical histories. However, patients may not wish to share every aspect of their healthcare and see every aspect of that history appearing within a standardised record or being readily available and accessible through a mobile device, albeit with a password.

These concerns are particularly acute for women and girls at risk of domestic abuse or honour-based abuse, for young people under 16, and for patients whose close relatives or associates work in the NHS. It is important to protect the long-standing right of patients to access sexual healthcare and related services anonymously, and the role this plays in providing inclusive public health services.

While I recognise that these matters will be addressed through secondary legislation, it would be helpful to understand how the regulations will be developed and consulted on. In particular, can the Minister provide any reassurance that explicit patient opt-in consent, on a by-episode basis, will be considered before highly sensitive records are included within the SPR, with patients retaining the ability to withdraw that consent at any point? I also echo the request of my noble friend Lady Browning for a timetable around the delivery of SPR.

Finally, I turn to other measures in the Bill related to women’s health. The move towards ICB commissioning may well create opportunities to tailor services more effectively to local needs. However, a key concern is whether women’s health will remain a national priority, rather than access to services varying according to where women live. An amendment to the Bill on implementation of the women’s health strategy was tabled in the other place. Six months have now passed since the publication of the refreshed plan, yet progress on its 117 actions appears limited.

An amendment was also considered on ensuring that waiting times for gynaecology and women’s health do not exceed average NHS waiting times. Gynaecology waiting lists have increased for five consecutive months, with more than 585,000 women in England currently waiting for care and less than 60% being seen within the 18-week target, which is well over the average for other NHS treatments.

These issues deserve consideration as we scrutinise the Bill. I recognise that our scrutiny ought to remain firmly on the contents of this Bill and we should resist turning it into a vehicle for every worthy cause, but we cannot allow women’s health to be treated as an afterthought in the reform and modernisation of our health service. Whether through maternity safety, digital patient records or the delivery of the women’s health strategy, these issues must remain central to the Bill’s scrutiny and implementation. I look forward to working constructively with this Government as the Bill progresses.

Lord Wormald (Crossbench)

My Lords, it is an honour and a privilege to be making my maiden speech today and to be doing so on a subject on which I have spent a significant part of my career. I should add my congratulations to my noble friends Lord Jabbar, Lady Lowe, Lord Singh of Solihull and Lord Smith of Ranmoor on also making their maiden speeches today.

Before anything else, I would like to put on record my thanks to the wonderful staff here, who have made joining the House so smooth, and also to all noble Lords on all sides of the House who have been so welcoming and helpful.

I join your Lordships’ House after 35 years of public service in the Civil Service across four government departments. I had the honour of leading the entire Civil Service as Cabinet Secretary. I have loved—almost—every minute of it. I might say more some other time about some of the minutes that were less lovely. In particular, I have worked with some truly amazing people: civil servants, public servants, and advisers and Ministers from across the political spectrum. While the Civil Service and the public service need to modernise and evolve, we should be prouder than we sometimes are of those who work across the public sector.

I spent the majority of my career working on education and health, and they remain my two great passions. I began my career in 1991, aged 22, at the then Department of Education and Science. I worked on city technology colleges, which were seen at the time as a failing policy but which, two decades later, had become the foundation of both academies and free schools. That is an interesting lesson in consistency.

I worked on education for 15 years and then returned from 2012 to 2016 as Permanent Secretary. Across all that period, I got to work with exceptional Ministers from all parties, many now Members of this House, who really cared about reading the evidence, both nationally and internationally, and focused on what worked. We have seen the results in England’s excellent performance in the recent international PISA study.

In 2016, I moved as Permanent Secretary to the Department Health and Social Care. Again, I got to work with some truly incredible people, a number of whom are speaking in the debate today. Time and again, I got to see the staff of the health and care service step up to the plate to deal with the next challenge, not least during the Covid pandemic. It brought home to me how, in those crucial public services, policy and legislation work only if they are enabling real public servants in real places to do their jobs better.

That brings us neatly to today’s Bill. There are many important features of the Bill—as many others have, I would pick out the clauses on data sharing as particularly crucial. But many of the most important things in health are not in the Bill, particularly in the Government’s three shifts, set out in the 10-year plan that others have mentioned towards prevention, towards community and towards digital. We ought to test the provisions of this Bill by questioning whether they are helping the health and care system move in the direction the Government have set out, and by doing so whether they are improving both patient care and population health. And we should ask where they risk being a distraction from those objectives—as, unfortunately, previous health Acts have sometimes been. We should be particularly careful in this regard of the clauses around the restructuring of NHS organisations.

But I will finish back where I started: it is an incredible privilege to join this House and to get to debate these crucial matters, and I look forward to the next phase of my public service with both pleasure and anticipation.

Baroness Harding of Winscombe (Conservative)

My Lords, I congratulate all five noble Lords making their maiden speeches today, but it is a particular privilege to follow the excellent maiden speech of the noble Lord, Lord Wormald. Many in this House will have had the experience, either as civil servants or Ministers, of the noble Lord’s calm wisdom and quick wit, both of which we have seen already today. They will add considerably to the work of the House.

Personally, I can honestly say, having worked alongside the noble Lord literally every hour of every day during the Covid pandemic, that despite his insistence that “Yes Minister” was in fact a training video, he has public service values second to none. Under extraordinary pressure he is calm and thoughtful and always finds time for the team around him. As we have seen today, the noble Lord, Lord Wormald, thinks deeply about the most important issues in our society: our education and our healthcare services. As such, I know that he has already played a significant role in improving the lives of people, young and old, across the country, and I have no doubt that he will continue to do so as a Member of this House.

In his quiet and thoughtful way, the noble Lord, Lord Wormald, has also said some important things about this Bill. We pride ourselves in this House in going into detail that the other place does not, and in doing so, we all like to think that we improve legislation. Often that is true, but we can also go down cul-de-sacs or adorn Bills with Christmas decorations and get distracted from the real problems a Bill is trying to address. As many have already said, those of us who have been in this House for a while know that health Bills are particularly susceptible to this. It is important that we keep in mind the three shifts that so many people have referenced today: to community, to data and digital—even I am now forgetting the third one—underpinned fundamentally by patients.

I want to make three points about the Bill. The first is about the shifting of the organisational deckchairs. In my career in business and in public service, I am always sceptical that restructuring things will actually solve a problem. We must ask ourselves whether, in centralising everything in the Department of Health and Social Care, we are centralising and decentralising the right functions. My experience with the NHS is that, more often than not, it gets it back to front. It is clear to me that digital things need to be centralised, but the decisions on who the right people are to run organisations out in systems, as the noble Lord, Lord Stevens, said earlier, is highly unlikely to be to be taken well in Whitehall. I am supportive of reducing the number of people working in NHS organisations that do not actually serve patients, of which NHS England is a very large example. It is right to create one central organisation in the Department of Health, but we need to be challenging. Are we putting the accountabilities in the right place? Are we pushing subsidiarity down as much as possible? And are we clear that it serves patients?

Secondly, on the single patient record, the clue is in the name: are we designing it for patients or for vested interests in the system? The trust that patients need to have in the data architecture of our healthcare system is going to be key. Although it is only one clause, Clause 52, I think we are going to spend a huge amount of time scrutinising it. Personally, I would like to see clearer indications of who will be consulted and how they will be consulted. At the moment, in Clause 52(6) the Secretary of State can consider whoever they think is appropriate in their consultation. That is alarming, because the system does not usually consult patients enough.

With the third area, again the clue is in the name: the patient’s voice. Like many others today, I am concerned about the abolition of Healthwatch—not because it is a panacea, because, as others have said, it is not. I come from the consumer business world, and compared to other consumer or citizen services, I think we all know that healthcare is not very good at listening to its users and patients. Even the best parts of our healthcare system tend to be quite paternalistic and think they know better than patients. I cannot get my head around how abolishing Healthwatch is going to make that better. I hope that through the course of this Bill, as the Minister said in her introduction, we will engage in a constructive debate on how we turbocharge the patient’s voice through our health and care system rather than the opposite.

There is undoubtedly enormous experience in this House on health and social care, and I very much look forward to working with everyone on this. As I started, I would like to finish: I hope that we will focus our healthcare system on the shift to community, the shift to prevention and the shift to digital—I remembered it this time.

Lord Tarassenko (Crossbench)

My Lords, I also congratulate my noble friend Lord Wormald on his excellent and engaging speech informed by his eight and a half years as Permanent Secretary of the Department of Health and Social Care, working with, I believe, seven Secretaries of State during that time. I declare an interest as I have held an honorary contract with the Oxford University Hospitals NHS Foundation Trust for the past decade enabling me to be an investigator on research projects involving patient data.

I welcome this Bill, especially the legal framework for sharing information through a single patient record. This represents a wonderful opportunity to improve patient care through the linking of multiple sources of health data, but delivering on this objective is fraught with technical difficulties and not just reading PDF files. Interoperability is an issue which continues to plague the NHS, and it is not clear yet how the single patient record data standards will be set, maintained and made binding on suppliers. There is also an opportunity to expand the legal framework underpinning the single patient record by giving our NHS data the status it deserves, making it a sovereign data asset at the core of an NHS digital sovereignty strategy. The first consequence of this would be a binding requirement for the single patient record data to be stored in servers located on British soil.

Secondly, we have been told by DHSC that there will be multiple contracts awarded for the development of the single patient record. An NHS digital sovereignty strategy would prioritise those technologies whose data, control and support remain within UK jurisdiction to reduce our reliance on foreign technologies within the NHS. The selection of Kainos Software Limited, a subsidiary of a FTSE 250 company, as the development partner for UK Biobank’s output checking system after a public procurement process shows that there are UK-owned companies capable of delivering state-of-the-art software solutions for the NHS.

We have been told that the use of data for research is not within the scope of the Bill, but the SPR systems, datasets and governance arrangements will also shape how health data is accessed and used for research. It would be a mistake, as the Health Data Research Service develops, not to address the barriers affecting this access. For example, the control of patient information—COPI—regulatory framework was first introduced as a temporary measure in 2002, more than 20 years ago, and we cannot wait for its reform to happen at some indeterminate time in the future. The Bill needs to set out a timetable for the Secretary of State to complete the process of reforming the COPI regime, following public consultation, within a fixed period of Royal Assent.

Recent polling has put the percentage of those willing to share their de-identified health records for research at between 75% and 80%, but such a high percentage depends on the public maintaining a high level of trust. Again, this will be easier if the single patient record is given the status of sovereign data asset that we all own within an NHS digital sovereignty strategy. A further implication of this status would be to set up a hierarchy of access to de-identified patient data from the single patient record for research, similar to that operated by MHRA for the primary care CPRD datasets, but expanded.

That should soon be followed by the development of our own sovereign AI model capability for the NHS, using longitudinal datasets from the single patient record, linking primary care and secondary care data with outcome data. These models would enable the early detection of diseases such as cancer and cardiovascular disease, and would contribute to the prevention agenda.

The use of the single patient record has the potential to improve direct patient care, but it is also an opportunity, through health data research, to make the UK a healthier nation at the end of the current 10-year plan for the NHS. We must not miss either opportunity.

Lord Smith of Ranmoor (Labour)

My Lords, I thank the Lord Speaker and noble Lords from across your Lordships’ House for the warmth and generosity of their welcome. Entering the House seems a daunting privilege to a new Peer, but the helpful and friendly welcome that I have been accorded should not go unremarked. I thank everyone for reminding me of the importance of this place.

It gives me great pleasure to make my first contribution in this debate on the Second Reading of the Health Bill. Before I do, I beg the indulgence of noble Lords to say a few words of thanks, beginning with the Clerk of the Parliaments, her staff, Black Rod and his team. In my first few days I have been rescued, reassured and pointed in the right direction by staff from across your Lordships’ House, especially the doorkeepers, who have saved me more than once. The highlight, witnessed by mercifully few noble Lords, was on day two, when I strode purposefully into the Chamber and sat on the Opposition Benches. Help was swift and subtle—and I will be very grateful if that level of support continues. I particularly thank my two supporters, my noble friends Lady Batters and Lady Kennedy of Cradley.

I have taken a Sheffield place name—it has been a bit of a day for Yorkshire—and the city and its surrounding countryside have shaped my life. My dad was a PE teacher and mum a teaching assistant. I was delighted that at 92 my mum was here for my introduction, but I must tell noble Lords that she was disappointed to find she was not the oldest person in the building.

I am the only family member who did not follow the family trade of educating young people—that is, until much later when I became the proud chair of Sheffield Hallam University. This excellent post-1992 university has a relevance to today’s debate; it is a significant NHS workforce training institution, particularly for South Yorkshire and the wider Yorkshire and Humber region. Its importance goes beyond nursing; it trains nurses, midwives, paramedics and a large range of allied health professionals.

I had a long career in feeding the nation. My time at the Food Standards Agency took me into the world of protecting consumers from all the risks associated with food: the acute, which is mostly food poisoning, and the chronic, of which obesity is the most significant. Then and now, I was both intrigued and shocked at the insidious impact that overweight and obesity is having on society: and it has not got better. I was a pupil at the first purpose-built comprehensive school in the UK. I invite noble Lords to do as I have recently and have a look at their school class photographs, and then look at their parents’ version and those of their own children, or perhaps even grandchildren. They will notice not just that the picture changes from black and white to colour and then to digital but that there is an alarming shift in the number of children frozen in time who are obviously preventably overweight, or worse. It gets worse the closer we get to today.

I can put some definitive numbers on the evidence of our eyes—the latest UK estimate is that obesity costs the NHS more than £9 billion a year—but, from my food policy perspective, the starkest evidence comes from the health inequalities now being observed. The Government’s own equality assessment specifically discusses obesity in this context. It records that children in the most deprived areas were more than twice as likely to be obese in reception and 2.3 times more likely by year 6 when compared with children in the least deprived areas. An obesity strategy implemented through the restructured NHS will have to be considered against our duty to reduce those inequalities.

Potentially more consequentially, the Bill moves substantial commissioning responsibility towards ICBs, including primary care, and establishes neighbourhood health plans. For obesity, that could mean a shift from nationally specified programmes to locally commissioned prevention and treatment. This matters enormously for obesity, because local variation in commissioning could produce new variation in access to NHS weight management services, weight management clinics, anti-obesity medicines, bariatric surgery pathways, diabetes and so on. Obesity was explicitly discussed during the Bill’s parliamentary scrutiny in the other place, when the Government’s obesity moonshot, weight loss medicines and the need for prevention were highlighted.

We should be in no doubt that the responsibility for the future health of the nation is at least shared with the food sector, which, to my concern, has yet to properly shoulder that responsibility. For your Lordships’ House, the Bill’s architecture potentially affects obesity policy, because the responsibility for population health and prevention sits within the wider NHS commissioning system, as well as in nearly every other government department.

It is a privilege to be one of your Lordships’ number. I look forward to actively contributing to the work of the House in the coming months and years, on both this Bill and our extensive workload.

Baroness Crawley (Labour)

My Lords, many congratulations to all our maiden speakers today. It is a special pleasure to follow the exceptional maiden speech of my noble friend Lord Smith of Ranmoor. His CV reads like the making of modern British food standards, but his emphasis on obesity means that I cannot now say that all of us who enjoy eating are very grateful to him.

A son of Sheffield and an alum of Leeds University, of which he is obviously extremely proud, my noble friend started his career at Northern Foods. He was appointed to the Food Standards Agency as CEO in 2008, after which he accepted a senior role at Tesco. He is now chair of Cranswick plc and one of the UK’s most experienced people in food retail.

Throughout his work with several Governments across parties, my noble friend has chaired the Trade and Agriculture Commission and has been co-chair of the Food and Drink Sector Council, among other significant posts. He is also a trustee of Natasha’s Foundation, the food allergy charity, which is very important in food safety today. I am sure all noble Lords will welcome my noble friend’s immense experience to our House and look forward to his many contributions to come.

I usually stay away from giving my opinion on health Bills; it is not my area of expertise and the NHS is challenged enough without my tuppence-worth. However, I could not stop myself with the Bill in front of us, because I was struck by its plan to enhance patient safety and the patient’s experience through a new single patient record—long in the making, as my noble friend Lady Jay said.

This record could transform patient care. As long as safeguards exist against cyber attacks and AI going rogue, and as long as transparency is always at the forefront of our mind with the creation of this record, patients will welcome it as much as we do tonight. I welcome my noble friend the Minister’s commitment to this specific part of the Bill in her opening remarks.

I support the Bill and its ambition. Of course, it has its critics. The trade union UNISON is concerned that the 10-year plan, which the Bill will make law, could produce a larger role for private healthcare. The Patients Association, while welcoming the Bill’s stated intention to put patients first and reduce bureaucracy, points out—as many noble Lords have—that

“any period of organisational change risks distracting from immediate patient care”.

I am sure my noble friend the Minister, who has a well-earned reputation for listening, will be aware of such concerns and will address them in her summing up.

As vice-president of RoSPA, the Royal Society for the Prevention of Accidents, along with the noble Baroness, Lady Watkins of Tavistock, and the noble Lord, Lord Jordan, our president, I saw in the proposed single patient record an opportunity for far more accurate and meaningful data than is currently the case: data from across the health service, to be used more effectively for patients’ well-being. As noble Lords will know, RoSPA’s mission is to campaign to prevent serious injury and save lives. However, as it stands, injury prevention is hindered by fragmented, incomplete and inconsistent NHS data. Data is often missing or provides only surface-level detail, which makes comprehensive injury prevention policies extremely difficult. As we know, information on injuries comes from multiple sources and agencies: hospitals, ambulance services, primary care, public health data, and so on. The Bill’s new information-sharing powers create a real opportunity not merely to further modernise digital records—to be fair, the old digital record has not always gone super smoothly—but to provide a stronger and safer evidence base for the prevention of accidents.

I will give noble Lords a couple of current examples. According to the latest NHS data, in 2024, seven people were admitted to hospital as a result of being bitten by a crocodile, two people were admitted for being bitten by a scorpion, and 53 people for being bitten by a rat. Three people were the victims of a volcanic eruption and 22 people were admitted to hospital due to a long stay in a weightless environment—I do not know what that means either. However, when it comes to falls, which are the biggest cause of accidental death and injury in this country, more than a third of admissions are recorded simply as “unspecified”. It cannot be right that we know more about injuries caused by crocodiles than we do about hundreds of thousands of falls, many of them affecting our ever-ageing population. During the passage of the Bill, will my noble friend the Minister meet me, the noble Baroness, Lady Watkins, and perhaps representatives of RoSPA to discuss how the Bill will improve the quality of injury data and, in doing so, enable prevention, save lives and reduce avoidable pressure on our overstretched NHS?

Lord Rennard (Liberal Democrat)

My Lords, I will make three points that the Health Bill should address. First, in the long run, the greatest threat of uncontrollable government spending levels is from escalating health and care costs if we fail to provide a solution to the growing crisis in social care—which is severely impacting on costs to the NHS—or deal with rising levels of ill health in an ageing population and rising levels of obesity, diabetes and disability, all of which are linked.

The excellent former Pensions Minister, Professor Steve Webb, provided me with figures, beginning in 2023-24, based on the proportion of GDP spent on health and pensions. The proportion of GDP spent on pensions at the start of this period was 5.6%. In 30 years, this figure is set to rise to over 7.3%, and over 50 years it is projected to reach 8.9%. Meanwhile, spending on health, as a proportion of GDP, is currently around 8%. In 30 years, this is projected to rise to over 11%, and over 50 years to nearly 15%—almost double the proportion of GDP spent on health today. As we debate the structural reorganisation of our health services, we must not lose sight of the overwhelming demographic changes and financial realities that we will face. The escalating costs of health and adult social care are driven relentlessly by rising rates of obesity, diabetes, complex multiple morbidity and an ageing population living with higher levels of disability.

My second and third points are both about limiting those rising costs. Smoking is still the single largest driver of preventable ill health and health inequality in the United Kingdom. It accounts for nearly half of the gap in healthy life expectancy between the richest and poorest communities. We have made great progress: recent ONS figures demonstrate that, across the UK, fewer than one in 10 people smoke. This achievement has required great determination to uphold good public health policy, with effective regulation to help prevent people taking up the habit and to help the majority of smokers who wish to quit. However, more can be done. I urge the Minister to commit to publishing a clear road map to a smoke-free country, underpinned by sustainable funding for that programme—including a targeted levy on tobacco industry profits that could raise billions of pounds for public health and address the funding gap. This money is needed by a healthcare system, not by the tobacco oligarchs who profit so much from products that kill half their customers and impose massive costs—both financial and well-being—on us all.

Thirdly, I highlight the growing costs arising from the complications associated with poorly controlled diabetes. Diabetes may already take up about 10% of the NHS budget, with 80% of those costs spent on the complications associated with it. By 2035, diabetes is projected to take up around 17% of the NHS budget. As this legislation abolishes NHS England and transfers its function centrally, we must guarantee that momentum is not lost in diabetes prevention, treatment and clinical innovation.

The Bill should place an explicit duty on the Secretary of State to promote innovation in diabetes care, specifically by accelerating the rollout of continuous glucose monitoring and hybrid closed-loop artificial pancreas technologies. Diabetes-related health inequalities, whether in access to insulin pumps or structured education, must be named as an explicit statutory consideration in the duty to reduce health inequalities.

With action on these issues, we can begin to close the looming gap between what the country can afford and what needs to be done for health and well-being in this country.

Baroness Redfern (Conservative)

My Lords, I congratulate noble Lords on their excellent maiden speeches.

With the abolition of NHS England, its functions are being transferred to either ICBs or the Department of Health and Social Care, as duplication currently exists in functions and job roles. Further clarification is required on the full timetable and cost of abolishing NHSE. Reducing bureaucracy, streamlining NHS structures and improving delivery must directly address severe capacity and accountability gaps, in particular in cancer treatment.

I thank all the front-line staff across the NHS who do incredible work 24/7. We so need standards to be served evenly across urban and rural areas, supporting a commitment for the NHS to be truly fair and fit for all. There is no doubt that a new approach is urgently required, bringing together people’s health and social care records digitally. This has to be secure and responsive to urgent requests in one place, so we need clarity on how the single patient record would work and how data would be assessed, governed and kept secure. There must be sufficient consultation, engagement and planning with all providers, including the independent sector. With a realistic and properly resourced implementation plan, this should address the full cost of developing and maintaining records and arrangements, including in cyber security.

I would like to focus on three areas. First, on eye tests, I call for explicit statutory safeguards for NHS sight testing and the mandatory inclusion of optometrists in ICB planning. This Bill must protect meaningful patient choice across all suitable NHS-funded providers and ensure that local commissioning decisions do not restrict capacity but safeguard ophthalmology referral pathways.

Secondly, I note the loss of 1,500 pharmacies in the last 10 years, which is concerning to people who access pharmacies up and down the country. Pharmacy teams must be recognised as central to delivering this 10-year plan. Pharmacies already increase access to care closer to home and support prevention strategies. The NHS in England spends more than £19 billion on medicines each year, the second-largest expenditure after its workforce. In the context of new trade deals on medicines and adjustments, the systems should be appropriately incentivised to optimise medicines for patients and reduce oversubscribing.

Thirdly, I highlight the importance of a national framework for improving access to radiotherapy services. They play a central role, particularly in cancer treatment. Significantly more staff are needed as the incidence of cancer rises and workforce shortages directly affect treatment capacity and waiting times. We need the ability to adopt to modern technology and an end to recruitment freezes. With equipment shortages and ageing infrastructure, machine deficits are approaching. Some have already exceeded their recommended replacement lifespan. We need steering, clear leadership, transparent accountability and strategic planning for radiotherapy, which is essential to the Government’s ambition on cancer waiting times: ensuring that every patient receives access at the right time.

Finally, in areas with no regional mayor, the requirement remains that ICBs must include at least one board member jointly nominated by an upper-tier local authority. Again, there is a requirement for clear lines of responsibility and accountability and transparency to Parliament, including on who should be accountable when services fail. We must also have inclusion for GPs. We all want the very best healthcare and the most efficient, first-class NHS, with reduced bureaucracy. I look forward to clarity on the issues raised and to having the Health Bill strengthened, so that patients can benefit promptly from treatments wherever they live.

Baroness Watkins of Tavistock (Crossbench)

My Lords, it is a pleasure to contribute to the debate and to have heard the previous maiden speeches. I look forward to the subsequent ones and note the great increase in representation not only from the north but in mental health, which everybody knows is my interest. I am very pleased to see that.

I want to say one thing before starting on what I have written. We have talked a lot about patients, but actually the public fund the NHS. The young in particular —people aged 20 to 40—use it relatively little, yet many of them contribute significantly. We are seeing complaints across Europe from younger people because they are not getting what they think they are paying for, either in education or in other areas. We have to be really explicit about what the NHS will provide for everybody from the centre, so that we do not get too much differentiation as delegation occurs. Otherwise, we will lose the commitment that those of us who have been supportive of the service for so long assume that the next generation want. I just want to put that on record.

I am really supportive of this Bill. I have some concerns about the ability of the health service to monitor, investigate and learn from its own performance with the new structures. I believe we have a responsibility to do that because, during a period of huge change, the health system needs to have in place the ability to monitor its effects and to flex and change to ensure that two things happen: that our manpower planning is right and that productivity increases because of the use of technology. If we do not, we will not be able to deliver.

Although I agree with much of Penny Dash’s review, like many others I do not believe that the HSSIB should be put into the CQC at the moment. Its predecessor, the Healthcare Safety Investigation Branch, was established following the Francis inquiry into Mid Staffs. Its purpose was clear: to provide independent, expert investigations into patient safety and to identify the systematic factors that contribute to patient harm. That independence is fundamental. The body investigates without apportioning blame or liability. It has worked hard to create a safe environment in which healthcare professionals can speak openly about safety concerns. As a nurse, and through my conversations with colleagues across the NHS, I know that the CQC is perceived very differently. I urge the Government to consider whether this is the right way forward.

I am pleased that the Secretary of State confirmed that there will be a maternity commissioner but, as the noble Lord, Lord Bradley, said, there may be a need for commissioners in other areas. I would support a further amendment allowing the Secretary of State to appoint commissioners in other areas of healthcare when significant concerns arise. Giving them this flexibility would allow expert commissioners to ensure that lessons are learned and, crucially, that recommendations are acted upon. We are waiting for several reports into severe problems in mental health services; this is an example of where I would like to see that flexibility when those come out.

I strongly welcome the commitment to the single patient record. If properly implemented, it could definitely improve continuity of care, reduce duplication and ensure clinicians have the information they require. That would be a significant step forward but, as other noble Lords have expressed, the amount of detailed personal information that will be shared across different parts of the health service, and indeed in legal services, may have to be carefully thought about. I would like to see an opportunity for advanced directives to be fully incorporated into the patient record, so that it is very straightforward in emergency care, and in end-of-life care, to address what patients really want.

Finally, I thank the Minister for her letter, which I received this morning and therefore incorporated into my last words. It related to a question I had previously asked about whether the mental health investment standard should be put on a statutory footing. The reply from the Government was clear that this funding is a priority and that it does not need to be stipulated in primary legislation. A probing amendment may be necessary on this issue, because such reassurance may not withstand a change of Administration in future years.

Lord Babudu (Labour)

My Lords, no Bill this Session will matter more to the health of the nation. I say at the outset that I welcome the Bill and the principles behind it. Whatever the aims in creating NHS England, the way in which it was set up and run makes accountability hard to place. It has added to what was already considerable bureaucracy. That is no criticism of the many exceptional professionals who have worked and continue to work in NHS England, but the Government are right to ask whether a different structure could deliver better outcomes for patients, at lower cost and greater speed.

We should also be honest about the costs of reorganisations. We have had many of them, and each takes longer to bed in than we seem to allow before the next one arrives. There is no perfect structure for the NHS; what it needs is one that is good enough and stable enough to let its people get on with their work. I hope that the Government will now set out plainly how the new system will work in practice and then complete the changes quickly.

I shall focus the rest of my remarks on three things: prevention, patient voice and integrated care boards. On prevention, the main drivers of our health lie well beyond the health system. Our health is shaped largely by the food we eat, the air we breathe, the homes we live in and the work we do. Too often, the poorest communities have the least healthy food, the most polluted air, the worst housing and the most insecure work. The 10-year health plan is clear that prevention must play a far greater role in improving the nation’s health. The plan’s goal to halve the gap in healthy life expectancy between the richest and poorest regions will not be reached via a hospital door.

I worry that the Bill is not yet explicit enough about this. It creates space for preventive work, commissioned by integrated care boards; it brings local authority and mayoral members on to those boards, but it does not make it plain that moving resources towards prevention, broadly understood, sits firmly within the expanded remit of ICBs.

Some will say that that space has always been there, yet time and again, the chance to fund prevention is lost to the demands of ever more expensive clinical care. In his 2024 investigation of the NHS, the noble Lord, Lord Darzi, found that the share of the NHS budget spent on hospitals rose from 47% in 2006 to 58% in 2022. Successive Governments have promised the opposite. Meanwhile, in the last decade, the public health grant was cut by more than a quarter per person in real terms.

The Bill gives the Secretary of State a new duty to promote innovation. It restates the duty to reduce health inequalities. Prevention has no equivalent duty, and this House has no good way to see whether money is moving towards it.

There is a precedent from this House for a clearer approach. In 2022, after pressure from noble Lords, including my noble friend the Minister, the then Government added a duty to their Health and Care Act. Each year, the Secretary of State must now publish whether NHS spending on mental health is expected to rise, both in cash terms and as a share of the total. That simple act of transparency keeps mental health spending in front of Parliament every year. I ask the Government to consider something similar for prevention: a clear duty and an annual statement of what the NHS and ICBs expect to spend on prevention, so that we can all see whether the shift the 10-year health plan promises is happening. Will my noble friend say whether this is something the Government will consider?

On patient voice, I have seen how local Healthwatch organisations up and down the country play a valuable role in raising the concerns of the communities they serve. Bringing that role closer to the centre creates a chance to champion those voices better, but it also carries an obvious risk that fewer voices are heard. The voices most at risk are those that are already heard the least.

I look forward to working with the Government to strike the right balance: fewer bodies capturing patient voice, real independence, the full diversity of voices still heard and a clear line from what people raise to what changes. I have also heard from patients who are worried about how the single patient record will work in practice. They see strong local voices as a key safeguard.

Finally, with the number of integrated care boards being reduced by a third, their running costs to be halved and with new commissioning duties such as screening, vaccinations and the work of local Healthwatches, many ICBs have rightly warned that they risk ending up with more to do and far less capacity to do it. In such cases, experience suggests that things that are deemed discretionary, such as prevention spending and listening to patients, are often the first to suffer.

I would appreciate it if my noble friend the Minister could set out what discussions the Government have had with ICB chief executives and chairs about the enabling measures they need to take a genuinely preventive, community-rooted approach. That is the shift from sickness to prevention that the 10-year health plan promises. This Bill is our best chance to make that shift real.

Baroness Hodgson of Abinger (Conservative)

My Lords, I declare an interest as chair of the governance board of ISCAS, the Independent Sector Complaints Adjudication Service. I too congratulate noble Lords on their excellent maiden speeches.

These proposed changes create the largest NHS reorganisation in over a decade. While healthcare reform is to be welcomed where it improves patient outcomes, systems alterations can cause confusion. Ultimately, we need to evaluate whether the changes will improve patient care and ensure accountability.

There is concern that the Bill will overcentralise decision-making and weaken independent challenge. Indeed, former Labour Minister the noble Lord, Lord Darzi, who led this Government’s investigation into the state of the NHS in England in 2024, said that

“a top-down reorganisation of NHS England and integrated care boards is neither necessary nor desirable”.

There has been much discussion about the creation of a single patient record and its potential to improve continuity, efficiency and patient safety. Clearly, there are many potential advantages, but only if we ensure robust safeguards around privacy. While medical professionals have a duty of confidentiality, it is important that personal information does not get into the wrong hands. It is a question not just of data security but of public trust.

Does the Bill help the GP system, the most vital part of our health system but at present under huge strain? A good GP service with continuity of care is crucial to aid prevention and thus decrease need. Studies show that, where GPs know their patients, admittance to hospital is lower, patients are less likely to die and their health is better. Today, many of our hospital A&E departments are overwhelmed by people who cannot get in to see their GPs, who appear to be asked to take on too many patients. We need to enable GPs to have the tools and time to do the job properly.

Like many, I am concerned about the proposed abolition of Healthwatch. An independent patient voice is essential for accountability. Surely, transferring this into an ICB could create a conflict of interest. Indeed, some suggest that it is tantamount to marking their own homework. Complaints need to be used for learning, but there is a tendency in many areas of healthcare not to be open when things go wrong, and challenging a service and addressing issues honestly can be used to improve care. I therefore urge the Minister to ensure that Healthwatch stays independent, and is improved and strengthened.

The Bill should be an opportunity to improve the way in which medical negligence is dealt with, in terms of both finance and the patient experience. Inevitably, from time to time, things go wrong, and in those cases patients or their relatives should receive compensation. The National Audit Office estimated that the accumulated clinical negligence liabilities as of 31 March last year were £60 billion. That figure has quadrupled since 2006-07, making it the second largest provision on the government balance sheet after nuclear decommissioning. In 2025-26, medical negligence cost over £3.2 billion. Not only is that a huge amount that could be spent on care, but the years it takes for a patient to bring a case to court add hugely to the stress and distress.

The annual cost to settle claims has more than tripled over the last two decades, and often the legal costs for claims under £25,000 vastly exceed the damages payable to claimants. Plans to control claimant legal costs by limiting the recoverable amount in lower-value damages cases have not been implemented following the change of Government in 2024. Can the Minister say why? Surely, we should be setting up a commission under an independent chair which includes clinicians, patient and legal representation to review the present situation and come up with a better model that would cut legal costs and give patients swifter resolution.

Of all the negligence costs, a significant proportion—42% in 2024-25, amounting to £1.3 billion—are paid out on maternity claims. The maternity failures highlighted by the Ockenden reviews and the Amos national maternity and neonatal investigations are truly shocking. The 2019 civil partnerships, marriages and deaths Bill required the Secretary of State to prepare a report on whether the law should be changed to enable coroners to investigate babies dying at birth. What happened to this report? It also gave the Lord Chancellor powers to amend the Coroners and Justice Act 2009 to enable coroners to investigate. This would stop the apparent present culture of cover-up in so many hospitals.

The negative situation regarding maternity leads one to question how efficiently hospitals function in other specialties and what the situation is regarding unnecessary deaths. It raises questions about the effectiveness of the CQC inspections. Is it really wise to transfer the Health Services Safety Investigations Body into the CQC at this time, potentially weakening the independence of patient safety investigations?

We need to make sure that we spend the healthcare budget in the most effective way to meet patients’ needs. Thus we must ensure any changes to healthcare through this Bill actually improve the system, lower costs and deliver results in better patient experiences and outcomes, not just rearrange the deckchairs. As others have already quoted in the other place, Winston Churchill once said:

“Healthy citizens are the greatest asset any country can have”.

Baroness Cass (Crossbench)

My Lords, I join others in congratulating those who made their maiden speeches and extend my commiserations to the noble Lord, Lord Singh, who has drawn the short straw in speaking as the last maiden speaker—but it is excellent to have another medic in the House. I declare my interest as an independent adviser to DHSC. As a paediatrician and somebody who has spent much of my career advocating for children and young people within the health system, it will not come as any surprise that I wish to focus my remarks on the implications of this Bill for children.

On the broad aims of the Bill, there is a strong case for simplifying structures, improving accountability and making better use of data. Like many others, I welcome the ambition behind the proposed single patient record, but with all the health warnings given by my colleagues, particularly the noble Lord, Lord Tarassenko, and others. None the less, we have to move on from a situation where Alexa knows within minutes that we are thinking about buying a new toaster but our GP may not know for several days that we have been diagnosed with cancer. In particular, there is real potential to improve continuity of care, particularly for children and young people with complex needs.

Many people have discussed all the operational practicalities of the Bill, but for me one particular concern kept recurring: children are largely absent from it. This matters because this Bill arrives at a troubling time for child health. The recently published State of Child Health report, produced by the Royal College of Paediatrics and Child Health, paints a sobering picture. Across a wide range of indicators, progress has stalled or gone into reverse. Vaccination rates have fallen; rates of childhood obesity are climbing, as the noble Lord, Lord Smith, told us; mental health difficulties have increased; and many health outcomes remain strongly associated with deprivation.

Most troubling of all is that the inequalities begin early and can persist throughout life. Children growing up in the poorest communities experience worse outcomes from the very start. Infant mortality is more than twice as high in the most deprived areas compared to the least deprived, and far too many children continue to face poorer physical and mental health simply because of where they were born and grew up. By the time a child starts school, substantial differences in health and development have often already emerged. So, if this Bill is intended to create a more accountable health system, it should also help us understand whether those inequalities are narrowing or widening.

A health system should be judged not just by how well it treats illness but by how effectively it supports all children to have the healthiest possible start in life. This raises a fundamental question: if the purpose of the Bill is to strengthen accountability in the NHS, accountability for what? Much of the discussion has focused on structures—the abolition of NHS England, the transfer of functions and the relationship between national and local bodies—but structures are not an end in themselves; the purpose of those structures is to improve health outcomes.

As the Bill progresses, I hope we can explore how children’s health outcomes can be made more visible within these new arrangements. We should know whether outcomes are improving, whether inequalities are narrowing and whether children are receiving timely access to the services they need. In that context, I will lay amendments that seek to ensure that waiting times for children are not lost within broader NHS performance measures. Delayed treatment in childhood can have consequences that extend far into adult life. It is right that we consider whether the new arrangements provide sufficient visibility and accountability for children’s access to care.

I also hope that we will consider how children and young people’s voices and interests will be represented within the new structures. Children often have little direct influence over the services they use, yet decisions made during childhood can shape health trajectories for decades. This Bill will reshape how the NHS is governed, and it therefore provides a valuable opportunity to ask not only how the system is organised but what outcomes it seeks to achieve. Children may occupy only a small part of the Bill, but they will live longest with its consequences. So I hope that, as the Bill progresses through this House, we can ensure that improving child health and reducing child health inequalities become a more explicit part of its purpose.

Lord Scriven (Liberal Democrat)

My Lords, I also welcome the maiden speeches of noble Lords. I thank them for their wise words and look forward to them contributing to your Lordships’ House in the future.

I come to this Bill as a former NHS manager, which will not endear me to many people—I understand that. I started my career in the early 1990s, and I have lost count of the number of reorganisations since: fundholding, health authorities, primary care trusts, strategic health authorities, clinical commissioning groups, integrated care boards and now the abolition of NHS England. Each arrived promising less bureaucracy and a freer front line. The King’s Fund calls this

“the largest reorganisation of the NHS in more than a decade”,

and it reminds us that structural reform alone can be

“a huge distraction and rarely improves care”.

I have lived through that distraction. Leadership time for years goes on new boards, new boundaries and people reapplying for their own jobs, not focusing on patients and improving health outcomes.

So let us start with simple questions: who is using the NHS and why? What can we do about it and where? Waiting lists remain stubbornly high—above 6 million. Healthy life expectancy has fallen to around 61. Neither is caused by organisational names on a letterhead; the answer lies in social care, in children’s early years and in prevention and early diagnosis. NHS structures are not the answer to those numbers, and any Government or Health Minister who think so are deluded.

So what is in this Bill? First, there is a power grab. The Secretary of State takes many of NHS England’s functions: powers to direct ICBs, even when they are performing well, as well as powers to remove an ICB chief executive and direct the chair on who should replace them. That is not accountability; that is political patronage. It also invites political interference in where capital is spent and directions on operational matters. Any such powers must be targeted, proportionate and subject to robust guardrails. I will test this Bill against those standards in Committee.

Meanwhile, ICBs have been ordered to halve their running costs—some 12,500 posts to be deleted—yet the Bill gives them new duties, not just in commissioning but in other things as well. Who will be able to act on those new powers with half the staff? A whole tier will be hollowed out, asked to do more, with inevitable inability to deliver. And what will happen? A consultancy tsunami and extra cost are on the way.

Then here comes the farce. Last week, ICBs were told that most planned cluster mergers will not go ahead next April; footprints must wait until 2028. The operational model is really still not there. Now we read that NHS England may go into the department or be a stand-alone body. Cut first, plan later. That is not strategy; it will cause health and planning chaos.

Patient safety is my deepest worry. The Bill moves the work of the Health Services Safety Investigations Body into the Care Quality Commission. First, does the HSSIB not have powers to investigate the CQC? How does that work in this new world of the Bill? The CQC itself warned in May of a conflict of interest. Staff speak up because the safe space is at risk. The Minister needs to understand this is a dangerous move and will seriously diminish patient safety. This is an area that I am sure I and others will return to in Committee.

On the single patient record, I support the principle: no patient should have to repeat their story, and technology only transforms care when it reaches the bedside. But trust is earned, not legislated. As reported in the Health Service Journal today, nearly 100,000 people have opted out of NHS data sharing this year alone amid mounting controversy over Palantir. Questions of who controls the data and who is accountable remain deeply unclear. The public need to be reassured on these issues, and the Minister must tell us plainly what role Palantir will play—and how its involvement will not cause further erosion of public trust.

I will judge the Bill through my own family’s experience—does it improve the healthcare and outcomes of people with learning disabilities? The noble Baroness, Lady Hollins, gave the statistics, so I will not go further, but it will be a point I will return to in Committee.

Changing the name of who issues directives will not improve healthcare and outcomes. Only stable leadership, focusing on commissioning the right things, along with true local autonomy and real accountability, will have significant impact. The Bill if left as it is will be another missed opportunity. That is why I will work to amend it in Committee, to make it fit for purpose and to improve healthcare and outcomes.

Baroness Nargund (Labour)

My Lords, I, too, congratulate the noble Lords making their maiden speeches today. I also congratulate my noble friend the Minister on introducing this very important Bill with such clarity and commitment.

Having served in the NHS as a front-line doctor for nearly 40 years, I believe this bold and transformative Health Bill offers a significant opportunity to modernise healthcare and tackle our nation’s persistent health inequalities. There is much in the Bill that I welcome and many areas that I would like to expand upon, but in the interest of time, I shall touch on four areas.

First, the abolition of NHS England is long overdue. Transferring its functions to the Secretary of State and integrated care boards removes unnecessary bureaucracy, as we have heard, and brings decisions and resources closer to patients and to where they will have the greatest impact on patient safety. These reforms could save £1 billion annually.

The abolition of NHS England means the abolition of one of the largest quangos. As a consultant who has worked for more than three decades, I have worked closely with NHS England and have seen too many tick boxes, too many checklists, too much bureaucracy and decisions not being made. I welcome this significant step. I am pleased that the direct commissioning functions are being transferred to ICBs with an aim to deliver a population health improvement plan for the whole area. The ICBs that are accountable for this must turn this ambition into action.

The single patient record is the highlight of the Bill. As we have heard from many noble Lords, it will improve patient experiences and outcomes. In my view, it is more likely to help retain doctors and nurses who are leaving the NHS because of the frustration of fragmented notes and the medical legal risk. It could also save around £20 million a year from reduced medical errors, reduced adverse drug reactions and duplicate prescribing, alongside better co-ordination of community services and an estimated 20,000 fewer A&E visits.

Of course, as we have heard, the strongest safeguards must be put in place for security, privacy and public trust. I welcome the reassurances from my noble friend the Minister on this and that clinicians will not be authorised to access an individual’s record without a legitimate clinical need.

However, I am concerned about the lack of clarity around sharing notes from private healthcare. Patients increasingly move between NHS and private healthcare—their medical history should move with them. I therefore ask for reassurances that there will be provision for patients receiving private treatment to have their care data shared for the single patient record.

I particularly welcome the duty to promote and reward innovation within our NHS. We have a proud history of innovation in the NHS. In my own field of women’s health, the development of IVF and the introduction of ultrasound in obstetrics and gynaecology were innovations which transformed lives globally, but now it is difficult for front-line clinicians to innovate. Innovation cannot depend on exhausted clinicians doing research in their spare time. They need protected time, support and opportunities to develop ideas into research that improves outcomes and reduces costs. If Britain wants to remain an innovation nation, the NHS must not simply adopt innovation; it must drive it. We need further clarification on the promotion and rewarding of innovation in the Bill.

Finally, neighbourhood health is an area about which I feel particularly strongly. The plans are welcome, but local health needs can truly be understood only if all stakeholders are involved in shaping those plans. I therefore urge the Government to ensure that voluntary, community and social enterprise organisations are closely involved in these plans and are represented on health and well-being boards.

The Bill can deliver a modern and efficient NHS, it can create growth and prosperity in every region, and it has the ability to tackle health inequalities. I look forward to discussing the Bill in Committee and contributing to the debate, and to supporting the Bill throughout its passage through your Lordships’ House.

Baroness Manzoor (Conservative)

My Lords, I also take the opportunity to congratulate all noble Lords on their maiden speeches, including my noble friend Lord Singh when he gives his.

As we have heard, the Health Bill proposes major changes to the NHS in England, and I welcome the ambition to reduce bureaucracy and improve accountability. But successful implementation of the Bill will depend on strong, effective leadership, managing significant organisational and operational risks, while maintaining a clear focus on health outcomes. Creating structural changes in key NHS organisations at the same time could create disruption, further duplication, inefficiency, poor value for money, workforce shortages and longer waiting lists, and it could widen health inequalities.

The Bill leaves much of the detail to secondary legislation. Therefore, can the Minister clarify which new regulation-making powers will be subject to affirmative resolution, which will use the negative procedure, whether Parliament will receive a clear timetable for implementation and how these reforms will improve health outcomes?

Like others, I feel strongly that any reform of NHS services should be rooted in a strong and independent consumer and patient voice. Moving patient experience functions into ICBs and local authorities creates significant independence problems, as organisations responsible for planning and commissioning services will also be responsible for gathering and responding to criticism of those services. The recent scandals in neonatal and maternity services evidence that, and I urge the Government to give this issue further thinking.

I share the ambition for a single patient record, but its successful implementation has challenges that will need to be addressed effectively and transparently. These challenges range from reliable interoperability across providers to data quality, cyber security, consent, confidentiality, information governance and public trust. The Bill creates powers to require NHS providers, including GPs, to disclose information for the record, but successful implementation will depend on a compatible system, reliable data and effective safeguards. Legislation alone cannot do this.

The record should also support the reduction of health inequalities, not inadvertently widen them. Digital exclusion, variations in access to services and differences in the quality of data about disadvantaged and underserved communities must be addressed so that the benefits of reform reach those with the greatest health needs. As the Minister and my noble friend Lord Howe have said, patient safety and public trust are key, but combining independent safety investigations with a regulator—the CQC, which itself is in difficulties—creates an important tension between learning and enforcement. The HSSIB’s investigative credibility depends on independence and a just culture. The CQC has regulatory and enforcement responsibilities. The legislation must preserve genuine independence, confidentiality and safe-space protections. Again, I urge the Government to give this further thought.

The proposal for a maternity and neonatal commissioner creates a particularly important accountability question in a delegated commissioning model. The commissioner will need clearly defined powers, responsibilities and resources to work effectively across the DHSC, the CQC, ICBs, trusts and professional bodies. Undertaking merely an annual report with no enforcement powers will not be sufficient.

Finally, these reforms will require sufficient workforce capacity, education, supervision and professional leadership. Structural reform alone will not improve health outcomes. Its success will depend on sustained investment, effective governance, reducing health inequalities, meaningful patient and professional involvement, and clear accountability for delivery. Therefore, will the Minister confirm that the Government will publish a comprehensive implementation framework, setting out clear responsibilities, timescales, milestones, resources and deliverables, with appropriate parliamentary scrutiny for implementing and delivering?

Baroness Gerada (Crossbench)

In the short time I have, I will restrict myself to just one issue, something very close to my heart, which has already been touched upon by a number of noble Lords today—continuity of care. As I said in my maiden speech not even a year ago, my very first patient as a GP was a young woman who suffered a stillbirth. More than 40 years later, I look after her children and now her grandchildren. That is continuity of care. Nothing in the Bill would stop that relationship, but nothing in it will protect it either. The Bill speaks of integration, joined-up information and prevention—all very welcome—but it says precious little about the one thing that evidence shows makes the biggest difference: a patient’s ongoing relationship with a clinician who knows them.

The Government say that the single patient record will prevent 6,000 admissions a year and 20,000 A&E attendances per year. To put that in context, that is 0.3 every day for every A&E, so one every three days. Continuity of care with a named GP is associated with five to 10 times that figure. A patient record tells a clinician what has happened; a continuing relationship tells them what it means, and only the second is linked to reduced mortality. When I know my patient, I know what is normal for them. They trust me enough to tell me what is really going on. That is how cancer or heart disease is picked up early. Someone who knows the patient notices that something has changed.

This is not a nostalgic anecdote. Repeated studies link continuity of care to lower mortality. A recent Norwegian study of 4.5 million people published in the British Journal of General Practice found that those who had seen the same GP for 15 or more years were about 30% less likely to be admitted as an emergency, 30% less likely to have an urgent out-of-hours contact, and 25% less likely to die than those whose relationship had lasted a year or less. Few medicines could claim that—in fact, I think no medicine could claim that. Continuity saves money. It results in fewer repeated stories, fewer repeated tests and fewer wasted appointments. Continuity works for hospitals as well, and we know that.

Continuity of care is the golden thread of healthcare. It matters not only for long-term conditions but for those living at the deep end, the lowest decile in our communities: the patients with multiple illnesses, the family in crisis, the homeless, and the person whose story takes years to tell. In practices serving our most deprived communities, need is greatest and lives are more complex, so if we are serious about reducing inequalities we must fund according to need. Access matters, but access is not continuity. A system designed solely to get someone seen quickly can make it harder to consult with a clinician who knows you.

Continuity does not just happen by accident: it must be designed and resourced into the system. As highlighted by the Royal College of GPs—and I urge noble Lords to listen to this figure—England has 142 fewer qualified GPs than it had in 2015. At the same time, the average number of patients per GP has risen by about 12%. My average surgery before I came to this House was about 70 patients per day, roughly the number of speakers in the debate today. Meanwhile, the number of doctors working in secondary care has increased over the same period by 46%, according to the British Medical Association.

I have three questions to ask the Minister. First, will she place continuity explicitly within the Bill’s duties on integration, prevention and reducing health inequalities? Secondly, will the Government make the resourcing and prioritisation of continuity part of how integrated care boards are held to account? Thirdly and finally, will the Minister address GP workforce inequalities that are affecting delivery of safe, relationship-based care, particularly at practice in the deep end?

Baroness Wyld (Conservative)

My Lords, I do not doubt for one moment that the Government are very well intentioned in bringing forward the Bill, and there are measures in it that I support. Like others, my worry is that it is heavy on structural reorganisation without yet a clear sense of how patients will benefit. I want to be fair-minded, and I thought that the Minister set it out very thoughtfully and rooted her comments in patient experience, which was appreciated. However, we know that structural reform does not automatically improve culture. Safety and trust are built by people, and I thought that the noble Lord, Lord Winston, spoke very movingly about the way people experience healthcare when it goes right and when it goes wrong, and we need to remember that.

I genuinely hope that we can improve the Bill to ensure that the patient’s voice is not drowned out and that it genuinely improves outcomes. Obviously, this applies to all patients, but in the time allowed I want to focus on maternity and neonatal services. As the Minister said, the Government have rightly identified maternity and neonatal as an urgent priority, and there are some measures in the Bill which reflect that intent, as referenced by my noble friends Lady Sugg and Lady Manzoor.

The commitment to bring forward an amendment to appoint a maternity and neonatal commissioner is one such measure, but this cannot be the sole solution. As my noble friends have said, this newly created office will need close attention as the Bill progresses, and we will need clarity from the Minister on the exact purpose and powers of that role. I point out that it is an enormous brief, spanning maternity and neonatal. We must ensure that equal weight is given to both services, which are distinct specialisms.

My worry is how long all this is taking. We have to remember why it came about, following the harrowing review by the noble Baroness, Lady Amos, where people bravely came forward. The Government promised a national action plan by this December. The commissioner is due to co-chair the taskforce implementing the plan, but of course there will need to be an appointment process and time for the office to be established. We need precision but also some pace. It would be helpful to know the timetable that has been set for the appointment and how the Minister envisages the taskforce making progress in the meantime.

I turn to the experience of families. Through Clause 19, as amended in the other place, the Bill places a statutory duty on ICBs to promote patient visiting and accompaniment rights. However, I stress that a parent is not a visitor—they are partners in care. To give one example, family integrated care is a model of neonatal care that integrates parents as equal primary caregivers for their baby alongside clinical staff, with strong evidence that this improves outcomes. This model has been implemented very well in units in England, but its implementation is not yet uniform. We need to look at how we can better safeguard family integrated care, and indeed wider parental involvement in care, as the NHS undergoes this transition. My concern is that the disruption brought about by restructuring may mean that we see even more patchy provision, and this is one issue I would like to return to in Committee. This should sit alongside wider efforts to improve accommodation and facilities with parents—an issue that has been raised with the Minister before. I just make the point that there is a lot that the Government could be getting on with alongside the Bill.

I turn briefly to the single patient record, which many have welcomed. I thought it was interesting that the Minister started with this. I recognise and support the Government’s ambition and I am pleased that they are prioritising maternity, and indeed frailty. I hope the Government have thought through how the single patient record will connect maternal health data with neonatal records. Currently, disjointed systems create dangerous information gaps. I genuinely hope this is a vital turning point, but core to this for all patients is trust, as many others have said.

The Minister is of course Minister for Women’s Health and Maternity, and I have genuinely welcomed engaging with her on many occasions. I accept that the Government have made some important commitments, but what is unclear to me is how effectively they are being brought together in a coherent programme of delivery. With over 700 recommendations across multiple inquiries, for women and families what matters now is results.

Baroness Barker (Liberal Democrat)

My Lords, I thank all noble Lords who have made their maiden speeches today for their contributions, which I have found most enlightening, and I welcome them to this House.

Like the noble Earl, Lord Howe, and other noble Lords, I bear the scars of many of these Bills. For me, this time it is different. For the last five years, I was carer for my wife, who had a very rare neurological condition; she died in June. Over the past five years, I have seen the NHS at its inspirational best and its infuriating worst. I will offer one observation of my five years.

I do not think anybody should be allowed to have a senior position of leadership or management, or the governance of an acute trust, until they have had a carer come and get them washed and dressed in the morning. That carer will probably be somebody who is here on a visa and with a sponsor, and are therefore likely to be at risk of modern slavery. They should then have to get themselves to an appointment at their hospital, in a wheelchair—they are not allowed to walk—and using only patient transport to get them there and back. Then they should have to do it again, another day, as the carer of the person in the wheelchair. Only when you have done that do you begin to understand what the statements and intentions on these websites look like and how hollow they can be.

The second thing I want to say is that everybody talks about care pathways—oh yes—but I do not think many people have ever seen one, and fewer still know who is in charge of them. That is why we should be so careful when talking about the single patient record. In itself, it will not magically transform care. What will transform care is people understanding what the purpose of that information is, whose data it is and who is ultimately responsible for it. Various members of staff, particularly the doctors, are absolutely right: there may be four different answers to who is technically and legally responsible for it—somebody I know has already begun to find that out. It is not going to be any clearer, and it is not going to help with patient care, unless and until those fundamental points are understood by absolutely everybody in the NHS.

I have to say, as a carer, that the noble Lord, Lord Hunt of Kings Heath, was right: the one thing that you dread when you cannot get an appointment is that you will have to speak to 111. I really do not want to sound as if I am in any way at all disrespectful, but my wife was a very complex patient—one of the most complex—and packing her off to 111 was never going to do any good to anybody. We really have to go back and look at that.

I also want to say that it is important that we get all the protocols around the single patient record worked up in great detail with the people who have the experience to understand it. I have a particular interest in HIV and in sex and reproductive health. People in those communities are used to living with difficult information, and sometimes they are more open with it than you might imagine but perhaps not to the people that you might think. They quite often want to go to a specialist clinic rather than to the GP, where the receptionist knows their mum. We need to think quite carefully about what information is included at the person-level SPR, with explicit consent for people to opt out on an episodic basis.

Finally, I talk these days a lot to the Neurological Alliance. Neurology patients know that we are on the brink of some really big discoveries in that field because of technology and medicine. They desperately want to be involved in the research—they understand that that is the way to stop other people suffering—and they really want to be assured that they can do so in a way that does not jeopardise their status and confidentiality or other people’s. If we are going to do anything in the Bill other than rearrange the deck chairs on the NHS “Titanic”, we really owe it to people to put a lot of work into consulting on how this single patient record will work.

Lord Sahota (Labour)

My Lords, with regard to the Bill I wish to speak on two topics: first, the health inequalities affecting our minority communities; and, secondly, the enormous contribution made to the National Health Service by Commonwealth doctors and nurses.

The National Health Service has always been one of our greatest institutions. It is the envy of the world, available according to need and not ability to pay. However, I have to say that some people from ethnic-minority communities continue to experience inequalities in access, treatment and outcome. Some patients face language barriers, some struggle to navigate an increasingly digital health service, and others feel that their symptoms or concerns are not always listened to or understood.

That is why I have some concerns about the proposed abolition of Healthwatch. Independent patients’ voices are particularly important to people who may already feel marginalised and reluctant to challenge the system. I therefore ask my noble friend the Minister this: as these reforms are implemented, how will the Government ensure that the voices of ethnic-minority communities—particularly those who face language, cultural or digital barriers—are not weakened but strengthened?

The proposed single patient record presents enormous opportunities, but we must ensure that digitisation does not inadvertently create another barrier. Elderly patients, those with limited English and people who are not confident using digital technology must retain the ability to access health through traditional means and to speak to human beings when they need to—in other words, face to face.

I want the Bill to provide an opportunity for us to recognise something fundamental about the history of the National Health Service. The National Health Service could not have developed as it did without the contribution of people from the Commonwealth. Nurses from the Caribbean and doctors from the Indian subcontinent and other parts of the Commonwealth came to Britain in the 1950s, 1960s and 1970s to help staff our hospitals, surgeries and community services. They often worked long and unsocial hours, and they served in the parts of the health service where the shortage was the greatest.

Many of them experienced discrimination, as highlighted by a BBC documentary some years ago. Some overseas-qualified professionals found that their qualifications and experience were not fully recognised. Others encountered barriers to promotion and progression —and some still do—but they stayed and persevered. They served their patients and helped build the National Health Service as we know it today. My cousin, Dr Harvinder Singh Sahota, who came to the UK in the 1960s, was one of them. He eventually went on to invent a perfusion balloon used in unblocking coronary arteries. That is what he did.

We were reminded powerfully of these doctors’ debt during the Covid-19 pandemic, when ethnic-minority healthcare workers were disproportionately affected. Many doctors, nurses, healthcare assistants, porters and other staff lost their lives while caring for others. We applaud them for their steadfastness. Our responsibility now is to ensure that our appreciation is demonstrated through not merely applause but equality and fairness in the workplace. Perhaps the greatest tribute we can pay to these Commonwealth doctors and nurses who help sustain our National Health Service is ensuring that the next generation is treated with the fairness, dignity and respect that some of their predecessors were sadly denied.

Lord Bird (Crossbench)

As a Cross-Bencher, I am here in the middle, and can look to this side and say that they have got things right and to that side and say that they have got things wrong. What I find so interesting is that it is almost like the debate you would have when the horse has escaped and you are bolting the door afterwards.

I was born in the slums of Notting Hill, after the Second World War and two years before the National Health Service started. In 1951, when I went to school at the age of five, they had us doing all the exercises, drinking milk and eating those little castor oil pills. What they were doing was intervening, with the idea of prevention. So I am one of those wise little gits from the underclass—the people who no part or political section of society has ever managed to penetrate. Those are the people who probably make up a large part of Reform, and who will drive us from this Parliament and into the abyss because they will create a different kind of political situation—those people who feel completely neglected and left behind.

I was born into the inheritors of poverty. What is so interesting about that is that you never arrive at the starting line. You often get to the starting line only late in life, or never at all. Why is that? According to the BMA, probably 50% of efforts in the NHS go into trying to address the problems of people who were born in poverty, who live in poverty and who continue to live in poverty because they have inherited poverty? We may want to make great changes in life, but we will not do so unless we address the reasons why people are ill—and the vast majority of people who are ill come from poverty. Until we do this exercise and get poverty off the back of the NHS—everything that I have heard today has been all about the emergency response to the problems of the NHS—the NHS is going nowhere.

According to the BMA and the doctors I speak to at Addenbrooke’s, 50% of the money in the NHS is spent on poverty. When is the NHS going to wake up and say to society and to the Government, “When are you going to allow us to do our job, which is to keep people in health, when we have to spend so much on the problems created by poverty?”

I find that extraordinary. We are grown-up people, wise people, the best. I do not think that there is anybody in this House, left, right or centre, who would not want a better NHS. I sit on the Cross Benches, looking at your Lordships. I look at the noble Earl, Lord Howe. His commitment to a better health service is there. I look at the noble Baroness, Lady Merron. She is totally committed. The only problem is that they do not agree on how to arrive at it. We have this brilliant uniformity. The unfortunate thing is that millions of people come from poverty, who fill up our A&Es, our prisons, our streets and our social security. Most of them will at some stage become a problem for the NHS.

My brother died in a place called Canvey Island—

Baroness Hyde of Bemerton (Labour)

I appreciate the noble Lord’s contribution, but he has spoken for—

Lord Bird (Crossbench)

Forgive me. I will finish by saying that my brother died in the NHS. Sorry, he died on Canvey Island. Forgive me, I should not have gone for a meal before this. Hundreds of thousands of pounds were spent on him, because nobody ever addressed the reasons why he came from poverty. The most expensive people in society are the poorest.

Baroness Bennett of Manor Castle (Green)

My Lords, it is a pleasure to follow the noble Lord, Lord Bird, and a challenge to maintain the House’s attention after his, as always, formidable and compelling contribution. Perhaps counterintuitively, like many early speakers in this debate, I will take the House back to 2012. I was heavily involved outside Westminster, often far from Westminster, in the resistance and reaction to the Health and Social Care Act 2012. My early years as the leader of the Green Party of England and Wales saw me frequently at protests, rallies and marches, opposing the changes that were brought in by the 2012 Act. It was, as the noble Lord, Lord Hunt of Kings Heath, said, a hugely unpopular reorganisation.

One group who did great work alerting the public to its damage was the one affectionately known as the “Darlo”: the Darlington mums who organised the modern-day Jarrow march, which I joined, to highlight the privatisation being hidden under the comfortable mantle of the NHS logo. I have to reflect on the speech of the noble Lord, Lord Winston, noting the issues created by the internal market and the focus on competition rather than compassion and care, in changes made to the NHS over recent decades. That led me back to a joint comment piece by Yanis Varoufakis, John McDonnell and I in the New Statesman in 2021, which called for the restoration of a market-free system that delivers care as a right, not a commodity. It noted rightly that what the British love about the NHS is freedom from the market.

In 2015, my honourable friend Caroline Lucas presented in the other place as a Private Member’s Bill, with widespread support, the NHS reinstatement Bill, of which this Bill might be described as a pale imitation. Crucially, Caroline Lucas’s Bill allowed commercial companies to provide services only if they were essential to patient welfare and the NHS could not do it itself. That might have been a model for this Bill; I regret that it was not. I will therefore be seeing how I can amend this Bill to address the continuing privatisation and financialisation of our NHS.

There are many issues and so little time, although I acknowledge the words of the Minister that a single Bill cannot solve every challenge facing the NHS. I will begin something of a shopping list that I will be trailing through the aisles of Committee. The Health Bill is currently silent on climate and environmental matters. That matters in both mitigating damage to climate and nature and dealing with the built-in damage on our nature-depleted islands. The state of nature reflects that of our public health, which is parlous, as the noble Lord, Lord Patel, outlined.

Healthcare in England is responsible for 4% to 5% of national carbon emissions, and around 40% of all emissions are produced by the public sector. Plastic use is enormous, and not all properly dealt with, despite the determined, innovative efforts by many in the healthcare system. I will ask the current Minister, as I have asked previous Ministers, to visit the County Durham and Darlington NHS Foundation Trust to see the wonderful work made on these issues there. It acknowledges that the environmental impact of care matters, particularly in serving an economically disadvantaged area.

Much of our focus will undoubtedly be on the many issues around the single patient record, something that already exists in Taiwan, as I saw on my recent visit there—I declare the support I received for that as recorded in the register—which I will bring to later discussions. The right reverend Prelate the Bishop of Newcastle spoke on the importance of trust in the context of the single patient record. The huge public concern about any involvement from Palantir is something I have raised in your Lordships’ House before, but overall sovereignty over those records—not to have our records and our NHS in the untender hands of US tech bros—is going to be a huge issue.

We must ensure that the Bill adequately acknowledges the needs of disabled people, as the innovative and important contribution from the noble Baroness, Lady Campbell, addressed, as indeed did the noble Baroness, Lady Hollins. If we ensure that the NHS caters to the needs of the most vulnerable, we will build a better NHS for everyone.

This Bill is mostly about structures, but we need to make sure those structures are dealing with issues such as antimicrobial resistance. That is something that we cannot afford to ignore.

Finally, while this is not a public health Bill, I will be interested to see the amendments to which the noble Lord, Lord Patel, alluded, for there is no doubt that, for the future of our NHS, we have to improve the health of the nation.

Lord Carter of Coles (Labour)

My Lords, I join others in congratulating noble Lords on their maiden speeches. They were excellent and most interesting, and I look forward to that from the noble Lord, Lord Singh, in a few moments.

Last Tuesday, I visited a friend in her local hospital; it was a delight—shiny and modern. She sang the praises of the NHS and had not one bad word to say—it was highly positive. It reminded me that much is superb in the NHS; we should not forget that. However, the difference between good and bad practice is palpable. I think we all recognise the need for continuous reform; we probably have to look at it every 10 or 15 years. I really welcome this Bill because it gives us a chance to take the next step in the modification of the National Health Service, although it will require, as we have heard tonight, significant amendments; as it stands, it will not be effective. The test will be whether it delivers sufficient benefits to pay for the disruption that it has caused and will cause in the next two years. We should not forget for one moment that this is going to do little to improve care or anything else in the National Health Service for three years. We have three more years of challenges as this becomes effective. I draw attention to my interests as recorded in the register.

The Bill has two objectives: the single patient record and the need to rationalise the NHS bureaucracy to streamline it to get through. Frankly, neither of these are new. The noble Baroness, Lady Jay, indicated that we have been on this journey for 20 years. I really wonder whether, when it comes into effect in 2027, we should get ready for a sort of silver jubilee to highlight the fact that we have been persistent—we have hung on to it. It is going to make an enormous difference. This is the real cutting edge of technology. It is not going to be easy, but it is critical.

Similarly, we have known for years that we need to de-layer the NHS. If we look around the world, we see that the characteristic of failing healthcare systems is layers. The successful systems strip them out and make very clear those relationships between commissioners, the people who actually deliver the care and regulators—it has to be absolutely clear, and that is what we need to do.

But perhaps we should ask ourselves: what is the problem we are trying to solve? A little look at where we stand today may be a good starting point. If we speak to patients in the system, as I did the other day, we learn that they are pretty grateful. They are very grateful to the staff for what they are doing. I think people are grateful for the investment where they can see it. If they were to think about it, I think they are grateful for the fact it is free at the point of delivery—we should never forget that. By contrast, if you are not in the system, it is pretty miserable. You are one of 7 million people waiting for treatment, and you cannot see a GP.

If people are in pain and are waiting, they are anxious and they cannot go to work and they are also disappointed: “This is not the NHS we were promised”. And the staff are not happy either. If we talk to HR professionals, they tell us that bullying, harassment and high sickness levels are indicators of a dysfunctional workforce; we have the highest in the world.

Finally, on the issue of money, where has the money gone? This is the key. In the last seven or eight years, real per capita expenditure in England on the NHS is up 14%. That is £650 per person. But output is down. Money up, output down—that is quite an achievement. If you compare that to Denmark, real per capita expenditure in those years has risen 1%. So, there is some lesson out there. We are clearly not doing things right.

But we are where we are, and we need this Bill to go through. The key points for the Minister are: first, patient choice—that is the best guarantee of people meeting those standards. Of course, I totally subscribe to Healthwatch, and I agree with the noble Baroness, Lady Coffey, that we need to make it work better. On staff, the key issue is management: the management needs to be sorted out. With regards to the Secretary of State taking powers to herself to intervene directly, I hope we can make it clear in the Bill later on that we need a better solution than that; we need clarity, so that people can get on with it. Finally, on the issue of money, will the Minister comment on the fact that we should scrap block funding? This is beloved of the Treasury because they can deal it out, but it is really the handmaid of inefficiency. What we need is a return to tariff, so that people are paid for what they do and innovate.

I look forward to supporting the Bill. It is a great chance to take this forward, and it presents an amazing opportunity.

Baroness Maclean of Redditch (Conservative)

My Lords, I would like to raise two key issues. First, many noble Lords have spoken about the single patient record, which appears to me to be laudable and sensible, but it is not enough. Around 25 years ago, I had a breast scan that showed an abnormality and I went to see consultant Ian Paterson at Spire Parkway Hospital in Solihull, a private hospital—the only time in my life I have had private healthcare. I had a minor op, but nearly two decades later it emerged that I was one of his many victims. My op had been unnecessary. He practised across the NHS and the independent sector. Like many thousands of women across the West Midlands, I put my faith in him to heal me. I was fortunate compared with many others. Some women were totally mutilated. Their breasts were removed without any justification. It is awful. They have had to wait years to find out the truth about their operations and treatment.

Ian Paterson is not the only rogue surgeon. For example, at Great Ormond Street, an independent review found that 94 children suffered harm attributable to the surgeon Yaser Jabbar. The Paterson inquiry reported in 2020. Its first recommendation was a single repository covering consultants’ whole practice across the NHS and the independent sector. It has not been implemented, and I cannot see any plans for it in this Bill. I hope noble Lords can see that that does serve a different purpose to the proposed single patient record. Without it, more criminal doctors could fall through the cracks. I pay tribute to Deborah Douglas, who chairs Breast Friends Solihull. She has campaigned assiduously for the inquiry and has helped so many other victims.

The second key point I would like to raise is the need to protect vulnerable young people within the area of gender medicine. Children distressed about their gender deserve compassionate, evidence-based care and rigorous safeguards. As we know, this is not always what happens on the ground. This can be seen in the scandal at WellBN, which was an NHS GP practice in Brighton. An independent patient safety investigation found inappropriate prescribing of puberty blockers and cross-sex hormones to 78 children, some without even a face-to-face consultation. Potential harm and serious failures of clinical governance were found. It was totally shocking, and these young children and their families were badly let down. This was happening within an NHS practice but outside the nationally commissioned specialist pathway.

That again adds weight to the argument that I have made about having oversight and governance of clinicians working across different settings. The NHS needs to be able to quickly flag up where this is happening and put a stop to it, because, after all, the NHS will be there—it is the NHS that has to pick up the pieces when things go wrong in private clinics, even for treatments that people have abroad. So, the test for the Government in this Bill is that failures such as these will be quickly identified and those doctors stopped before more patients come can be harmed.

In this context, I also want to raise the issue of support for adolescents and young people who have had gender reassignment surgery and who now regret having undergone that life-altering surgical treatment and want to detransition. The Cass review recommended provision for these patients, yet the Written Answer to the Question I tabled says that consultation for the service will begin only in the autumn of 2027, and presumably services are still a few years beyond that. It is much too long for young people to wait when they have already been through so much. We do not have reliable figures for how many this affects, and many struggle to come forward. Some detransitioners describe shame and rejection by communities they had previously felt part of and been supported by. They need help now, so will the Minister say where this detransition service will fit into the new structures?

I welcome the Bill. I want to help make it stronger. Patients need independent voices, effective oversight and timely action when things go wrong.

Baroness Martin of Brockley (Labour)

My Lords, it sounds like I am not alone in broadly welcoming the Bill. Many of its ambitions, not least the single patient record, are ones that I strongly support. Done well, the SPR will transform patient care, streamline decision-making and help realise the potential of the UK’s incredible health data, so I am delighted that this Government are grasping the nettle and getting on with it. The SPR helps to pave the way to use technology, specifically AI, more effectively to spot disease earlier, to personalise treatment and to help people stay well for longer. I would like us all to think more ambitiously about AI in health and across our public services.

But today I want to focus my remarks on two opportunities created by this Bill that can help support our economy. The first is research. Commercial clinical trials are a crucial feature of our health system. Just this morning I was at the Oak Cancer Centre at the Royal Marsden where they are researching and testing cutting-edge treatments that will improve survival rates and can transform the quality of life of cancer patients. However, clinical trials are important not only for patient outcomes. According to research for the ABPI by Frontier Economics, in 2022 alone industry clinical trials generated £7.4 billion-worth of GVA for the UK economy and created 65,000 jobs. The Bill rightly places a new duty on the Secretary of State to promote innovation, but it is essential that this duty at the top translates into delivery on the ground. That is why we need robust accountability mechanisms to ensure that ICBs build real capacity for clinical trial infrastructure. How will the Secretary of State work with ICBs to deliver on this vital duty?

The second opportunity is how we use health spending to help grow our economy. Health is one of the largest areas of public spending in this country. How that money is spent is one of the most powerful levers the Government possess to support innovation, back UK entrepreneurs and create good jobs in every part of the country. The Prime Minister understands this. At the innovation summit in Manchester on Friday, he was clear that this Government will, in his words,

“make British public procurement work harder”.

Indeed, the First Secretary of State has already taken welcome steps to reform central government procurement rules, and through the life sciences sector plan and DHSC’s SME action plan the direction of travel is clear. My concern is whether this Bill does enough to support the Government’s goal to use procurement to strengthen our economy.

As I have discovered over several increasingly acronym-heavy weeks, health procurement is pretty complicated, but the thing that is clear is that the Bill transfers vast commissioning responsibilities from NHS England to ICBs. The DHSC’s figures show that ICBs will control around 93% of NHS healthcare commissioning budgets. That is about £179 billion in the next financial year alone. That represents huge purchasing power. I asked my noble friend the Minister in correspondence whether ICBs fall within the Government’s SME procurement targets. I am grateful for her reply, but, sadly, it confirmed that they do not.

That is not the only area where there is a risk of a mismatch between rhetoric and action. When asked whether it would encourage contracts for the single patient record to be awarded to UK firms, the DHSC said that this was a matter for the Cabinet Office and that it was taking a “supplier-agnostic approach”. I understand and totally respect the importance of open competition, but if our flagship health technology programme cannot be used to back homegrown innovation, what can? I ask my noble friend the Minister whether the department will consider a system-wide stocktake of how health commissioning and procurement can better support UK enterprise and innovation so that this House and the public can see where the opportunities lie and how we can realise them.

Both points come down to a single principle: turning ambition into delivery. This Government have set out bold goals for an innovative NHS and for public procurement that drives British growth. I support both wholeheartedly, and I look forward to working constructively with my noble friend to help make them happen.

Lord Hampton (Crossbench)

My Lords, I was not going to speak in this debate because, unlike the veterans of many of the previous Bills, I know very little about the subject apart from a vague agreement that the NHS is an extraordinarily good thing. Then I read a briefing from the Royal College of Paediatrics and Child Health, which had some serious concerns. As noble Lords can imagine, as a secondary school teacher I then got quite involved. The RCPCH has concerns that children remain “largely invisible” in this Bill and the wider NHS reforms, mentioned by several noble Lords. This is echoed by One Cancer Voice, which is concerned at the loss of specialist cancer capacity and expertise which would particularly affect children and young people.

I did a word search on the Bill: “children” appears 20 times, but only in relation to previous Acts on children, and “child” appears once, in a sentence on child abuse. That is not much. Could the Minister tell us why children do not appear as a distinct group? I remember this issue a few years ago on the then Victims and Prisoners Bill, where we had a real struggle to differentiate children and adults as victims. Children and young people often experience long waits for treatment, which is particularly critical for the young. Again according to the RCPCH, in community health 25% of children are waiting more than a year, compared to 1% of adults. There also needs to be better reporting on waiting times and outcomes for the young. The Milburn report talks about how inequalities start before birth, a point made very powerfully by my noble friend Lord Bird. We need meaningful statutory targets to reduce health inequalities.

At the moment, another interest of mine is training and skills. I give a shout-out to the MoD, which is the biggest provider of all types of apprenticeships in the UK, with its roughly 200,000 employees. It is difficult to compare like with like, but the NHS has 1.5 million employees. I know it has had all sorts of issues with apprenticeships, but given the opportunities for social mobility and the NEET crisis, I would like the Minister to take the opportunity of this Bill to commit the NHS to become the biggest provider of apprenticeships and formal training in the country. Now there is a legacy.

Lord Sikka (Labour)

My Lords, the Bill focuses more on structural change than patient outcomes. When patients share confidential information with their GP, they do not expect companies, politicians or others to access it, yet that would be facilitated by the single centralised patient record. I would like to hear more about how the Government will preserve the confidentiality of patient information. This Bill pushes centralisation and hands the Secretary of State power over day-to-day decisions of the NHS, which would slow down local responsiveness as the Minister’s decisions are awaited.

And what about patient outcomes? In May 2010, 2.3 million patients awaited 2.6 million NHS England hospital appointments. By July 2024, 6.4 million patients were waiting for 7.6 million hospital appointments. Currently, 6.21 million patients await 7.33 million appointments, and the waiting list has increased for the third time in the last four months. Can the Minister explain why the Bill has no targets for reducing NHS queues?

The rich can have medical treatment whenever they want. The rest pay with their lives. In August 2023, from a small sample, the then shadow Chancellor, Rachel Reeves, estimated that 120,695 people a year died while waiting for a hospital appointment. From a much larger sample, the Times estimated that 300,000 people a year died while waiting for hospital treatment. Yet there is no official data published to show the number of lives sacrificed to appease the gods of fiscal rules, bond markets, austerity, low wages and poverty. Can the Minister explain why that is the case? Methodology for estimating the number of deaths clearly exists and has been used by very senior politicians.

The Bill does not expand NHS capacity. The UK has 2.4 NHS beds per 1,000 people, as compared to 12.6 in Japan, 7.7 in Germany, 6.6 in Austria, 5.4 in France and the OECD average of 4.2. Homerton University Hospital NHS Foundation Trust has 0.9 hospital beds per 1,000 people, less than the average for Mexico. Bedfordshire Hospitals NHS Foundation Trust has 1.7 beds per 1,000 people, about the same as Colombia. People are dying prematurely. Can the Minister give a commitment as to when the Government will hit the OECD average?

This Bill facilitates further privatisation of the NHS. During Second Reading and Report in the Commons, MPs asked questions about Clause 10 and the possibilities of further privatisation. The Government did not respond. Can the Minister now respond and explain what the long-term plan is?

All too often, Ministers say that the NHS will continue to be funded from the public purse and be free at the point of delivery, but remain silent about what happens between those two points. We have seen cataract surgery, knee and hip replacements, blood tests, scans, physiotherapy and many other services handed to the private sector. The NHS is fast becoming a shell, doling out contracts to the private sector. Some £12 billion-worth of contracts were handed to private operators in 2023-24 and 2024-25, generating £1.6 billion of profit for those private operators, which inevitably means that there is less available for other front-line services. Cataract surgery has a profit margin of 32% to 43%. Most of the profits for private operators are booked in offshore tax havens and UK taxes are dodged altogether. Yet I see nothing whatever in this Bill or anywhere else on how to deal with that. Can the Minister explain how the Government will stop the creeping privatisation of the NHS and profiteering from it?

Lord Singh of Solihull (Conservative)

My Lords, I rise with gratitude, humility and, I must confess, some astonishment. I came to Britain at the age of 30 with three £1 coins and a job offer. The fact that I am standing here says something remarkable about British democracy. I thank the noble Baroness, Lady Falkner, and my noble friend Lord Godson for supporting me during my introduction. As the other noble Lords giving their maiden speeches have said, Black Rod, the doorkeepers and the clerks have been unfailingly courteous and kind to a new and nervous Member.

Being fifth to give my maiden speech makes it seem like a mature reflection rather than a maiden speech, but here I am. I come from a very modest background. Neither of my parents went to school. My grandfather, who died in 1948, scarcely believed that India had been ruled by some people called “white”. My father, when he was nine, left home because the family could no longer feed him. He sought refuge in a Sikh temple, taught himself four languages, and wrote several books. He poured his meagre earnings into educating his children. From his life I learned that our beginnings do not have to determine where we end up.

My Kashmiri Sikh clan has faced violent displacement, across generations. My first experience of ethnic violence was the 1984 killings of Sikhs that followed Mrs Gandhi’s assassination. I was training to be a surgeon. I channelled my horror and distress into running a small clinic for affected children. There was a boy who occasionally went up to the roof of high-rise apartments and threaten to jump unless his father’s killers were caught and punished. I would have to talk him down. Later his skin would burst out with blisters. How does mental trauma become a sign on the skin? That is the question that drew me into psychiatry. My mother was horrified. She was worried that I would catch mental illness. My father had a different worry. A surgeon is a catch. Who would marry a psychiatrist?

Nearly 30 years later, I went with a BBC team to look for that boy. We could not find him. We were told that he had taken his own life. But we met others in their 40s who used to come to our clinic as children. They had rebuilt their lives. We speak often of post-traumatic stress, but there is also post-traumatic growth. People do not just survive trauma. They can learn from it. They adapt. They grow. They can even flourish. That is the belief with which I started early intervention in psychosis, getting young people’s trajectory from a serious illness back to normal life. Like the recent ADHD review shows, a diagnosis is just a description of difficulties. It need not become a prophecy for the future. With other colleagues we developed early intervention which is now admired internationally.

That brings me to the Bill before your Lordships. We have heard about the importance of continuity. I did some work showing that when young people turn 18, from child to adult services they come to a cliff edge with a precipitous drop in care. A young person turns 18 overnight. Their needs do not change overnight. They should not have to tell their story all over again, so this ambition for a single patient record is a very good one. We produced a tool that helps young people navigate the transition from child to adult services. It works. But, as others have mentioned, we need safeguards to make sure that it is implemented in such a way that confidentiality is maintained. I have worked in countries where the mentally ill are still chained and incarcerated, so I realise how precious our NHS is. I am a critical friend of the NHS. There is much to improve, but something very precious to protect.

I finish where I began. In 1927, a hungry nine year-old boy sought refuge in a temple. Today, 99 years later, his son stands before your Lordships. The children of 1984 taught me that, despite adversity, lives can be rebuilt. That is what I hope to bring to this House: respect for evidence, faith in education, compassion for suffering, and a firm conviction that circumstances, adversity or diagnosis should not set limits to a human life.

Baroness Cash (Conservative)

My Lords, it is a great pleasure to follow my noble friend Lord Singh. I congratulate all noble Lords who have given a maiden speech today, but I particularly welcome him to our Benches and to explain that, while we have heard about his intelligence and his phenomenal career in psychiatry, he is typically very humble and has not described his true character of kindness and humility and the fact that he really is a true radical, because when he sees an intractable problem, and when he sees received wisdom, he does not hesitate to challenge it. That is why he pioneered the treatment of psychosis, which was one of the greatest mental health reforms since the era of deinstitutionalisation, while his work with young people in the 16 to 24 age bracket has kept people off the streets and many of them from suicide—again, ground-breaking.

Perhaps the greatest courage of all that my noble friend has shown is in challenging another received wisdom that treatment in psychiatry was racist. At great personal cost to himself, he undertook a massive piece of research, studying all the studies to date, to find that the evidence simply was not there. He did that, first, because it was an intractable issue but, secondly, because he was worried that young people of colour and young Black people were not coming forward to seek the treatment they needed. At no small cost to himself, he put them first, yet again. He has enormous expertise in health, and I know he is going to bring great wealth to these Benches.

I turn to the Bill. It is late and we have had a lot of comment on different aspects of the Bill. I want to focus on inequality, with my shadow Minister hat on, in respect of the inequalities that are not addressed by the Bill as currently drafted. The NHS still fails in too many respects to treat patients equally or safely, as required by law. There are too many failures to record data accurately, and it worries me enormously that, while I welcome a single patient record, we still do not record things accurately and have not done the work needed to fix that before embarking on what is really a major change, with all the risks that other noble Lords have raised today. The Bill represents an important opportunity to do something about it, but the record must be consistent and reliable to ensure patient safety for both sexes.

Women are 50% more likely to be misdiagnosed after a heart attack because the textbook symptoms are male. The British Heart Foundation estimates the cost of that to be more than 8,000 women losing their lives over a decade. Screening for aortic aneurysm depends on knowing whether someone is male. Osteoporosis in men goes undiagnosed because it is assumed to be a woman’s disease. Drug doses, side-effects, reference ranges and screening calls all run off sex data. There is a reason why every major research funder in this country now requires studies to account for sex. Yet it is only in the wake of the Sullivan review that the former Secretary of State, Wes Streeting, accepted that we should record biological sex data on patient safety grounds. However, is just not good enough that this protection exists as merely an administrative standard, revisable at any time. The Bill is an opportunity to make the requirement statutory.

The same accuracy should apply to ethnicity. The NHS is still recording ethnicity against categories drawn from the 2001 census. Even then, the Nuffield Trust found recording to be incomplete, inconsistent and least reliable for the patients that it most needs to count. Black women are almost three times more likely than white women to die during or after pregnancy. The parliamentary inquiry into sickle cell care found avoidable deaths and serious failures in hospital care. Services cannot be planned, costed or audited on data of this quality. Equal treatment begins with being seen. We need sex recorded as fact and ethnicity recorded as the patient states it, in current census categories.

Then there is physical safety. Between January 2019 and October 2022, police forces in England and Wales recorded more than 6,500 rapes and sexual assaults in hospitals—33 a week, with one in seven occurring on a ward. Barely 4% led to a charge. Those figures were established by the Women’s Rights Network report written by Professor Jo Phoenix. The law is clear; the Supreme Court has confirmed it. The statutory code of practice about single-sex meaning biological sex is in force, as is the requirement for single-sex spaces, but the NHS is still failing to implement that judgment. Take Sandie Peggie and the Darlington nurses—these women should not need tribunals to secure a safe changing room. There could not be stronger arguments for the need to mandate in statute the provision of single-sex spaces. Women, children and the disabled should not be at risk of rape or sexual assault because hospitals are ignoring the law, and patients and staff should be safe and dignified in single-sex wards, changing rooms and bathrooms.

Accountability is attached to all of this, and I have not yet addressed the issue of children and the elderly. There is so much about the Bill in respect of how we treat people equally before the law at some of the most vulnerable times of their lives. I look forward to working constructively with the Government through the passage of the Bill to address these.

Lord Londesborough (Crossbench)

My Lords, as speaker 59 of 70, it is a pleasure to have had the privilege to witness no fewer than five very fine maiden speeches. I salute the noble Lord, Lord Singh of Solihull, for his perseverance. He had to sit patiently through over 50 contributions before he was allowed to stand up and make his stunning debut. I welcome him to the House.

This is a critical and complex piece of legislation. Although it is well-intended, there are some potentially very serious gaps—there always are when you reorganise and reverse structures. I will focus on the proposed neighbourhood health plans and Clause 25 specifically, which I feel has considerable scope to be strengthened. First, I acknowledge that I am not a healthcare expert; I am better known in this place for speaking about our economy and our entrepreneurship—which is my background—and the disturbing state of our public finances, on which NHS funding depends.

Three years ago, I tabled an Oral Question on our treatment of migraines and the impact on the workforce. There are 10 million migraine sufferers in the UK, and I am one. I was astounded to discover that this was the first time this House had debated this condition since 1962, despite its £10 billion annual impact on the economy—that in itself tells you something. This, and follow up questions, brought me into contact with the Migraine Trust and the wider Neurological Alliance—the latter representing the one in six people in our population who suffer from conditions such as epilepsy, dementia, Parkinson’s and Tourette syndrome, as well as migraine. We are talking here about a £96 billion annual cost to the UK economy, of which at least £30 billion is potentially avoidable.

As a patient, stakeholder and employer, I have become increasingly concerned about the huge gaps in our healthcare system for those people living with long-term, complex or fluctuating conditions. To illustrate, I refer back to migraines. Some 5 million to 6 million sufferers in the UK still lack a diagnosis, while less than a third of those who have a diagnosis receive any form of specialist care. Many have to see a GP—I should say GPs—six times before they are diagnosed, while huge and fast-growing numbers end up in A&E, representing another inefficient drain on our health resources. The result is that we as a nation lose 55 million working days-worth of productivity every year, at a cost of £5 billion to £10 billion—and that is just for the condition of migraines.

This sort of data is critical when we come to examine how the neighbourhood health plans under Clause 25 will function and operate, and, crucially be held accountable for performance, for it is these NHPs that will be tasked with identifying how the assessed needs of persons with long-term, complex or fluctuating health conditions, including neurological conditions, are to be met. That raises the question of what the measurable objectives and datasets will be for improving access, co-ordination, experience and outcomes, and for reducing unwarranted regional variations. Currently, there appears to be no explicit recognition of complex and fluctuating conditions in the neighbourhood plan guidance. This appears to be a serious omission. Can the Minister please comment? Further, will statutory guidance explicitly cover neurological conditions and co-ordination across primary, community and specialist pathways?

These questions become all the more pertinent if we lack a clear and fully funded home for the national neurological leadership—a point that the noble Baroness, Lady Leaman, made in relation to autism and ADHD. The risk is that health devolution, restructuring or reorganisation—whatever we want to call it—may disrupt joined-up care and actually weaken accountability, especially if NHPs fail to efficiently and promptly connect people with complex conditions to highly specialist services.

Baroness Walmsley (Liberal Democrat)

My Lords, I approach this Bill from the perspective of public health and the prevention of ill health, because of my work in the House. First, on children’s health and well-being, and an aspect of prevention to which this Government are committed, I will be joining the noble Baroness, Lady Cass, and others in questioning how the Bill will improve the future health of our children through greater accountability for child health spend and outcomes.

The abolition of NHSE, the return of many of its duties to the department and the Secretary of State, and the commissioning of services to the ICBs when they are being merged and boundaries changed, is a major reorganisation to be done at the same time as reducing costs by 50%. It is very dangerous. I will seek to establish how this reorganisation will actually improve our health, especially that of children.

Clause 4 is crucial and it needs to be strengthened and widened. It specifies the Secretary of State’s duty to

“have regard to the need to … reduce inequalities”

in both access to health services and health outcomes. That is not good enough.

My recent work chairing committees is very relevant to this clear duty. In 2024, I chaired the Food, Diet and Obesity Committee, and the Labour Government have responded positively to many of our recommendations. I currently chair the Childhood Vaccination Committee and I hope for a similar result. That committee will report early next month. While I cannot reveal our recommendations, I can reflect on the public evidence the committee has heard and how it relates to this specific duty on the Secretary of State.

The evidence to both committees was clear about the magnitude of health inequality in our country. We heard evidence about the drivers of this inequality and its relationship to ill health, quality of life, life expectancy, and cost to the NHS and the economy. Unequal access to affordable nutritious food, the ubiquity of cheap, poor-quality food and the advertising power of large food companies were shown to be barriers to poorer demographic groups maintaining a healthy weight. How will the Secretary of State work across government to address these barriers?

The vaccination committee has heard that there are several interconnected drivers of low coverage, resulting in wide differences in the rates of vaccinations received by different groups. This has led to preventable ill health, hospital admissions and deaths, as well as additional costs. I am hopeful that, under Clause 4, the new Secretary of State will be as open to adopting our recommendations about vaccination as her predecessor was to taking action on healthy food.

I therefore ask the Minister: how will this duty be carried out? Will there be a regular report to Parliament about what action her department has taken to reduce health inequalities, such as by improving and equalising access to health services, reducing obesity and increasing coverage of vaccination against preventable diseases? Will the Secretary of State report on the outcomes of these actions? Will there be specific inequalities targets against which the department, the ICBs and health service providers will be held to account? How will the targets be arrived at, monitored and enforced, and what will be the principles on which funding is allocated?

Clause 7 changes the Secretary of State’s duties around training, from maintaining an effective education and training system to ensuring that there are sufficient appropriately trained staff to meet NHS workforce needs. I can say no more than this: evidence is emerging that staff shortages of health visitors, GPs, nurses and midwives are affecting vaccination at various levels in the system. Time pressures mean that health professionals cannot answer patients’ questions, and the training in how to do so effectively is deficient. Training must include how to communicate empathetically with patients to enable them to make informed decisions. This will be a specific challenge under Clause 7.

Evidence is already emerging that the transfer of commissioning is causing confusion, decreasing morale and risks the loss of local knowledge of communities, which is crucial in responding appropriately to variation in vaccine coverage. I therefore ask the Minister how the Government will ensure that the skills and knowledge currently found among NHSE staff are retained and whether crucial budget lines will be protected? Who will monitor the performance of ICBs and hold them to account, and what is the system of quality assurance?

Lord Mawson (Crossbench)

My Lords, the new Prime Minister is right to focus his Government on people and place and to encourage collaboration across the sectors, but the practical details really matter. If we review the Bill alongside the Government’s neighbourhood framework, NHS England’s published position on the role of the voluntary, community and social enterprise sector, guidance on the wider determinants of health and recent NHS Confederation and community health partnerships on neighbourhood health and estate optimisation, we see that this Bill, while containing some helpful provisions, does not translate the stated shift from sickness to prevention into sufficiently clear duties, financial commitments or reporting requirements.

My colleagues and I, in our working lives, are involved in building with private and public sector partners the new integrated health infrastructure across the country at place that is going to be crucial if we are ever to get beyond the fine words of countless politicians on all sides and get upstream into the prevention agenda—I declare my interests. In the modern world, health is everybody’s business. The present biomedical model is creating a profound dependency culture across the country and is totally unaffordable going forward. Some of us are being practical and attempting to plant in the ground the seeds of these new more joined-up communities that so many talk about, but the challenge is to do it, not to talk about it.

Now in the real world, large parts of the public sector are restructuring, so everyone is looking for a new job. Here we have yet another restructure of the NHS, with another Government in danger of restructuring parts of the restructuring that is already taking place. Collaboration, yes, but not chaos. We need to be practical. There is likely to be another election before any of this settles down and can properly function. If we want to deliver, beware of the danger of too many moving parts.

For practitioners like me who are trying to be helpful in the real world, it is often like trying to build a house on the sand. So what do we make of the Bill? I invite the Government to consider six practical measures that will save money.

First, neighbourhood health plans should be required to address the wider determinants of health, including housing, employment, education and skills, food security, transport, digital inclusion, the environment, loneliness and social connection. This should not displace the responsibilities of local government but should require the NHS to recognise how these factors affect demand and to identify where joint action would improve health.

Secondly, each ICB and its partner local authorities should be required to establish a published mechanism for meaningful VCSE participation in neighbourhood planning. There are limits to what the state can achieve. This should include involvement in assessing needs and opportunities, designing responses, identifying underserved groups and reviewing outcomes. It must mean participation before decisions are made, not consultation after the principal decisions have already been settled.

Thirdly, every neighbourhood health plan should be informed by a proportionate social capital and community assets audit. This should identify local voluntary and faith organisations, trusted networks, existing preventive services, public and community buildings, and formally void NHS space and accommodation that is paid for but materially underused. It should also identify barriers relating to cost, tenure, accessibility and suitability. It is ridiculous that almost £90 million is spent annually on NHS empty voids in buildings at a time when many community organisations face prohibitive accommodation costs, particularly in London and other cities, despite delivering low-cost activities that address isolation.

Fourthly, ICBs should be required to identify transparently what they spend on prevention and community capacity.

Fifthly, smaller community organisations need proportionate routes to funding. Multiyear grants, simplified agreements and collaborative commissioning arrangements should be available where continuity and local trust are central to the effectiveness of an intervention.

Sixthly, the Bill should introduce a broader public value or best value assessment for preventive investment. The social and business sectors may be cheaper than the public sector.

None of these proposals diminishes the importance of clinical services. On the contrary, they are intended to protect those services by reducing avoidable demand and enabling people to remain healthier and more independent.

Neighbourhood health must mean more than healthcare delivered near a home. It must mean creating health within neighbourhoods, supporting individual agency and recognising the local organisations that sustain well-being long before statutory services are required. My question to the Minister is: what will the Government do about the £90 million that is wasted on empty rooms in NHS buildings? Will they do deals with the voluntary, charity and social enterprise sectors and open up those spaces?

Lord Rooker (Labour)

My Lords, I congratulate the maidens. We are a rich nation that allows citizens to miss out on scientific advances. We are not good at preventive medicine, particularly micronutrients. I have checked the latest nutrition survey. There are many losers, but in the main they are women of childbearing age. I will give two examples. The first is iodine. Girls aged 11 to 18 and women of childbearing age—16 to 49—are below the threshold. Good levels are required during pregnancy and are vital for brain formation.

The second is folate—vitamin B9. In women of childbearing age, the figure for low folate was 83%. Folate is crucial to helping prevent neural tube defects in early pregnancy. The neural tube, which forms the spine and brain, closes at 27 days after conception, when many women do not know they are pregnant. Half of pregnancies are unplanned, so it is vital that folate status is improved before pregnancy. It is disastrous that Governments and so-called independent scientific advisory committees have ignored the 1991 Medical Research Council vitamin study, which demonstrated the connection so clearly between neural tube defects and folate deficiency.

The new policy of fortification of flour, agreed by the previous Government and implemented by the current Government, required a change in the Bread and Flour Regulations in January 2025. This means that the UK will catch up next year with over 80 countries that operate mandatory fortification.

The USA adopted mandatory fortification in 1998 and fortifies wheat flour, cornflour and rice. A December 2015 open access paper by JK Morris et al said in its abstract:

“If the USA levels of folic acid fortification from 1998 onwards had been adopted in the UK, an estimated 2014 fewer NTD pregnancies would have occurred”.

The writers concluded:

“Failure to implement folic acid fortification in the UK has caused, and continues to cause, avoidable terminations of pregnancy, stillbirths, neonatal deaths and permanent serious disability in surviving children”.

Since 2015, there has continued to be around 150 to 200 live births per year and 800 terminations following the 20-week scan. The non-economic cost to women and their families is monumental distress. In financial terms, the impact assessment covers a range of situations and conditions, but, generally, the lifetime costs of a neural tube defect live birth are in excess of £2 million.

There are strong grounds for an inquiry as to why this policy was delayed for decades. The Scientific Advisory Committee on Nutrition has, over the years, when over 80 nations were fortifying on the basis of UK research from 1991, put up barrier after barrier to adopting the policy. Following a debate on a Bill on 8 July 2016, the then Minister, the noble Lord, Lord Prior, wrote to me in negative way on SACN’s behalf. I passed the letter to Lord Turnberg, a leading medic, now retired from the House, who wrote to the Minister—and I include just one sentence.

“In summary your advisors”—

that is the committee—

“seem to have ignored much of the scientific evidence that leads to the opposite conclusion to the one they have reached”.

In the BMJ in 2024, Nicholas Wald, who led the MRC study in 1991, quoted among others Sir Harry Burns, the former Chief Medical Officer for Scotland, on the new policy:

“Imagine you have a wound requiring five stitches to prevent infection or further harm. And yet, you are informed that only one stitch will be administered. While admitting that it will close only 20% of the wound, you are told to be content with one stitch because it is ‘better than nothing’ and ‘a good start’”.

The new UK policy from January 2027 is “one stitch fortification”. Nick Wald, whom Ministers and officials refused to talk to, and always have done, concluded in the same article:

“it is not enough. It will result in more deaths and birth defects every year that could have been prevented”.

There is a powerful case for an inquiry into the issue of the failure of professional duty in respect of public health policy, where we have started to adopt a policy half-heartedly, decades after other countries followed the UK research.

Baroness Kidron (Crossbench)

My Lords, I feel I should start by declaring that I have a son who is a senior civil servant in the Department of Health and Social Care, and also that I am not a health expert, so both he and the House will be pleased to know that my comments are entirely about the question of data.

The UK holds one of the world’s most valuable research assets in its health data, yet we risk both underusing and undervaluing it. Only this morning, 30 medical researchers wrote to me about their health data research service, a significant investment that promises to enable approved researchers to access UK health data safely and securely. These researchers, echoing concerns from NHS trusts, charities and the private sector, described a current environment with fragmented datasets, burdensome approvals and lengthy delays, sometimes requiring permissions for each dataset. They also suggest that these proposals come after research proposals in the 10-year health plan, the life sciences sector plan and the industrial strategy—plans that span departments and commitments from other arms-length bodies. Therefore, how the data is saved, secured and shared is material. Better access could transform UK research, discovery and growth, as the noble Baroness, Lady Martin, powerfully set out.

Our health data is not only underused but also undervalued. During the passage of the Data (Use and Access) Bill, I proposed, with the support of my noble friend Lord Tarassenko, a sovereign data asset class with NHS data a prime example. Since that time, contracts and memoranda of understanding have been signed with Palantir, OpenAI, Microsoft and Anthropic, each involving access to aspects of data held in trust for the public, including that in the NHS. The controversy over Palantir usefully illustrates worries of vendor lock-in, excessive access to UK datasets and products that underdeliver or cost too much. But my concern is more fundamental. We are spending hundreds of millions of pounds on technology that creates capability elsewhere. Why not use the expenditure on that scale to build sovereign capability of our own? We are an enormous purchaser of technology. Government procurement should not mean accepting whatever the market offers in health or anywhere else. It should establish purpose, contractual conditions, data standards and privacy, and help create capability that we retain here in the UK.

My third point of concern is about inquest data. Coroners identify patterns where systems have failed catastrophically. Taken together, their prevention of future death reports could provide a valuable resource for public health research, identifying emerging risks and preventable deaths. Yet, unlike Canada and Australia, the UK has no systematic means of collecting and accessing them. Dr Georgia Richards of King’s College London has set up the national coronial database to gather evidence. Her herculean task could become an effective system of prevention and public health and address the inequality that the Bill sets at its heart. I hope the Government will support an amendment to collect coronial reports systematically. It is a small measure with enormous consequences.

Finally, I want briefly to talk about emerging forms of data. Neurotechnology, including consumer devices capable of reading brain activity, is developing rapidly. According to UNESCO, global private investment in neurotechnology companies increased twentytwofold between 2010 and 2020, reaching approximately $7.3 billion annually. Harry Lambert, a barrister, founder of the Centre for Neurotechnology and Law, has written a series of fantastic articles in the New Law Journal about technology that we once associated with science fiction but is already here. It offers enormous opportunities for healthcare, but without swift action risks a dystopian future with unprecedented threats to privacy and freedom of thought.

Improving access to health data, retaining its value for the public, learning systematically from preventable death reports and updating the law for emerging technologies would ease frustration, prevent harm and create opportunity for the UK.

Baroness Lister of Burtersett (Labour)

My Lords, the Government made clear in their child poverty strategy that:

“Tackling child poverty is at the heart of the government’s Health Mission and its ambition to raise the healthiest generation of children ever”.

The size of the challenge is underlined by the Royal College of Paediatrics and Child Health. Most indicators of children’s health and well-being show a worsening situation or stalled progress, with children in deprived areas experiencing the poorest outcomes.

It is therefore welcome that the child poverty strategy states that

“Addressing healthcare inequity is at the heart of the 10 Year Health Plan”,

and refers to a

“new statutory duty to improve health and reduce health inequalities”.

Yet despite the Government’s laudable commitment to tackling health inequalities and their understanding of the importance of this to their child poverty strategy, as we have heard, such a statutory duty to take action is conspicuous by its absence in this key piece of health legislation.

In the Commons, Minister Smyth reiterated that

“reducing health inequalities remains a priority for this Government

However, she did not give a very convincing explanation as to why simple empowerment to treat this as a priority is sufficient. In contrast, the Health Equals coalition, supported by a wide range of organisations, including a number of the royal colleges, argues that a statutory duty is essential if the Bill is to provide the legislative framework to enact the 10-year health plan, and that it is key to the preventive approach, emphasised by my noble friend Lord Babudu, which Minister Smyth herself prayed in aid when opposing an amendment that would have required a cross-government health inequalities strategy.

An important dimension of health and other inequalities are the difficulties faced by marginalised groups, such as homeless people, in making their voices heard. The Government have taken important steps to address this—for instance, through the co-production of the Timms PIP review and the ongoing engagement with parents and children in poverty in the development and implementation of the child poverty strategy. In a foreword to the strategy, some of the parents involved in Changing Realities wrote:

“Our involvement in this strategy has strengthened our belief that lasting solutions come when policies are shaped with people, not just for them”.

It is thus disappointing that the homeless and inclusion health charity Pathway warns that the Bill goes in the opposite direction in removing independent oversight of the NHS and failing to ensure that ICBs seek the views of inclusion health groups.

The Government have given an assurance that the new arrangements will ensure that the experience of “seldom heard” groups and diverse communities inform service design and delivery, thereby contributing to a reduction in inequalities, but once again there are no statutory provisions in the Bill. Can my noble friend the Minister therefore explain what mechanisms are proposed to ensure that the views of “seldom heard” groups are able to inform service design and delivery? It was encouraging that on Report in the Commons there was a commitment to look at this issue again with Members in both Houses. Can my noble friend tell us what is now being proposed on this?

One group vulnerable to poverty and ill health are carers, who we have heard about, yet there is no statutory duty for ICBs to identify carers and there is no co-ordinated approach to carers’ support across the NHS. I therefore support Carers UK’s call for a clear duty to be placed on ICBs to identify unpaid carers and ensure that records of them are kept.

In conclusion, given the Government’s clear commitment to reducing health inequalities and to raising the healthiest generation of children ever, not least as an important element in their child poverty strategy, I hope they will be open to strengthening the Bill to make a reality of these commitments, as called for in many of the helpful briefings we have received.

Baroness Shawcross-Wolfson (Conservative)

My Lords, we have before us an enormous Bill that upends the functioning of the NHS. We are less than six months away from the abolition of NHS England and we do not yet have clarity on the future operating arrangements. On 8 September, the Secretary of State promised to update Parliament shortly on next steps, but this has not yet happened. Parliament, and much more importantly NHS staff, are still in the dark. In the words of the NHS Alliance:

“There is an urgent need to resolve the division of responsibilities … and to clarify the future role of the national centre, NHS regions and ICBs”.

I would be grateful if the Minister could tell us when this update will come.

I raise my concerns from the moral low ground. In government, I saw the reorganisations brought about by the Health and Social Care Act 2012 and the Health and Care Act 2022. On both occasions, I believe we underestimated the wider cost of reform, and I fear that this Government are falling into the same trap. Of course, there is the financial cost: NHS England’s accounts show more than £530 million on exit packages in 2025-26 alone. However, even more difficult to manage, as the noble Lord, Lord Scriven, reminded us, is the frictional cost of change. Uncertainty means talented people leave, decisions are paused and capacity is lost. Finally, there is the opportunity cost—the “dilution of leadership bandwidth”, to borrow a phrase from my noble friend Lord Howe. What else could this ministerial time and official energy have delivered?

Take the NHS workforce plan, which was originally promised for 2025 and then spring 2026. In June, Ministers promised publication imminently. Now we are told that we will be updated on the publication timetable in the usual way, in due course. We have gone from imminent publication to no date for even announcing a publication date, but Clause 7 makes the Secretary of State entirely responsible for workforce planning and training. The workforce should be at the heart of any reorganisation, so, again, I would be grateful if the Minister could tell us when the workforce plan will be published.

Although the Bill promises local responsibility, it significantly expands ministerial powers, as other noble Lords have pointed out; indeed, the noble Lord, Lord Hunt of Kings Heath, and my noble friend Lady Coffey welcomed more direct ministerial control. I have great regard for the current Secretary of State. I also have great regard for the Secretary of State who introduced the Bill and for the Secretary of State who took it through Second Reading in the other place. The Minister would, I am sure, profess confidence in every future Secretary of State appointed by her Government. However, as the noble Lord, Lord Stevens, reminded us, no one in your Lordships’ House could honestly say that they would trust the judgment of any and every Secretary of State appointed by any and every future Administration. So we must debate whether checks and balances are needed to temper these new powers.

Let me give three examples. First, Clause 10 allows the Secretary of State to pursue changes in the public/private provider balance if they consider that to be in the interests of the health service—not in the interests of patients but of the health service. This could potentially be used to significantly increase private provision, as the noble Lord, Lord Sikka, pointed out, or to significantly reduce it. The clause requires no consultation, no published explanation and no parliamentary approval. Are we really comfortable giving any and every future Secretary of State that power?

Secondly, Clause 11 allows the Secretary of State to direct integrated care boards even when they are performing well. No failure needs to be established and no appeals process is being created. If the Government wanted a top-down NHS, I could understand this approach, but the Minister told us that the Government’s aim is to ensure that decisions are made as close to the community as possible. Why create this power without safeguards to prevent its misuse in future?

Finally, Clause 52 establishes the framework for a single patient record. I am a passionate supporter of this proposal, but supporting the SPR cannot mean leaving its crucial design choices to this, or a future, Secretary of State. I echo other noble Lords in asking how sensitive mental or sexual health information will be recorded. Who will be liable if errors occur? What security protections are necessary? These questions, and many more, remain unanswered in the Bill. Future regulations may require our approval, but they cannot be amended, and arrangements set out in guidance will receive even less parliamentary scrutiny. Given the enormous risks of bringing together such sensitive information, Parliament should settle the basic protections now.

It is in all our interests for this reorganisation to deliver for patients, and I know that the Minister will work constructively with this House to improve the Bill. I very much hope that we will be able to agree that the test for any new ministerial power is not whether we trust those who would hold it today but whether we would entrust it to those we would oppose tomorrow.

Baroness Grey-Thompson (Crossbench)

My Lords, I declare my interest as a patron of the Wheelchair Alliance. I support the Hugh’s Law campaign and I am a member of the APPG on Spinal Cord Injury. I thank the Spinal Injuries Association for its work. My husband had a spinal cord injury 40 years ago, and I have made many friends once they have had an injury, but a few years ago a non-disabled friend had a traumatic injury, and it was stark to see how some services had changed—and not for the better.

My experience of the NHS as a patient has generally been excellent, but over the summer I was quite unwell and had two stays in hospital. There is currently an ongoing discussion about the treatment I did and, possibly more importantly, did not receive. Let me give a top-line summary. I was asked three times why I had a wheelchair beside my bed. My notes are quite clear: I am paralysed. Specialist dressings had to be brought in from home. The district nurse was able to order them—I could even get them with next-day delivery—but they were not available on the ward. Earlier, the noble Lord, Lord Winston, explained how he was able to intervene to help somebody; that is not the norm. Worryingly, I was also asked why I did not tell anyone that I sit in your Lordships’ Chamber. That should not impact my care, and it is not okay.

This Bill should improve integration, reduce bureaucracy and strengthen patient care, with patient safety being not just simplified, as the impact assessment states, but improved. We cannot lose national expertise, clinical standards and accountability, upon which patients with rare and complex conditions depend. Spinal cord injury services require highly trained multidisciplinary teams, specialist rehab facilities and co-ordinated care pathways extending well beyond individual integrated care boundaries. I am concerned that we could be preparing individuals to be looked after by the care industry rather than developing independence.

The Bill envisages transferring further specialised commissioning responsibilities to integrated care boards and retaining national service specifications and clinical policies, supported by seven offices for pan-ICB commissioning. The question that we must answer is how consistently the national service specification which currently exists and covers children and adults will be maintained and enforced under the proposed arrangements. National standards are effective only if there are clear mechanisms for monitoring compliance and addressing failures.

The Spinal Injuries Association, working with the APPG on Spinal Cord Injury, clinicians and patients, has raised concerns about the potential fragmentation of services, geographical inequalities and the sustainability of specialist centres. These concerns require careful examination before further commissioning responsibilities are transferred. Will His Majesty’s Government publish a service-specific impact assessment before transferring responsibility for spinal cord injury services, including on the implications for patient outcomes, workforce capacity, specialist centres and geographical access? How will the offices for pan-ICB commissioning be held accountable for maintaining national standards? Who will intervene where commissioning decisions result in unacceptable regional variation? Will the Government commit to publishing comparable national data on access to specialist rehabilitation, waiting times, capacity and patient outcomes so that it is possible to assess whether these reforms are delivering equitable care?

Specialist charities and voluntary organisations provide essential peer support, advocacy and practical assistance with rehabilitation, housing, employment and independent living. The single patient record has been raised many times. The benefits and projections have been outlined, but will it include mechanisms, subject to explicit patient consent and appropriate data protection safeguards, specifically to improve referrals and connections to these specialist organisations? Who owns the data and how it will be used needs to be transparent so that it cannot be used against patients in any future insurance schemes.

The central issue is not simply where commissioning responsibilities sit but whether the new arrangements can demonstrate that national standards are maintained, specialist expertise is protected and patients receive equitable access to care. I look forward to examining this further in Committee.

Baroness Royall of Blaisdon (Labour)

My Lords, it was very good to hear the noble Baroness, Lady Campbell, in her own voice, and a real privilege to hear five excellent maiden speeches.

I welcome this Bill, which I believe will protect and strengthen our NHS as it is modernised and made more accountable with more innovation. I fully support the abolition of the NHSE, which should never have been there in the first place. It is ludicrous that one arm’s-length body should be responsible for nearly one-tenth of the economy. That cannot be right.

I am concerned, however, about the disruption of more reorganisation and job cuts for an overstretched workforce, while understanding the need for ICBs to take on many more responsibilities. There appears to be a misalignment with the recent cost reduction requirement to reduce the ICB headcount by 50%. More skills, not fewer, are necessary, including in driving innovation. The close link between the NHS and mayoral strategic authorities is welcome, but one representative on each ICB is not enough.

I would be grateful for an assurance from my noble friend the Minister that ICBs will have the necessary capacity to deliver at local level and that implementation of the Bill will not delay the development and delivery of health priorities. The proposed reforms to NHS structures and employment arrangements could leave some healthcare professionals without consistent statutory employment protections when services are reorganised. Successful reform depends on retaining the specialist expertise, experience and commitment of the workforce. This is particularly concerning to smaller specialist professions, where workforce stability is particularly important. Restructuring must support staff and not hinder their ability to care.

One health priority is the implementation of the Government’s very welcome commitment to universal access to fracture liaison services, which will reduce unnecessary hospital admissions. I support the noble Lord, Lord Black, and everything he said. As is so often the case, it is those already facing disadvantage who suffer most. The UK’s health inequalities are wider than ever. The gulf in life expectancy between the most and least deprived parts of England is now 19.4 years for men and 20.3 years for females. As the Health and Social Care Committee in the Commons recommended, the Bill presents an opportunity to strengthen the duties on the Secretary of State and other Ministers to reduce inequalities through cross-government action.

Silo working does not deliver equality. Such changes should ensure consistent duties across central and local government, ensuring the necessary balance between prevention and healthcare, supporting the strategic shift which is central to the 10-year health plan and devolution agenda. Many noble friends have spoken of inequalities, so I hope that we will be able to make progress in the House on this, remembering that prevention and inequality are inextricably linked.

Men face huge inequalities when it comes to the diagnosis and treatment of prostate cancer, the most common cancer in the UK. There is a stark north-south divide in PSA blood tests to check for early warning signs, and there is a postcode lottery on early diagnosis. Those living in areas of high deprivation are 29% more likely to find out that they have prostate cancer when it has already spread. The disease kills one man every 45 minutes in the UK. But many of these deaths are preventable, so I will be tabling an amendment requiring the Secretary of State to lay before Parliament a prostate cancer early detection implementation plan, including a funding assessment, a service specification, workforce implications and an equality impact assessment.

Much has been said about the single patient record—long in gestation—which is much needed. I will get to that in Committee, but I believe that the independence of a strong patient voice is vital. The link between citizens and their local Healthwatch organisations is invaluable. It is a bridge between people and what can feel like an alien system. I acknowledge that the current system is wanting, but reform, not abolition, is the answer. We should build on the excellent example of Healthwatch Leeds, which demonstrates the power of the local voice. I ask the Government to work with local councils to develop an improved model.

I end by agreeing with all noble Lords who have said that the test of this Bill will be whether it can be trusted to deliver for the patients in this country, in the future, whoever may be in power.

Baroness Pidgeon (Liberal Democrat)

My Lords, this has been a wide-ranging debate with excellent contributions from across the House. I particularly pay tribute to the high-quality maiden speeches from the noble Lords, Lord Wormald, Lord Smith of Ranmoor, Lord Singh of Solihull and Lord Jabbar, and the noble Baroness, Lady Lowe of Armley. I look forward to working with them on this Bill and beyond. I also thank my noble friend Lady Barker for describing her very real experience of being a carer and navigating the health service with her wife.

Anyone who has had any interaction with the National Health Service knows that it is creaking at the seams. People are struggling to get GP appointments. Access to NHS dentists is impossible in many parts of the country. People are waiting for hours and hours for care in our stretched A&E departments. The shocking state of our maternity services we have discussed many times in this Chamber. The country is crying out for change in our health service. The Bill does bring changes, but mostly structural ones. It will do nothing in the short term to improve patient experience and outcomes, as the noble Lord, Lord Carter of Coles, highlighted. As the King’s Fund has rightly pointed out, as was mentioned by my noble friend Lord Scriven:

“Evidence from previous reorganisations suggests structural reform alone … rarely improves care unless it is clearly linked to practical changes in … services”.

The narrative from the Government is about neighbourhoods, and I welcome the neighbourhood health plans in the Bill, but plans and rhetoric are not enough. The money has to follow if we are to deliver services at the most appropriate level centred around patients and their needs—not simply for the convenience of the commissioner and the large trusts. We on these Benches believe that a primary care investment standard should be in the Bill to increase spending on primary care services to support this shift to neighbourhood health.

As the Royal College of General Practitioners has pointed out,

“the current system focuses too much on hospitals and not enough on general practice. This has led to the proportion of the NHS budget spent on general practice falling to its lowest point in at least 10 years”.

This is not sustainable. As I have raised several times in this House, there are around 600,000 people waiting for hospital eye appointments. Many of these could easily be dealt with on the high street locally, if commissioning for these basic services was universal and genuine patient choice was supported. As ICBs develop their commissioning roles, it would be helpful to understand the level of basic foundation services that everyone should have a right to, wherever they live. This is a concern that the noble Baroness, Lady Redfern, also raised. My noble friend Lady Janke raised the important role of community pharmacies as another part of primary care. Primary care must be fully at the table with ICBs if neighbourhood health is truly to work, and this needs to change in the Bill. Continuity of care is crucial, as the noble Baroness, Lady Gerada, set out.

As we have heard loudly and clearly, there are serious concerns about the abolition of NHS England, with the Secretary of State becoming the decision maker in micro decisions throughout the NHS—a politician getting involved in decisions that are for management. Government needs to remain strategic, not operational. Blurring the distinction between day-to-day NHS management and political accountability is not going to end well. That is why the new operating model needs to be published as soon as possible, clearly setting out the responsibilities of the Secretary of State, the department and ICBs, so that we can better scrutinise the Bill. Perhaps the Minister can advise when we might see this important model.

So many charities I have met are concerned about specialist commissioning and the capacity and capability of ICBs in this area. Too often NICE guidelines are being ignored and there are concerns that this may also happen with NICE recommendations, with delays in implementation. The Bill is an opportunity to strengthen confidence in access to innovation and strengthen implementation of NICE recommendations across the NHS. I hope the Government will support amendments in this area.

Charities are also concerned about the potential loss of central clinical expertise. How will the Minister ensure that sufficient expert clinical roles and expertise are incorporated into the department beyond the five cross-cutting national priority programmes? Diabetes is one such area, as outlined by my noble friend Lord Rennard.

A number of other important health matters have been raised, such as public health and vaccinations, by my noble friend Lady Walmsley; the need to reduce inequalities in mortality for people with a learning disability and autistic people, by my noble friend Lord Scriven, also raised by the noble Baroness, Lady Hollins; and the issue of unpaid carers, including respite care, by my noble friend Lady Tyler, also raised by the noble Baroness, Lady Lister. My noble friend Lady Leaman talked about the impact of these structural changes on those with ADHD and autism—important issues to consider as we scrutinise the Bill. The noble Baroness, Lady Cass, and others flagged the absence of children and young people.

The Bill as it stands plans to abolish Healthwatch England and local Healthwatch organisations, stripping away the independent patient voice. For over 50 years, there has been a statutory independent patient voice in the health and social care system, and this needs to continue. The Government have confirmed that they are reviewing this part of the Bill. I hope they will remove this section and go further and strengthen Healthwatch organisations across the country.

We have received report after report of failings in the health service. Patients often will not take action, even when they have experienced poor care, as they fear it will impact their ongoing treatment. That is why we need an independent patient voice to listen to patient feedback, expose challenges and drive change locally. Other noble Lords have supported this, including the noble Lord, Lord Hunt of Kings Heath, the noble Baroness, Lady Jay, the noble Lord, Lord Patel, and the noble Baroness, Lady Lowe, who made a passionate speech outlining what was happening in Leeds—and many others.

The Healthwatch organisations I have spoken to and heard from have been effective in working with local communities and being able to bring to health and care organisations any concerns, or wider issues that need to be addressed. This cannot be done by an internal team in a trust or council. We await movement from the Government ahead of Committee.

Let us talk about safety. The Health Services Safety Investigations Body was established to investigate specific cases or incidents of severe harm and to produce lessons rather than blame, rather like the model used for aviation and rail safety investigations. It established the safe-space model in law to encourage disclosures from professionals without fear of sanction, so the decision to scrap HSSIB is a major concern and is fraught with risk. A trusted and efficient safety investigation process is the best way of restoring trust, learning from system failure and preventing costly public inquiries. Dr Tim Meek, president of the Association of Anaesthetists, has said:

“It is vital that HSSIB retains its complete independence from the NHS, the organisation that it is principally tasked to investigate. This lesson has been learned in other high-stakes industries, and we should take note”.

We hope the Government will reconsider this proposal. Putting this as part of the CQC will not be acceptable to anyone, as has been expressed clearly by noble Lords today, including the noble Baroness, Lady Watkins of Tavistock.

Maternity services have rightly been a focus, and I know they are a real concern to the Minister. Recent figures show that 75% of the public are concerned about hospital birth standards following recent safety inspection ratings. Women are overwhelmingly worried, with 79% expressing anxiety over maternity care, especially given that not one NHS maternity unit in England has an outstanding safety rating and two-thirds of units have been flagged as unsafe. We want to see 24/7 consultants on every maternity ward and one-to-one midwifery care. To drive the change, we need a maternity commissioner with the right resources and powers to make change happen. The Government have indicated that they will support this proposal, and we hope that we can move forward to drive the change that is needed for women and babies. Perhaps the Minister can clarify how the role will sit with the national maternity and neonatal taskforce and what powers the commissioner will have to ensure the change that is needed.

The Liberal Democrats welcome the move to create a single patient record. This is potentially the only bit of the Bill that could transform patient experience and outcomes. People are tired of having to repeat their medical histories countless times to different medical and other professionals, and patient harm can occur when clinicians have not had a patient’s full medical history. However, as has been highlighted by noble Lords, this must come alongside new privacy protections and safeguards for patients. Patients do not want their health data sold and used. There are challenges in developing the single patient record, and we look forward to working with others to ensure that safeguards are in place that enable this development in a safe way. Data security and patient trust must be at the core, and the noble Baroness, Lady Kidron, set out some of the key concerns around data in this area.

My noble friend Lord Foster of Bath had hoped to speak in this debate, but unfortunately he has Covid—I think it must be going round. I know he has a particular concern about the current levels of medical support, not least mental health support, for prisoners, both in prison and when they leave, and has questions about how the new arrangements will improve the situation. I hope the Minister will agree to meet my noble friend to discuss this issue, and maybe the noble Lord, Lord Bradley, as well, who has also raised concerns today on that point.

The one glaring omission from the Bill is social care. We have a crisis. The new Prime Minister recognises this crisis. Fixing social care is crucial to enabling our health service to function better. Better support for the frail and vulnerable is essential. There is the opportunity while we consider the Bill to look at enabling options to help speed up delivering on social care. I hope the Government will consider this as the Bill progresses.

To conclude, in so many ways it is easy constantly to look at the structure of the NHS, and Government after Government have played with this time and again. In my view, the key is to get services out of hospitals into local communities and high streets centred around the patient, shifting resources to primary and community care, which helps with the preventive agenda and also frees hospitals to do what they do best. Will this Bill make a difference to patient care? Will it strengthen the patient voice? Will it improve patient safety and reduce bureaucracy? These are the measures of success, and we on these Benches will table amendments to improve safety, services and, most importantly, outcomes for patients.

Lord Kamall (Conservative)

My Lords, I begin by thinking the Minister for the way she introduced the Bill, and all noble Lords who spoke in this debate. For reasons which noble Lords will understand, I will not name them all, but I was particularly touched by the speech of the noble Baroness, Lady Campbell of Surbiton, in her own voice thanks to AI, and moved by the speech of the noble Baroness, Lady Barker, in which she shared her personal sad experience.

I thank those who made their maiden speeches, including the noble Lord, Lord Jabbar, who spoke of the need for accountability; the noble Baroness, Lady Lowe of Armley, who shared her experience of Touchstone in Leeds and the importance of the independent patient voice; the noble Lord, Lord Wormald, with whom I worked when I was a Health Minister; the noble Lord, Lord Smith of Ranmoor, who spoke of the importance of a healthy diet; and my noble friend Lord Singh of Solihull, who humbly shared a hint of his considerable experience in psychiatry. Each maiden speech demonstrated the experience and wisdom that we can look forward to in future debates. If it is any reassurance to the noble Lords, I often still wonder what I am doing here—and, frankly, if I go over my speaking time I fear that many noble Lords will ask the same question.

Before I go further, I declare my interest as a professor of politics and international relations at St Mary’s University in Twickenham, where I recently taught an MBA course in healthcare policy. I am also helping the university with its new medical school.

As my noble friend Lord Howe said, we on these Benches support removing the unnecessary duplication of functions between NHS England and DHSC, as most noble Lords do. But as we heard from the noble Lord, Lord Stevens, and others, the reorganisation was announced without any clear idea of the costs and benefits. My first question to the Minister is this: when will these costs and benefits be explicitly published, and when will the operational model referred to by the noble Baroness, Lady Pidgeon, be published, so that we can have a clearer idea of how this new world will work?

I do not doubt the Government’s good intentions, but legislation must be judged not on intentions but on whether it improves the patient experience and health outcomes. This means listening to patients when they tell us something is wrong and ensuring that those warnings result in change. That is precisely why an independent patient voice matters. As noble Lords have said, Healthwatch organisations provide that independent patient voice, gathering the experiences of patients and communities and ensuring that they are heard by those responsible. They speak truth to power.

While not perfect, the independent patient voice for health should not be seen as simply measuring satisfaction. It warns of failures in the quality and safety of care, and it raises flags for others to look at. Look at the volume of compensation from NHS Resolution, to the value of billions of pounds: behind each one of those figures are patients and families whose lives have been profoundly changed and, sadly, in many cases scarred. They may take many years to recover, if ever.

The Government’s proposals to bring that patient voice in-house to integrated care boards and local authorities raises important questions about independence. I understand the reasons for returning powers to Ministers, but if those responsible for a system are also responsible for gathering criticism of it, how can Ministers guarantee that patients will have the same confidence to speak candidly, especially those from more deprived communities who do not often get a chance to speak to those in power?

Given that the Prime Minister, when Mayor of Greater Manchester, wrote to the Secretary of State warning that dissolving Healthwatch would risk losing an independent and trusted patient voice, I wonder what conversations are ongoing within the new Government on proceeding with its abolition.

Similarly, we share the concerns of the noble Lord, Lord Hunt, about proposals to abolish independent health governors. They provide an important role in accountability and we must think very carefully about what happens if you remove that level of accountability.

That question of independence leads me to the proposed abolition of the Health Services Safety Investigations Body and transferring its functions to the CQC. HSSIB performs a different but equally important function, investigating patient safety concerns not to apportion blame or liability, and not to point fingers, but to understand systemic failures and prevent them happening again. Its investigations operate within statutory confidentiality protections.

Ministers have offered reassurance about maintaining autonomy, but legitimate questions remain. Will patients, families and healthcare professionals have the same confidence in the safe space principle when the investigating body sits within the regulator? How will its genuine independence be protected? These are questions that need to be answered.

And, frankly, is the CQC able and competent to take on these functions? During the Mental Health Bill, these Benches supported the Government on resisting calls for an independent mental health commissioner, instead supporting beefing up the CQC’s capacity on mental health. However, as the noble Lord, Lord Bradley, remarked, it is interesting that the Government have since decided to establish an independent maternity commissioner, rather than ask the Patient Safety Commissioner or the CQC to take on that role. Even more recently, I and other noble Lords have repeatedly tried to engage with the CQC on concerns that many healthcare providers have over the CQC’s understanding of, and its ability to regulate, sports and public events. To be frank, I have not been impressed. I do not say this lightly, but I currently have no confidence in the CQC to regulate these events.

It is worth noting that the widely respected incoming chair of the CQC, the noble Baroness, Lady Neuberger, told the Health and Social Care Committee only last month that the CQC was not currently a trusted and respected regulator. Given that assessment, what evidence can the Minister point to that demonstrates that the CQC is ready to take on the responsibilities currently held by HSSIB? The objective should be fewer safety failures, not fewer safety organisations.

A number of noble Lords have heard, and perhaps repeated, the mantra that you cannot solve healthcare until you fix social care. So we welcome the Prime Minister’s commitment to bring forward the Casey review, but I am sure that noble Lords will want to probe the Government further on their plans for social care during this Bill.

Like many other noble Lords, we support in principle the single patient record. As I found to my frustration when I was a Health Minister, patient information remains unconnected across different parts of the health and care system. The Government themselves note that clinicians can be left working with an incomplete picture while patients find themselves repeatedly giving the same medical history. A properly implemented single patient record could be transformative, giving clinicians access to the right information at the right time, improving continuity of care, supporting early intervention and ultimately improving patient safety.

But that does not mean that we will give the Government a blank cheque on this. There remain legitimate questions. Noble Lords may be aware of questions around what can be described as voyeur medical staff who access patient records after national scandals even though they have no medical reason to do so. Or there is the case of the senior consultant, as reported in the Guardian recently, who accessed and inappropriately shared the medical of information of her ex-boyfriend’s current girlfriend. Such stories beg the question of who will be able to access and edit a patient’s record. How will patients know who has accessed their records? In addition, how can inaccurate information be corrected, and what additional safeguards will protect particularly sensitive information?

I was contacted by a lady who found that notes from her psychotherapy at a south London trust, including correspondence on her concerns about a GP practice, were available through the London Care Record, including to the practice about which she had complained. She had been previously assured that this would not happen and she had to pause her therapy after making this discovery.

We are not against a single patient record. In fact, we are in favour of it, but there have to be the right safeguards. Different parts of the NHS continue to use different systems. Indeed, the Government acknowledge this, and so we have to look at this system of interoperability. While patients will benefit from a single patient record, they must have confidence that the most sensitive information that they provide will remain properly protected. Otherwise, we will be creating a health service that is better in sharing information but in which patients have less confidence.

We are discussing these reforms in the context of an ageing population, increased demand for health and care, a decline in people paying into the system relative to those who take out, and public scepticism about immigration to replace our ageing workforce and taxpayers. We have more doctors and nurses than ever before, but we need more capacity. The former Health and Social Care Secretary, Wes Streeting, recognised this and thought that AI could be the solution. But what are patients doing? They are turning to independent healthcare providers. This is not new. My father’s membership of the Transport and General Workers’ Union included treatment for him and my mother at an independent Premier Health hospital. Today, trade unions offer private health insurance or health plans as part of their membership package.

In seeking to increase the capacity supply of healthcare, is there a way that we can work together across the political divide on an increased role for non-state providers to complement the NHS, especially healthcare mutuals such as Benenden Health, charities, friendly societies, co-operatives, social enterprises, non-profit private providers and, where appropriate, private providers? If and where appropriate in this Bill, I hope we can agree to increase independent healthcare capacity to complement, not replace, the National Health Service. This will of course include appropriate access to the single patient record and appropriate safeguards.

These Benches accept that reform may deliver savings, yet we await a timeline and proper cost-benefit analysis. Removing unnecessary duplication, improving productivity and making better use of technology are objectives that we support, but the measure of successful reform is whether taxpayers receive value and patients receive better care. The prize is considerable, but so too is the responsibility. On these Benches, we will be constructive in our approach. Where the Government make a clear case, we will support them. Where we have concerns, we will challenge and scrutinise. We will work together with noble Lords across the House to deliver a Bill that enables a better system of healthcare for patients, no matter where they live and whatever their background.

Baroness Merron (Labour)

My Lords, I am grateful for the considered contributions from all sides of the House. They have, to put it mildly, been wide ranging, informative and challenging, as I would expect. I ask for the understanding of noble Lords that the time available to me will not allow me to answer every point made. Indeed, more questions will doubtless be unanswered than answered. But I restate my commitment to work with noble Lords as the Bill progresses and we will revisit many of the topics in the weeks to come.

I will also reflect on the points made, particularly those that are not within the remit of the Bill, because a number of them were extremely helpful. I make the general point that not all matters that have been raised, as I know noble Lords are aware, are for primary legislation or necessarily for this Bill, though I blame not one noble Lord for taking the opportunity to raise them. Again, that is as I would expect. We should also resist the urge to do something here in legislation when there are other means that could achieve the same outcome, as is usual when it comes to legislation. There are quite a lot of health warnings there.

I particularly thank noble Lords who brought not only their professional experience but their personal experience or that of those who are near and dear to them. They included my noble friend Lord Winston, the noble Baronesses, Lady Maclean, Lady Barker and Lady Grey-Thompson, and the noble Lords, Lord Bird and Lord Scriven. Our personal experiences absolutely inform how we see the way forward. I also associate myself with the congratulations on five excellent maiden speeches, from my noble friends Lord Jabbar, Lady Lowe and Lord Smith, and the noble Lords, Lord Wormald and Lord Singh. I associate myself with many of the points made by our new colleagues, including that where we start does not determine where we have to end up—that resonates very much with me—and that we should be proud of those who work in public service, and indeed we are. We are blessed to have all five of our new colleagues join us in your Lordships’ House and we very much look forward to hearing more from them.

A number of points have been made about where the National Health Service is at present, and it is important to make a few comments. I welcome those who have acknowledged the improvements that we have made and the position that we started from. As of March this year, we had met the interim target of 65% of patients waiting up to 18 weeks, when we were nowhere near that just over two years ago, and we will go further. Patient satisfaction is rising. When I was a Health Minister in the previous Labour Government, it was at its highest, but sadly it went to its lowest. We are rebuilding that, and I am glad about the improvement.

Similarly, this summer, in June, July and August—noble Lords will know the extra pressure of the heatwaves that were experienced then—a record 4.7 million-plus treatments, procedures and appointments were carried out, more than in any previous summer. I would be happy to bore your Lordships’ House, if that is what it does to the House, with more evidence of the upward trajectory, but it is only fair not to talk down the NHS where we have improvements, and I am glad that so many noble Lords acknowledged that.

I shall run through some of the points that were raised. I was most grateful for what I will call broad support for the Bill. There were many supporters, including my noble friends Lord Hunt and Lady Thornton, who both set out better than I would—so I do not need to repeat it—the impact of previous legislation and changes to the structure of the NHS. I also heard support from the noble Baronesses, Lady Coffey and Lady Neville-Rolfe, among others.

I have heard the argument that much of this could be done without legislation. I suggest that it is far better for the law to reflect the reality of the system that we want, one that has clear roles and responsibilities. To make the point, as many noble Lords have supported the abolition of NHS England: that cannot be abolished without primary legislation.

With regard to transition arrangements, points were raised by the noble Baronesses, Lady Gerada and Lady Wyld, and the noble Lord, Lord Scriven, among others. We are committed to transparency and parliamentary scrutiny throughout this process. We will continue to publish updates and revised impact assessments, and we will expect to be held to account, as I know noble Lords would expect.

There are strong arrangements in place to monitor delivery, including oversight of workforce risks, knowledge transfer and service continuity, but these changes are not distracting from our focus on performance. I understand why that concern was raised, as I understand the reasons for all the concerns that were raised today, and I know we will work through them all. This summer, as I mentioned, has been the busiest in the history of the NHS, yet more patients than ever before were seen within four hours in A&E despite record demand.

With regard to costs, savings and benefits, which were raised particularly by the noble Earl, Lord Howe, and the noble Lords, Lord Stevens and Lord Kamall, with the abolition of NHSE and the restructuring of ICBs we expect savings of up to £1 billion a year by the end of this Parliament. That will be driven primarily by reductions in headcount, and we expect that savings will build year on year rather than being realised immediately.

On the impact assessment, as usual the focus will be on the impacts of primary legislation rather than secondary and consequential decisions. Our approach to the impact assessment—which the noble Lord, Lord Stevens, kindly raised—is in line with the HM Treasury Green Book guidance and the Better Regulation Framework, as I am sure noble Lords recognise.

I was glad that my noble friend Lord Carter made the point about the need to rightly be focused on outputs. The input of money has clearly not delivered what any of us would have wanted over some considerable time, and our focus on and measurement of outputs is absolutely crucial.

I confirm to my noble friend Lady Nargund that, as I said earlier, integrated care boards will be the strategic commissioners of health services. They will take ownership of areas that are currently delegated to them, such as primary medical care and dentistry, as well as delegated specialist services, such as adult HIV services—as was raised by the noble Lord, Lord Black, and the noble Baroness, Lady Barker—and dialysis. To support ICBs and ensure national consistency, we will use the power of direction over ICBs to set out the expectations of, for example, access criteria or the types of services to be commissioned.

On ICB membership, the Bill will reform the required membership of ICB boards to align them more closely with their role as strategic commissioners. I assure my noble friend Lord Bradley that the requirement for a member of an ICB to have mental health experience—as he referred to—remains unchanged.

On the accountability of ICBs—which was raised by the noble Earl, Lord Howe, and the noble Baronesses, Lady Redfern, Lady Walmsley, and Lady Shawcross-Wolfson—integrated care board commissioning will continue to have clear performance and accountability arrangements in legislation, including a requirement to publish annual reports and accounts setting out how they have discharged their functions and delivered against their targets.

I wrote a very long list of noble Lords who referred to Healthwatch and the patient voice. I had to strike a pen through that, because, unsurprisingly, nearly every noble Lord referred to it. We do not believe that the current structures consistently and effectively connect patient voice or lived experience to the decisions that shape services and deliver outcomes. As I mentioned earlier, our feeling is that, by placing responsibility directly with ICBs and local authorities, we will enable patient insight to inform commissioning, service planning and improvement. That said, we recognise—as I said at the outset and re-emphasise now—the strength of feeling about these changes and the reasons that noble Lords are raising their concerns. I have already stated our commitment to work with noble Lords to review these measures and ensure that any arrangements really do empower local communities and provide transparency on what people have told the system and on how it responded. This is an area for further work.

A number of noble Lords—including the noble Baronesses, Lady Manzoor, Lady Pidgeon and Lady Watkins, and the noble Lords, Lord Patel and Lord Lansley—raised HSSIB and patient safety. As I stated at the outset, I cannot overemphasise our commitment to listening to noble Lords on this important matter. I want to see a strong link between investigation, system learning and improvement, and helping safety insights lead more directly to lasting change. I agree that patient safety depends on a culture in which concerns can be raised, lessons are learned and meaningful improvement follows. I therefore emphasise our commitment to listening further to noble Lords.

Most noble Lords, rightly, also raised the single patient record. I am grateful to the noble Lord, Lord Kamall, and the noble Baroness, Lady Pidgeon, for their support from their Front Benches for this, which is central to our ambition for a modern, joined-up NHS. I know that noble Lords understand the reason that we have raised it.

The noble Lord, Lord Tarassenko, was helpful in raising the important issue of health data for research. We know that data from the single patient record could offer significant opportunities, including more intelligently planning our health services and conducting life-saving research. However, the primary focus of the SPR is to offer and support direct care. The Bill does not create any new legal gateways to accessing health data for secondary purposes, such as planning and research, important though they are; nor does it enable data to be collected for these purposes. But it does contain a savings provision that the SPR can be a source of data for secondary uses, such as planning and research, where there is a separate legal basis to do so. This will ensure that we do not miss opportunities but guarantee that strict legal security and confidentiality standards—which are the concerns, rightly, of noble Lords—are met. That will include existing data protection legislation.

I heard noble Lords, including the noble Baroness, Lady Kidron, and the noble Lord, Lord Kamall, among others, raise important points about data, security, public trust and privacy. When it comes to health data in particular, trust is everything, as many noble Lords, including the noble Baroness, Lady Harding, have said, which is why the SPR will be designed with the highest standards of cybersecurity and information governance. Let me emphasise this: access to patient information will be restricted to authorised users only, with an audit trail of who has accessed the patient’s data, to clamp down on some of the serious transgressions that we have seen of late. I will come back to the noble Lord, Lord Patel, on the point about the common law duty of confidentiality.

With regard to the federated data platform, I heard concerns from the noble Lord, Lord Scriven, and the noble Baroness, Lady Bennett, about Palantir. Let me say again that the single patient record is different; it is intended that it will be delivered through contracts with multiple suppliers. I heard my noble friend Lady Martin’s wish that those would be UK providers, on which I certainly would share her wish and intent.

On women’s health and maternity, I am grateful for the acknowledgement from a number of noble Lords, including the noble Baronesses, Lady Wyld, Lady Sugg, Lady Manzoor, Lady Pidgeon, Lady Hodgson, and others. I appreciate the acknowledgement of the work that has already taken place and the direction that the Government are taking. We are, as we speak, working up the amendments for the maternity and neonatal commissioner. I look forward to engaging further on this, because it is a priority of this Government to urgently tackle the systemic issues across maternity and neonatal care which have been going on for so many years and are totally unacceptable.

By the end of the year, we will be publishing a single national action plan. It will be overseen by the national maternity and neonatal taskforce, and it will drive improvement in maternity and neonatal care exactly where it matters—to families, to clinicians and to others. The plan will include recommendations from the independent investigation of the noble Baroness, Lady Amos. We are most grateful to the noble Baroness for her work. It will include findings from the Thirlwall report and from the reviews led by Donna Ockenden. We need a single national action plan which will fundamentally drive a systemic and sustained improvement that we have not seen. The taskforce will hold the system to account, and I look forward to this House holding us to account as well.

The issue of health inequalities was raised by the right reverend Prelate, the noble Baronesses, Lady Hollins, Lady Cass and Lady Tyler, and my noble friend Lord Sahota. The Bill reaffirms our commitment to achieving greater equality in the provision of health services—both the ability to access these services and the outcomes achieved. ICBs will lead on improving services because of their clarified role as strategic commissioners. However, they have to deliver demonstrable improvements for disadvantaged groups and underserved communities, including those in the rural, coastal and deprived urban areas.

We will also, as part of our 10-year health plan, distribute NHS funding to better align it with health need. That includes establishing a neighbourhood health centre in every community, beginning with—not ending with—places where health and life expectancy is lowest.

Briefly, on adult social care, our commitment, emphasised by the Prime Minister, is on building a national care service, and that is why we have brought forward the timetable for the vital independent commission of the noble Baroness, Lady Casey. In the meantime, we are acting on early recommendations, including on dementia, motor neurone disease and safeguarding.

I assure your Lordships’ House that the mental health investment standard will continue to apply, in the same way that this Government are committed to improving outcomes and reducing health inequalities for those with learning disabilities, autistic people and people with ADHD, as acknowledged by the noble Baronesses, Lady Hollins, Lady Browning and Lady Leaman.

I am immensely grateful to noble Lords for their contributions in what has been a very helpful debate. I note, as others have done, that the Bill marks another ground-breaking moment for this House: the first use of AI, to give voice to the noble Baroness, Lady Campbell—I know that she is watching us online. I pay tribute, as we all do, to the work that the noble Baroness has done to make the rules of this Chamber more accessible. We are all very fond of Baroness Campbell mark 1, and we are looking forward to getting even more fond of Baroness Campbell mark 2, as she referred to her AI voice. Let us hear more of it. I assure her that we remain committed to personalisation and personal health budgets, as in the 10-year plan.

I know that we will continue these discussions in Committee, both in and outside the Chamber. For now, I commend the Bill to the House.

Bill read a second time.

Commitment and Order of Consideration Motion

Baroness Merron (Labour)

I beg to move the commitment Motion standing in my name on the Order Paper.

Amendment to the Motion

Lord Rooker (Labour)

My Lords, I will not detain the House, but this is an identical amendment to the one I moved to the two previous Bills: the Representation of the People Bill and the Hillsborough Bill. Basically, the idea is to strengthen the role of the elected Members of the Commons. It is not to attack the Commons; it is to strengthen their role. They are in a position where every Bill is guillotined there under a programme Motion. We started it in 1997 and it was a good idea then but, like all good ideas, it has got a bit iffy, because the effect is that the Government always want to boast about the numbers of Bills, at the expense of the scrutiny of the Bills.

For the Bills arriving in this House, as a result of inadequate scrutiny we end up sending far more amendments back to the Commons than would otherwise be the case. When they arrive down there, the Government Whips complain to the elected Members that it is all the fault of the upper House and we need reform. But, basically, reform in the Commons is needed.

When we return amendments to the elected Members, their time is limited due to the original programme Motion. So they need more time for scrutiny. Effectively, the Government have taken some powers from Parliament that they ought to give back. I am asking for a list, and the Government have it, by the way, because the Bill team must have it. Noble Lords can work it out for themselves. The Bill team will know what has been added to the Bill that was not debated.

Briefly, what is in this Bill that the Commons has not scrutinised is not as clear as it is for the two previous Bills that I have drawn to the attention of the House. Report was over two days in the Commons. Two days —that is great. The programme Motion was changed from the one originally set out. Day 1 was Monday 7 September and the proceedings are normally chopped at 10 pm—that is normal. But the Bill did not start until 7.26 pm because the Government laid no fewer than three Statements, with no injury time for the Bill. That is the point. Between 7.26 pm and 10 pm, the Commons dealt with 50 new clauses and more than 40 amendments. They occupied 44 columns of Hansard, in two and a half hours. You cannot really be certain about how many were added to the Bill from just looking at the Hansard; it is not possible.

Day 2 was on Tuesday 8 September. The start was 4.45 pm and the chop was 6 pm. Noble Lords heard that correctly: 6 pm. In one and a quarter hours, there were at least five new government clauses, 25 other new clauses and 20 amendments, some of which were government amendments. At the 6 pm chop, another six new government clauses were added on the nod to the Bill—that can be seen clearly. I am not certain about any amendments. For day 2, I did not count the columns in Hansard; I think I have made my point about the first day.

The total time on Report was less than four hours. That is the reality. So, when the time comes later this year or early next year with these Bills—when we get in a tussle with the other House about the amendments we are sending and when threats are made—I want a good audit trail of what we have tried to do. We are trying to strengthen the Commons so that we end up with less work to send back to them, giving them the chance to scrutinise the Bills properly, rather than putting into Bills massive numbers of new clauses that have never ever been debated. That is a crazy way to do legislation. I cannot believe that someone is not advising the Prime Minister that we will come unstuck on this. I beg to move.

Lord Howard of Lympne (Conservative)

My Lords, I support this amendment. I shall be brief and endeavour not to repeat the points which have just been made in the excellent speech by the noble Lord, Lord Rooker.

The truth is that, as a result of the changes the noble Lord referred to, the House of Commons has largely abdicated its responsibility for scrutinising legislation. The burden of scrutiny has passed to your Lordships’ House and legislation frequently comes to your Lordships unconsidered, unsatisfactory and undesirable.

Of course, your Lordships cannot tell the Commons what procedure they should adopt. But your Lordships are the masters of procedures in this House, and the modest change which is suggested in the amendment, and which has been put forward by the noble Lord, Lord Rooker, would assist your Lordships in that responsibility of scrutinising legislation. To know from the start which clauses have not been considered at all in the other place would clearly signal to your Lordships the extent to which scrutiny was essential in this House. I cannot think of any good reason against the proposal contained in the amendment and I strongly support it.

Viscount Stansgate (Labour)

My Lords, I would like to tell my noble friend the Chief Whip that if my noble friend Lord Rooker presses his amendment to a vote, I will oppose it. But he makes some very good points, and I hope the House will listen very carefully to what he has said.

Baroness Merron (Labour)

My Lords, the amendment that the noble Lord, Lord Rooker, has tabled seeks information on the amendments debated in the Commons. In keeping with responses to similar amendments on other Bills, I felt it would be helpful to your Lordships’ House to set out the scrutiny that the Bill had in the House of Commons.

The Bill had its Second Reading in the House of Commons on Monday 1 June. The House of Commons then ordered that the Bill should be committed to a Public Bill Committee for its Committee stage. The Public Bill Committee itself decided its sitting pattern. The Committee completed its scrutiny in 17 sittings over nine days, and as usual, all clauses and schedules were considered, as were all proposed amendments and new clauses that were selected by the chair. The Bill’s Report stage took place over two days on Monday 7 and Tuesday 8 September. The House of Commons ordered that consideration should conclude one hour before the moment of interruption on the second of these days. All proposed amendments and new clauses selected by the chair were considered.

I have no doubt that noble Lords will add to the work of the Commons with their usual high-quality scrutiny, and there will of course be time to debate all the issues that noble Lords raise—the noble Lord, Lord Rooker, in particular—on the detail as the Bill progresses through your Lordships’ House.

Lord Rooker (Labour)

I am grateful to my noble friend, but, frankly, she is the third Minister to read out, in effect, the same speech, and it is not good enough. I am not arguing about what the Commons did at Second Reading, in Committee, and everything else. The issue is that on Report, material is put in the Bill that has never been considered. That is the point. They have considered all the rest of the Bill, but on Report, the Government come forward with, sometimes, dozens of new clauses, some of which are put in the Bill without any debate. That is the point we should be made aware of. They could be printed in italics, and the Bill team must know about it.

I am not attacking my noble friend—she is just doing her job—but the fact is that there will be a note on each of the amendments she gets to say, “By the way, this clause was never debated in the Commons—just to be aware”. So, the material is there. I just want a government note about it. I am not making this up—if I was, someone would have challenged me. I just want an official note about what has not been scrutinised in the Commons. I accept the Bill has been scrutinised, but it is the material that has been added at the last minute—massive amounts of it—that has not been scrutinised. I beg leave to withdraw the amendment.

Amendment to the Motion withdrawn.

Motion agreed.

House adjourned at 10.44 pm.