Terminally Ill Adults (End of Life) Bill (Eighteenth sitting)
Wednesday 5th March 2025
(1 day, 13 hours ago)
Public Bill CommitteesTerminally Ill Adults (End of Life) Bill 2024-26 View all Terminally Ill Adults (End of Life) Bill 2024-26 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 5 March 2025 - (5 Mar 2025)
The Committee divided: - Ayes: 9 / Noes: 13 - Question accordingly negatived.
The Committee divided: - Ayes: 8 / Noes: 14 - Question accordingly negatived.
The Committee divided: - Ayes: 3 / Noes: 19 - Question accordingly negatived.
The Chair
Will hon. Members please ensure that all electronic devices are turned off or switched to silent mode? Tea and coffee are not allowed in the Committee Room. We are continuing line-by-line consideration of the Terminally Ill Adults (End of Life) Bill. I remind Members that the most valuable of all talents is never using two words when one will do. I take that from Thomas Jefferson.
Clause 5
Initial request for assistance: first declaration
Naz Shah (Bradford West) (Lab)
I beg to move amendment 290, in clause 5, page 3, line 13, at end insert
“who is not a physician associate or doctor in any training grade or in postgraduate training or a locum tenens post and—”.
This amendment would exclude physician associates and doctors in training from acting as a coordinating doctor.
The Chair
With this it will be convenient to discuss the following:
Amendment 185, in clause 5, page 3, line 14, leave out from “who” to end of line 15 and insert
“meets the requirements specified in regulations under subsection (3A)”.
This amendment and Amendment 186 impose a duty on the Secretary of State to make regulations about the training, qualifications and experience required in order to act as the coordinating doctor.
Amendment 335, in clause 5, page 3, line 14, after “such” insert “specialised”.
This amendment is linked with NC12.
Amendment 52, in clause 5, page 3, line 15, leave out from “State” to end and insert
“must specify by regulations, including experience of managing terminal illnesses,”.
This amendment would require the coordinating doctor to have experience of managing terminal illness.
Amendment 359, in clause 5, page 3, line 18, at end insert—
“(ba) who has conducted the preliminary discussion in accordance with section 4,”.
This amendment requires that the coordinating doctor has conducted a preliminary discussion prior to witnessing the signing of the first declaration.
Amendment 186, in clause 5, page 3, line 23, at end insert—
“(3A) The Secretary of State must by regulations make provision about the training, qualifications and experience that a registered medical practitioner must have in order to act as the coordinating doctor.
(3B) The regulations must include training about—
(a) assessing capacity;
(b) assessing whether a person has been coerced or pressured by any other person.
(3C) Subject to that, the regulations may in particular provide that the required training, qualifications or experience is to be determined by a person specified in the regulations.”
See the statement for Amendment 185.
Amendment (a) to amendment 186, after
“(b) assessing whether a person has been coerced or pressured by any other person.”
insert
“(c) specific and up-to-date training on reasonable adjustments and safeguards for autistic people and people with a learning disability.”
Amendment 340, in clause 5, page 3, line 23, at end insert—
“(3A) The Secretary of State must make regulations under subsection 3(a) specifying specific and up to date training on reasonable adjustments and safeguards for autistic people and people with a learning disability.”
Amendment 427, in clause 5, page 3, line 23, at end insert—
“(3A) In Wales, all reasonable steps must be taken to ensure the practitioner under subsection (3) has fluent proficiency in the Welsh language if services or functions in the Act are to be provided to an individual in Welsh.”
Amendment 20, in clause 5, page 3, line 25, at end insert—
“(4A) Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”
This amendment would require the registered medical practitioner acting as the coordinating doctor to have undertaken training on domestic abuse, including coercive control and financial abuse.
Amendment 336, in clause 8, page 5, line 13, after “such” insert “specialised”.
This amendment is linked with NC12.
Amendment 337, in clause 19, page 13, line 20, after “such” insert “specialised”.
This amendment is linked with NC12.
New clause 12—Obligations related to training—
“(1) No registered medical practitioner or other health professional is under any duty to opt in to undertake specialised training wholly or largely relating to the provision of assisted dying in accordance with this Act.
(2) No medical practitioner or other health professional who has carried out training as may be specified by the Secretary of State under—
(a) section 5(3)(a),
(b) section 8(6)(a), or
(c) section 19(2)(b),
is under any duty to participate in the provision of assisted dying under the terms of this Act.”
This new clause would set out that a registered medical practitioner or other health professional is not under any duty to undertake training in relation to the provision of assisted dying. And anyone who undertakes such training is not under a duty to provide assisted dying under the Act.
Naz Shah
Amendment 290 was tabled by my hon. Friend the Member for York Central (Rachael Maskell). Clarity is needed on who a medical practitioner is. With the regulation of physician associates, there was much unease from the British Medical Association and others on the role and function of the new profession. Although I do not want to debate the merit of this today, it is clear that involvement in the assisted dying process requires someone of significant experience to support a patient while undertaking complex assessments and co-ordinating their care between specialists and others.
In some jurisdictions, we have heard that clinicians have extensive clinical experience, whereas they do not in others. Therefore, being able to determine the level of experience and competencies of the medical practitioner is important to ensure that the patient is receiving care from someone who has significant practice expertise. A doctor in training, whether as a specialist or general practitioner, although making very specific clinical decisions, should not be deemed as having the experience, competencies or breath of experience for the purposes of this process. An associate practitioner should also not be deemed to reach these thresholds. Amendment 290 would therefore show the public that the person who would act as the co-ordinating doctor held such experience, and that there was no doubt in their standing to register for such a role. The public can already be confused on the exact status of the clinician they are under or indeed the profession itself. Including this safeguard would ensure that the patient’s interests are upheld.
Rachel Hopkins (Luton South and South Bedfordshire) (Lab)
It is a pleasure to serve under your chairship, Mr Dowd.
I rise to speak in support of amendment 185, in the name of the hon. Member for Spen Valley, the Bill’s promoter, regarding training requirements that need to be made by regulation. It would place a duty on the Secretary of State to make regulations about training qualifications and experience required in order to act as a co-ordinating doctor. Similarly, amendment 186 says that the regulations should specifically include training relating to the assessment of capacity and assessing whether a person is being coerced or pressured by any other person. Proposed new subsection (3C), introduced by amendment 186, would make provision that
“the required training, qualifications or experience is to be determined by a person specified in the regulations.”
In making those regulations, reflection of expertise is vital. We heard from many experts who gave us evidence about the importance of training, development and mentorship, which we would expect to see covered in the regulations. Placing those requirements in regulations would mean that they could be developed through consultation with experts and stakeholders, after gaining a wide range of feedback. It would also future-proof the requirement of any training to be developed and strengthened through future experience.
As part of the safeguards in the Bill, the key principles around assessing capacity and potential coercion are really important. I am therefore minded to press the hon. Member for Spen Valley also to support amendment 20, in the name of my hon. Friend the Member for Lowestoft (Jess Asato), which states:
“Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”
That would provide further clarity, and would further strengthen training on assessing coercion in all senses of the word as part of the safeguards, which many Members, even in the earlier debates, have said that it is so important that they see. I agree, and I hope that the promoter of the Bill will support amendment 20.
Daniel Francis (Bexleyheath and Crayford) (Lab)
I rise to speak to the amendments in my name—namely, new clause 12 and amendments 336, 337 and 335. Yesterday, we spoke about the evidence we received from the British Medical Association. I accept that there is some crossover between my amendments and the amendments of the Bill’s promoter, my hon. Friend the Member for Spen Valley, on training.
The British Medical Association stated, with regard to my amendments:
“We strongly urge MPs to support these amendments which would define the ‘training’ explicitly in the Bill as specialised training to provide assisted dying, undertaken by those who opt in…We have been vocal that the Bill should be based on an opt-in model…during the Committee’s oral evidence sessions. Reinforcing this, we believe NC12 and Amendments 335-337 would make two important aspects of this provision in the Bill clearer:
1. That providing assisted dying is not, and would not in the future, be expected of all doctors—the Bill’s current all-encompassing reference simply to ‘training’ does not preclude this training being prescribed as standard general medical training via the regulations, in which case it would apply to all doctors and make the opt-in redundant. Specifying that it is ‘specialised’ training on the face of the Bill, and making clear that there is no obligation on doctors to undergo the training, would safeguard the opt-in model in the Bill’s first principles.
2. That only those who undergo specialised, tailored training on assisted dying could provide the service – during the oral evidence sessions, there has been much discussion about the importance of specialised training for those who opt in to carry out the service. Specialised training for those providing the service is essential for doctors and provides additional protection and safeguards for patients—it should be explicitly referenced in the Bill.”
We heard in our oral evidence sessions from others, including Dr Ahmedzai, on the need for training. He said:
“I personally believe that it would be advantageous if there was formal training, as Dr Clarke has mentioned, specifically to have the kinds of conversations that we now talk about, such as about psychological issues and suicidal tendencies.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 69, Q82.]
I now turn to two amendments in my name: amendment 340 and amendment (a) to amendment 186. Both amendments relate to training for those with learning disabilities and autism. We had a similar discussion on a previous clause, and I know that further amendments are likely to be tabled on the matter, but as I said yesterday, they are not currently on the amendment paper.
I heard and welcome what my hon. Friend the Member for Luton South and South Bedfordshire has said about amendment 20. Putting that training in the Bill is hugely important, and I believe the same is true in relation to training for those with learning disabilities and autism, as set out in to amendments 340 and amendment (a) to amendment 186, particularly given my concerns and those of others about whether we end up with clause 3 relating to the Mental Capacity Act 2005.
Dr Marie Tidball (Penistone and Stocksbridge) (Lab)
I thank my hon. Friend for his amendments, and I agree with their principle. My concern is that, again, people with mental disorders are left out. Does he agree that, if there were a way to amend the Bill later so that they could be incorporated in these proposals, that would be a positive step forward?
Daniel Francis
I would welcome that as a positive step forward—I think there is probably still some work to do in that regard. My hon. Friend and I will have conversations on the wording of that future amendment, but at the moment we are discussing the amendments that stand before us. Any future amendments that may be tabled are not for us currently to consider.
Dr Tidball
As my hon. Friend knows, I have a great deal of respect for him, so I gently say that if he brings forward similar amendments later in the Bill, I would be delighted to talk to him and I ask him to include mental disorders.
Daniel Francis
I hear that, and I think my hon. Friend and I are on the same page on many of these matters. I think there were some drafting issues when I discussed amendments with Mencap at an earlier stage.
I commend to the Committee the six amendments in my name in this group: new clause 12 and amendments 336, 337, 335, 340 and amendment (a) to amendment 186.
Danny Kruger (East Wiltshire) (Con)
I want to quickly indicate my support for the amendments tabled by the hon. Member for Bexleyheath and Crayford, amendment 290 in the name of the hon. Member for York Central and amendment 20 in the name of the hon. Member for Lowestoft about specific training on domestic abuse and coercive control.
I will now speak to my own amendments, which would require there to be a preliminary discussion before the signing of the first form. At the moment, the Bill allows someone to make the first declaration and state, “I wish to be provided with assistance to end my own life”, without any preparatory discussion about what that entails. It is significant that we heard evidence from Professor House—a professor of old-age psychiatry—that the preferences of the person doing the assessment can bias the capacity assessment. As he explains, we are much more likely to declare that somebody has capacity when they say they want to have the treatment we are offering them, but can we really be sure that the request is freely made and reflects the patient’s wishes?
The fact is, we still do not know from the framework of the Bill how the process would be implemented, but the assessor is likely to be one of a small number of doctors who are willing to do this work on the NHS or somebody who is working for a private provider. Research suggests that the assessing physician’s own personal values and opinions may bias their judgment of a person’s mental capacity. Effectively, research says that the doctor will say that a person has capacity for treatment when he or she wants them to have it or believes that they should. That is significant.
We see from other jurisdictions that the assessment process can quickly become a tick-box exercise in which proper consideration is not given to what might be going on behind the declared wish. In Oregon in 2023, only three people were referred for a psychiatric evaluation by the assessing doctor—down from 33% of people in the early years. It is clear that evaluators have become less cautious when they come to sign the initial paperwork. In California, less than 1% of patients requesting an assisted death are referred for a mental health assessment. These are significant warning signs for us.
I am aware that the hon. Member for Spen Valley has tabled a helpful amendment—amendment 419—to clause 6, which is the clause dealing with the requirement for proof of identity. As I said yesterday, this retrofits a requirement for a preliminary discussion before the process can proceed. It is good that the hon. Member recognises the point that a proper preliminary assessment must be done before the declaration is signed, but I simply do not understand why that should be in clause 6; surely it should be in one single, consistent place, here in clause 5, relating to when the co-ordinating doctor first meets the patient to witness their form. I hope we might recognise that if the principle is being conceded by the amendment tabled by the hon. Member for Spen Valley, we should put that change into its rightful place.
It is worth nothing that at the moment someone could get a proxy to sign for them. The proxy does not need to know the patient or be known to them; they just need to be a person of good standing in the community. They need to undertake no training at all. We have been talking during in this debate about the importance of training, but the proxy who signs on the patient’s behalf does not need to have any training to inform the judgment that they are
“satisfied that the person understands the nature and effect of the making of the declaration”.
Frankly, a stranger to the person, who is not a medic, can sign that declaration on their behalf. At the moment, they can do so without a preliminary discussion taking place. It is only after making that crucial declaratory statement that the co-ordinating doctor discusses the person’s diagnosis. I welcome the tabling of amendment 419, but I think it is in the wrong place. If we do not ensure that that preliminary discussion takes place when we are debating this group of amendments, it might be too late if amendment 419 does not pass, or if it is unsatisfactory, as I think it is.
There is another related problem. Amendment 419 would allow the co-ordinating doctor to confirm that a preliminary discussion has taken place. That means that the discussion could have taken place before the first declaration—in a sense, that is welcome, because that discussion should be taking place—but it does not have to take place with the co-ordinating doctor. The co-ordinating doctor, who is taking responsibility for the whole process of the assisted death for this patient, is not required to have this preliminary discussion themselves. They are not required to go through the very important process of properly discussing the assisted death and informing the patient of what it entails and what the other options are.
My amendment 359 would enhance the significance of the preliminary discussion. It would mean that the doctor who witnesses the declaration—who co-ordinates the process of the assisted death—has had the fullest possible discussion with the patient, and that they genuinely take responsibility for guaranteeing that the patient is fully informed and aware of all of their options. I urge the Committee to support these amendments as well.
Liz Saville Roberts (Dwyfor Meirionnydd) (PC)
I am very glad that amendment 427 has now been unstarred for today, because it develops on what I initiated yesterday with amendment 413, when we were discussing identifying the preferred language of the individual and whether that is Welsh or English.
Of course, if we have identified the preferred language of an individual, we would then take every step to make sure that we satisfy them and that we provide services in their preferred language. The amendment also recognises, when we are talking about specific individuals, possibly in a specific location, whether providing that is possible or not. I have tried to reflect that in using the terminology “all reasonable steps” to ensure that the practitioner has “fluent proficiency” in Welsh if that is the preferred language of the individual with whom they are conducting the initial conversation. Bear in mind, of course, that practitioners who can hold a conversation with fluent proficiency in Welsh will also be able to hold a conversation with fluent proficiency in English.
The “all reasonable steps” phraseology comes from legislation already extant in Wales in relation to educational tribunals, which again recognise that it may not be possible to find an individual with sufficient proficiency. We are trying to find a balance here between the pressure of time and being able to move ahead without having a bureaucratic thicket while also acknowledging that if we do recognise an individual’s preferred language, that we do take “all reasonable steps”.
As with amendment 413, amendment 427 is an amendment that I tabled having met an officer from the Welsh Language Commissioner’s office last week. It would establish a pathway for people for whom Welsh is their preferred language. Reflecting the comments from the Minister and the Bill’s promoter, the hon. Member for Spen Valley yesterday, I need to know—as do the Committee and the Senedd—whether this needs to be on the face of the Bill or whether it could be elsewhere.
I do not intend to push amendment 427 to a vote today, but we very much need clarity on this issue. I suspect that this may not be so easy to clarify as yesterday’s point. We are talking about the rights of individuals in one of the most difficult, emotional, intimate discussions of their lives. We need to reflect that those individuals have a clear right to use the language which they have a choice in law to use. We must make sure that we get everything correct in this Bill. Diolch yn fawr iawn.
Naz Shah
I rise to speak to amendment 20, which was tabled by my hon. Friend the Member for Lowestoft (Jess Asato).
The key point for me is that doctors are not specialists in coercive control, but this amendment would give them training to spot abusive and coercive relationships, which are difficult to detect. Domestic abuse and coercive control have a disproportionate effect on women and disabled people, and if doctors just rely on their experience to detect coercive control and abuse, they are more likely to miss cases. Some doctors will be more experienced or more perceptive than others. This amendment is not a perfect safeguard, but it will improve the chances of doctors stopping people being coerced.
The amendment would ensure that co-ordinating doctors must have undertaken training on domestic abuse, including coercive control and financial abuse. It is a significant and distinct amendment. In particular, it addresses the issue of repeated coercive control, which so far has been overlooked in the Bill. I believe that amendments seeking to improve safeguards against coercion that do not address the issue of repeated coercive behaviour are inadequate in protecting vulnerable people, particularly women.
It is regrettable that in our witness sessions we did not hear from any experts on repeat coercive control. Such testimony would have been valuable, helping the Committee to understand why this specific environment puts people at risk with regard to the Bill.
We have already spoken a great deal about coercion in this Committee and other Members have referred to that. We have raised concerns about someone coercing another person into the process of assisted dying in a one-off incident. However, we have not yet discussed the very real issue of repeated coercive control and what it means to live in that environment, nor the implications that the Bill may have for people in those situations.
Dr Hannah Denno submitted written evidence to this Committee. She wrote:
“As a doctor I am not trained to detect coercion, and I do not believe that the Bill pays sufficient attention to the detection of those who are under pressure from themselves or others to end their lives. The Bill describes two independent medical assessments, both can be carried out by doctors who have never previously met or cared for the patient.”
Kim Leadbeater (Spen Valley) (Lab)
I just want to provide some reassurance to my hon. Friend the Member for Bradford West. I have met my hon. Friend the Member for Lowestoft and today I will support amendment 20, which she has tabled. I hope that provides some reassurance to my hon. Friend the Member for Bradford West.
Naz Shah
I am grateful to my hon. Friend for that intervention and I am really grateful that she is supporting the amendment. However, the reason I am making this speech is that I do not think the amendment goes far enough in terms of providing safeguards within the Bill. So, I will make some progress with my speech and then I will address some of the issues that are not addressed in this particular amendment, and set out how we can go further, as well as highlighting some of my concerns.
I return to what Dr Denno wrote in the evidence that she submitted. She wrote that she was:
“not trained to detect coercion”.
And she also wrote that
“Social workers are better placed to screen for coercion but are not mentioned in the Bill.”
Since that submission, my hon. Friend the Member for Spen Valley has tabled an amendment that would mandate a social worker to sit on a panel to consider each application for assisted death. However, I am afraid that I must repeat several points about these panels, points that have already been made frequently. These panels are under no obligation to interview the applicant for assisted death in person. Panel members may do so if they have any concerns, but they may not. That makes it harder for panel members to detect possible coercion.
There is also an absence of any mechanism for people who know assisted dying applicants to report any concerns they have that that person is being coerced into this form of action. The panels are not used in that way, which is the way that multidisciplinary panels are used in the NHS to decide on the pathway for a patient. Instead, the panels introduced by my hon. Friend’s amendment would wait until the two doctors have submitted their statements on the applicant and then the panel members would scrutinise those statements. If they spot problems with the way that the doctors have determined that the patient is not being coerced, then, yes, they would call the patient in for more scrutiny. However, they will first have to come to that conclusion without seeing the patient. That is not a very robust safeguard.
Kim Leadbeater
I am in the process of tabling an amendment that would change the panel to that effect, so that it would speak to the patient. Hopefully, that provides some more reassurance for my hon. Friend. I am sure that we are working very effectively through the Committee process to achieve what we all want to see.
Naz Shah
I am pleased to hear that my hon. Friend will table further amendments, but I have not seen that amendment, so I cannot speak to it.
I would slightly beg to differ with my hon. Friend in terms of making progress in the way that I would like to have seen. I would just gently remind her that I am not convinced that we are. I think we are making good progress, but I also voted against one clause stand part and had lots of concerns about another one, so we will agree to disagree on that one.
The non-governmental organisation The Other Half observes in its written evidence to this Committee—TIAB 104—that the Bill makes no provision to identify family members who may benefit financially from the death of a patient, and, therefore, the Bill is unable to protect the vulnerable. That is something that I have said before in this Committee.
This amendment makes training in respect of financial abuse mandatory. It is vital that a medical practitioner is trained on how to identify coercion—we can all agree on that—but coercion is different from domestic abuse. Coercion may be relatively obvious to spot, but, in contrast, coercive and controlling behaviour is much less obvious. It can be subtle. It can be hidden, and unexpected to an outsider. It requires much more sensitive questioning and a degree of a doctor-patient relationship to identify. Multiple people have raised that a patient-doctor relationship is important for spotting that, and, currently, there is nothing in the Bill to say that the two independent doctors have to have met the patient before.
That subtle coercion could have happened over years. We have repeatedly heard from people giving evidence that it is really hard to spot, and the reason it is hard to spot is because it is a matter of trust for a patient to be able to tell somebody—for a victim of coercive control to be able to express that. Even recognising that there is subtle coercion going on is hard for victims of that coercion to understand.
If there is domestic violence—again, I say in this Committee that I first campaigned on domestic abuse in the mid-1990s, and I am not convinced that the stats have changed much. I will refer to some more later on, as I make progress, but it takes women, on average, 40 times to leave an abusive partner—40 times—and it took me a long time to leave my abusive forced marriage when I was very young. The coercion that happens is so subtle and, again, when it is repeated coercion, it is hard to even recognise it as a victim, let alone for a professional to be able to see it. Even when a professional may pick up on it, it is acknowledgment from the victim—that they recognise what is happening—that is important, and that often is not the case.
Again, multiple people have raised that the doctor-patient relationship is important, and there is nothing currently in the Bill to ensure that there is a long-standing relationship between the doctor and the patient. Therefore, it is unreasonable to assume that someone in an abusive relationship, or who experiences coercive and controlling behaviour on top of their terminal illness, would be willing and able to disclose that to a stranger, even if that stranger is a doctor.
On top of that, research suggests that a significant proportion of medical staff in the UK do not feel that they have had adequate training to spot domestic abuse. Research by YouGov and the charity SafeLives in 2018-19 found that half of UK healthcare professionals are untrained to spot domestic abuse.
I understand the current difficulty in ensuring that doctors have a prior relationship with patients; it may not be practically possible. In many cases, where patients will know their doctors, or even know them well, it is even more vital that both doctors have been thoroughly trained in spotting coercive-control behaviour.
Like the other Labour MPs on the Committee, I was elected on a manifesto pledge to halve violence against women and girls within the next 10 years. We must not forget that as we scrutinise this legislation; I want my colleagues and I to remain committed to that in this Bill.
This Bill will have particularly grave consequences for women, since we know that domestic abuse disproportionately affects them. The crime survey for England and Wales estimated that 2.3 million people aged 16 years and over experienced domestic abuse in the year ending March 2024. Of those, 1.6 million were women and 712,000 were men. In the same year, there were only 51,183 domestic abuse-related prosecutions—a very small number compared with the number of people who experienced domestic abuse. That is in addition to the abuse of our elderly, on which Age Concern submitted evidence. Those figures demonstrate that we already frequently struggle with bringing domestic abuse cases to prosecution stage. They show that even the dedicated members of our caring professions have trouble detecting domestic abuse. If something is hard, we need to train our doctors to do it.
Our society already diminishes the status of elderly, infirm women and I have concerns that the Bill will further entrench that. We need to be aware of and ensure that we address the problem of mercy killings in the Bill. That issue is distinctly gendered and the Bill as currently worded will have a distinctly gendered impact if we do not address it. In 2024, The Other Half carried out a review of more than 100 UK cases of so-called mercy killings. It found that
“‘mercy killings’ are not the wanted, ‘hastened’ deaths that need assisted dying.”
Instead, the review found that:
“They are overwhelmingly violent domestic homicides of women, by men: and show that our society is still poor at detecting and responding to domestic abuse.”
Some groups are more vulnerable to domestic abuse than others. A higher proportion of people aged 16 and over with a disability—a group that we know is vulnerable in relation to the Bill—experienced domestic abuse in the last year than those without a disability.
The law and Parliament have, unfortunately, taken a very long time to even start adequately responding to these problems. Coercive control was first recognised as a distinct offence in English law only in the Serious Crime Act 2015. As written, the Bill would not mandate training to the doctors whose role it would be to consider assisted dying cases. Of course, no training can be perfect, but to allow the Bill to go forward without ensuring that doctors have training in this complex matter would be negligent. It would mean that we were failing to even try to carry out our responsibilities to protect people, especially women, in abusive and coercive relationships.
I appreciate that my hon. Friend the Member for Spen Valley has said that she will accept the amendment, but it does not go far enough. The question is: how do we prevent abusers making use of the Bill if it becomes law? The amendment gives us one way of mitigating that risk to a degree. We already have issues recognising domestic abuse. The amendment cannot perfectly solve that problem, but it would take steps to do so.
We must safeguard vulnerable people who live subject to coercive and controlling behaviour on a daily basis from opting for assisted dying as a result of that environment. Thorough and specific training on spotting that is vital for doctors. I am grateful that my hon. Friend, in accepting the amendment, will ensure that some of that training will be forthcoming. Even one abused person being driven by their abuser to use assisted dying is one too many. I am confident that all hon. Members would agree with me on that deeply important point.
In the last few days, I have been looking at suicide, and one of the issues that has come up is that last year, for the first time in our history, suicide by victims of domestic violence overtook deaths from what we would term intimate partner homicide. In the last two weeks, there have been further reports highlighting that the number of women driven to suicide because of the experience of domestic violence has risen. Tomorrow, my hon. Friend the Member for Birmingham Yardley (Jess Phillips) will read the name of every woman who has been killed in the last year, as she does every year. Two of those women were my constituents, and many more kill themselves to get away from their abusers.
The Chair
Order. I understand where the hon. Member is coming from, but I think she is very close to moving outside the scope of the amendment, so can I ask her to bear that in mind? As I have said, this is a very sensitive issue and I am giving people latitude, but that cannot go too far. I do not want to interrupt Members, but I will if they do not stick to the confines of the amendment.
Naz Shah
I am grateful, Mr Dowd. I will bring my remarks back to the issue in the amendment, which is related to training. I will also bring them back to the issue of interpreters.
In November 2023, the Imkaan group issued a report, “Life or Death?” It literally is a matter of life and death. The report talked about the use of interpreters, training and minoritised women. Imkaan said that
“The availability and use of quality interpreting services can be critical to women’s access to safety and protection”
and that the current position on police use of interpreters breaches the Equality Act and amounts to indirect discrimination. It also breaches the commitments under the Istanbul convention. I appreciate that that issue is about police training, but surely the principles are exactly the same. We have a service—the police and domestic violence services—which supports victims of coercive control and of domestic violence. Unfortunately they come into contact with it, as our NHS and our medics do, way too often for my liking.
The Chair
Order. The issue of interpreters is not within this group. I am just trying to look for that and it is not in this group, so I am afraid the hon. Lady is out of scope of the clause. It is in a later group, so perhaps she could pick it up then.
Naz Shah
I thank you, Mr Dowd. My apologies. I have made a mistake, but I was referencing the comments of the right hon. Member for Dwyfor Meirionnydd about the use of languages, which is the subject of one of the amendments; that is my understanding. But again, I am happy to be guided by you, Mr Dowd.
To come back to the issue of training and domestic violence, in Committee, we heard evidence from Dr Jamilla Hussain about minoritised women. Again, from the data collection of ethnic minority groups, training is right at the top of the agenda, whether it be training of doctors or specialists.
Language is important when it comes to training as well. When people are training or trained to look at coercive control and to spot that coercive control, there is often an interpreter between them and the victim who is being assessed. They may be an ethnic minority woman or a man from an ethnic minority background whose first language is not English, so that training would need to include cultural sensitivities in relation to spotting coercion and control, and to repeated coercion in particular.
These are subjects that are already taboo for people to discuss. We know the issue of domestic violence is hard to spot. We have repeated that time and again, as have others. We talk about training, but that has to go further when it comes to victims or people seeking assisted dying who are from ethnic minority backgrounds and who have different cultural understandings. I talked about yesterday that. The hon. Member for Reigate also talked about the issue: the understanding of assisted dying among ethnic minority communities is very different if there is a language barrier.
I would like to ask the promoter of the Bill, my hon. Friend the Member for Spen Valley, whether her amendment will go further in addressing some of the inequalities and intricacies that are presented when we are dealing with women from ethnic minority communities or elderly people from ethnic minority communities. I would be happy to sit down and talk her through those issues, so that I can support the development of her amendment to address the concerns I have raised today.
Danny Kruger
The hon. Lady talked earlier about the tragedy of victims of coercive control who commit suicide. Does she consider that the amendments we are looking at will help to address that challenge? What specific support does she think victims of coercive control would need to prevent them from taking that terrible step?
Naz Shah
The hon. Member asks a very important question. When I am talking about reflective services for black and minority ethnic communities, which is something I have delivered training on and worked on in a previous role, I often use the example of my mother, who was a victim of domestic violence. Had she been arrested by a woman instead of a man, her experience might have been different. Had she had a solicitor who was a woman, not a man, her experience might have been different. Had she had judges who were women, not men, her experience might have been different. Let us now add another layer to that. Had the police officer been a woman from the background she was from, they might have understood it.
The same analogy potentially applies to patients who are asking about going down the route of assisted dying, because it is helpful if somebody comes from the same cultural background. If a female victim of domestic violence or coercive control meets a specialist doctor who looks very similar to the hon. Member for East Wiltshire—a white, middle-class male—and he does not have that cultural understanding, he will then rely upon training, and he will no doubt rely upon an interpreter to translate.
That is the kind of thing I am trying to tease out, and these are the kinds of protections I want to see in the Bill. If we want a Rolls-Royce service, and if this is to be the best Bill in the world, it cannot ignore the most vulnerable in society. If the patient is a disabled woman, it is whammy upon whammy and layers upon layers of intersectionality that the Bill does not address. That is why I want to see the Bill strengthened.
I want to talk about the training that doctors get and the training in palliative care. We heard from Dr Jamilla Hussain, who was very clear about the fear among minoritised communities because of what happened during the covid pandemic, with “do not resuscitate” orders and their whole experience. Some people potentially died who could have been saved because they did not have the trust in NHS services to access them.
In this instance, it is important that we have a first doctor. That first doctor might have no relationship with the patient because their regular doctor does not want to engage in the process. Let us take the example of a patient in Bradford West who has had a diagnosis of terminal illness. They might well have a doctor or consultant who has been dealing with them for six months or even a year, to the point where they have reached the terminal stage. They might have a relationship with that doctor, who might have spoken their language and might be from a particular faith background but who does not want to engage in the assisted dying process. According to the Bill, that doctor would then have to refer that patient on to somebody who is prepared to have that conversation, but that person might not have that training or those language skills, and they might not—
The Chair
Order. The hon. Lady needs to keep her remarks to amendment 20. I have looked at other amendments to which this is relevant, including amendment 186, but that has been starred. I exhort the hon. Lady to focus on the particular issues covered by amendment 20.
Naz Shah
Thank you, Mr Dowd. My understanding is that this all relates to amendment 20, and I am happy to clarify why. Ultimately, this is about the professional’s intervention with a patient, and the amendment is about training people adequately to assess coercive control and domestic violence. I am trying to demonstrate—I accept that I might not be doing it well enough—that there is a pathway and a catalogue of things that relate back to the person who is being assessed. I am trying to explain to the Committee in detail, because I feel very strongly about it, what that care pathway might look like for somebody, and why the amendment, although I welcome it, does not safeguard the most vulnerable in society. I am happy to be guided if that is not what I am doing, but that is certainly what I am attempting to do. May I carry on, Mr Dowd?
The Chair
The hon. Lady should take this in the spirit in which it is intended. Dipping in and out of issues throughout the course of a speech is okay, but I am afraid that dipping in and out of issues that are not relevant is not, and we are getting to the stage where the information she is imparting is not necessarily relevant, in significant elements, to the amendments that we are dealing with.
The Chair
Order. My ruling from the Chair cannot be challenged. I exhort the hon. Lady to stick to the amendments before us. If she does not, I will have no other option but to intervene and move the debate on.
Naz Shah
Thank you, Mr Dowd.
I come back to the issue of potential coercive control, which is what amendment 20 addresses. As I have outlined, there are patients who could be in that position. Given the examples that I have put before the Committee, I argue that the amendment, although it is brilliant in getting us to a better place than where we started out with the Bill—I am pleased that my hon. Friend the Member for Spen Valley has indicated that she is happy to discuss strengthening the safeguards—does not go far enough, for the very reasons that I have outlined, and no doubt will outline further when speaking to other amendments.
The Minister for Care (Stephen Kinnock)
It is a pleasure to serve under your chairship, Mr Dowd. As I have said, the Government remain neutral and my role is not to offer a Government view on the merits of the amendments, but to provide a factual explanation of their technical and practical effect to assist the Committee in its scrutiny.
The Government remain committed to ensuring the legal robustness and workability of all legislation, so I have worked closely with my hon. Friend the Member for Spen Valley on some amendments. Where changes have been mutually agreed by my hon. Friend and the Government, I will offer a technical, factual explanation and rationale for the amendments. Those include amendments 185 and 186 in this group. The Government remain neutral on the Bill and do not have a position on assisted dying.
This group relates to the necessary training, qualifications and experience of the co-ordinating doctor. As drafted, clause 5 gives the Secretary of State the power to specify the training, qualifications and experience required for a registered medical practitioner to act as a co-ordinating doctor, but there is no legal duty for the Secretary of State to do so. Amendments in this group either seek to change that power to a legal duty, or would introduce specific training, qualifications and experiential requirements for a registered medical practitioner to act as a co-ordinating doctor.
Amendments 185 and 186 tabled by my hon. Friend the Member for Spen Valley would introduce a duty on the Secretary of State to make regulations regarding the necessary training, qualifications and experience of the co-ordinating doctor. Giving the Secretary of State a duty rather than merely a power would ensure certainty as to the training, qualifications and experience that the registered medical practitioner must have in order to act as a co-ordinating doctor. The Secretary of State’s duty in this respect would include making provision in regulations about training for co-ordinating doctors relating to assessing capacity and assessing whether a person has been coerced or pressured by another person. Amendment 186 would also enable the Secretary of State, subject to the specific training requirements already mentioned, to delegate the determination of the training, qualifications and experience needed for a co-ordinating doctor to a person specified in the regulations. That would allow that determination to be delegated to a body or bodies with appropriate expertise, in line with other aspects of training for healthcare professionals.
Danny Kruger
Will the Minister clarify that point? Is he suggesting that because fewer doctors might be eligible or willing to conduct the preliminary assessment, we should not require it at that early stage?
Stephen Kinnock
What we are trying to say is that the important thing here is to ensure that, when the Secretary of State brings the regulations forward, the hands of the Secretary of State are not tied too tightly, so that the Secretary of State is able to bring together the right people, to deliver the right training, to achieve the outcomes that are required through the regulations. Our assessment is that this amendment would, in essence, narrow the pool of people available to do the training. That would seem to pre-empt the idea behind doing this through regulations, which is to ensure that there is up-to-date training that is responsive to where we may or may not be two years down the line from the Bill having its commencement. It is about having that flexibility and that ability to build capacity.
Amendment 340 would place the Secretary of State under a duty to make regulations requiring a co-ordinating doctor to have specific and up-to-date training relating to reasonable adjustments and safeguards for autistic people and people with a learning disability. I note that amendments 185 and 186, if passed, would impose a duty on the Secretary of State to specify the training, qualifications and experience that the co-ordinating doctor will need.
The consequence of this amendment would be to require the Secretary of State to introduce a further requirement on the co-ordinating doctor—to have undergone training relating to reasonable adjustments and safeguards for autistic people and people with a learning disability. In considering whether the amendment is required, I note that the Health and Social Care Act 2008 requires that all CQC-registered health and adult social care providers ensure that their staff receive specific training on learning disability and autism.
Amendment 427 would impose an obligation to take all reasonable steps to ensure that the co-ordinating doctor is proficient in the Welsh language if services or functions under this legislation are to be provided to an individual in Welsh in Wales. The amendment does not make it clear who would be obliged to ensure that those steps were taken, or who would assess and enforce whether the “fluent proficiency” standard was met.
Liz Saville Roberts
What the Minister is referring to is the appropriate authorities, because areas related to training and regulation of registered practitioners in Wales are devolved to the Welsh Government. I will be touching on that later, but I would beg him to approach the amendment in that spirit.
Stephen Kinnock
I know that we are coming on to the question of appropriate authorities and I absolutely see and understand the spirit in which this amendment is suggested. The challenge is just about the potential for it to lead to operational issues, such as a reduced pool of registered medical practitioners who are able to carry out the function of a co-ordinating doctor under this legislation.
Liz Saville Roberts
That is exactly why the amendment includes a reference to “all reasonable steps”. It is with that in mind. This is reflected in other legislation where similar concerns have been expressed.
Stephen Kinnock
I thank the right hon. Lady for that. We go back to the point about the true significance of the 2011 Welsh Government Measure, which sets a basic foundation for the duty of the Welsh Government to ensure that Welsh language provision is provided through the Welsh NHS. There is absolutely no debate about that point; that is nailed on. The question is simply how we ensure, if we are to amend this Bill along the lines that the right hon. Lady suggests, that that does not create a lacuna or confusion in the system. I think we need to sit down and discuss that, to ensure that whatever we propose is watertight.
It may be helpful to note, as in discussion of amendment 413, that regardless of this amendment, under the Welsh Language Measure of 2011 the NHS in Wales has a statutory duty to deliver its services to the public in both Welsh and English. That legislation gives the Welsh language official status in Wales, and the Measure states that individuals in Wales should be able to conduct their lives through the medium of Welsh if they choose to do so. The Welsh Government’s active offer for health is intended to support all staff across NHS Wales to provide a service in Welsh for patients without their having to ask for it.
Under amendment 20, regulations made by the Secretary of State on the necessary training, qualifications and experience of the co-ordinating doctor would be required to include mandatory training relating to domestic abuse, including coercive control and financial abuse. Amendments 185 and 186, tabled by my hon. Friend the Member for Spen Valley, would require that regulations made by the Secretary of State on the necessary training, qualifications and experience of the co-ordinating doctor covered training related to assessing capacity and whether a person has been coerced or pressured by another person. But I note that, as my hon. Friend the Member for Spen Valley has said, she is minded to support amendment 20, which clearly would ramp up the requirement, as previously discussed.
As I have said, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed, but to clarify the intent of the Bill, we have worked with my hon. Friend the Member for Spen Valley in relation to amendments 185 and 186, which would place the Secretary of State under a duty to make regulations regarding the necessary training, qualifications and experience of the co-ordinating doctor. That would include specific training on assessing capacity and assessing whether a person has been subject to coercion or pressure.
I hope that that explanation and those observations have assisted the Committee. I thank hon. Members for their attention.
Kim Leadbeater
I rise to speak first to my amendments 185 and 186, which would make important changes to impose a duty on the Secretary of State to make regulations about the training, qualifications and experience required to act as the co-ordinating doctor, as the Minister says. Moving from “may” to “must” would make it a legal requirement that such training take place and would thereby strengthen the Bill. In its present form, the Bill gives the Secretary of State that power to make such regulations but does not legally require him or her to do so.
Amendment 186 would ensure that regulations must include training about
“(a) assessing capacity;
(b) assessing whether a person has been coerced or pressured by any other person.”
Colleagues will appreciate that it is difficult for me to resist the temptation to put the entire training manual in the Bill—we all want to show the thorough approach that has been taken—but doing so would not make for good, clear legislation and can be limited in terms of flexibility and future-proofing. However, given the importance of the matters of capacity and coercion, I felt that it was important that this level of detail be specified in the Bill, because those issues have been at the heart of so many of our deliberations on this hugely sensitive and important issue.
My hon. Friend the Member for Bexleyheath and Crayford, who tabled amendment (a) to my amendment 186, has made a compelling argument, as always. Like my hon. Friend the Member for Penistone and Stocksbridge, I have some concerns that the amendment would limit the number of disabled people who are covered and that it would not cover people with mental disorders, but I understand the concerns around autistic people and those with learning disabilities.
I am also mindful, given that people with Down’s syndrome will typically have some form of learning disability, that amendment (a) may help to address some of the concerns that were expressed yesterday about ensuring that the Bill meets their needs and takes them into consideration. I take on board the Minister’s comments about the Health and Care Act 2022, but I am minded to support the amendment and work with my hon. Friend the Member for Bexleyheath and Crayford and others as necessary to make any further changes as the Bill progresses.
Jack Abbott (Ipswich) (Lab/Co-op)
I am grateful to my hon. Friend for supporting that amendment. We have often debated the level of detail that should be set out in the Bill. I fully appreciate that she does not want to include the whole training manual; I will not discuss my amendment, which concerns culture and trauma-informed care, because I recognise that it is much too detailed in that respect. However, does she agree that where possible, and where it does not create unintended consequences or loopholes, we should reassure not just colleagues across the House but members of the public, who want to see these sorts of thing on the face of the Bill?
Kim Leadbeater
My hon. Friend is absolutely right. If the Bill passes, it will be a huge change. We have a duty to the public to show that we are including sufficient detail in the Bill and to provide reassurance in any way we can. To be honest, I would quite like to put the entire training manual in the Bill, but I appreciate that from a legislative perspective that is not possible. However, there are occasions when, for the avoidance of doubt, we should make certain provisions clear on the face of the Bill.
That brings me to amendment 20, which was tabled by my hon. Friend the Member for Lowestoft, who has a huge amount of experience and expertise in the field to which it relates. Her amendment states:
“Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”
At the moment, there are no safeguards for terminally ill victims of domestic abuse, financial abuse or coercive control. That concerns me, and it feeds into the points made by my hon. Friend the Member for Bradford West.
If a victim of domestic abuse or coercive control—it is often a woman, as we know—is also terminally ill, I can only imagine what a lonely place that is. At the moment, that person is under no supervision. Sadly, there have been instances in which those people have taken their own life. They will continue to be the victims of their incredibly difficult personal circumstances on top of having a terminal illness, which is an absolute tragedy. Opening up the conversation with doctors and healthcare professionals about their circumstances has to be a good thing. It will shed light and transparency on what must be an incredibly difficult situation.
Jack Abbott
On a point of order, Mr Dowd. I think my hon. Friend the Member for Spen Valley said that if amendment (a) and amendment 186 are agreed to, that will negate the need for amendment 340. I seek clarity on whether that is the case.
Liz Saville Roberts
I beg to move amendment 144, in clause 5, page 3, line 14, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 5(3)(a) (training, qualifications and experience of coordinating doctors). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
The Chair
With this it will be convenient to discuss the following:
Amendment 145, in clause 5, page 3, line 24, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of requiring the Welsh Ministers to consult regarding the making of regulations under Clause 5(3)(a) (training, qualifications and experience of coordinating doctors). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 146, in clause 6, page 3, line 34, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 6(3) (forms of proof of identity). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 147, in clause 8, page 5, line 13, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 8(6)(a) (training, qualifications and experience of second doctors). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 148, in clause 8, page 5, line 28, leave out
“Secretary of State must consult such persons as the Secretary of State”
and insert
“appropriate authority must consult such persons as the appropriate authority”.
This amendment has the effect of requiring the Welsh Ministers to consult regarding the making of regulations under Clause 8(6)(a) (training, qualifications and experience of second doctors). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 149, in clause 11, page 7, line 13, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 11(1) (replacing the coordinating doctor on death etc). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 150, in clause 19, page 13, line 21, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 19(2)(b) (training, qualifications and experience of other doctors). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 151, in clause 19, page 13, line 31, leave out
“Secretary of State must consult such persons as the Secretary of State”
and insert
“appropriate authority must consult such persons as the appropriate authority”.
This amendment has the effect of requiring the Welsh Ministers to consult regarding the making of regulations under Clause 19(2)(b) (training, qualifications and experience of other doctors). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 152, in clause 20, page 13, line 35, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 20(1) (meaning of “approved substance”). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 153, in clause 28, page 17, line 3, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 28(1) (prescribing, dispensing, transporting etc of approved substances). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 154, in clause 30, page 18, line 12, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make a Code of Practice in Wales under Clause 30. A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 155, in clause 30, page 18, line 31, leave out “Secretary of State” and insert “appropriate authority”.
This amendment is linked to an amendment that allows the Welsh Ministers to make a Code of Practice in Wales under Clause 30. A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 156, in clause 30, page 18, line 33, leave out
“Secretary of State must consult such persons as the Secretary of State”
and insert
“appropriate authority must consult such persons as the appropriate authority”.
This amendment has the effect of requiring the Welsh Ministers to consult regarding the making a Code of Practice for Wales under Clause 30. A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 157, in clause 32, page 19, line 21, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 32(1) (powers to ensure assistance is available). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 158, in clause 32, page 19, line 22, leave out “Secretary of State” and insert “appropriate authority”.
This amendment is linked to an amendment that allows the Welsh Ministers to make regulations under Clause 32(1) (powers to ensure assistance is available). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 159, in clause 33, page 19, line 34, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 33(1) (notifications to Chief Medical Officers). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 160, in clause 33, page 20, line 16, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 33(2)(h) (notifications to Chief Medical Officers: notifiable events). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 161, in clause 35, page 21, line 30, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of requiring the Welsh Ministers to review the operation of the Act in relation to Wales. A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 162, in clause 35, page 21, line 35, at end insert
“or the Senedd Cymru (as the case may be)”.
This amendment has the effect of requiring a review carried out by the Welsh Ministers under Clause 35 to be laid before the Senedd.
Amendment 163, in clause 35, page 22, line 8, leave out “Secretary of State” and insert “appropriate authority”.
This amendment is linked to an amendment that requires the Welsh Ministers to review the operation of the Act under Clause 35.
Amendment 164, in clause 37, page 22, line 30, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 37(1) (modification of form of declarations and statements). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 165, in clause 38, page 22, line 34, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 38(1) (power to make consequential and transitional provision etc). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 166, in clause 38, page 22, line 37, leave out “Secretary of State” and insert “appropriate authority”.
This amendment is linked to an amendment that allows the Welsh Ministers to make amendments under Clause 38(1) (power to make consequential and transitional provision etc). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 167, in clause 39, page 23, line 9, at end insert
“or, where the regulations are to be made by the Welsh Ministers, the Senedd Cymru”.
This amendment has the effect of making certain powers of the Welsh Ministers subject to the affirmative procedure before the Senedd Cymru. A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 168, in clause 39, page 23, line 12, at end insert
“or, where the regulations are to be made by the Welsh Ministers, the Senedd Cymru”.
This amendment has the effect of making certain powers of the Welsh Ministers subject to the negative procedure before the Senedd Cymru. A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 169, in clause 40, page 23, line 23, at end insert—
“‘appropriate authority’ means—
(a) in relation to England, the Secretary of State;
(b) in relation to Wales, the Welsh Ministers.”
This amendment to the interpretation provision in Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales. A series of linked amendments change references to the Secretary of State to appropriate authority in order to allow the Welsh Ministers to make regulations in relation to Wales.
Amendment 170, in clause 42, page 24, line 21, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 42(2) (commencement). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Amendment 171, in clause 42, page 24, line 26, leave out “Secretary of State” and insert “appropriate authority”.
This amendment has the effect of allowing the Welsh Ministers to make regulations under Clause 42(4) (commencement: transitional and saving provision). A linked amendment to Clause 40 defines appropriate authority to mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales.
Liz Saville Roberts
Diolch, Gadeirydd. As Professor Emyr Lewis of Aberystwyth University told this Committee in oral evidence, because this Bill is a private Member’s Bill it has not gone through the usual process of engagement with devolved Governments. I recognise that there will be amendments and changes and amendments to amendments, but I can speak to the principle here and we will have to adapt as we move ahead, as we are learning to do in this Committee.
The Wales Act 2017 formally acknowledged the Sewel convention by amending section 107 of the Government of Wales Act 2006 with a declaration stating—this is important—that
“it is recognised that the Parliament of the United Kingdom will not normally legislate with regard to devolved matters without the consent of the Senedd.”
It is in that spirit that work needs to be done to ensure that the devolved legislature in Wales and the complexities of legislating across reserved and devolved matters are fully considered and represented in the Bill. That is what these 28 amendments seek to do.
The use of the term “appropriate authority” does two things. First, in the here and now, it recognises the complexity of which competency lies where and with which Minister or Secretary of State. Secondly, it future-proofs the legislation, which we know is important. If and when there are any changes to devolved powers and competencies, the appropriate authority can move with time with the specifics of who is responsible for what.
Amendment 169 would amend clause 40 to include a definition of “appropriate authority”, the term that is used in my other amendments. It would mean the Secretary of State in relation to England and the Welsh Ministers in relation to Wales, where those powers are devolved rather than reserved. The amendment would provide for my other amendments, which would modify each relevant mention of powers provided to the Secretary of State in the Bill, to supply Welsh Ministers with equivalent powers in Wales.
Amendment 144 would amend clause 5 to allow Welsh Ministers the same powers as the Secretary of State in England to specify the training, qualifications and experience of the medical practitioner representing the co-ordinating doctor, because that matter is devolved to Wales. Amendment 145, similarly, would require Welsh Ministers to consult persons they consider appropriate before making the relevant regulations in Wales.
Amendment 146 would amend clause 6 to allow Welsh Government Ministers equivalent powers to make provision around proof of identity. Amendment 147 would similarly amend clause 8 in relation to the training, qualifications and experience of the independent doctor; we are talking, of course, about the co-ordinating doctor.
And so on, and so on. I assume that hon. Members now understand the purpose of my various amendments. I am more than willing to explain them further if necessary, but otherwise I will skip ahead.
Amendments 155 and 156 would modify clause 30 so that the Welsh Government are provided with a power to issue a code of practice over arrangements in relation to this legislation in Wales. That might be a useful route into further discussions on the specifications of the codes of practice; it might also be significant in discussions with the hon. Member for Spen Valley and the Government about how to recognise legislative differences in safeguarding and the Welsh language.
Amendments 157 and 158 are also important. They would provide Welsh Ministers with the power to make regulations under clause 32 to ensure that assistance is available through the health service in Wales. That is the responsibility of Welsh Ministers. As Committee members know, Senedd Cymru voted against a motion to support an assisted dying law by 26 to 19, with nine abstaining. There are a number of issues of which we need to be aware when bringing an England and Wales law into Wales. To ignore them would be irresponsible; we do so at our peril, frankly, especially given that clauses 33 and 34 will place explicit obligations on Welsh Ministers and the chief medical officer for Wales.
I put it on the record that I am disappointed that the Committee was not able to question the chief medical officer for Wales. I understand that he was invited. As there are matters in the Bill that we do not deal with every day in this place, that would have been useful. The Bill is unprecedented, certainly for a private Member’s Bill, in respect of the support, information and advice that the Committee needs, and that would have been an obvious opportunity for us to receive advice. I understand that the chief medical officer has advised on other pieces of legislation, including vaping, although that was Government legislation.
Kim Leadbeater
I can confirm that the chief medical officer for Wales was invited to give evidence. I do not know the circumstances of why he did not. If it is helpful for me or other colleagues to meet him, the offer is definitely open.
Liz Saville Roberts
I am grateful for the hon. Lady’s intervention.
Amendments 161 to 165 relate to clauses 35, 37 and 38. Amendments 161 to 163 would provide for the Welsh Government to review the operation of the legislation in Wales, which is vital to understand the specifics of the Welsh context and to learn and adapt as appropriate. To not allow Welsh Ministers that power would be to dismiss the particularities of health policy in Wales, as well as the additional implications of contextual differences. I strongly believe that we require an impact assessment to understand those differences properly within the context of health being devolved to Wales, alongside significant population differences in relation to demographics, age and sickness.
Danny Kruger
I will speak briefly in support of the amendments. The right hon. Member for Dwyfor Meirionnydd may want to intervene to request that the Minister respond to a couple of additional points.
It is very uncomfortable that the Bill ignores the devolution settlement in this way. It is regrettable that it was introduced in its current form in the knowledge that the Senedd in Wales rejected assisted dying a month earlier. That suggests either that originally little thought was given to including Wales in the Bill or that, subsequent to the vote in the Senedd, it was decided that the Bill would be imposed on Wales. It would be helpful to have clarification about the original intent.
I very much echo the points that the right hon. Lady made. She is absolutely right about the appropriateness of giving the Welsh Government powers to manage the Bill’s operation and implementation if it passes. I would suggest a stronger process of implementation, reflecting the advice given by Professor Lewis, who gave evidence to us on Welsh law. In the light of the vote in the Senedd to reject assisted dying, he pointed out:
“The vote was against ‘the principles of assisted dying’, not only about how the NHS in Wales might be affected. It was a decision which the majority of the Senedd made about those principles, having reflected on the…issues raised.”
Professor Lewis proposed a straightforward way of respecting that vote while recognising that, if this Bill passes, it will apply to Wales. He suggests that we should
“provide for different commencement provisions in the Bill. As things stand, under clause 42 of the Bill, most of the Bill will not come into force until the Secretary of State has brought it into force, with the approval of the UK Parliament. Why not provide that the Bill will only come into force in Wales when and if the Welsh Ministers bring it into force with the approval of the Senedd?”
The objection might be made that cross-border issues would be created if Wales does not proceed but England does. Nevertheless, that is a matter that devolution can cope with. It will have to cope with the cross-border issues that will arise if the Scottish Bill does not proceed, and of course we have cross-border issues between Wales and England with respect to organ donation, so I do not accept that the two countries need a uniform policy. I do not know whether the right hon. Lady or the Minister wish to comment on the suggestion that the Bill should commence in Wales only if Ministers bring it forward with the approval of the Senedd.
Liz Saville Roberts
The evidence for a commencement date would be associated with an impact assessment in Wales. That is why it is so important that Welsh Ministers have the power to get the information they need and to implement any changes that come forward.
Danny Kruger
I absolutely agree with the right hon. Lady. There is a whole set of challenges, including in England, in respect of the impact assessment and the Bill’s commencement. Nevertheless, my suggestion is that we strengthen her proposal to empower Welsh Ministers to proceed. We should respect the devolution settlement and reflect what she describes as the “correct and rightful powers” of the Welsh Parliament to ultimately decide whether this law were to come into effect in Wales.
Stephen Kinnock
Amendments 144 to 171, tabled by the right hon. Member for Dwyfor Meirionnydd, relate to the powers and duties vested in the Secretary of State under the Bill. The purpose of the amendments is to change all references throughout the Bill from “Secretary of State” to “appropriate authority”. Amendment 169 defines “appropriate authority” as the Secretary of State in relation to England and as Welsh Ministers in relation to Wales. I note the intent of the promoter of the Bill, my hon. Friend the Member for Spen Valley, that the Bill’s provisions extend and apply to both England and Wales.
The amendments would mean that all the powers and duties vested in the Secretary of State are instead shared between the Secretary of State where they relate to England and Welsh Ministers where they relate to Wales. I would like to put on the record the Government’s continued commitment to devolution and to working with the devolved Governments. Having taken a neutral position on the Bill and the matter of assisted dying, the Government are still committed to working with the Welsh Government to resolve legal and technical issues and discuss constitutional matters that might arise thoughtfully and amicably.
With regard to the phrase “appropriate authority”, the challenge is that in each case throughout the Bill the appropriate authority would be determined by the devolution position of the clause in question—what is the underlying question that the clause seeks to address, and is that a reserved or devolved matter? I have discussed this with parliamentary counsel and others, and the concern is that a blanket provision of this nature may well be premature at this stage. Until we have finalised and determined the constitutional nature and impact of each clause, putting a blanket provision in place may run counter to that process.
Liz Saville Roberts
I have a simple question: in relation to the Sewel convention, if not now, when? We should have clarity on these points. I hope the Minister will forgive me if this is slightly longer than an intervention, but he gives me no option in the here and now but to withdraw the amendments, because I will not push them to a vote if it is likely to be lost. However, these are serious questions. How does this respect the Sewel convention? As a Back-Bench MP, I am not in a position to answer that, and I would have expected the Government to provide clarity on these points earlier than Committee stage. I assure the Minister that I will push this issue on Report if we do not have a satisfactory resolution on the Sewel convention.
Stephen Kinnock
It is, of course, the right hon. Lady’s prerogative to press amendments as and when she sees fit. I am simply flagging that terminology such as “appropriate authority” risks tying the hands of the legislative process in a way that could have perverse outcomes. A clause that should be the lead responsibility of Welsh Ministers could instead end up in the hands of Secretary of State due to the lack of clarity or relative vagueness of the term “appropriate authority”.
The Government’s suggestion is to work through each clause and be specific about the lead responsibility in each case—is it the Secretary of State or Welsh Ministers? We are open to discussing whether it is better to do it that way or with the terminology “appropriate authority”; we are simply flagging that there are risks associated with that term.
Liz Saville Roberts
Before the Minister sits down, will he commit to engaging with me on this issue to identify the specific needs in the spirit of what I have bought forward?
Stephen Kinnock
Yes, absolutely, and before Report. Let us ensure that we do that, and that parliamentary counsel is in the room. I am not a constitutional lawyer, so we definitely need people in the room who can speak to these issues. Of course, it also needs to be done in close dialogue with colleagues in the Welsh Government, particularly given what was said earlier about the need for a legislative consent motion.
The Chair
For clarity, amendments negatived in Committee, if they are pressed today, can be tabled again on Report. I say that in case the right hon. Lady wished to press the amendment and it was defeated. I hope there was clarity from me on that.
Kim Leadbeater
I welcome this important debate about the impact of this potential legislation on Wales. I thank the right hon. Member for Dwyfor Meirionnydd for her valuable contributions. I also welcome the Minister’s commitment to meet the right hon. Lady and me for discussions with parliamentary counsel and the relevant authorities.
This is really important. The criminal justice system covers England and Wales, so it is important for the Bill to do the same, given that it disapplies the Suicide Act in certain very carefully defined circumstances. But health is, of course, devolved and the Welsh Government quite rightly make decisions on the Welsh NHS. I want to make it clear that I recognise that reality and its importance, and I am fully committed to observing the same conventions that the Government would if this were a Government Bill.
As has been said, I am working with UK Government officials to ensure that the right steps are taken at the right time, and I would expect to engage colleagues in the Welsh Government as the Bill progresses. Indeed, I really look forward to doing so and would be happy to visit the Senate if appropriate—although, as Members can tell, I need to work on my Welsh a bit. I look forward to continuing these conversations.
Liz Saville Roberts
I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Amendment proposed: 359, in clause 5, page 3, line 18, at end insert—
“(ba) who has conducted the preliminary discussion in accordance with section 4,”—(Danny Kruger.)
This amendment requires that the coordinating doctor has conducted a preliminary discussion prior to witnessing the signing of the first declaration.
Question put, That the amendment be made.
Danny Kruger
I beg to move amendment 360, in clause 5, page 3, line 23, at end insert—
“(e) who, If receiving remuneration for the provision of services in connection with the provision of assistance to that person in accordance with this Act, makes publicly available an annual statement setting out total turnover from the provision of services under this Act and the number of patients assisted, and such other information as the Secretary of State may specify by regulations.”
This provides that if the coordinating doctor receives remuneration for providing assisted dying, they must then make a public annual statement about their operation.
The Chair
With this it will be convenient to discuss amendment 361, in clause 5, page 3, line 28, at end insert—
“(7) Regulations under subsection (3)(e) are subject to the affirmative procedure.”
This is linked to Amendment 360.
Danny Kruger
The amendment speaks to the general confusion we remain in about how the assisted dying law would be implemented and who would operate it. We are in a great cloud of unknowing about whether we are talking about an NHS service or a private service. If there were to be a private service and people were to be paid to deliver it outside the NHS, the amendment would clarify obligations regarding how their remuneration would be recorded.
There is an established precedent for publishing financial interests where there is a potential for a conflict of interest. Senior officials in NHS England, NHS trusts and the Medicines and Healthcare products Regulatory Agency must declare financial interests—including relationships with pharmaceutical companies—in public registers. Those interests include consultancy fees, gifts, hospitality, shareholdings in pharmaceutical companies or research funding, because there is a concern that those influence drug approvals, procurement and healthcare policy and that there is a risk of bias.
NHS England guidance on managing conflicts of interest encourages the detailed disclosure of significant payments from pharmaceutical companies, often with exact figures or ranges for payments above a £500 threshold. The Association of the British Pharmaceutical Industry runs Disclosure UK, which requires pharmaceutical companies to publicly report payments to healthcare professionals and organisations. It would be appropriate to follow this well-established precedent and ensure that people involved in the administration of assisted dying are accountable for the transparency for their remuneration.
Clause 5(3) recognises that there could be a conflict of interest and that there is a risk that someone who is related or might benefit financially may not be a neutral assessor of someone who wishes to die, but clause 40(4), which comes rather late in the Bill—it should be up front—specifies that
“a registered medical practitioner is not to be regarded as benefiting financially or in any other material way from the death of a person by reason only of the practitioner receiving reasonable remuneration for the provision of services”.
Here is where we discover that the Bill does envisage remuneration, but people being remunerated are excluded from the definition of people who financially benefit from the service. To me, that feels dangerous.
Although it has not resolved the question of whether assisted dying is to be an NHS service, the Bill clearly envisages the establishment of a private market for these services, perhaps with a specialist service like Dignitas. Are we content with the Bill’s assertion that remuneration is not a matter for scrutiny? What level of remuneration would we consider reasonable? What level would we consider excessive—remuneration that is capable of influencing a doctor’s thinking? Would they be paid for administering assisted death on a per patient basis, or as a cumulative practice?
As MPs, should we not have some unease at the idea that this could be a highly profitable specialism for private practice? Transparency on what is being charged and who is profiting from the service would help us to understand what is happening in the system that is being established. I suggest that we bring more sunlight into the system, as we do in many other areas.
It is notable that there is little public data on what is charged, or how much revenue assisted dying generates for medical practices, in other countries where assisted dying is a private service. That is regrettable, and I hope we will not replicate that here. We do know that at Dignitas, which is a not-for-profit, the cost for a single patient is between £5,000 and £8,500 in fees alone. What is reasonable remuneration for a practice that provides assisted dying here in the UK? The term is entirely undefined, and I would be grateful for any clarity.
Kim Leadbeater
I understand the hon. Gentleman’s keenness to get to the debate on clause 32, on the provision of the service—we will come to that in due course—but this conversation is about the amendment. To be clear, there is no expectation that assisted dying would be set up as a private enterprise or service. It would be delivered within the provision of the NHS.
Danny Kruger
I am glad to have that suggestion. Clause 32 is extremely broad. It basically empowers the Secretary of State to set up a service in any way they choose, potentially including in the private sector. The hon. Lady says it is not envisaged that would happen, as she is suggesting this should be an NHS service. I am grateful for the clarity, but I wish it were clearer in the Bill.
Danny Kruger
I am glad to hear we will have more clarity. Having assisted suicide as an NHS service is fraught with enormous risks, along the lines we have discussed and will no doubt continue to discuss. At least we have that clarity. If the hon. Lady is going to rule out private provision and profit making or remuneration of people outside the NHS, I would be grateful for amendments specifying that. That would help to address this question.
My amendments would mean that if there is private provision of assisted suicide, as the Bill currently allows, the public and Parliament could understand who is being paid what, which I think is very appropriate.
Jack Abbott
To give the Committee a sense of clarity, is the hon. Gentleman saying he wants the finances to be in the public domain, so that if provision were to go down a private route, everyone would know what an individual is charging for these services? Or is he suggesting a cap on services? What is the intention of his amendments?
Danny Kruger
My amendments state that if a medical professional is paid for delivering assisted suicide, the money they receive should be transparent. The answer is therefore the former.
I do not propose any cap. If we end up with a private service, although the hon. Member for Spen Valley has just told us that we will not, it might be appropriate to create a scale of charges. My suggestion is that we need absolute clarity. I also think we should use the affirmative procedure to approve the regulations on the transparency of finances. This should be something that Parliament expressly approves.
Kit Malthouse (North West Hampshire) (Con)
My interpretation of what the hon. Member for Spen Valley said is that, as long as the service is available on the NHS, it is up to me whether I go private. In such circumstances, I could have it on the NHS if I really wanted. If I chose to go private, as I might if I were having a baby at the Portland hospital or cosmetic surgery at King Edward VII’s hospital in Marylebone, why would my hon. Friend the Member for East Wiltshire want to know the private arrangement between me and my physician?
Danny Kruger
I am grateful for that clarity, although we now seem to be less clear than we were. I understood the hon. Member for Spen Valley to be saying that there will not be private provision, but my right hon. Friend is saying that there may be.
Danny Kruger
It would be helpful if the hon. Lady clarified whether private provision will be allowed under the Bill, because I think we have a party split. My right hon. Friend the Member for North West Hampshire supports private provision, but the hon. Lady suggests this should be done only on the NHS.
Kim Leadbeater
This service, like many others, will be delivered through a range of providers, as alluded to by the right hon. Member for North West Hampshire. I understand the keenness to have this debate now, but we will come on to it further down the line. The hon. Member for East Wiltshire is right that this is really important.
Danny Kruger
It certainly is. Okay, so it could be either. This will be an NHS service, with all the implications for general practice, doctor-patient relations and secondary care and social care, but there will also be an opportunity to deliver it privately, without any clarity or transparency on who is being paid and how.
In answer to my right hon. Friend the Member for North West Hampshire, this is different from cosmetic surgery, as even cosmetic surgery is regulated. In many ways, there is more regulation of the administering of Botox than there is in this Bill. The administering of assisted dying is of a significantly different category and gravity. It is appropriate and important that financial interests are clearly revealed and made public, particularly with the new intervention we are creating. If other hon. Members do not support the amendment, what provisions do they propose that would reveal where there may be potential conflicts of interest and how we may regulate this?
Dr Simon Opher (Stroud) (Lab)
I thank the hon. Member for East Wiltshire for the amendment. The set-up of this scheme is similar to other NHS services. Essentially, a medical professional will opt in to provide the service. That will involve extensive training followed by a short exam, as it does in Australia and California, after which they will be accredited under the scheme—that is how I understand it will happen in the UK. No one is forced to provide the service, but training is offered and many doctors take that up. Therefore, it is a medically based service.
The British Medical Association will then negotiate the fee for doing the assessment with the Department of Health and Social Care. That is not about agreeing to provide the service; it is about doing the assessment. That is mirrored in many aspects of general practice, which itself is a private service contracted to the NHS. It is very complicated. It would be inaccurate to portray this as a private service, where people may profiteer, as it is based on medical professionals performing a duty for which they are trained and for which the price is clear to the general public, because it is negotiated and published.
On publishing the number of patients seen by a single doctor and the fees that doctor has accrued from the scheme, that is not something that happens for things like minor operations, which we perform outside general medical services, although we are rewarded by the Government at a set fee. There are other such services—inserting a coil, for example—where we are given a certain amount of money.
How this is arranged is very complicated. Doing appraisals, being a trainer and all these things have a price attached, and we need training before we can perform the service. I see this scheme as no different. The problem with publishing how many patients have been seen by a single doctor regarding assisted dying is that it puts a target on that doctor. As we have seen with abortion clinics and even this Committee—certain Committee members have been targeted by the press for what they have said—this is a very sensitive issue, and it would not be fair to publish the figures so that doctors could be targeted in the press and made to feel unworthy in all those ways. It is extremely difficult.
Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)
The hon. Gentleman makes a powerful argument about doctors being vilified in the press, but does he believe there is a risk that it may go further and present a genuine safety risk to those doctors?
Dr Opher
Exactly. That is what worries me. I acknowledge what the hon. Member for East Wiltshire said about pharmaceutical sponsorship, but I do not think that has anything to do with what we are talking about here. What we are talking about is specifying what doctors are doing as part of their daily job, for which they are trained. It would not be fair to publish those figures and put those doctors at risk.
Naz Shah
I appreciate what my hon. Friend is saying, because I have mixed views on this. I would like to understand what would be appropriate. My concern is that there will be a difference, because doctors normally have these set-ups for treatment options but, in this instance, the service is not a treatment, so to speak. I genuinely want to understand: in his eyes, what would a good service that provided scrutiny and accountability look like?
Dr Opher
There are examples. Appraising other doctors, for instance, is specified as a job that doctors are trained for, and it is paid at a set rate agreed with the Department of Health and Social Care. There are many instances where this occurs. I totally agree that the fee a doctor attracts for the service should be clearly specified and in the public domain, but I do not agree that a single doctor should be identified as having seen, say, 10 patients who have requested assisted death. I think that is unnecessary, will not lead to increased patient safety and will make it less safe for the medical practitioners too.
Stephen Kinnock
Amendments 360 and 361 introduce requirements on the co-ordinating doctor. Amendment 360 would insert an additional condition into the definition of a co-ordinating doctor and would require a co-ordinating doctor who receives financial payment for providing assisted dying to make an annual statement declaring publicly their total turnover from providing the service, the number of people they have assisted and any other information specified in regulations.
The related amendment 361 would require that any regulations specifying the information to be made available must be subject to the affirmative procedure. It is not clear whether the amendments are intended to apply to both private and NHS providers. It could create difficulty if the requirement were to apply to NHS providers, as a doctor is unlikely to know the total turnover from providing an assisted dying service.
As the Bill’s promoter, my hon. Friend the Member for Spen Valley has said that her intent is to ensure that the assisted dying service is available as an integral part of the NHS. Officials are working on amendments to later clauses to establish the operating model for her consideration.
Rebecca Paul (Reigate) (Con)
Does the Minister not think the word “remuneration” refers to the amount of income received specifically by the doctor, rather than by any organisation or company?
Stephen Kinnock
As my hon. Friend the Member for Stroud has just said, the picture is very complex because there are tariffs for services. Doctors receive a tariff for each service across the entire panoply of everything they do, particularly general practitioners who provide a very wide range of services. They are remunerated on the basis of a tariff that is negotiated in the GP contract between the Department of Health and Social Care and, primarily, the BMA. When a doctor operates in that environment, it is difficult to pick out their turnover from a particular service.
As my hon. Friend the Member for Stroud said, picking out an individual doctor and saying how much money they have made from a particular service, whether assisted dying or any other service, would put a particular focus on that doctor. We are drawing a distinction here with what the tariff could and should be, which we will need to discuss alongside the operating model in later clauses. Moving from being transparent on the tariff to saying, “That doctor over there made this much money from providing this service,” is a whole new ball game.
Danny Kruger
I am grateful to the Minister for raising a number of points, including the extraordinary revelation that we are about to find out how the Bill will operate in practice, with amendments yet to be developed even though we have been debating the Bill for a couple of weeks.
The difference between the tariff and a doctor’s income is fine, but if the tariff is to be clearly specified—no doubt it will be—how could it be complicated to determine how many tariffs a particular practice has received? I recognise that there is a separate question about whether it is appropriate to reveal that, but why is it difficult to identify how many individual tariffs a particular practice has received?
The Minister has described the tariff income, but my other concern is about the sponsorship, gifts, hospitality and fees of all sorts that the pharmaceutical companies are always trying to administer. Will he address the question of whether that should be transparent as well?
Stephen Kinnock
The challenge in the hon. Gentleman’s amendment is the term “total turnover.” A GP would have to extrapolate from the service provided to a whole range of other costs that may apply—for example, the share of the overhead they pay into their primary care network, the share of admin costs or the rent on their building. The definition of total turnover is the entire cost and entire revenue from the tariffs. As officials have made clear, this additional level of complexity would be an onerous task, although not necessarily impossible.
Total turnover is one side of this issue; the other, much more salient point is the quantum leap between having transparency on a particular tariff and pointing at a specific doctor and saying, “You over there—you did this much work on that much tariff, and that’s how much money you made for it.” There is a big difference between the two.
Naz Shah
I also do not like the idea of doctors being identified in such a way, as they have with abortion clinics, but I am trying to understand how we will protect these services. If it is an NHS provision and specialty, with doctors in certain practices signing up to provide services for assisted dying and becoming either the primary or the secondary doctor, by definition those will be the practices to which people will refer. That will become common knowledge, just as it is for musculoskeletal or podiatry services, for example. In this instance, there would be an assisted death service, and there would clearly be practices that do not provide it. How would we then protect the doctors? How will the Government respond to all these concerns?
Stephen Kinnock
If we are specifically talking about the amendments tabled by the hon. Member for East Wiltshire, he is saying that the total turnover from providing this service should be publicly available—it should be published—so I assume he thinks it should be on a website that everybody can see.
My hon. Friend the Member for Bradford West is asking about the knowledge that, if someone wishes to seek an assisted death, they can go to a particular practitioner or service. That is baked into the Bill, and clearly those doctors who wish to opt into the service will be doing so with their eyes open—they will know that they are providing that service. We must ensure that doctors feel protected if there is a sense of risk.
It would of course be deeply regrettable if there were to be threats or risks to doctors, but the evidence from other countries suggests this has not led to some of the deeply unfortunate things we have seen around abortion clinics, for example. It does not seem to have led to that, but of course we as a Government always need to be vigilant in monitoring all our services to ensure that our excellent medical professionals are getting the support they need.
Rebecca Paul
I thank the Minister for that useful explanation. Does he agree that the setting of the tariff will be key, because it could either incentivise or disincentivise the provision of the service?
Stephen Kinnock
I agree. Like any other aspect of what doctors and general practitioners do, this service is based on remuneration. They are professionals and should be remunerated as such, so the tariff will be important. It is also important that we do not jump ahead into defining the operating model. As I said, officials are working on this with the Bill’s promoter, and it will be made clear when we get to the relevant clauses.
Kim Leadbeater
Hopefully the Minister and other colleagues are reassured that, if the Committee agrees to the introduction of the voluntary assisted dying commission, monitoring will be very intense and reporting will be very robust. That might allay some of the fears that have been raised today.
Stephen Kinnock
As I have repeatedly said, the Government are neutral on the fundamental question of the Bill, but we are absolutely committed to ensuring it is workable should it receive Royal Assent. The role of the commission will be pivotal in ensuring that the Bill is workable and that all the necessary monitoring and regulation mechanisms are in place.
Terminally Ill Adults (End of Life) Bill (Nineteeth sitting)
Wednesday 5th March 2025
(1 day, 13 hours ago)
Public Bill CommitteesTerminally Ill Adults (End of Life) Bill 2024-26 View all Terminally Ill Adults (End of Life) Bill 2024-26 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 5 March 2025 - (5 Mar 2025)
The Committee divided: - Ayes: 8 / Noes: 13 - Question accordingly negatived.
The Chair
I wish to notify the Committee that I have selected amendment (a) to amendment 420 for a separate decision. When amendment 420 is moved, I will invite Danny Kruger to move amendment (a) to amendment 420 formally.
Let me also say that I will not tolerate the word “you”, that I will not tolerate long interventions and that Members are to address the Chair, not other members of the Committee. If we stick to those rules, I am sure we will get along just fine.
Clause 5
Initial request for assistance: first declaration
Amendment proposed (this day): 360, in clause 5, page 3, line 23, at end insert—
“(e) who, if receiving remuneration for the provision of services in connection with the provision of assistance to that person in accordance with this Act, makes publicly available an annual statement setting out total turnover from the provision of services under this Act and the number of patients assisted, and such other information as the Secretary of State may specify by regulations.”—(Danny Kruger.)
This provides that if the coordinating doctor receives remuneration for providing assisted dying, they must then make a public annual statement about their operation.
Question again proposed, That the amendment be made.
The Chair
I remind the Committee that with this we are discussing amendment 361, in clause 5, page 3, line 28, at end insert—
“(7) Regulations under subsection (3)(e) are subject to the affirmative procedure.”
This is linked to Amendment 360.
Kim Leadbeater (Spen Valley) (Lab)
I have nothing further to add in this debate.
Danny Kruger (East Wiltshire) (Con)
In the light of the suggestion from the hon. Member for Spen Valley that there will be further amendments later, when we can discuss the shape of the provision and presumably any remuneration, I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Amendment proposed: 186, in clause 5, page 3, line 23, at end insert—
“(3A) The Secretary of State must by regulations make provision about the training, qualifications and experience that a registered medical practitioner must have in order to act as the coordinating doctor.
(3B) The regulations must include training about—
(a) assessing capacity;
(b) assessing whether a person has been coerced or pressured by any other person.
(3C) Subject to that, the regulations may in particular provide that the required training, qualifications or experience is to be determined by a person specified in the regulations.”—(Kim Leadbeater.)
See the statement for Amendment 185.
Amendment made to amendment 186: (a), after
“(b) assessing whether a person has been coerced or pressured by any other person.”
insert
“(c) specific and up-to-date training on reasonable adjustments and safeguards for autistic people and people with a learning disability.”—(Daniel Francis.)
Amendment 186, as amended, agreed to.
Kim Leadbeater
I beg to move amendment 187, in clause 5, page 3, line 24, leave out subsection (4).
This amendment is consequential on NC8, which contains a single duty to consult before making regulations under various provisions of the Bill.
The Chair
With this it will be convenient to discuss the following:
Amendment 188, in clause 5, page 3, line 28, leave out subsection (6).
This amendment is consequential on Amendment 233, which contains a single set of provisions about the procedure for regulations under the Bill.
Amendment 192, in clause 6, page 3, line 36, leave out subsection (4).
See the statement for Amendment 188.
Amendment 199, in clause 8, page 5, line 28, leave out subsection (8).
See the statement for Amendment 187.
Amendment 200, in clause 8, page 5, line 30, leave out subsection (9).
See the statement for Amendment 188.
Amendment 206, in clause 11, page 7, line 24, leave out subsection (3).
See the statement for Amendment 188.
Amendment 211, in clause 19, page 13, line 31, leave out subsection (5).
See the statement for Amendment 187.
Amendment 212, in clause 19, page 13, line 33, leave out subsection (6).
See the statement for Amendment 188.
Amendment 213, in clause 20, page 13, line 39, leave out subsection (3).
See the statement for Amendment 188.
Amendment 215, in clause 28, page 17, line 11, leave out subsection (3).
See the statement for Amendment 188.
Amendment 216, in clause 30, page 18, line 37, leave out subsection (4).
See the statement for Amendment 188.
Amendment 217, in clause 30, page 18, line 38, leave out “that procedure” and insert “section 39”.
See the statement for Amendment 188.
Amendment 218, in clause 32, page 19, line 31, leave out subsection (4).
See the statement for Amendment 188.
Amendment 219, in clause 33, page 20, line 24, leave out subsection (5).
See the statement for Amendment 188.
Amendment 222, in clause 38, page 23, line 1, leave out subsection (2).
See the statement for Amendment 188.
Amendment 233, in clause 39, page 23, line 6, leave out subsections (3) to (5) and insert—
“(5A) The Secretary of State may not make a statutory instrument containing (whether alone or with other provision) regulations under section 5(3A), 8(6A), 30(3) or 32 unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.
(5B) Any other statutory instrument made by the Secretary of State containing regulations under this Act is subject to annulment in pursuance of a resolution of either House of Parliament.”
This amendment brings together the various provisions about the procedure for regulations and makes regulations under clauses 5 and 8 about training, qualifications and experience subject to the draft affirmative procedure.
Amendment 225, in clause 40, page 23, leave out line 23.
The amendment is consequential on Amendment 233.
Amendment 226, in clause 40, page 23, leave out line 37.
The amendment is consequential on Amendment 233.
New clause 8—Duty to consult before making regulations—
“(1) Before making regulations under section 5, 7, 8, 13, 19 or 21, the Secretary of State must consult—
(a) the Commission for Equality and Human Rights, and
(b) such other persons as the Secretary of State considers appropriate.
(2) The persons to be consulted under subsection (1)(b) must include —
(a) persons appearing to the Secretary of State to have expertise in matters relating to whether persons have capacity, and
(b) persons appearing to the Secretary of State to have expertise in matters relating to whether persons have been coerced,
unless the Secretary of State considers that, having regard to the subject-matter of the proposed regulations, it would not be appropriate to consult such persons.”
This new clause imposes a duty to consult before making regulations under various provisions of the Bill.
Kim Leadbeater
This group of amendments is consequential on new clause 8, which would create a single duty for the Secretary of State to consult before making regulations under various provisions of the Bill. It would consolidate the previous requirements to consult in relation to clauses 5, 8 and 19 and expand the duty to cover additional clauses. It would require the Secretary of State to consult the Equality and Human Rights Commission and such other persons as the Secretary of State considers appropriate. The persons to be consulted under subsection (1)(b) must include persons appearing to the Secretary of State to have expertise in matters relating to whether persons have capacity, and persons appearing to the Secretary of State to have expertise in matters relating to whether persons have been coerced.
This is an important strengthening of the Bill. It applies to multiple clauses: clauses 5, 7, 8, 13, 19 and 21. The duty to consult experts, particularly on issues around capacity and assessing for coercion, is an important change that reflects the detailed debate that the Committee has undertaken on those two important issues.
Amendment 233 brings together the various provisions about the procedure for regulations. It would make the regulations to be made under clauses 5 and 8, on training, qualifications and experience, subject to the draft affirmative procedure, so that Parliament has to debate and approve them first. Again, that would strengthen the Bill.
Danny Kruger
In a sense, this is a technical set of amendments that consolidate the provisions for secondary legislation. However, it reflects the seriousness of a concern that I and others have raised, which is that so much in this Bill will be left to the discretion of Ministers, often through the negative procedure.
It is important to reflect briefly on the questions that we are considering. The hon. Lady has mentioned quite a few of them, but we are talking about the training of doctors; the High Court procedure, if there is one; the substances that may be used in the administration of assisted death; the prescribing of those substances; the registration of deaths; the codes of practice to be introduced; provision through the NHS; notification to the chief medical officers; changing the schedules in the Bill, and so on.
Those are important matters. I recognise that many of them are complicated and technical, and that it is appropriate to leave them to a degree of professional and ministerial discretion. Nevertheless, my great concern, which relates to the parliamentary procedure—you may have a view on this, Mrs Harris—is that we are having this debate without the benefit of a delegated powers memorandum to explain why each power has been taken, the nature of it, the reason for taking the power and the procedure to be selected.
In a recent report on the Bill, the Hansard Society notes that under the Government’s “Guide To Making Legislation”, a delegated powers memorandum would normally be published prior to Second Reading for a private Member’s Bill on issues of conscience on which the Government are neutral. The report explains that a delegated powers memorandum gives
“details of each power in the bill, including its context, its scope, to whom the power is delegated, and the parliamentary scrutiny procedure…the reasons for taking the power; and…why.”
It points out that
“where the responsible department recommends that the Government should support the Private Member’s Bill or remain neutral then a DPM should be produced for consideration by the relevant Cabinet Committee—the Parliamentary Business and Legislation (PBL) Committee—alongside other key documents such as the explanatory notes, a legal issues memorandum, and an impact assessment”.
We have not yet had an impact assessment either.
The Chair
Order. I ask the hon. Member to speak to the amendments. You have gone out of scope.
Danny Kruger
I am sorry about that. I am trying to make the point that the amendments would all grant a large number of powers to Ministers through the statutory instrument procedure. That is why I am referring to the Hansard Society report.
Danny Kruger
I understand, but it would be interesting to know whether the Government have produced a delegated powers memorandum, and when it will be published.
I have four quick points to make about my concerns about the amendments and new clause 8. First, new clause 8 provides that when making the SIs, the Secretary of State must consult the Equality and Human Rights Commission. That is a very positive step, but the other provisions on who should be consulted are, on closer inspection, illusory. The Secretary of State must consult those with expertise on capacity and coercion—that is all great—unless he or she considers that
“it would not be appropriate”.
What the new clause gives with one hand, it takes with the other. It would be good to identify in the Bill who the groups are that the Secretary of State must consult for each power.
Secondly, the vast majority of the SIs made under the Bill, as amended by the amendments, are to be made by the negative procedure. The last time that an SI subject to the negative procedure was annulled by the House of Commons was 1979. The procedure gives only the outward appearance of involving Parliament again. The SIs take effect when signed by the Minister, subject only to a motion of either House to annul them. However, by strong convention the Lords will do no such thing, and the convention in the Commons is that the Government will make time to debate such a motion only if it is put forward by the Opposition Front Bench, and it is at the Government’s discretion.
This being a matter of conscience, it is unlikely that any Opposition Front Bench would be in a position to table such a motion, and no one else has any standing. In practice, that means that there will be no opportunity for parliamentary scrutiny on, which lethal substances may be approved, for example, or on what events should be notified to the chief medical officer. These are not mere details.
Thirdly, on some of the matters addressed in the amendments it is doubtful whether the use of delegated powers is even appropriate, because even if there is a debate and a vote in Parliament, debate on an SI is limited to 90 minutes only and an SI is not amendable. In fact, the House of Lords Delegated Powers and Regulatory Reform Committee considered it improper that the Assisted Dying Bill introduced by Baroness Meacher gave the power to the Secretary of State to decide which substances should be allowed to cause death, because it was an inappropriate question for an SI.
Finally, and perhaps most substantially, clause 32 will establish a vast Henry VIII power. It allows Ministers even to amend primary legislation, and those changes would be subject to a simple yes or no vote in the Commons, without the possibility of amendment. It has been suggested in the Hansard Society podcast with the drafter of the Bill that the power is there because provision on the NHS could be made only if section 1 of the National Health Service Act were modified, removing the duty of the Secretary of State to improve the “physical and mental health” of the public. I look forward to seeing whether the amendments that have been promised include that. However, they will not necessarily amend the National Health Service Act, because that could be done under the statutory instruments created in these amendments.
If such a foundational piece of legislation as the National Health Service Act needs to be modified to allow this law to pass, surely it would be better to do it on the face of the Bill. I want to know why a Henry VIII power is needed. I hope that the Government might bring forward the relevant amendments to the Bill so that a Henry VIII power is not needed. I see that the hon. Member for Spen Valley is nodding, which is encouraging.
I stress that the Committee must bear it in mind that this power would exist on the statute book forever, unless the statute is repealed, so any Government could use this power. The last time that a Parliament found its voice to reject an SI by the negative procedure was back in the 1970s. When we come to a decision on amendment 233 and new clause 8, I will seek to make further amendments.
Daniel Francis (Bexleyheath and Crayford) (Lab)
It is a pleasure to serve under your chairship, Mrs Harris. It would be remiss of me not to comment briefly on new clause 8, given that throughout this process I have consistently raised issues around evidence given by the Equality and Human Rights Commission, and given that new clause 8 states that before making a recommendation the Secretary of State must consult the commission.
I remind hon. Members that the commission has told us that it strongly recommends that
“at the earliest opportunity, Parliament is provided with further information and assurance about the bill’s compatibility with equality and human rights.”
It went on to say that its concerns were that the Bill
“may also particularly impact disabled people. We recognise that this bill is focused on assisted dying for adults who are terminally ill, and does not propose access to assisted dying on the basis of disability or chronic conditions. However, there is not always a clear line between terminal illness and disability. Disabled people can also suffer from terminal illness, and illness may itself amount to a disability.”
It has also stated:
“A vital factor in determining how to manage access to assisted dying will be the concept of mental capacity…It will be important to ensure that all decision-makers involved in the process have a full and clear understanding of the law around mental capacity under the Mental Capacity Act 2005.”
I welcome new clause 8, which is in the name of my hon. Friend the Member for Spen Valley, as it would ensure that the Equality and Human Rights Commission is consulted. We await its comments, which hopefully we will have before Report, on whether the concerns that it raised, both in writing before Second Reading and in their oral evidence, have been allayed. However, I welcome this initial commitment, and we will see where that brings us on Report.
The Minister for Care (Stephen Kinnock)
It is a pleasure to serve under your chairship, Mrs Harris. The amendments have been tabled by my hon. Friend the Member for Spen Valley in consultation with the Government. This reflects the Government’s role in ensuring that the Bill is legally robust and workable. The amendments relate to the regulation-making powers and bring together various provisions about procedure and requirements for regulations and consultation.
I will address the amendments in two groups, starting with new clause 8 and its consequential amendments 187, 199 and 211. The new clause contains a duty to consult before making regulations; it is intended to consolidate three subsections that contain duties to consult before making regulations, as set out in the original draft of the Bill under clauses 5, 8 and 19. In addition to retaining the existing duties to consult before making regulations in clauses 5, 8 and 19, the new clause requires the Secretary of State to consult before making regulations under clauses 7, 13 and 21, and brings together these requirements under a single duty.
The new clause would place an additional requirement on the Secretary of State to consult the Equality and Human Rights Commission, as well as such other persons that the Secretary of State considers appropriate. The latter group must include persons with expertise in matters relating to whether persons have capacity or have been coerced, unless it would not be appropriate to consult such persons.
I turn to amendments 233, 188, 192, 215 to 219, 222, 225, 226, 212, 213, 200 and 206. There are provisions throughout the Bill, as it is currently drafted, about the procedure for making regulations. All regulations, except for those made under clause 5(3)(a), clause 8(6)(a), clause 30(3) and clause 32, are required to be made under the negative procedure. Amendment 233 would bring together the various provisions about the procedure for making regulations into a single clause, clause 39, thereby removing repetition in the Bill. The amendment seeks to achieve that by replacing subsections (3) to (5) in clause 39 with the following:
“(5A) The Secretary of State may not make a statutory instrument containing (whether alone or with other provision) regulations under section 5(3A), 8(6A), 30(3) or 32 unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.
(5B) Any other statutory instrument made by the Secretary of State containing regulations under this Act is subject to annulment in pursuance of a resolution of either House of Parliament.”
The amendment would require that any regulations made under those provisions must be laid before, and approved by, a resolution of both Houses of Parliament. This procedure, the draft affirmative procedure, will apply to regulations setting the training, qualifications and experience of both the co-ordinating and the independent doctors, establishing a code of practice and securing arrangements for the provision of assisted dying under the Act. Any other statutory instrument made under powers within the Bill will remain subject to the negative procedure.
As I have said, the Government have taken a neutral position on the substantive policy questions. These comments relate to the legal and regulatory side of the Bill, and I hope that my observations are useful to the Committee.
Kim Leadbeater
I have nothing further to add.
Amendment 187 agreed to.
Amendment made: 20, in clause 5, page 3, line 25, at end insert—
“(4A) Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”—(Daniel Francis.)
This amendment would require the registered medical practitioner acting as the coordinating doctor to have undertaken training on domestic abuse, including coercive control and financial abuse.
Amendment made: 188, in clause 5, page 3, line 28, leave out subsection (6).—(Kim Leadbeater.)
This amendment is consequential on Amendment 233, which contains a single set of provisions about the procedure for regulations under the Bill.
Clause 5, as amended, ordered to stand part of the Bill.
Clause 6
Requirement for proof of identity
Kim Leadbeater
I beg to move amendment 189, in clause 6, page 3, line 30, leave out
“where a person makes a first declaration”
and insert
“in relation to the making of a first declaration by a person”.
This amendment adjusts the wording so as not to suggest that a first declaration has been made before it is witnessed.
The Chair
With this it will be convenient to discuss the following:
Amendment 190, in clause 6, page 3, line 31, leave out
“at the same time as that declaration is made”
and insert “before signing that declaration”.
This amendment provides that the required two forms of proof of identity must be provided before the person signs the first declaration.
Amendment 291, in clause 6, page 3, line 33, at end insert—
“(2A) At least one of the forms of identity required under subsection (2) must contain photographic proof of identity.
(2B) The person must, at the same time as that declaration is made, provide proof that they have been resident in the UK for at least a year to the coordinating doctor and the witness mentioned in section 5(2)(c)(ii).”.
This would require a person to produce a form of photographic ID and proof they have been resident in the UK when making the first declaration.
Amendment 292, in clause 6, page 3, line 34, leave out “may” and insert “must”.
This places an obligation on the Secretary of State to make regulations on proof of identity.
Amendment 191, in clause 6, page 3, line 35, at end insert—
“(3A) The coordinating doctor may witness the first declaration only if satisfied that the requirements of subsection (2) have been met.”
This amendment provides that the coordinating doctor may witness the first declaration only if satisfied that the requirements of subsection (2) are met.
Amendment 419, in clause 6, page 3, line 35, at end insert—
“(3B) The coordinating doctor may witness the first declaration only if—
(a) the coordinating doctor has conducted a preliminary discussion with the person or is satisfied that another registered medical practitioner has conducted such a discussion, and
(b) the coordinating doctor has made or seen a written record of the preliminary discussion.”
This amendment provides that the coordinating doctor may witness the first declaration only if satisfied that a preliminary discussion of the kind mentioned in clause 4 has taken place and that a written record of it has been made.
Amendment 293, in clause 6, page 3, line 36, leave out “negative” and insert “affirmative”.
This will change the process to the affirmative procedure for statutory instruments specifying acceptable forms of ID for the first declaration.
Kim Leadbeater
Amendment 419 provides that the co-ordinating doctor may witness the first declaration only if satisfied that a preliminary discussion of the kind mentioned in clause 4 has taken place and that a written record of it has been made. The co-ordinating doctor must have made or seen a written record of the preliminary discussion. Amendment 189 adjusts the wording so as not to suggest that a first declaration has been made before it is witnessed to clarify that proof of identity must be provided before the declaration is signed and witnessed.
Amendment 190 provides that the required two forms of proof of identity must be provided before the person signs the first declaration. Amendment 191 provides that the co-ordinating doctor may witness the first declaration only if satisfied that the requirements of clause 6(2) are met; that is to say, that the patient has provided two forms of identity to the co-ordinating doctor. This is a relatively straightforward set of amendments to tidy up the requirements around proof of identity.
Naz Shah (Bradford West) (Lab)
I rise to speak to amendments 291, 292 and 293, which were tabled by my hon. Friend the Member for York Central (Rachael Maskell). I do not intend to press them to a vote; they are probing amendments. They all relate to the amendments tabled by my hon. Friend the Member for Spen Valley about the identification required of applicants for assisted dying. They do not change those requirements; they take a more logical and businesslike approach to proving that those requirements are met.
Amendment 291 would change the current requirements on identification and require applicants for assisted dying to produce a piece of photo ID and proof of residence in the UK for the previous year. As currently written, clause 6(2) states:
“The person must, at the same time as that declaration is made, provide two forms of proof of identity to the coordinating doctor and the witness mentioned in section 5(2)(c)(ii).”
Subsection (3) states:
“The Secretary of State may, by regulations, make provision about the forms of proof of identity that are acceptable for the purposes of subsection (2).”
Surely that is not tight enough.
In particular, the Bill as written does not specify that either form of proof of identity should be photo ID. That may be a major omission. For much less significant decisions, the law of England and Wales requires at least one form of photographic ID. For example, there is currently a requirement to have photo identity to work on the parliamentary estate, vote, or have a bus pass or railcard. None of those is as important as applying for an assisted death.
I remind hon. Members that assisted death is a process that would end in a person being issued with and then taking a mixture of lethal drugs. In a hospital setting where drugs are dispensed, rigorous processes are undertaken to verify the patient. Drug errors are not uncommon. The previous Health and Social Care Committee’s report into pharmacy witnessed how clinical practice was being improved to reduce drug errors. Given that a lethal dose is dispensed as part of this process, the identification mechanisms are weak and should be addressed in this preliminary stage through the provisions set out in this amendment. It is possible that the wrong person could be prescribed the medication. That would be an extreme case, but we are talking about creating a wholly new power that would relate to life and death. We are talking about making assisted dying available to people who are, in many cases, extremely distressed. People in extreme circumstances will sometimes do extreme things. We should expect some extreme cases and seek to guard against them.
Amendment 291 would provide such a safeguard. The Bill says that to qualify for assisted dying, applicants must have been resident in the UK for at least a year, but it does not ask them to provide any proof of that residence. In such a serious matter, we surely cannot simply accept someone’s word that they live in the UK. Making that a requirement without a test to establish it de-values the importance of the criteria for qualifying.
Amendment 292 would change clause 6(3), which currently reads,
“The Secretary of State may, by regulations, make provision about the forms of proof of identity that are acceptable for the purposes of subsection (2).”
The amendment would change that “may” to a “must”, as the former treats the identification process with reduced seriousness. If the word “may” stays in legislation, there is no obligation to have rigour in the identification process. As drafted, the Bill is more open for abuse.
Amendment 293 seeks to place the regulations concerning identification under the affirmative procedure, which the hon. Member for East Wiltshire mentioned earlier. Assisted dying is so important that no regulations made under it should be drawn using the negative procedure. As Members will know, if a statutory instrument is made under the affirmative procedure, it must be approved by Parliament within a certain timeframe, which is usually 28 or 40 days. If that does not happen, the change to the law made by the statutory instrument will not take place. In the Bill as drafted, these regulations are covered by the negative procedure, which means that if and when the Secretary of State decides to change them, they could go through on the nod unless Members raised an objection. A statutory instrument laid through the negative procedure becomes law on the day the Minister signs it and automatically remains law unless a motion rejecting it is passed by either House within 40 sitting days.
Placing all changes to regulations under the affirmative procedure would ensure that we have scrutiny by Parliament. We should all approve this. Our responsibility for this legislation will not end when and if it becomes an Act of Parliament. These amendments speak to tighter safeguards and parliamentary scrutiny for all new regulations made by the Secretary of State in relation to identity and residence. All hon. Members should support them.
Danny Kruger
I will quickly echo the points well made by the hon. Member for Bradford West in support of the amendments in the name of the hon. Member for York Central. It is important to specify the form of identity that will be presented. The person presenting themselves for an assisted death needs to be who they say they are. At the moment, the power to specify the forms of proof of identity has no minimum requirements. As written, it does not require the Secretary of State to specify what is acceptable.
Two specific aspects we have to pay particular care to are age and residency. The process must be accessible only to over-18s. I am concerned that we rejected amendments yesterday that would have prevented people under 18 having the conversation. In light of that, it is even more important that we make it clear that people who access assisted death must be adults. We need to ensure that the forms of identity are specified and that Parliament can satisfy itself that they are robust.
Kim Leadbeater
We did not reject proposals for the preliminary discussion not to be taken by people under 18. We actually put a clause into the Bill that would ensure that the preliminary discussion was not taken with someone under 18.
Danny Kruger
That is right. The preliminary discussion will not, but there is nothing to stop the conversation beginning before the person is 18. I know they cannot formally begin the process of an assisted death, but the concern—although I will not revisit the debate—was that the topic should not be raised or discussed with children, and we did not succeed in that.
The proposal is to ensure that we have proper ID—a passport, driving licence or other combined photo ID and proof of age, so a birth certificate must be paired with something if it is to be robust. We think such questions should be reflected more clearly in the Bill. All sorts of ID would not be appropriate, such as student ID, a sworn statement with no underpinning official record and other such things, which we want to avoid.
Stephen Kinnock
This group of amendments refines the requirements related to the first declaration, clarifying the witnessing process, identity verification and regulatory obligations. I will take the amendments in turn.
In executing our duties to ensure that the legislation, if passed, is legally robust and workable, in this group the Government have worked with my hon. Friend the Member for Spen Valley on amendments 189 to 191 and 419. Amendment 189 would clarify the requirement for proof of identity when making a first declaration. It would adjust the wording to make it clear that proof of identity must be provided before a person signs a declaration, ensuring no ambiguity about when the requirement applies.
As with amendment 189, amendment 190 clarifies the requirement for proof of identity when making a first declaration. This amendment would make it clear that a person must provide two forms of proof of identity before signing the declaration, rather than simply at the same time. That ensures that both the co-ordinating doctor and the witness have received the necessary proof before the declaration is signed.
Amendment 191 ensures that the co-ordinating doctor can witness the first declaration only if they are satisfied that the person has provided two forms of proof of identity. The doctor must therefore first be satisfied that the required proof has been given to them and to the witness before proceeding with witnessing the signing of the declaration.
Amendment 419 requires that, before witnessing the first declaration, the co-ordinating doctor must be satisfied that a preliminary discussion has taken place, whether that was conducted by the co-ordinating doctor or another registered medical practitioner. The co-ordinating doctor must also have made or seen a written record of the preliminary discussion.
Amendment 291 adds to the requirement around proof of identity when making a first declaration. It requires that one of the forms of ID provided to the co-ordinating doctor and witness be photographic. The person must also provide proof of residence at this stage of the process. I note we would expect this type of issue to be considered by the Secretary of State when making regulations about forms of proof of identity that are acceptable, as already provided for in clause 6(3). Requiring a person to provide proof that they have been resident in the UK for at least 12 months appears to impose a different residency requirement to other parts of the Bill. Specifically, “being resident” is a looser test than being “ordinarily resident”, in clause 1, and “in the UK” is broader than “in England and Wales”, also in clause 1. In consequence, our assessment is that this amendment may make the Bill less legally coherent.
Rebecca Paul (Reigate) (Con)
I want to raise a question on photo ID. My apologies, I probably should have spoken sooner. Thinking this through as we have debated, I think photographic ID is important to avoid mistaken identity and fraud, and to make sure everything works as it should. With respect to this process, would the Minister normally expect photographic ID to be an acceptable or appropriate form of identification?
Stephen Kinnock
Yes, I believe so. Photographic ID would be the standard to which we would aspire. I do not know whether there was anything else under her question? I think the answer is yes.
Sojan Joseph (Ashford) (Lab)
Could the Minister clarify whether the requirement for one year of residency in the UK means that a foreign citizen studying at a university here would be able to consider assisted dying?
Stephen Kinnock
I thank my hon. Friend for that intervention. We have the term “ordinarily resident” in the UK in clause 1. Obviously if the Committee sees fit to accept the amendment it would change to “resident”, which is a looser term. This matter would also be one for the Home Office, as the custodian of our rules and regulations on immigration, but my sense would be that if we stick with “ordinarily resident” then someone who is not ordinarily resident in the United Kingdom would not qualify for assisted dying.
As the Bill currently stands, the Secretary of State has the power but not the obligation to set these requirements in regulations. This amendment would remove this discretion and require the Secretary of State to specify what forms of ID must be provided.
Amendment 293 ensures that regulations on acceptable forms of proof of identify must be approved by both Houses of Parliament before coming into force, by requiring these regulations to follow the affirmative rather than the negative procedure. As I said earlier, the Government’s position is neutral, but I hope my observations—
Kim Leadbeater
This is a thought based on the comments by the hon. Member for Reigate. The issue of photographic ID is worth giving consideration. Photo ID is used in multiple settings for different reasons. My slight concern is that some of the people we are thinking about with this Bill would be older and I think of some of my own family members who no longer have driving licences, passports or potentially any form of photographic ID. I would be concerned this could be a barrier for terminally ill people. Considering we are making this a robust process, which I totally agree with, I would be concerned that might present an issue.
Stephen Kinnock
I thank my hon. Friend for that intervention. She makes a very good point. It is definitely something that needs to be explored, to ensure that people are not being excluded for the reasons she set out. It is a different example, but when voter ID was introduced a special ID card was created by the Government to cater for exactly the situation she set out. We have to find a way of ensuring that people are not excluded because of that technicality. She makes a valid point.
Kit Malthouse (North West Hampshire) (Con)
Scanning back through my experience of the health service, I do not remember ever having to show my ID, whatever the procedure or medical service. I do not remember showing ID to witness the birth of my children or my wife having to show her ID. I am not sure that is common in the health service. Why would we introduce it for this? I can go in and have a heart bypass and not be asked to show my ID. My assumption is that often people will have been—
Stephen Kinnock
This section of the Bill covers the issue of ID and says that proof of ID is required. I am simply responding to the requirements of the Bill. I am more than happy to have a debate about ID cards and all sorts of other issues more broadly—
Stephen Kinnock
I look forward to having that debate on another day. Unless other colleagues want to intervene, I will now sit down, to the delight of the Chair.
Kim Leadbeater
You will be delighted, Chair, that I have nothing further to add.
Amendment 189 agreed to.
Amendments made: 190, in clause 6, page 3, line 31, leave out
“at the same time as that declaration is made”
and insert “before signing that declaration”.
This amendment provides that the required two forms of proof of identity must be provided before the person signs the first declaration.
Amendment 191, in clause 6, page 3, line 35, at end insert—
“(3A) The coordinating doctor may witness the first declaration only if satisfied that the requirements of subsection (2) have been met.”
This amendment provides that the coordinating doctor may witness the first declaration only if satisfied that the requirements of subsection (2) are met.
Amendment 419, in clause 6, page 3, line 35, at end insert—
“(3B) The coordinating doctor may witness the first declaration only if—
(a) the coordinating doctor has conducted a preliminary discussion with the person or is satisfied that another registered medical practitioner has conducted such a discussion, and
(b) the coordinating doctor has made or seen a written record of the preliminary discussion.”
This amendment provides that the coordinating doctor may witness the first declaration only if satisfied that a preliminary discussion of the kind mentioned in clause 4 has taken place and that a written record of it has been made.
Amendment 192, in clause 6, page 3, line 36, leave out subsection (4).—(Kim Leadbeater.)
See the statement for Amendment 188.
Clause 6, as amended, ordered to stand part of the Bill.
Clause 7
First doctor’s assessment (coordinating doctor)
Amendment proposed: 296, in clause 7, page 4, line 2, leave out from “must” to end of line 3, and insert
“after a first declaration is made by a person, arrange a time and which is convenient for both the medical practitioner and the person date that does not jeopardise the care of other patients, to carry out the first assessment.”—(Naz Shah.)
This amendment replaces the requirement that the coordinating doctor to arrange a first assessment as soon as practicable with a requirement to arrange it for a mutually convenient time which doesn’t jeopardise the care of other patients.
The Chair
With this it will be convenient to discuss the following:
Amendment 127, in clause 7, page 4, line 2, leave out
“as soon as reasonably practicable”
and insert “within 10 working days”.
The amendment requires the coordinating doctor to carry out an assessment under the Act within ten working days.
Amendment 128, in clause 7, page 4, line 23, leave out “as soon as practicable” and insert “within 10 working days”.
This amendment would require the coordinating doctor to refer a person within 10 working days rather than as soon as practicable to another registered medical practitioner to carry out the second assessment.
Amendment 129, in clause 8, page 4, line 29, leave out
“as soon as reasonably practicable,”
and insert “within 10 working days”.
This amendment would require the independent doctor to carry out the second assessment within 10 working days rather than as soon as practicable to another registered medical practitioner to carry out the second assessment.
Amendment 130, in clause 16, page 11, line 19, leave out “as soon as practicable,” and insert “within 10 working days”.
This amendment would require the coordinating doctor, where they are a practitioner with the person’s GP practice to record the making of the declaration or statement, or the refusal to make the declaration or statement, in the person’s medical records within 10 working days rather than as soon as practicable.
Amendment 131, in clause 16, page 11, line 23, leave out “as soon as practicable,” and insert “within 10 working days”.
This amendment would require the coordinating doctor, where they are not practitioner with the person’s GP practice, to give a registered medical practitioner from that practice notice of the making of the declaration or statement, or the refusal to make the declaration or statement, in the person’s medical records within 10 working days rather than as soon as practicable.
Amendment 132, in clause 16, page 11, line 27, leave out “as soon as practicable,” and insert “within 10 working days”.
This amendment would require the coordinating doctor, where they are not a practitioner with the person’s GP practice to record the making of the declaration or statement, or the refusal to make the declaration or statement, in the person’s medical records within 10 working days rather than as soon as practicable.
Amendment 133, in clause 17, page 11, line 38, leave out “as soon as practicable,” and insert “within 10 working days”.
This amendment would require the coordinating doctor, where they are not a practitioner with the person’s GP practice to record the making of the declaration or statement, or the refusal to make the declaration or statement, in the person’s medical records within 10 working days rather than as soon as practicable.
Amendment 134, in clause 17, page 12, line 2, leave out “as soon as practicable,” and insert “within 10 working days”.
This amendment would require the medical practitioner to whom notice or indication of the cancellation of declaration is given to notify a registered medical professional from the person’s GP practice within 10 working days rather than as soon as practicable.
Amendment 135, in clause 17, page 12, line 5, leave out “as soon as practicable,” and insert “within 10 working days”.
Amendment 136, in clause 21, page 14, line 12, leave out “as soon as practicable,” and insert “within 10 working days”.
Amendment 137, in clause 21, page 14, line 15, leave out “as soon as practicable,” and insert “within 10 working days”.
Amendment 138, in clause 21, page 14, line 18, leave out “as soon as practicable,” and insert “within 10 working days”.
Amendment 139, in clause 22, page 14, line 27, leave out “as soon as practicable,” and insert “within 10 working days”.
Amendment 140, in clause 22, page 14, line 30, leave out “as soon as practicable,” and insert “within 10 working days”.
Amendment 141, in clause 22, page 14, line 33, leave out “as soon as practicable,” and insert “within 10 working days”.
Jake Richards (Rother Valley) (Lab)
I was expecting someone else to have spoken in support of amendment 296, but I will be very brief. The tone of the debate so far has been respectful, and it should continue to be so. I hope that this will not be characterised as a personal attack on my hon. Friend the Member for York Central, who tabled the amendment, or anyone else who supports it, but this is a shocking amendment. It is shocking because I doubt that the motives behind it are to improve the Bill or make it safer. In fact, I fear that the motives are to build a political attack to support opposition to the Bill, rather than to be constructive in improving it.
I have come to that conclusion because there is no concept in any other piece of legislation, or in any healthcare guidance in operation, that would ever presuppose that a clinician would undertake a consultation, assessment or meeting that would ever put other patients in danger. I fear that this amendment has been tabled because some people are attempting to assert, perhaps not purposefully or wilfully, that the introduction of an assisted dying system would somehow force clinicians to put other patients at risk. If that is the assertion, that is wrong and—in my view—shocking. It is a shocking indictment on their view of our medical practitioners in the NHS.
Danny Kruger
The hon. Gentleman is impugning the motivation of his colleague, the hon. Member for York Central, who is herself an experienced practitioner in the NHS. To suggest that she has tabled this amendment improperly is a serious accusation, which I cannot believe that he really wants to make against his colleague. He said that the amendment’s intention is to suggest that assisted dying would cause problems in the NHS, but the explicit terms of the amendment are to ensure that that does not happen. Of course, no practitioner would want to take choices that would prejudice other patients’ care.
The Chair
Order. Mr Kruger, you are down to speak and you can make your point then. I want interventions to be short.
Jake Richards
I am grateful, Chair, and I can take further interventions on any further points from the hon. Gentleman, but I will deal with that one. This is not a personal criticism of my hon. Friend the Member for York Central. I do not doubt that she has good intentions. What I stated was that her opposition to the principle of the Bill is guiding some of the amendments that she has tabled, and this is one of them.
Jake Richards
Not only do I question the motives behind amendment 296 but its necessity is—to put it politely—mind-boggling. We have attempted to navigate a balance between ensuring that, when clinicians are dealing with this process, they do so safely, and not mandating them to undertake such conversations, assessments and procedures in a straitjacket. Put simply, this amendment attempts to manage diaries. Primary legislation should not do that. We cannot use primary legislation to manage clinicians’ busy diaries, as this amendment attempts to do. It is not only unnecessary but challenges the integrity of our clinicians and what they do every day. Therefore, I will be voting against it, if it is pressed to a vote.
Danny Kruger
I was not intending to speak on this amendment, but since you have called me, Mrs Harris, I will quickly respond to the comments of the hon. Member for Rother Valley. I sincerely think that he should withdraw the suggestion that the amendment was made in bad faith and his remarks about the motivation of the hon. Member for York Central. She clearly tabled it only to make the Bill safer, which is the purpose of all the amendments, even if there might be very good reasons to disagree with them, so I regret that attack on her integrity.
On the point that we should simply rely on the integrity of clinicians—although the hon. Member for Rother Valley has not done so in respect of the hon. Member for York Central, who is herself a clinician—of course we do that. Nevertheless, the laws we make and the guidance we introduce send strong signals about priorities. The purpose of the amendment is to ensure that doctors do not feel that the obligations created by the Bill impose a duty on them to prioritise the assisted death procedure over other priorities. In fact, it would give clinicians genuine autonomy and freedom to make their own decisions—obviously, in consultation with colleagues and patients—about the appropriate prioritisation of the treatments and services they are offering.
The hon. Member for Rother Valley made the point that there is, in a sense, an attempt to suggest that the Bill should not become law because of the pressures it could impose on the NHS. I think that such pressures are a valid concern. When we create new laws, we should consider what new burdens they will place on existing services. We should consider whether the new service will be introduced and implemented safely, and its knock-on implications for the wider system.
Jake Richards
The point is that the amendment is not about the wider system; it is about a clinician’s individual decision making. Does the hon. Gentleman agree that that is a very different prospect?
Danny Kruger
Well, that concern for the individual clinician is in the context of their wider obligation to treat their patients well and to manage a resource—their own time—in a way that is equitable to all the patients they have to see. As often in these debates, we are really considering the extent to which we should be putting into the Bill an obligation on doctors to do the job that we hope that they are doing anyway. We do have such rules in the system to clarify what we expect of clinicians, however, and I think they would be appropriate in this case, given the resource requirements—which are unknowable, but with common sense one can see that they will be quite significant—that this new service would entail for many clinicians in the NHS.
Jake Richards
If the Government were to introduce legislation to expand the NHS’s role in how it undertakes operations in a certain area, would the hon. Member suggest that similar amendments should be added to that legislation, or it is just about this issue?
Danny Kruger
There is no rule that can be applied universally in the abstract. All rules take their value from how they are introduced. On the hon. Gentleman’s hypothesis, I do not in principle suggest that every new treatment and every new obligation that is created in the NHS should require laws determining how clinicians prioritise them. In the case of a new service—I am trying not to use the word “treatment”, because I do not accept it as such, but it sounds like it will be treated as an NHS treatment—that is very significant and whose resource implications are unknown, it strikes me as appropriate that, as far as possible, we should be clear that doctors should manage the resource demands placed on them by the Bill in the context of their other obligations to patients.
Kit Malthouse
Can my hon. Friend not see that, as the hon. Member for Rother Valley said, the amendment is based on what could be construed as an offensive assumption: that doctors otherwise might or would? Effectively, it is the legislative equivalent of the “When did you stop beating your wife?” question.
Danny Kruger
I am afraid to say that we do impose obligations on doctors to do the things that we expect them to do. If that is offensive to doctors, so is all the guidance from the General Medical Council. It might well be argued that the amendment is otiose, because of course we would expect doctors to manage their resource requirements appropriately and to consider other patients. Nevertheless, the point that is being made in defence of the amendment, about which I feel strongly, is that we are creating a new service with unknowable resource implications, with strong parliamentary backing behind it, and with a whole set of guidance that will be created ex nihilo by the Secretary of State and that Parliament will have little control over.
Because we have not seen the amendments on the design of the service, we do not even know what the service will involve and how much work it will take. It is therefore appropriate to specify explicitly that doctors have an obligation to consider the potential impact on other patients.
Kit Malthouse
I understand where my hon. Friend is coming from. To give us fair warning, if the Committee votes the amendment down, how will he portray that publicly? Will he say to the public that the Committee has voted for doctors to harm other patients?
Danny Kruger
I am grateful for your ruling, Mrs Harris, but I hope you will not mind if I do respond to the question.
Danny Kruger
Okay. I might address the question at a future point, because the issue of how we reflect on these proceedings outside this place has come up privately.
Kim Leadbeater
I do not consider for one second that there is any ill intent behind the amendment, but I am slightly concerned about the language, which is what I think my hon. Friend the Member for Rother Valley meant. The issue is the suggestion that a doctor would, in any circumstances, jeopardise the care of other patients. We are talking about doctors a lot, and we have the utmost respect for medical practitioners, but I imagine that that would be a worrying concept to have in writing from their perspective.
Danny Kruger
I respect that point, and it is a fair charge: that doctors would not do this. Nevertheless, as I have been stressing, we are in uncharted territory, and there is a genuine concern about the resource implications of the Bill.
The Bill clarifies and emphasises things in lots of other places—“for the avoidance of doubt” and so on—and the amendment would clarify that the procedure under the Bill would not take precedence in a clinician’s time over other matters that they also consider to be pressing and urgent. That is an appropriate safeguard for doctors.
Jack Abbott (Ipswich) (Lab/Co-op)
The problem with the amendment, which has been mentioned before—I will not go as far as my hon. Friend the Member for Rother Valley and say that it would essentially nullify the Bill—is that it is entirely subjective. It is not guidance or a clear point of reference; it is entirely subjective to each individual doctor.
Danny Kruger
I am afraid that the English language is rather subjective. The service would rely on guidance or case law that had been built up, although one hopes that there would not have to be court cases in respect of it. The interpretation of the language of the Bill would be the duty of clinicians and, ultimately, NHS trusts and their lawyers.
Jack Abbott
A lot of the conversations we have had in Committee have been about eliminating the lottery that exists in our healthcare system. What the hon. Gentleman is suggesting will be exactly that: a lottery according to each individual clinician and doctor.
Danny Kruger
We cannot have it both ways. We cannot give doctors and clinicians autonomy, which the Committee has repeatedly seen as a ground to reject all sorts of obligations that I and others have proposed to ensure that doctors do the job in a specific way, and then suggest the opposite in this instance. I recognise what the hon. Gentleman says, and he may be right that that is inappropriate.
Danny Kruger
The hon. Lady is absolutely right. We should not forget that doctors are indemnified against any civil claims under the Bill. Nevertheless, they will want to protect themselves against the accusation that they inappropriately prioritised one case over another. That is the purpose of the amendment, and I urge the Committee to support it.
I will finish with this point. I am ashamed to say it, because my party was responsible for the NHS for the 14 years until last year, but the fact is, as Labour Members said frequently when they were in opposition, that there are enormous resource constraints on the frontline in the NHS. I do not think that is inappropriate to consider, when we create a new service, how it might have an impact on existing treatments in the NHS. Leaving aside all the ethical questions, including on coercion and capacity and our concerns in that respect, what will this mean for hard-pressed GPs and clinicians of all sorts on the frontline? What protections can we offer them when they make difficult decisions about whether to support an assisted death application?
The Chair
I remind Members that the running of the Committee will be much smoother if we do not have: long interventions; Members refusing to bob when they wish to speak and hoping that they will catch my eye; and conversations from a sedentary position. I will not tolerate any of those any longer.
Juliet Campbell (Broxtowe) (Lab)
I will speak to amendment 127, which is a probing amendment. I will not press it to a vote, but the reason I tabled it is that I felt that the phrase “as soon as reasonably practicable” was a little vague. I was taking into consideration the fact that we often talk about people who have six months to live, who are eligible for the assisted death, but sometimes people learn later on and do not have six months. If people are thinking about having an assisted death, there might be some pace at which the doctors need to work together—the co-ordinating doctor and whoever else they speak to.
I put 10 days, because I needed to put something down, and that is why I am saying amendment 127 is probing, but I do think that we need to be a little tighter with the timeframe in which we enable doctors to speak to each other, so that the patient is aware of what is happening. Also, if the patient wants to change their mind and is speaking to another doctor, they would know what timeframe they have got. The amendment is probing, and I will not press it to a vote.
Rebecca Paul
I think most points have been covered, so I will be brief. The point of the amendment 296 is to recognise the challenges faced by medical practitioners in the NHS. It is really well intended. I suspect that there are different ways to do this, which we could discuss, but the amendment would recognise that medical practitioners will come under a lot of pressure.
The very nature of the assisted dying process means there is pressure to move quickly—for obvious reasons. If someone is in pain and an assisted death is what they have chosen to do, they are going to want to move forward at pace. It cannot be as usual, with however long it can take in the NHS—often for a normal procedure. The point of the amendment is simply to be cognisant of the fact that other patients, too, require healthcare. This comes back to the debate we have had many times about what is healthcare and what is not. It is one of the issues that comes up when we have assisted dying amalgamated with general healthcare in the NHS.
We are hearing concerns from doctors on the frontline. In written evidence, eight doctors, six of them GPs, say that the NHS lacks both the time and the capacity to create the new role of co-ordinating doctor with its grave responsibilities. The statistics bear out their concerns. In a 2024 survey by the Royal College of General Practitioners, over 40% of UK GPs who responded said that they were “unlikely” to be practising still in five years’ time; 40% feel stressed to the point of “not coping” at least once a week; and 79% are concerned about having fewer GPs at their practice and its impact on the quality of care that their practice can deliver. The reality of the matter is that we have to recognise that the introduction of assisted dying places another pressure on our health system, and to try to address that head on.
Kim Leadbeater
The hon. Lady is making some interesting points, but would she agree that we are talking about not new patients, but existing patients who are already in their last few months of life? It will not create a whole new pressure on the health service, because they are already receiving treatment.
Rebecca Paul
I thank the hon. Member for that point. There will absolutely be some occasions where that is the case, but assisted dying is a different pathway—and we have a whole Bill on it, so there will be other formalities and safeguards. We are all here to make sure that rigour is applied to that pathway. With the best will in the world, there will always be more work and pressure, especially time pressure, on doctors. That time pressure will be critical.
Danny Kruger
I completely agree. The hon. Member for Spen Valley makes the important point that these patients are, indeed, being treated already; one would hope that the palliative care process would continue alongside their application. It is absolutely right that they are being treated, but as my hon. Friend the Member for Reigate says, there would be additional work being done for them. Does she agree that there is also an opposite threat—that the resource being expended on the patient might be less as a result of the assisted death that they get? I am afraid to say that that would introduce a terrible new incentive into the system, as happens elsewhere.
Rebecca Paul
This is a complex issue, and that is why I welcome the debate on this group. There are lots of things that need to be thought through to make sure that, if assisted dying is legalised, we manage it in the most effective way for patients.
Dr Simon Opher (Stroud) (Lab)
I thank the hon. Lady for making this point, which is important, although probably not specifically relevant to what we are talking about in general with regard to making the Bill safe. Has the hon. Member for East Wiltshire not just completely contradicted the whole point of the amendment, however, by saying that we really do not know whether this process will cost more or less time for the NHS?
Rebecca Paul
Different situations will give a different result. It is a complex situation. We could have a patient who, if they did not have an assisted death, would be on a palliative care pathway, which might not involve as much time from their GP—the assessing doctor, in that instance. If they moved on to the assisted dying pathway, however, the assessment process would need to start, and it has to happen quickly for all the reasons that I have set out.
The Bill relies on doctors being highly conscientious and hard-working, but it also risks taking them for granted if it makes no allowance for the present realities that they face in our healthcare system. This amendment tries to reflect and recognise that.
In November, the hon. Member for Stroud said,
“I have watched with horror as our NHS has gone from being the best health service in the world…to being a service on its knees.”—[Official Report, 6 November 2024; Vol. 756, c. 358.]
If the NHS is to get off its knees, surely we cannot afford for assisted suicide to jeopardise the care of patients who already struggle to get an appointment. We must recognise that there are people out there who cannot get an appointment to see their GP, and reflect that in the Bill.
Sojan Joseph
I rise to speak briefly to amendment 296. We all know how the NHS operates, how the appointment system works in the NHS and how long people have to wait to see a doctor. I do not think that my hon. Friend the Member for York Central tabled the amendment with any ill thought, but just to highlight the issue. I do not think that the amendment will make the Bill any safer or stronger, or safeguard anything, but the Committee needs to acknowledge it.
I will quote the Royal College of Physicians, which represents 40,000 doctors who primarily work in hospitals, including on palliative care. The Royal College of Physicians took a neutral position on the Bill. In its written evidence, it highlighted,
“We recognise that the ultimate decision on assisted dying rests with society through Parliament, however any changes to the law will significantly affect clinical practice beyond palliative care…Should the law change, the RCP strongly argues that assisted dying must not divert resources from end of life and palliative care provision, which are not currently adequate.”
With amendment 296, my hon. Friend the Member for York Central is trying to get the Committee to acknowledge that some NHS departments work with vacancies of 50 medical professionals. A patient who has been waiting for six months should not have their appointment cancelled because the provision here is prioritised. I think that is what my hon. Friend meant with her amendment, and I commend her thought about wider NHS provision.
Danny Kruger
I appreciate the point that the hon. Gentleman is making, and that he will not be able to support the amendment, but does he acknowledge that its purpose is to clarify the triage process that needs to be done by doctors? It is a perfectly appropriate request to make of doctors.
Sojan Joseph
I agree. It highlights the point that the impact assessment will be very important here, to see from where the resources are being pulled to provide this. The Committee should acknowledge amendment 296.
Stephen Kinnock
These amendments introduce requirements on the timing within which the co-ordinating doctor must carry out a first assessment once the first declaration is made by a person. I will turn first to amendment 296. As currently drafted, clause 7(1) requires that the co-ordinating doctor must carry out a first assessment
“as soon as reasonably practicable”
after a person has made a first declaration. Amendment 296 would require that after the first declaration is made, the co-ordinating doctor must arrange a mutually convenient time and date for the first assessment to take place, but it removes the stipulation that the assessment must be carried out as soon as reasonably practicable. The amendment would also require the date and time agreed not to jeopardise the care of other patients. The effect of the amendment may be to lengthen the period between the first declaration and the first assessment, in some cases.
Amendments 127 to 141 seek to ensure that the assessments, declarations and statements made throughout the Bill are finalised and recorded within 10 working days of being started. The amendments achieve this by inserting the term “within 10 working days” in place of
“as soon as reasonably practicable”
in clauses 7, 8, 16, 17, 21 and 22. This would put in place a time-bound limit that the medical practitioner must adhere to when carrying out the first and second assessments, when recording information in medical records at various stages, including the High Court declaration, and when recording other matters in medical records.
Our assessment suggests that in most circumstances, although it would depend on the facts of a particular case, the requirement to do an action as soon as practicable would generally amount to a requirement to do the action sooner than in 10 working days’ time. In terms of the operational effects, having a set timeline may give greater certainty to individuals seeking assistance. However, it may limit doctors’ discretion to set the timeline based around the patient’s wishes. These are matters for the Committee to weigh up and consider.
Kim Leadbeater
That has been a very useful discussion. I have nothing to add.
Daniel Francis
I beg to move amendment 347, in clause 7, page 4, line 4, leave out from “to” to the second “the” in line 5 and insert—
“ensure that steps have been taken to confirm that”.
This amendment would remove the emphasis on the role of the coordinating doctor in making these assessments.
The Chair
With this it will be convenient to discuss the following:
Amendment 294, in clause 7, page 4, line 5, after “doctor” insert—
“based on provided evidence that”.
This amendment would require that the doctor bases their assessment on provided evidence.
Amendment 14, in clause 7, page 4, line 15, at end insert—
“(2A) The coordinating doctor must take the report required under subsection (2B) into account in making an assessment under paragraph (2)(b), (f) and (g).
(2B) One or more qualified persons must have conducted a separate interview with the person and made a report to the coordinating doctor on the matters specified in subsection (2C).
(2C) The matters that must be covered in the report required under subsection (2B) are—
(a) any evidence of duress or coercion affecting the person’s decision to end their life,
(b) any difficulties of communication with the person interviewed and an explanation of how those difficulties were overcome, and
(c) the capacity of the person interviewed to understand the information given to them under paragraph (9)(2), (b), (c) and (d).
(2D) A person shall be taken to be qualified to conduct an interview under subsection (2B) if that person—
(a) is a registered medical practitioner who—
(i) is registered in the specialism of psychiatry in the Specialist Register kept by the General Medical Council, or
(ii) has such training, qualifications and experience as the Secretary of State may by regulations specify,
(b) has not provided treatment or care for the person being assessed in relation to that person’s terminal illness,
(c) is not a relative of the person being assessed,
(d) is not a partner or colleague in the same practice or clinical team as the coordinating doctor,
(e) did not witness the first declaration made by the person being assessed, and
(f) does not know or believe that they—
(i) are a beneficiary under a will of the person, or
(ii) may otherwise benefit financially or in any other material way from the death of the person.
(2E) Before making regulations under subsection (2D)(a), the Secretary of State must consult such persons as they consider appropriate.
(2F) Regulations under subsection (2D)(a) are subject to the negative procedure.”
This amendment, and its consequential and linked amendments (15, 16, 17, 18 and 19), would provide for an independent assessment, via an interview conducted by a specialist, of a person’s capacity to make the decision to end their own life, their clear, settled and informed wish to do so, and that they have made the first declaration voluntarily and without coercion.
Amendment 15, in clause 8, page 4, line 38, at end insert—
“(2A) The independent doctor must take the report required under subsection 7(2B) into account in making an assessment under subsections (2)(b)(d) and (e).”
This amendment is linked to Amendment 14 and requires the independent doctor to take into account an assessment that would be required under that amendment.
Amendment 16, in clause 8, page 5, line 16, at end insert—
“or conducted the interview under subsection (7) (2B)”.
This amendment is linked to Amendment 14 and ensures that the independent doctor cannot be the same person who undertakes the assessment that would be required under that amendment.
Amendment 284, in clause 9, page 6, line 27, leave out from beginning to “refer” in line 28 and insert “must”.
This amendment would require a referral for the purposes of assessing capacity for both assessments.
Amendment 17, in clause 9, page 6, line 27, leave out paragraph (b).
This amendment is consequential on Amendment 14.
Amendment 6, in clause 9, page 6, line 27, leave out “may” and insert “must”.
This amendment would require the assessing doctor to refer the person being assessed for a mental capacity assessment if the assessing doctor had doubt as to the person's capacity.
Amendment 280, in clause 9, page 6, line 27, after “assessed” insert—
“or,
(ii) the person has a mental health condition;”.
Amendment 370, in clause 9, page 6, line 29, leave out
“registered in the specialism of psychiatry”
and insert—
“a practising psychiatrist registered in one of the psychiatry specialisms”.
This is a drafting change.
Amendment 18, in clause 9, page 6, line 32, leave out “or (b)”.
This amendment is consequential on Amendment 14.
Amendment 19, in clause 9, page 6, line 34, leave out “or (b)”.
This amendment is consequential on Amendment 14.
Daniel Francis
I will not press amendment 347 to a vote, but I will speak to it, and to this group of amendments.
First, I shall turn to amendments 14 to 19, tabled by my hon. Friend the Member for Hackney South and Shoreditch (Dame Meg Hillier), which would require a co-ordinating doctor to refer the patient to an independent psychiatrist, or someone else qualified, as decided by the Secretary of State. That practitioner would then produce a report that the co-ordinating doctor must take into account when assessing whether the person has capacity, has a clear, settled and informed wish to end their life, and has not been coerced or pressured.
These amendments would replicate the existing practice of assessment for living organ donors. If we use a psychiatrist’s assessment for those who are donating an organ—a serious decision—how much more serious is this decision to end one’s life, and how much more necessary is the psychiatric assessment? It feels illogical to offer psychiatric assessments to patients who may donate organs, but not to those who may end their life. The wording of these amendments mirrors the regulations that have been applied through the Human Tissue Act 2004 (Persons who Lack Capacity to Consent and Transplants) Regulations 2006.
For organ donation, there is a separate body—the Human Tissue Authority—which oversees the network of assessors. These amendments do not suggest a separate body for assessors in the context of assisted dying, instead suggesting that the assessor should be a registered psychiatrist or someone qualified, as decided by the Secretary of State. This ensures control over who can be an assessor while also being flexible.
My hon. Friend the Member for Spen Valley, the Bill’s promoter, said in oral evidence that she had looked at the model of assessment for capacity and coercion that is used for living organ donation, so I will be interested, when we get to that point of the debate, to know why the Bill does not model its assessments on those that are already done for organ donation.
These amendments would strengthen the Bill by ensuring that patients are properly assessed as having capacity to make such a huge decision and would help to spot coercion. As it stands, the Bill has no mention of the doctors giving assessments having psychiatric specialisms. These amendments would ensure that a specialist meets the patient, which is vital. We have heard already how difficult it can be to spot coercion, especially repeat coercion.
Sean Woodcock (Banbury) (Lab)
Given that this is a significantly more serious decision than organ donation, these amendments would seem a very appropriate change to consider.
Daniel Francis
I agree. An assessment by a specialist would protect patients and give another opportunity to spot coercion—something that we all want to safeguard against.
I welcome the acceptance of amendment 20, tabled by my hon. Friend the Member for Lowestoft (Jess Asato), ensuring that doctors will be better trained to spot these issues, but that is only the start. We need the same in-depth assessment that living organ donors would get. Patients must fully understand the decision they are taking, and doctors must be convinced that they are capable of making it.
For organ donation, the NHS recommends that potential donors meet a mental health professional at an early stage, particularly in cases where people have a history of mental illness. As we have already noted, those diagnosed with terminal illnesses are likely to also have mental health issues. Dr Sarah Cox, in her oral evidence, cited a study by Professor Louis Appleby, the Government’s suicide prevention adviser. Dr Cox said:
“If we look at the evidence of suicide, we know that it is increased in people with serious illnesses.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 82, Q105.]
Sojan Joseph
We have discussed this issue many times. Within the Bill there is a provision for clinicians to refer to a psychiatrist if in any doubt. Does the hon. Member think that having that conversation at an earlier stage would be beneficial, rather than at a later stage?
Daniel Francis
I agree with my hon. Friend about the number of amendments in this vein, but clearly the amendments suggested by my hon. Friend the Member for Hackney South and Shoreditch bring us into line with existing regulations. In her evidence, Dr Cox said:
“If we look at the evidence of suicide, we know that it is increased in people with serious illnesses, but it is actually increased in the first six months after diagnosis, not in the last six months of their lives, so it is about the trauma of the diagnosis.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 82, Q105.]
It is likely, therefore, that those diagnosed with a terminal illness will experience mental distress that could affect their capacity to make a decision about an assisted death. In her written evidence, Dr Virginia Goncalves, a retired clinical psychiatrist with over 30 years of experience in the NHS, writes:
“In my consultant psychiatrist role, I have encountered many desperate and suicidal patients wanting to end their lives after struggling with longstanding mental distress, who could have easily sought the option of assisted suicide if it had been available to them! But however depressed and hopeless they felt, with a compassionate and hope filled approach from their care givers and the correct medical and psychological treatment, the vast majority recovered enough to be able to have a ‘life worth living’. In so many cases, these patients have thanked me later for not giving up on them! Not once have I heard anyone say ‘you should have let me die when I wanted to do it’.”
A meeting with a psychiatrist or other psychological specialist will protect people who may otherwise not have chosen assisted dying. I emphasise again that we already ensure that patients who will donate an organ have this assessment, so why not those seeking an assisted death? We must protect vulnerable terminally ill people from being coerced into assisted death, and psychiatrists and other specialists are best placed to spot that. That is why the assessment is included for living organ donation.
Daniel Francis
Absolutely. This amendment, of course, is widely supported by Committee members for that very reason. As I was saying, we already use that assessment for organ donation, and Members supporting this amendment believe that should be the case for those that are seeking an assisted death.
I now move on to amendment 284, in the name of my hon. Friend the Member for York Central. This amendment would change clause 9(3). Currently, that subsection lays out, and I will quote the language of the Bill, that the assessing doctor,
“(b) may, if they have doubt as to the capacity of the person being assessed, refer the person for assessment by a registered medical practitioner who is registered in the specialism of psychiatry in the Specialist Register kept by the General Medical Council or who otherwise holds qualifications in or has experience of the assessment of capability;”
This amendment would change the word “may” to “must”. In other words, the assessing doctor would have a duty to refer the person being assessed to a consultant psychiatrist if they had any doubt about that person’s capacity. I argue that this is a change that we both should make, and can easily make. If a doctor has doubts about the capacity of an applicant, it is good practice for them to refer that person to a doctor or a specialist in that field.
Dr Opher
Could I ask which amendment the hon. Member is talking about? Is it 284 or 6? Amendment 284 says that psychiatric assessment is mandatory in all cases, whereas amendment 6 says it is mandatory if capacity is in doubt. I just wondered which one he was talking about, because I support one and I do not support the other.
The Chair
Dr Opher, maybe you want to catch up on the papers and then intervene when you have a question to ask.
Daniel Francis
As my hon. Friend will know, my name is down as a supporter of amendment 6. I will get to that in due course. At the moment, I am speaking to amendment 284. I hear what my hon. Friend says—I am talking about the merits of amendment 284, but will get to amendment 6 in my closing comments.
On amendment 284, if a doctor has doubts about the capacity of an applicant, it is good practice to refer that person to a doctor with specialist expertise in that field. That would be true if the doctor was assessing the capacity of a patient to take any important decision, and is surely especially true when we are talking about a decision of this importance. I accept that people will have different views on amendment 6, when we get to it, from those they hold on amendment 284. Amendment 284 would put a duty on doctors to do something that is good practice. Most doctors in most circumstances would do it anyway, but in some cases, some may not. My hon. Friend the Member for York Central, who tabled this amendment, believes that we should write this law as tightly as possible so that doctors have that duty.
Amendment 294, which was tabled by my hon. Friend the Member for York Central, would require the doctor to base their assessment on provided evidence. Again, that is something that most doctors would do anyway in the extremely serious circumstances of a person’s applying for assisted death.
Many laws that we consider in this House relate to things that we are familiar with and understand well; but as my hon. Friend the Member for Bradford West said last week, some laws, such as this one, concern new matters. They are about things to which we need to give due consideration, as we are doing in scrutinising the Bill, because we need to understand the issues that arise. Those laws can introduce powers that could be dangerous if not properly safeguarded. This Bill, as has been accepted, needs strong safeguards. The aim of my hon. Friend the Member for York Central in tabling this amendment was to spell out that a doctor’s assessment of someone seeking assisted dying should be based on evidence. That would make it much less likely that any doctor would not pay sufficient attention to evidence they were presented with.
Lastly, as my hon. Friend the Member for Spen Valley knows, I am a long-standing of supporter amendment 6—I was in that base going into Second Reading. Alongside my concerns about clause 3, which she has heard at length, this matter was a key concern of mine going into Second Reading. I was therefore an early supporter of this amendment to change the wording around the referral from “may” to “must”. That was discussed on Second Reading. I do not want to speak for my hon. Friend, but I think she shares similar views to mine on the matter and suspect that the matter may be supported when we get to that debate.
Jake Richards
I will be brief. I will talk about my amendment 280, which I will not press to a vote. There remains an area that needs more exploring in this legislation—it has come up in debates already, but needs to be looked at further—namely, that a person may have capacity but have other mental health conditions that may impair their judgment. In those circumstances, a more thorough assessment than the two-doctor stage there is at the moment would be right. In reality, that is very likely to happen under the current structure of the Bill. My amendment simply attempts to make sure that it is mandatory. Having had discussions with my hon. Friend the Member for Spen Valley, I know that she is sympathetic to that.
There are amendments in the next group that aim to do the same thing. They, along with my amendment, may not be quite right. I urge the Government to look at this issue and see how we can work together to come to a conclusion, because I think that all members of the Committee would want that. I also support amendment 6, as I think everyone does.
Dr Opher
I apologise, Mrs Harris—I have got slightly confused with all the amendments. I do not have a speech that has been prepared for me, or anything like that, but I would like to make some comments. I think this is about the role of psychiatry and capacity, and how we deal that in the Bill. All these amendments reflect that. I would like to concentrate on whether we should actually mandate referral for all patients to a consultant psychiatrist, or adopt amendment 6, which suggests that if one of the two assessing doctors has concerns about either capacity or mental health, they should refer the patient to a psychiatrist. Those are the two choices I think we have here.
Danny Kruger
I appreciate the hon. Member’s point, and it is very logical that it should only be in the case of doubt, but does he not recognise that in the case of organ donation, it is mandatory? If people have this proper assessment when they are giving an organ, why should they not be asked to have one if they propose to give their life?
Dr Opher
That is an interesting point, but we are not discussing organ donation, and we are dealing in a different environment here; the patients we are talking about are about to die, and all we are giving them is the right to control the moment and manner of that death. I acknowledge that using a psychiatrist in organ donation has its benefits, but in this service, getting every patient—who, for example, are frail and ill by definition, because they are about to die—to see a psychiatrist is frankly neither applicable nor appropriate.
Kim Leadbeater
My hon. Friend makes a powerful point. If we think about some of the people we have met—the families who have lost loved ones to terminal illness and the patients who are terminally ill—they are very clear in their decision. For me, it would be another barrier to those patients, who are dying people, to make them see a psychiatrist for every single case.
Danny Kruger
It is a very important point. Yes, we are talking about those people, but we are also talking about a different category of people who have a terminal diagnosis of six months or more, and may only be reasonably expected to die within six months. I am not just talking about people at the very end of their life, who are at death’s door; we are talking about people who qualify for the Bill, which is a much larger category of people, so it is appropriate to require them to do this.
Dr Opher
I agree with all of this. I think psychological assessment is incredibly important in all patients, and I personally specialise in it from a primary care basis. But we are suggesting here that the two other doctors have no ability to do any sort of psychological assessment, and that is simply not true.
Dr Opher
I apologise to my hon. Friend; I will continue for a little bit. We use secondary care and psychiatrists when we have a doubt about our decisions. If we have a doubt, then it is entirely appropriate to use psychiatrists in that instance, and we must do so. That is why I approve of amendment 6.
Kit Malthouse
As I understand it, I do not think if someone is donating an organ that they do actually have to see a psychiatrist; they have to see somebody who is an appropriately trained assessor from the Human Tissue Authority. To me, that sounds equivalent to the second doctor in our process—someone who is appropriately trained to assess patients and what they need to do. This talk of it having to be a qualified registered psychiatrist, compared with an organ donation, is incorrect.
Dr Opher
I completely agree with the right hon. Gentleman. By amending clause 12 to include social workers, who specialise in spotting coercion, there would be a psychological component in that panel. I emphasise that the first two doctors are trained in psychological assessment—they have to be to become a doctor, and we must respect their knowledge and decision making. Psychiatrists will be incredibly useful in difficult cases of capacity, but using them in every case would not be using them in the best capacity.
Naz Shah
My hon. Friend is being generous with his time. I do not question the capability of those doctors, but how does that square with the concerns of the Royal College of Psychiatrists that if a doctor has never met the person before, they cannot make an assessment on coercion? That might impact on capacity.
The Chair
Dr Opher, I remind you yet again that “you” is me, and I have not asked you any questions. It is “my hon. Friend”.
Dr Opher
I am grateful that you have not intervened as well, Mrs Harris. You did say that I am allowed to call you “you”.
I will finish on this serious point. Amendment 6 has much power, and we would all agree that if the first or second doctor has doubts, they must—not may—refer to a psychiatrist. Expecting every patient who requests assisted death to have a psychological or psychiatric assessment is simply not necessary, and it would not improve the safety of this Bill.
Lewis Atkinson
Thank you, Mrs Harris—you really are giving the Minister some exercise during these long sittings.
Amendment 14 likens assisted dying to organ donation. I understand that an organ donor, before the point of independent assessment, has had no other independent assessment, which is in stark contrast to this Bill. The idea that, by failing to support this amendment, we are somehow adopting a weaker framework than for organ donation is patently false.
As the Bill sets out, there are already at least two assessments by independent doctors. As per the amendments we have already agreed, those doctors must have training, as specified by the Secretary of State, on the assessment of capacity and coercion. The rationale behind this amendment is already met, and it is significantly more strenuous than the framework for independent assessment in the event of organ donation.
Danny Kruger
I am not sure that is right. The amendment insists that this referral and assessment should happen at the earliest stage possible, in the same way as for organ donation. One of the confusions of the Bill is that multiple different conversations could happen. The purpose is to ensure that this conversation with a psychologist or social worker, as per organ donation, happens at the very earliest opportunity.
Lewis Atkinson
I disagree with the hon. Gentleman’s reading. The amendment talks about the co-ordinating doctor, as in the first independent assessor, and that is the case in the provisions we have already adopted. Clearly, the co-ordinating doctor may consult—and must consult, as per the amendment we are about to get to—psychiatric or other expertise, if there is any doubt in their mind. Amendment 14 would not bring forward that assessment earlier than elsewhere. I urge hon. Members to bear in mind that the idea that this proposal is somehow weaker than the current human tissue regulations is absolutely false.
On the point made by my hon. Friend the Member for Bradford West, the amendment does nothing to address coercion by a medical professional who knew the person beforehand. Under the amendment, it is by definition an independent person who has no prior relationship with the person.
Stephen Kinnock
Thank you so much, Mrs Harris—I will try again.
Although it is up to Parliament to pass or reject this Bill, the Government remain committed to ensuring its legal robustness and workability. For that reason, we have worked closely with my hon. Friend the Member for Spen Valley, and we have mutually agreed some amendments, including amendments 370 and 202. This group of amendments relates to the assessment process for determining a person’s ability to make a first declaration. I will take them in turn.
As the Bill stands, the co-ordinating doctor is responsible for ascertaining whether, in their opinion, a person applying for assistance to end their own life has met the eligibility criteria in clause 7(2), as part of the first doctor’s assessment. Amendment 347 would change the co-ordinating doctor’s role from ascertaining whether, in their opinion, the criteria in clause 7(2) are met to instead ensuring that steps have been taken to confirm that those criteria are met. Its practical effect would be that the co-ordinating doctor could rely on the assessment of other, non-specified, persons to confirm that the eligibility criteria have been met.
Amendment 294 provides that the co-ordinating doctor, in ascertaining whether, in their opinion, the criteria in clause 7(2) are met, would be required to base that assessment on evidence that has been provided. It does not specify who would provide the evidence, what types of evidence would be considered acceptable or whether the co-ordinating doctor could disregard evidence if they consider it appropriate to do so. It could create uncertainty for the co-ordinating doctor in carrying out the first assessment.
Amendment 14 would require the co-ordinating doctor, when making the first assessment, to take into account an additional report. The report would be made by a qualified person and would cover duress and/or coercion, communication needs and capacity. It would be informed by an interview between the specialist and the person applying for assistance to end their own life. The specialist must have expertise in psychiatry or other qualifications set out in regulations. There are various exclusions aimed at avoiding conflicts of interest.
Amendment 15 would similarly require that the independent doctor, in making the second doctor’s assessment, takes the report into account. Amendments 16 to 19 are consequential to amendment 14.
In practice, the amendments would represent a change at the medical assessment stage from requiring two professionals to requiring three. They also represent a departure from usual practice for professionals applying the Mental Capacity Act 2005. The requirement to interview the person and write a report that must, in all cases, address capacity may amount to an assessment of capacity in itself. That would undermine a core principle of the Mental Capacity Act, which is the presumption of capacity.
In addition, the test of capacity set out in the amendments is more limited than the test of capacity under the Mental Capacity Act. It covers only capacity to understand information, not capacity to retain, use or weigh it.
Amendment 284 would require the co-ordinating and independent doctors to, in all cases, refer the person seeking assisted dying to a psychiatrist for an assessment of their mental capacity. Although that is set out in the explanatory note from my hon. Friend the Member for York Central, the amendment does not specify the type of assessment that is required. Putting aside specification of the type of assessment, the overall intention of the amendment is that, in order to be eligible for assisted dying, a capacity assessment would always be required, irrespective of whether there is a proper reason to doubt that the person has capacity. That would differ from the Mental Capacity Act, under which capacity is presumed unless it is established that the person lacks it.
Amendment 6 would require the assessing doctor to refer all cases where there is doubt about mental capacity for an assessment by a doctor who is an expert in psychiatry. This is a power, as currently drafted, but the amendment would make it a duty. Requiring, rather than permitting, the assessing doctor to make a referral when capacity is in doubt would remove their discretion on whether to refer a person to a doctor who is an expert in psychiatry. Instead, it would be required in all cases where there is doubt about capacity.
Kim Leadbeater
I will do the easy bits first. As the Minister said, amendment 370 in my name is a drafting change to the definition of a psychiatrist, which is obviously very important. These useful amendments have enabled us to have this discussion, and they all come from a good place in trying to enhance safeguarding within the Bill.
On organ donation, my sister-in-law has had two kidney transplants. On neither occasion, to my understanding, did a psychiatrist speak to either her or the organ donor, who in one instance was her brother—my sister-in-law would be very upset that I have mentioned her in Parliament. My understanding of the law is that someone may be referred to a mental health specialist. I am happy to be corrected if that is not the case, but I do not think a consultation with a psychiatrist is compulsory.
As I said to my hon. Friend the Member for Stroud, it is absolutely right that we support amendment 6. From the start, I have been clear that we should move from “may” to “must” in referring to a psychiatrist where either doctor has any doubt. That is a sensible approach, and it covers most of today’s discussion.
However, introducing a whole new system that would almost sit alongside the Bill, and that would change the process, is unnecessary. Those are my conclusions, based on what has been another very interesting discussion.
Daniel Francis
I will not come back on anything but, obviously, I will press some of these amendments in due course.
I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Amendment proposed: 294, in clause 7, page 4, line 5, after “doctor” insert
“based on provided evidence that”.—(Daniel Francis.)
This amendment would require that the doctor bases their assessment on provided evidence.
Question put, That the amendment be made.