Terminally Ill Adults (End of Life) Bill

Baroness Finlay of Llandaff Excerpts

Friday 5th December 2025 Lords Chamber

I look forward to hearing from the noble and learned Lord, Lord Falconer. If he is to suggest that 18 is still the appropriate age, I would be keen to hear the rationale as to why he will not be accepting the wise amendments of noble Baroness, Lady Berger.

[Baroness Finlay of Llandaff (CB)]

My Lords, the noble Baroness, Lady Berger, has opened up an important point in this debate and her excellent opening speech certainly highlighted many of the issues.

The noble Lord, Lord Winston, spoke about cognitive reasoning. The evidence is that cognitive reasoning is well-developed at the age of 18 but that other aspects—such as being sensitive to stress and social influence, impulse control and emotional regulation—do not develop by that age. The evidence is that these carry on developing until the age of 25.

I found it interesting to hear that noble Lords consider that the age limit for children or young people driving in cars with peers should potentially be raised. That is because of the problem of peer pressure. When I had the pleasure of having a visiting professorship in the Netherlands, I came across a fairly horrifying case of a young man in his late teens who had been diagnosed with a very aggressive tumour. His friends all came round and said, “When are you going to go for euthanasia?” He had not even had discussions on treatment, and this happened to be a tumour that was going to be very chemotherapy sensitive. I was quite shocked at the influence that a peer group can have on somebody.

The noble Baroness, Lady Hayter, spoke about suffering and pain. One of the difficulties we have with the Bill is that neither “suffering” nor “pain” occurs anywhere in it.

I wonder whether the noble and learned Lord, in considering how he manages this group of amendments, will recognise that one solution may be to require an enhanced assessment of those between 18 and 25 if the age limit is not going to be raised. Young people should have a more in-depth assessment, not only of their—

[Lord Scriven (LD)]

The noble Baroness will know that, at present, an 18 to 25 year-old with a terminal diagnosis has the legal capacity to withdraw consent to treatment. Do they go through a different capacity assessment from somebody who is over 25?

[Baroness Finlay of Llandaff (CB)]

I am delighted that the noble Lord has asked me that question, because it reminds me of a patient I had. He was a young man with an advanced testicular tumour and had refused treatment. He was referred to me, and I looked after him for a couple of years, during the time that he became more and more ill with his metastatic disease. He consistently refused treatment. However, when he was moribund, and his parents had come in and were sitting at the bedside, he suddenly asked me, “Is it too late to change my mind and have treatment?” At that point, I was indebted to my local oncologist, who I phoned, and we arranged transfer that day to the Royal Marsden Hospital, which then treated him because that was his wish. My assessment every time I saw him was not to persuade him to have treatment but to allow him to talk about his fears and difficulties. That is the role of specialist palliative care when you are looking after these young people who are very vulnerable. I am simply suggesting that, due to the way the Bill is written, the assessments may not be adequate.

[Lord Scriven (LD)]

I listened to the noble Baroness’s individual case. My question was very specific. Is somebody who is 25 or over given a different mental capacity assessment based on their wish to withdraw treatment from somebody who is 18 to 25? That is the specific question based on what the noble Baroness is now suggesting happens in the Bill.

[Baroness Finlay of Llandaff (CB)]

The issue with the Mental Capacity Act is that each assessment must be done individually. It relates to the decision that is to be made, the size of the decision, the time and the personal characteristics. There is no absolute. If we are talking about safety in relation to the Bill and avoiding abuse, I am simply trying to suggest that one way forward may be to ensure that the assessment of young people’s eligibility is particularly thorough. That may mean having different criteria and looking at whether they have pain or suffering.

[Lord Winston (Lab)]

I wonder whether the noble Baroness might be kind enough to clarify. She is, after all, a hugely respected individual in the field, of which she is such an expert—I do not doubt that for a moment. Sarah-Jayne Blakemore, a fellow of the Royal Society, has been spending her time looking at peer pressure. That is what her publications have largely been about. Is the noble Baroness really suggesting that a young person of, say, 18, dying of a horrible and painful cancer, would be subject to peer pressure? They might be subject to pressure from doctors but I doubt that they would be subject to peer pressure.

[Baroness Finlay of Llandaff (CB)]

I was simply relating what I found when I was in the Netherlands relating to peer pressure on young people because of the normalisation of euthanasia across that society.

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[Baroness Berger (Lab)]

My Lords, I will very briefly raise my serious concerns about the three amendments that remove the specification for domestic abuse training. They are Amendments 290, 366 and 931. In the Commons, this was a significant area of concern for all MPs, specifically the risk to those suffering domestic abuse, and, as such, the sponsor of the Bill there accepted the amendment that introduced explicit requirements for training on domestic abuse, including

“coercive control and financial abuse”.

I listened very closely to the intervention from my noble and learned friend about the definition contained in Clause 56(2) that refers to control and financial abuse. But just because the definition of domestic abuse in the Bill includes coercive control and financial abuse, that does not mean training on domestic abuse will always include both those things. A training provider would not have an obligation under the Bill to cover all aspects of the definition, whereas the Bill, as currently drafted and as we received it, includes specifically both coercive control and financial abuse in that training. I urge my noble and learned friend to reconsider those amendments, based on the contributions in the other place, and to ensure that training covers and encompasses all those specific elements.

[Baroness Finlay of Llandaff (CB)]

My Lords, I have some questions for the noble and learned Lord, Lord Falconer, about his Amendment 6, because my concerns also relate to the amendment in the name of the noble Lord, Lord Moylan. It does not seem to reflect the way that seriously ill children behave.

I have looked after children dying of malignancies. They knew that they were dying and asked really straightforward questions. They would ask about how they would die and would want to have in-depth conversations. I recall one little boy who asked me if he could play football in heaven, after another little boy in an adjacent room had died a few weeks earlier. These children asked for explicit details and wanted to have lots of conversations. Another one said that he would die after his goldfish died. Sadly, that was prophetic and when he was close to death, he asked his divorced parents to come in and promise to look after his siblings together. These children know each other; they want to ask questions and need to have them answered.

I am not sure how, with Amendment 6, doctors are meant to respond to these children when they ask questions. At the moment, you respond gently and openly, and explore with them what they are really asking about in an age-appropriate way. I have a concern that this could make people feel risk-averse about having open communication with these children, and let children remain isolated with their fears. They hear about assisted dying on the news and in the media; the ethical aspects are part of the senior school curriculum in some areas. I am really concerned that Amendment 6, while well-intentioned, and the adjacent amendments, might actually make the day-to-day looking after of these children as they are dying more difficult.

Amendments 170 and 405 seem to lower the threshold for communication. I am grateful to the noble Baroness, Lady Coussins, for pointing out that whenever an interpreter is used they must be a registered public service interpreter, to avoid the poor communication scenario which I referred to last week. Speech and language therapists are essential, so can the noble and learned Lord, Lord Falconer, explain how with one would judge “effective”, as is listed in his amendment, and assess “reasonable steps”? These seem very subjective and I am not sure how they would be monitored. Others have spoken to the other amendments, so I look forward to hearing the comments from the noble and learned Lord.

[Baroness Berridge (Con)]

I will speak briefly to raise attention to Amendment 170, which has recently been added to the group. In an effort to short-circuit, we will come to the issues of interpreters much later on.

I have laid Amendment 174, which quite simply says that an interpreter must be over the age of 18. It will not surprise the noble Baroness, Lady Merron, that I have a whole cluster of amendments to deal with what may be inadvertent situations that are not covered off for under-18s. I invite the noble and learned Lord to look at that amendment to see whether it can swiftly be clarified and dealt with, along with the others that relate to children.

In this group, I will also speak to the noble and learned Lord’s Amendments 332, 417 to 419 and 425, which I believe are a genuine attempt to deal with the report from the Delegated Powers and Regulatory Reform Committee. It advised the sponsor of the Bill to remove the Clause 15 power and to align the other clauses, because there were inconsistent wordings. I want to reiterate that reassurance was given in the other place that there would be one second opinion by another doctor. This goes back to the noble and learned Lord’s opener: when we talk about “cannot”, we need to cover that off in the Bill. The Bill was covering death or illness—obvious situations where the function cannot be fulfilled—but “will not” is obviously a different scenario.

Unless the doctor is unable to perform that function, for whatever reason, if we do not stick to the word “cannot”, we will potentially get the opening up of the ability to choose a number of doctors and maybe having some kind of discussion. Then they may not want to act, which may be for the reasons outlined by the noble Baronesses, Lady O’Loan and Lady Goudie. Then we might have a number of assessments or discussions that do not become a formal refusal which is then documented. I do not think the noble and learned Lord intended, by changing Clauses 10 and 13, to broaden the scenarios where a further referral could be made to any situation in which the doctor is unable or unwilling to continue; I think this has happened inadvertently. I know that my noble friend Lord Harper has laid amendments regarding particular scenarios beyond “death” and “illness”, and I think that the Minister in the other place, Mr Kinnock, mentioned family circumstances or emergencies. Perhaps the way ahead here—I am trying to pre-empt a further group, when we get to it—is that we could have a clause that outlines more circumstances than the two that are in the Bill.

Obviously, as lawyers, we know we can never cover every circumstance that would justify a doctor saying, “I can’t do this function any more”, not “I won’t”. Perhaps there could be a system whereby a doctor who wants to withdraw, and his or her circumstances are not in the paragraphs, should have to go to the panel and say, “I’ve got a situation that isn’t within the framework of the legislation, but I can’t for these reasons perform that function”. So I hope the noble and learned Lord will not move those amendments, as he has promised, but we could come back to this in the group that deals substantively with exploring scenarios where the doctor cannot act.

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Moved by

[Baroness Finlay of Llandaff]

10: Clause 1, page 1, line 8, leave out paragraphs (c) and (d)

[Baroness Finlay of Llandaff (CB)]

My Lords, we now come to issues around residency. My Amendment 10 is a probing amendment. I had to word this this way, because I was trying to put in other wording about residents in the Crown dependencies who may be treated in England or possibly Wales, but I was told that that was out of scope. After several attempts at wording, this seemed the only way for us to address the issue. I make it clear that I do not want make England and Wales a destination for death tourism. Therefore, I will be withdrawing Amendment 10, but it is the only way I can address this major loophole.

In the Select Committee on the Bill, I raised the issue of those who live in the Isle of Man, Jersey or Scotland, where proposed legislation has different eligibility criteria to the criteria outlined in the Bill. Many patients from across these borders are treated in England. Patients from Jersey regularly go to Southampton in ambulance flights or, if the sea is calm, by sea. Similarly, patients from the Isle of Man go to Liverpool. They go for treatment procedures, including radiotherapy and all types of investigations and procedures, because on those islands the facilities are, understandably, relatively limited. A cross-border flow from Scotland is therefore less than this.

A patient who is seriously ill may be transferred for treatment. When they are aware that they have a rapidly progressive, serious and life-threatening illness, they may want to be transferred back to their home to avail themselves of an assisted death in that area. We know that, at the time of being given bad news, suicidality and thoughts of death are at their most prominent, because patients are shocked and often have not actually considered their own mortality in depth; therefore, it is when they are being treated in England that they are most likely to raise the question of an assisted death when legislation is passed in their own jurisdictions.

In Select Committee, I asked Minister Sackman from the Ministry of Justice what the position would be for a doctor, nurse or other healthcare professional involved in arranging transfer back to the Isle of Man or Jersey, knowing that that transfer would facilitate an assisted death outside England and Wales, and the patient would not be eligible under the parameters of the Bill. The response from both the Minister and from Paul Candler, who was her accompanying official, was that it would indeed be a criminal offence to facilitate such a transfer, because they would be caught by the Suicide Act. As Paul Candler explained, the Bill essentially carves out from prosecution people who are acting in England and Wales in conformity with the scheme set out in the legislation. So an assisted death being arranged outside England and Wales is outside the parameters of the scheme of the Bill and would therefore be caught by the 1961 Suicide Act.

I asked the same question of Sir Max Hill, as he was Director of Public Prosecutions. His reply was that if you are operating as a medical or other professional within the legal jurisdiction of England and Wales, you must obey the law of England and Wales. He said:

“the guidance is simply to obey the law of the country in which you are acting, taking decisions and the rest of it. I think, I am afraid to say, that it is as simple as that”.

I ask the noble and learned Lord, Lord Falconer, what is the position for doctors and nurses treating any very seriously ill patient, principally in Liverpool or Southampton, who may say, in the course of an in-depth conversation about their illness, the potential course of it and so on, when they may be contemplating death for the first time, that they want to go home to have an assisted death in their own home? What discussions has he had with the Medical Defence Union and the BMA about this legal liability? What is the legal position of these doctors if they actually accede to the patient’s wish to return home?

I will now turn to my other Amendment in this group—

[Lord Pannick (CB)]

I am sure that the legal advice the noble Baroness has been given is absolutely correct. My point is that surely this problem arises now. This Bill does not change the position in any way.

[Baroness Finlay of Llandaff (CB)]

With all due respect, I am not aware that the legislation has actually been enacted in either the Isle of Man or Jersey.

[Lord Pannick (CB)]

Until it is enacted, there is not a problem. When it is enacted, the problem arises, whether or not this Bill is enacted.

[Baroness Finlay of Llandaff (CB)]

We are discussing the wording of this Bill, with due respect. I raise this as a concern for clarification. It needs clarification because, if noble Lords are anticipating that this Bill and the legislation in the other jurisdictions will pass, we cannot leave a legal loophole or difficulty that might jeopardise the care of patients coming to England from the Crown dependencies. That is why I have raised it.

I turn to Amendment 11. Currently, the Bill speaks of the person being “ordinarily resident” in England and Wales, but there is a problem with “ordinarily”. In 1983, Lord Scarman stated in a House of Lords judgment that

“‘ordinarily resident’ refers to a man’s abode in a particular place or country which he has adopted voluntarily and for settled purposes as part of the regular order of his life for the time being”.

So far, so good. However, in the healthcare context, the 2012 Review of Overseas Visitors Charging Policy said:

“The vagueness of the definition means that OR”—


ordinary residence—

“is difficult to interpret and apply on an individual case basis”.

People fell through the gaps and the NHS was not recovering its costs. Then, during his time as Immigration Minister, the noble Lord, Lord Harper, pointed out that

“we need to do a better job of making sure that front-line professionals have a simpler system”.—[Official Report, Commons, Immigration Bill Committee, 7/11/13; col. 290.]

The problem with the definition in the Bill is that it could cover someone who is now living in another country but has an address of convenience in England and Wales for whatever reason. We know that there are thousands of empty properties owned by people who are not living permanently in this country. Apart from the more than 187,000 homes that are owned by people living permanently abroad, there are 5.5 million people who are British passport holders or have residency visas to live in the UK but are living abroad permanently. What will be the position of these people if they wish to access an assisted death here? Currently, they would not be eligible for NHS treatment if it were to be funded by the NHS. If they came to live in the UK for a year, they would then become eligible for the NHS, but, with the prognosis of six months or less, they would be expected to be dead within that time. Of course, this assumes that there is any accuracy in prognostication, which there is not.

Let me put to your Lordships a scenario that is, sadly, not infrequent. A person working for the Foreign and Commonwealth Office in an embassy abroad becomes seriously and terminally ill and is repatriated to the UK. Their house is rented out and they have to give notice, so they go to live in a different area—one, they hope, with good specialist palliative care services that can provide them with support. However, not being able to be in their own home and surrounded by their own things, and without contact with people who would otherwise have a role in their lives, they easily become very depressed.

Let us look at that scenario under this Bill. Suppose they decide that they want an assisted death. They will not have been resident for 12 months prior to making a first declaration to request an assisted death. Will that person, who may have worked all their life in service of this country, now be ineligible? I see that the noble and learned Lord, Lord Falconer, is nodding that they would. I believe that, under the wording of the Bill—

[Lord Falconer of Thoroton (Lab)]

Hold on—my nods must not be misinterpreted. I understand the question. If, for example, you live in Britain and you go and become the First Secretary in the US, you do not cease to be ordinarily resident in the UK. If you are a soldier and serve for nine months abroad, you do not cease to be ordinarily resident. I was nodding only to say that I have got the question, but I would not necessarily agree with the solution that the noble Baroness proposes.

[Baroness Finlay of Llandaff (CB)]

I am grateful for that clarification and we will come back to the noble and learned Lord’s comments on these issues afterwards.

[Baroness Butler-Sloss (CB)]

If one reads Clause 1(1)(c), it not only says that the person has to be ordinarily resident but that they have to have been

“so resident for at least 12 months”.

Consequently, unless being in an embassy is still seen as being resident for the previous 12 months, the point that the noble Baroness made is entirely right.

[Baroness Finlay of Llandaff (CB)]

I am most grateful for that intervention, because many people who work in the embassies abroad do not live in the embassy; they live in apartments, houses or whatever in its vicinity.

The wording of the Bill prompted my probing amendment, so I ask the noble and learned Lord, in the light of this, whether he is comfortable with the vagueness of the term “ordinarily” or whether he sees merit in reconsidering this wording carefully to clarify the residency requirement to avoid death tourism and ensure that others are not discriminated against. I beg to move.

[Baroness Coffey (Con)]

My Lords, I had originally tabled Amendment 15, which I withdrew, because it looked like I was trying to be nasty and stop the bucket list for people or stop them going on holiday, but that was not my intention. My intention was to think about residency in a proper way. Bearing in mind previous comments from the Minister, I have ended up replacing one amendment with four in order to be precise throughout the Bill.

In essence, I am not convinced that simply being ordinarily resident is enough. I say that because you can be ordinarily resident in more than one country. You can only be domiciled in one country. The issue here is: who is the Bill trying to cater for? I think, frankly—bearing in mind Amendment 23, proposed by my noble friend Lord Frost—that we should be looking at UK citizens and those whom the Government have decided to give indefinite leave to remain, and keep it at that. The element of “ordinarily resident” is that you can have settlement for a purpose. The single purpose could be that you just state that your settlement—your purpose for being ordinarily resident—is simply to take advantage of this Bill. I do not think that is enough.

As regards the amendments that have been tabled by my noble friend Lord Lansley, I also do not want this extending to someone being able to live anywhere in the United Kingdom. Indeed, my noble friend Lord Moylan has perhaps anticipated some of the situations where people have moved abroad and then want to come back. The essence of the Bill should be that it is focusing on providing provision in this country for people who permanently live in this country, which is why “domiciled” is a better test than simply “ordinarily resident”, because, as I say, you can be ordinarily resident in more than one country.

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[Baroness Merron (Lab)]

I am sorry to hear of the noble Baroness’s surprise. I am simply setting out where the Government have particular concerns within the scope to which I referred. My noble and learned friend Lord Falconer may be able to comment more appropriately, if he wishes to do so, on the points that she raises.

Amendment 14, in the name of the noble Lord, Lord Moylan, would widen the eligibility criteria to include UK citizens of pensionable age who are living abroad. There are two main issues with this amendment. The first is that the UK has obligations under international agreements that enable residents of partner countries to receive certain benefits, including some health service provision, in the UK. These agreements are, as I mentioned, with the EU, EEA states and Switzerland. As I set out, these agreements prevent restrictions based on nationality, although they permit those based on residency. Therefore, the amendment would have the effect of opening access to provision of assistance under the Bill to EU, Swiss and EEA residents of pensionable age, provided that they satisfy other eligibility criteria. Widening access only to UK nationals of pensionable age would be contrary to the UK’s obligations under those agreements.

Secondly, by including those who have “moved to live abroad”, the amendment would enable pensionable-age citizens from Northern Ireland or Scotland who have moved abroad to access the provision of assistance, in accordance with the Bill, if they satisfy the other eligibility criteria.

For all the other amendments in this group, on which I make no comment, any workability concerns are less significant. For example, Amendment 10 would remove two eligibility criteria from Clause 1, while Amendment 13 would change the requirements relating to ordinary residence in England and Wales. As Clause 1 is largely descriptive, these amendments would have limited legal effect without corresponding amendments being made to operative provisions later in the Bill.

While these are choices for noble Lords, these amendments may introduce inconsistencies and ambiguity into the Bill. As noble Lords will be aware, these amendments have not had technical drafting support from officials, so the way in which they are currently drafted means that they may not be fully workable, effective or enforceable—but, of course, the issues raised are rightly a matter for noble Lords to consider and decide on.

[Baroness Finlay of Llandaff (CB)]

Given that Jersey and the Isle of Man, if I am correct, are not EEA countries, how is the contract for health service delivery affected by this Bill in the light of the problems that I highlighted right at the beginning of what has turned into quite a lengthy debate? I was trying to look at a carve-out for those countries so that those contracts could continue, but I was told that it was deemed out of scope of the Bill.

[Baroness Merron (Lab)]

I am sure the noble Baroness will understand that I am restricted in the comments that I can appropriately make here. I heard my noble and learned friend Lord Falconer say that all these matters needed consideration, and I am sure that he will expand further on that very point.

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[Lord Falconer of Thoroton (Lab)]

My Lords, I honestly think that is a smokescreen. The Bill says, in a way that the law has recognised time and again—because this Parliament has to make choices from time to time about who gets benefits—that the benefits of the Bill should be given only to those who ordinarily live in this country. That phrase has not given rise to problems. The courts understand it, doctors understand it and the panels will understand it. If we in this Parliament cannot say that we will give rights only to those who are ordinarily resident, which is a phrase that means something, we will never be able to determine who is entitled to our rights. I say, with the greatest respect to the noble Baroness, Lady Coffey, that what we are trying to do in the Bill is clear. I invite the noble Baroness, Lady Finlay, to withdraw her amendment.

[Baroness Finlay of Llandaff (CB)]

My Lords, I will now sum up at the end of this very interesting debate. I am relieved to hear that people do not want doctors to be immigration officers. I am a little disappointed that the noble and learned Lord, Lord Falconer, has not accepted the amendment from the noble Earl, Lord Howe, because it is so straightforward. If, as the noble and learned Lord says, it would not be a problem for over 99% of patients, it would not be a problem to be satisfied. It would add a degree of security for doctors who are being asked to provide these assessments of eligibility.

I was also glad to hear from the noble Lord, Lord Harper, that those working for the Foreign, Commonwealth and Development Office, in embassies or wherever, are covered, and that that is not a problem. The noble Lord, Lord Carlile, raised the issue of those working as volunteers abroad for a very long time. I hope that the ability that applies to Foreign, Commonwealth and Development Office workers also applies to those working for charities, such as some of the major charities, who may be abroad for a very long time but view their permanent home as the UK.

I remain concerned about Jersey and the Isle of Man. What conversations has the noble and learned Lord had with the Public Bill Office about how to get this in scope? My attempts have failed, and I understood that here in the House of Lords we are not able to widen the scope of the Bill. I worry that without widening the scope of the Bill, we will not address it, and those doctors treating patients with all kinds of really serious illnesses, particularly in Liverpool, as referred to by the Front Bench, and in Southampton, could inadvertently find themselves in a very difficult position, which would be an unintended consequence of this legislation.

[Lord Falconer of Thoroton (Lab)]

I do not know whether the noble Baroness has discussed with the Public Bill Office the BMA’s proposal in relation to this, which is that it is not a crime under the Suicide Act if the assistance you give is not unlawful in the Isle of Man or Jersey. The idea that that is out of scope seems obviously wrong, because the Bill is crafting an exception to the Suicide Act. If the noble Baroness and I go to see the Public Bill Office and explain that, I would have thought that there would be no difficulty about the scope.

[Baroness Finlay of Llandaff (CB)]

I would be delighted to go with the noble and learned Lord, because he may have a little more success. The Public Bill Office has been unfailingly helpful. This is no criticism whatever of it; it has worked incredibly hard. With that and the promise of going to see it with a matter of urgency, I beg leave to withdraw the amendment.

Amendment 10 withdrawn.

Terminally Ill Adults (End of Life) Bill

Baroness Finlay of Llandaff Excerpts

Committee stage
Friday 21st November 2025 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

3: Clause 1, page 1, line 4, leave out “a” and insert “an independent”
Member’s explanatory statement
The person’s decision must be taken devoid of encouragement to end their life from any other person and is compatible with the current Director of Public Prosecution guidelines on prosecution for assisting suicide.

[Baroness Finlay of Llandaff (CB)]

My Lords, we come to a key concern in this Bill—the very real risks of coercion and pressure to seek an assisted death. While the Bill acknowledges coercion, it does not fully address the dynamics of domestic abuse at the end of life nor the intersectional risks faced by women, those who are disabled, whether long-term or through illness, and those from ethnic minority backgrounds.

ONS data showed that, from March 2023 to March 2024, 2.3 million people over 16 were subject to domestic abuse. This equates to one in 20 of the population between 16 and 65 years old, yet only 45,000 of them in England and Wales are known to the police. In the older population, the incidence is even higher. Hourglass has estimated that one in five experiences some sort of abuse. Since the start of the Covid-19 pandemic, incidences of domestic abuse reported to third sector and statutory agencies have increased by over 60%. A systematic review by Michelle Myall and colleagues covering 2000 to 2021 found that the incidence of abuse increased in terminal illness. These results resonated with Jamilla Hussain’s findings in Bradford.

People with life-limiting illness experience a range of abusive behaviours in three broad categories: coercive and controlling behaviour, emotional and physical abuse and neglect, and financial abuse. Financial abuse is particularly rife in its many forms. Take the relative who goes to the cash machine for their relative who is ill and quietly pockets some of the cash or quietly steals valuables, or the family keen for their relative to die before a fixed-term life insurance runs out. Yes, I have seen it. They wanted a new car.

Emotional abuse includes telling the person that they are a burden—directly, or indirectly through conversations that are designed to be overheard by the person who is ill. Some are told that they are not dying quickly enough. Abuse affects treatment decisions and can lead to people missing out on curative treatment through making adverse decisions about their care. For some women, death is the only way out that they can see from their situation. It reflects the national data, where suicide is now the commonest cause of domestic abuse-related deaths.

The Oregon data shows that feeling a burden to family or carers has been stated as an end-of-life concern by over 47% of people having an assisted death. This was higher than the under 30% who cited inadequate pain control or concern about it as a reason. After the noble and learned Lord, Lord Falconer, gave evidence to the Select Committee, I rechecked the official reports. Oregon does not collect data to understand whether there have been problems with coercion or report on those who are turned down for lethal drugs.

This Bill has been publicised as being about pain but does not mention pain at all. Specialist palliative care can deal with pain. Detecting the coercive threats, humiliation and intimidation, which are usually subtle and consistently maintained out of sight of anyone in authority, is far harder. It is the complaints about the heating bills, family carers being fed up with having to prepare drinks and food, groaning when asked for something—there are so many ways to give the message that you are a nuisance and would be better off dead. Abuse impacts patients’ mental health and well-being and leads to feelings of loss of control, entrapment, powerlessness and depression.

However, health and care professionals lack confidence in identifying abuse. It is rarely detected by doctors. Why? Because dependence limits disclosure. Illness increases women’s dependence on the perpetrators, making disclosure harder in the last months, weeks and days of life, even when professionals ask directly. Disclosure requires time to build trust with the same professional, who understands how abuse presents at the end of life in different cultural contexts and who can offer practical support such as safe housing, financial help and, if needed, support for dependents. Without this, disclosure is too risky.

Most women in Dr Hussain’s group said that they would not dare to disclose abuse during an assisted dying assessment as currently set out. They felt that the process was too brief, too medicalised and too uncertain to guarantee their safety. I recall a patient whose pain was not controlled on 1,000 milligrams of morphine per day. After a few days in our hospice, she disclosed to a care assistant at night the years of worsening abuse that she had endured. Total distress from hidden abuse had given her total pain. Social work intervention and safeguarding in place was the solution. She went out to a new home needing only 60 milligrams a day.

Disclosure is more likely in a trusted relationship with someone whom the person can know, whom they can look in the eye, knowing that they will work hard to improve their situation. In today’s NHS, continuity of care is not the norm. It is fragmented, with inadequate transfer of information between sectors. Patients do not see the same person time and again, whether doctor, nurse or other professional. That is why it is essential that information is sought, from police callouts to a domestic disturbance, local authority records to reveal any safeguarding issues in the household, clinical teams who have been involved, social care, community carers and family members who may well be aware of abuse but had not known how to disclose it.

Another type of subtle subliminal pressure is also addressed in this group of amendments—that arising from whatever the doctor suggests. Under the Montgomery and McCulloch rulings, patients must be informed of all possible treatments which are appropriate to that condition. If a doctor says that there is also the option of an assisted death, the patient will hear that as, “I know what lies ahead for you and you should consider ending it now”. A Canadian lawyer told me of his friend who had a stroke. On being taken out of the ambulance, he was asked whether he wanted treatment or MAID—medical assistance in dying—Canada’s term for assisted death. He also told me of patients being repeatedly asked by different doctors in the hospital about MAID, and the corrosive effect that this has.

The amendment in the name of the noble Baroness, Lady Fox of Buckley, and others, is particularly important. It does not prevent conversations but it would stop subtle coercive influences from doctors, who may be under pressure, who may feel that they have to raise this—just as the problems of DNR orders arose during Covid—or with some of the abuses of medical power and inappropriate surgery that were in the headlines not that long ago. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have a few amendments in this group. My Amendment 118 seeks to introduce

“an independent financial review and background check on close relatives before eligibility can proceed. It aims to block eligibility where there is known financial abuse risk”.

My Amendment 462 aims

“to make coercion/financial abuse checking a shared statutory duty of both the Commissioner and the multidisciplinary Review Panel”.

The noble Baroness, Lady Finlay, has set out some of the issues and concerns about coercion, which I do not need to repeat. I am a long-standing supporter of Hourglass, an amazing organisation devoted to combating the abuse of older people. It is neutral on the Bill, but its chief executive said in evidence to the House of Commons that

“there is an epidemic of abuse against older people at the moment. Some of it is due to the economic climate that we are in, with people just wanting to have their inheritance now, and some of it is due to the fact that older people feel like a burden”.—[Official Report, Commons, Terminally Ill Adults (End of Life) Bill Committee, 29/1/25; col. 160.]

--- Later in debate ---

[Lord Falconer of Thoroton (Lab)]

I am very grateful to my noble friend for mentioning that, because that is what was being whispered to me but I did not have the statistics. I am very grateful to him for providing them.

[Baroness Finlay of Llandaff (CB)]

My Lords, this has clearly been a long debate, and I think for good reason. As one noble Lord said, coercion and pressure are a major concern for many people about the way the Bill is written. I will very briefly respond. I am well aware of the time, but a lot of points have been made. Noble Lords will all be relieved to know that I am not going to go through them all.

First, the word “encouragement” is taken from the Director of Public Prosecutions guidelines, and for good reason, because the Director of Public Prosecutions recognised the power of a person in authority over a person who is vulnerable. That is why it tends towards the prosecution of assistance coming from a person in authority. I would include doctors in that, but it was also thought to include prison staff, nurses and others employed in that role.

[Lord Pannick (CB)]

I am sorry to interrupt. There have been a number of references to the DPP’s guidelines. For accuracy, will the noble Baroness accept that paragraph 45.5 of the guidelines says:

“A prosecution is less likely to be required if … the actions of the suspect may be characterised as reluctant encouragement … in the face of a determined wish on the part of the victim to commit suicide”?

[Baroness Finlay of Llandaff (CB)]

For the sake of accuracy, I completely accept that. Perhaps the noble Lord might also see, while I am speaking, whether I am correct that the guidelines would tend towards prosecution if a person in authority was encouraging. That was my understanding.

I will raise a few points. The noble Lord, Lord Hunt, absolutely hit the nail on the head when he pointed out that, if we had had a royal commission and went through the processes and so on fully, we might be in a different place now. One of the big problems we have encountered in looking at this Bill is what has been deemed to be in or out of scope. If you do not have the services available, you do not have true choice. That is a real problem, yet those of us who have tried to table amendments to bring specialist palliative care provision into scope to match and stay parallel with any developments in assisted dying services have repeatedly been told—I have checked, and it is in the Companion that we cannot extend scope—that this was deemed out of scope. Therefore, we feel a bit stuck about how we can make sure that people get the services they need.

The Minister pointed out something in the Bill that has been a concern to a lot of us: that the family do not have to be informed. Behind that is the concern about grief. Let us take a 19 year-old with an osteosarcoma with metastases. The parents have been looking after him from childhood through to all his treatment, doing all they can to enhance his quality of life. He says that he now wants to go for an assisted death, and he does not want his parents told. The first thing that the parents hear is a phone call to say that he is now dead, having had lethal drugs. They may be aware of a whole lot of issues that have been going on in that 19 year-old’s life, which they would have shared with those involved in his care. This is pretty close to some patients whom I have looked after, because someone developing into an adult when terminally ill is very difficult, as are the transition issues.

There is another aspect to that. Having spoken to and heard from people who have a relative who has gone for euthanasia—it is usually euthanasia rather than assisted suicide—they often feel devastated that their love was not enough to support the person. They feel that they have failed, and they ask why they could not have helped the person find ways forward or access the services they need. I will quote from the commission chaired by the noble and learned Lord, Lord Falconer, with Demos, on the lack of services. It states:

“The Commission does not accept that any of these forms of pressure could be a legitimate motivation for a terminally ill individual to seek an assisted death. Therefore, it is essential that any future system should contain safeguards designed to ensure, as much as possible, that any decision to seek an assisted suicide is a genuinely voluntary and autonomous choice, not influenced by another person’s wishes, or by constrained social circumstances, such as lack of access to adequate end of life care and support”.


The motivation behind many of the amendments discussed today has been precisely to deal with that problem.

I will address two more things, beginning with the concept of how sure someone has to be. The civil standard of proof of 51% seems remarkably low when determining the eligibility of someone having lethal drugs. The implication in the debate in the other place was that the doctor should not ask the person, “Why is it that you want to end your life?” Yet in clinical practice, whenever patients say, “I’ve had enough; I do not want to go on”, you answer that with one question, another question and then another question. It feels like an onion: you take layer after layer off, and you find out what is happening. You find many remediable aspects to their situation—they might often seem trivial to some people, but they have been wearing the patient down.

I am horrified, frankly, whenever I hear of inadequate care and of people not getting the pain relief that they need. Morphine does not kill you; it is a good drug for pain relief, given appropriately in the right dose at the right time for the right reason. That is what prescribing analgesia is about. That is completely different to giving a massive overdose of lethal drugs—and, as we know, not all the ones in the world have been fully assessed.

--- Later in debate ---

[Lord Watts (Lab)]

Would the noble Baroness agree for one second that, even if someone has good hospice care and the best medications that they can, there are still patients who suffer and have pain before death, despite all the actions of the people who are trying to alleviate that?

[Baroness Finlay of Llandaff (CB)]

I thank the noble Lord for the intervention. Perhaps it might be helpful for us to have a conversation outside this Chamber. But I would just say that pain is complex. It is not only physical; it has multiple components. Of the patients I have had the most difficulty looking after, we discovered that there were very many issues in the psychosocial and emotional domain: things that had happened in the past, some of which we did not know about at the time. But I do not want to go off message from these amendments, which are really important.

These amendments were put down in good faith to address the concerns expressed all around the Committee. I am disappointed that we have not got to the point of saying that we will all sit down together. I think that those of us who have drafted amendments will sit down together and discuss how we should bring something back on Report to manage the situation that we highlighted today, which is a very profound concern over coercion, abuse and all the other factors that go along with that. Apart from that, I beg leave to withdraw the amendment.

Amendment 3 withdrawn.

Terminally Ill Adults (End of Life) Bill

Baroness Finlay of Llandaff Excerpts

Committee stage
Friday 14th November 2025 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

2: Clause 1, page 1, line 4, leave out “capacity” and insert “ability”
Member’s explanatory statement
This links to a proposed change to clause 3.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as a consultant in palliative medicine in Wales—I have a paid session there. I have received incidental part-time research support from Living and Dying Well, of which I am a non-remunerated director, and I am a patron of several hospices and hospice services in Wales and across the UK.

Before I start addressing this, I thank the Chief Whip for the message that was sent out previously. I hope that the usual conventions and respect for each other will be observed. It was a pity that clearly there was an error yesterday, with a letter that was sent to the press and was being tweeted about at 3 pm. It was addressed to your Lordships, but we did not receive it until 7 pm, and that was after a blank email had arrived. That was an error, but I hope we can be vigilant about the way that we communicate with each other and that we engage in meaningful and respectful conversations.

I wanted to raise that because there has been a question about the number of amendments that are in my name. I am most grateful to the Public Bill Office, which has worked incredibly hard to support us. Forty-four of my amendments are corrections to wording relating to other bits of the Bill and were tabled at its advice to make the intention of another amendment clear. Please could nobody think that the numbers count? It is the quality of the discussion and the intention behind it that matter, because we are really trying to make this legislation work. It has been difficult because financial aspects relating to palliative care have been deemed to be out of scope.

This Bill is called the Terminally Ill Adults (End of Life) Bill. Every patient who is terminally ill has palliative care needs—100%. Some have them at a minor or relatively easily solved level, others have them at a major and complex level. I worry that we are forgetting the importance not only of palliative care but of specialist palliative care in the way that we talk about services being delivered, and the danger that people will not be able—I go to the word “ability”—to make a proper, informed decision if they do not have the choice to have the care that they need and, if they have complex needs, access to specialist palliative care that has links to pain services, radiotherapy, palliative surgery and all the other aspects of specialist services that I have been privileged to work with over decades. I am well aware they are missing in many parts of the country because we have black holes, I am afraid, in the provision of palliative care in some places. It is literally a postcode lottery.

If you are going to make a decision, and you have the ability to make a decision, you must be able to understand the information given to you. That means that you must have accurate facts that you can understand, be free of pressure and coercion—we will come on to that—and have the capacity to make that decision. We will come on to that.

I will focus on the facts that you may need to make a decision. The diagnosis might be wrong: we know that, at post-mortem, one person in 20 is found to have died of something different from the disease for which they were being treated. The prognosis might be wrong: we know from a really good systematic review that a six-month prognosis has a 48% chance of being right. You might be influenced by fear and experiences from decades ago that do not apply to modern medicine and modern specialist palliative care in these days, or you might have misinformation from the internet. It might even be that you put the wrong wording into the internet. Only last week I heard of a patient who believed herself to be dying because she had misunderstood the information that she had. She thought that she had a terminal illness and would be dead shortly. Actually, it was not a progressive terminal illness, but the communication of complex information meant that, when she heard what she thought she was frightened of, she could not take on any more information. The word “safety”, which my noble friend Lady Grey-Thompson raised, is paramount if we are to enable people to make safe decisions. We know that palliative care can identify remediable causes of distress and misunderstandings.

--- Later in debate ---

[Lord Falconer of Thoroton (Lab)]

I will answer that one. No, you cannot do it by power of attorney. You have to do it yourself.

[Baroness Finlay of Llandaff (CB)]

My Lords, given this very long debate, I will try to respond briefly. I declare that I had the privilege of being the first chair of the National Mental Capacity Forum, which was set up following the post-legislative scrutiny of the Mental Capacity Act precisely because of the problems with its implementation. I worked in that role all through Covid. As the noble Baroness, Lady Browning, said, unfortunately, although it is a fantastically good piece of legislation, its implementation depends on the person who is implementing it. Although there has been training, and we worked very hard to get training in, it has unfortunately not always improved things as much as one might hope.

The other thing I draw to your Lordships’ attention is Section 62 of the Mental Capacity Act, which concerns the scope of the Act. It says:

“For the avoidance of doubt, it is hereby declared that nothing in this Act is to be taken to affect the law relating to murder or manslaughter or the operation of section 2 of the Suicide Act 1961 (c. 60) (assisting suicide)”.


It was with that background that I became concerned that the quality of the information the person has depends on the knowledge of the person giving that information, as well as the ability of the person to retain it. I spoke about choice at the beginning of my speech. I am sorry that the noble Baroness, Lady Thornton, is not in her place, because choice is essential if we are giving patients opportunities to make decisions, but we have to have real choices. That is why I spoke about the black holes where there is no adequately provided palliative care.

Unfortunately, although the Bill has had a money resolution—forgive me if that is the wrong phrase, but there has been a commitment to fund the provision of a service if the Bill becomes an Act—it has not been matched by concurrent funding in the long term for specialist palliative care. That is a concern, but we will come back to it later.

There is another very small point that I want to make: can we please avoid using the term “commit suicide”? It is not a crime to take your own life, and “commit” is a deeply offensive term. We are talking about people who, for whatever reason, decide to take their own lives and end their lives early. We should remember that as we go forward in our debates, out of respect for everybody who has been bereaved by the tragedy of suicide or attempted suicide.

When it comes to life and death decisions, though, I suggest to the Committee that it is fundamentally different to have the decision of accepting that your disease process is going on, that your dying is inevitable and that you wish to withdraw your dialysis or ventilation. Those are decisions in which I have been involved with patients for decades. We can now take people off ventilators very gently and calmly without any of the distress that was previously associated with that, and they die of their underlying disease.

What we are talking about is suicide prevention versus suicide assistance and the point at which you decide, as a clinician with a patient in front of you, whether you are going to be working with suicide prevention, improving quality of life, or whether you are going to stop that because you are going down a different route, and some of the evidence we had was to that effect. However, because of time and the way that things have gone on, I beg leave to withdraw my amendment.

Amendment 2 withdrawn.

Learning Disabilities Mortality Review Reports

Baroness Finlay of Llandaff Excerpts

Thursday 13th November 2025 Lords Chamber

[Baroness Merron (Lab)]

These are indeed tragic deaths, and avoidable in a number of cases, as the noble Lord rightly says. I can do better than agree to meet him and his colleagues—I have already got agreement from Minister Zubir Ahmed, who is responsible for this area and will be very pleased to meet them.

[Baroness Finlay of Llandaff (CB)]

My Lords, will the Government commit to working further with the National Mental Capacity Forum? One of the leads that comes out in this report is a failure to implement adequately, particularly in giving support to people. Parents are often very important in providing support to a person with learning difficulties, but when that person is an adult they can feel excluded, and they are often very worried as to what will happen after they have died and the person remains alive.

Artificial Intelligence: Safeguarding

Baroness Finlay of Llandaff Excerpts

Tuesday 4th November 2025 Lords Chamber

[Baroness Merron (Lab)]

I certainly agree that this is the way we need to go, and discussions happen regularly with companies, as the noble Lord says. It is probably also worth saying that we have already seen some early signs of improvement in terms of protection for users from online harms, and over 6,000 services are implementing what we would regard as highly effective age assurance, which brings protection to millions of children. Of course, DSIT is monitoring and evaluating the Online Safety Act. Where evidence shows that further intervention is needed to protect children, we will not hesitate to act.

[Baroness Finlay of Llandaff (CB)]

My Lords, digital mental health technologies with clinical purposes are classified by MHRA as medical devices. Therefore, what action can the Government take, working with MHRA and Ofcom, to ensure that these chatbots actually promote suicide prevention policies and do not act as suicide promotion sites?

Tobacco and Vapes Bill

Baroness Finlay of Llandaff Excerpts

Committee stage
Thursday 30th October 2025 Grand Committee

[Baroness Watkins of Tavistock (CB)]

My Lords, I broadly support these amendments but also agree with my noble friend Lord Patel that there is probably no reason to have oral pouches at all. It is something that we could carefully consider deleting from our society. If you are trying to withdraw from tobacco, nicotine patches are just as effective as pouches and do not cause the problems that have been so readily described today. While the debate has been going on, I looked back, and it was 1950 when Sir Richard Doll proved the relationship between tobacco and lung cancer. It has therefore taken us 75 years to get to this point, with the Bill. There is sufficient evidence in relation to pouches for us not to decide that we need a 75-year prospective trial to show their damage.

[Baroness Finlay of Llandaff (CB)]

My Lords, I too support the amendment, and I have a question for those who have tabled it, which relates to proposed new subsection (2)(b), saying the product is

“not intended to be inhaled or chewed”.

I am afraid that as someone who has been looking at tobacco control measures for many years now, through legislation, I am slightly concerned that, as we get rid of one thing, the nicotine manufacturers will find another way of bringing in a substance that is, in effect, addictive, which is promoted to young people, and is a way to get them started on the inevitable chain of addiction that leads to promotion.

When we look at the evidence around nicotine, we see that, yes, it is highly addictive, but the other thing that happens with an addictive substance is that you become tolerant to the effect, to that boost. Therefore, the addict seeks higher and higher doses to get a greater and greater hit. In the long term, as my noble friend Lord Patel pointed out, it is not only blood pressure and so on; there is a problem with platelet stickiness. We do not know what this will do in the microvasculature in the brain in the long term, because these high-dose nicotine products have not been around long enough and we have not had enough brains that have come to post-mortems—I am sorry to put it so bluntly—of people who have been using them for a long time. The hit that they get is greater than they would get from smoking a cigarette.

[Baroness Fox of Buckley (Non-Afl)]

I want to clarify how we make policy based on evidence if that evidence is unknown unknowns about what might possibly be the problem with something. It is absolutely the case that, where there is proof of harm, evidence is given and medical papers are produced. They have not been produced on this issue—I have looked—so it would be useful to see lots of peer-reviewed evidence that showed harm. To suggest that something could be a harm because we have not had long enough to find out whether it is a harm does not seem to be the basis of sensible evidence-based policy.

[Baroness Finlay of Llandaff (CB)]

I completely take that criticism; it is a fair comment. However, we know the damage to the brain microvasculature from smoking over the long term and that these substances are highly addictive. We also know that when we previously took through tobacco control measures, we never anticipated vapes or pouches. The evidence therefore is that those producing nicotine products are very imaginative and creative, and there is concern about this being used as a gateway to further addictive products. That is why I question whether proposed new subsection (2)(b) is necessary or adds anything to Amendment 13, which otherwise should be strongly supported.

Terminally Ill Adults (End of Life) Bill

Baroness Finlay of Llandaff Excerpts

2nd reading
Friday 19th September 2025 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my roles in palliative medicine, caring for thousands of dying patients over decades, and in Living and Dying Well.

The Bill as written does not improve patient choice or control. True choice would ensure patients can get the care they need. Control will rest with the doctors who can initiate the conversation and are the gatekeepers on eligibility for lethal drugs.

Supporting a patient who wants to stop treatment is not assisted suicide. Stopping unwanted treatment allows life to close in a timely way. The person dies of their underlying disease; it is good care.

Training in palliative care is lamentably poor across most of health care. Ignorance of pain and symptom control management is widespread across the globe. Morphine to control pain does not kill, although some mistakenly think it does; it provides comfort as life slips away.

Specialist palliative care can save millions a year to the NHS through care that meets need, substantially improves well-being and comfort, and avoids unnecessary interventions. It does not keep people alive who do not want to keep living.

The Bill’s impact assessment suggests that there will be up to 4,500 assisted deaths by year 10. The Bill does nothing for the over half a million people dying each year on whom it will have a profound impact, many with needs not addressed but wanting to live better right to the end of their lives. They are unheard, already often made to feel a burden; they fear being persuaded to take lethal drugs; and they face their local services being further eroded to fund the assisted death service. It is unethical for us to pass poor legislation for a state-provided NHS assisted death service while leaving the care of half a million dying people to be patchy, often inadequate, and, at best, subsidised ad hoc by struggling charities.

Throughout, we have heard horror stories of bad care and inadequate or appalling management, especially out of hours. The Bill does not require any attempt to relieve pain or suffering, even if they are present. It puts power in the hands of the two assessing doctors, who may know nothing about the condition of the person, who cannot detect undue influence or coercion and whose motivation may be opaque. Prognosis is a guess and diagnostic errors are common. These doctors do not need to be certain; only on the balance of probability do they need to believe that the criteria are met. With no oversight of their assessment, how can a panel approve the death with any certainty when there is no ability to appeal against a panel approval and no coroner oversight? How many wrongful deaths a year is acceptable? No system can be 100% safe.

Providing massive drug overdoses in an unlicensed way to end life is not a therapeutic act and has no place in health and social care provision. Evidence, not heard in the other place, from other jurisdictions reveals complications, slow deaths, complex grief in the bereaved and profound clinical distress. Whether or not you feel that some people should be able to have an assisted death or even euthanasia, this Bill, as written, is deeply flawed. It must have essential scrutiny.

Some noble Lords have suggested that a timetable has been agreed. That is not the case. It has been agreed to have a Select Committee that will complete its work in November, allowing the Committee of the whole House to get under way promptly to undertake that scrutiny, which is absolutely essential.

Learning Disabilities Nursing

Baroness Finlay of Llandaff Excerpts

Tuesday 17th June 2025 Lords Chamber

[Baroness Merron (Lab)]

I pay tribute to the noble Baroness for her work as a campaigner in this area, particularly through Team Domenica. I know that through my office she will be meeting the Minister for Care next month to discuss all these important issues. It certainly is the case, and is totally unacceptable, that people with a learning disability die earlier on average than the general population. In England alone, we are talking about 1.5 million people with a learning disability, and they have significant health inequalities. Learning disability nursing is one of the four specialist fields of nursing, and those areas will be attended to in the forthcoming workforce plan. That will tie in with the 10-year plan, which is the first plan that will be published and noble Lords will not have to wait too long for it. The commitment to improving care for those with learning disabilities, and, if I might say so, with autism, is absolutely going to be in there; the noble Baroness will recall the discussions that we had, for example, on the Mental Health Act. I hope that this will show the way in which we are going, but I certainly agree with her about how much more there is to do.

[Baroness Finlay of Llandaff (CB)]

My Lords, will the Government undertake to ensure that in their workforce plan the training of undergraduate nurses in all courses, and for undergraduate medics and allied health professions, includes training on managing a situation where people have degrees of impaired mental capacity, and that judgmental views on disability are removed from any aspect of discussion because they are prejudicial to the way that people are handled when they present as emergencies? The problem is that people with learning disabilities can present at any time of the day or night to any of the services.

[Baroness Merron (Lab)]

The noble Baroness is quite right. One of the difficulties is that sometimes there is misdiagnosis, where it is incorrectly assumed, for the very reasons that the noble Baroness gives, that the presenting condition is the learning disability when actually it is a different condition. I agree about the need that the noble Baroness outlines. In reports such as the LeDeR review and Transforming Care, there is a national focus on reducing health inequalities and increasing awareness of this very point about diagnostic overshadowing. I will ensure that that is key to what we are doing.

Human Medicines (Amendments Relating to Hub and Spoke Dispensing etc.) Regulations 2025

Baroness Finlay of Llandaff Excerpts

Tuesday 17th June 2025 Grand Committee

[Viscount Stansgate (Lab)]

My Lords, I broadly support these regulations. I hope that my noble friend the Minister will not mind my intervening briefly to ask a couple of questions; I have no wish to detain the Committee.

Obviously, I understand that community pharmacies have been playing an increasingly expanded clinical role in treating minor illnesses and improving medicines’ safety and optimisation. To improve the efficiency of dispensing, these regulations will help support community pharmacies in taking on a more clinical role. The purpose of these regulations, which is to free up smaller pharmacies and enable them to undertake hub-and-spoke models, is, I am sure, a good one. First, does my noble friend the Minister have any idea of how welcome this will be to smaller pharmacies? Is it expected that a great deal of them will undertake these new arrangements outwith the previous restriction on being in the same legal entity?

Secondly, having recently been to my local pharmacy and having talked to the pharmacists there, I was struck by the strain that they are under, both in terms of their workload and financially. Am I right in thinking that this hub-and-spoke model, which will be made more widely available, will in some way help smaller pharmacies deal financially with the situations that they face? Am I wrong in thinking that there is a financial dimension to this? If there is, I would be very grateful for any reply that the Minister can give, but, in summary, these regulations are a step in the right direction.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am most grateful to the Minister for the comprehensive way in which she introduced this instrument, including how it corresponds with all the documentation that we have. I am glad to see that it applies to Wales; we have many small pharmacies with cross-border flow and many roads going across the border, so this SI will make things much easier.

Like the noble Viscount, Lord Stansgate, I have some questions. I hope that at least some of them will be answered; some of them may need time. One of my concerns is about how the finances of this will work, because pharmacies depend on a dispensing fee. Who will get the fee? Will that be down to local negotiation? Will the fee be split?

However, the principle of freeing up time for the pharmacist to undertake more clinical duties is to be welcomed. They are often the first point of call for patients now. They often know the patient. They spot the person who looks less well and can advise them appropriately. They can also advise on drug side-effects, if a person goes into the pharmacist and asks about new symptoms that they might have.

However, I wondered where the liability sits if there is an error. If I understood right, it would sit with the hub if it were in what is dispensed, but there may be a difference in liability for information given to the patient. One hopes this will never happen, but some of those governance issues need to be thought through in detail.

I note that the pharmacists are already taking impressive extended roles in some areas. For example, there is a scheme in Bristol where pharmacists are taking blood for PSA assessment and reaching a population who would not otherwise present for screening for cancers. If we have pharmacists doing more health screening that would certainly free up GP time. Again, pharmacists will need to be remunerated for that.

I was interested to see that the international evidence is a little variable. Germany, Finland, Belgium and Denmark already using a hub-and-spoke dispensing model but the evidence is not overwhelmingly conclusive. In hospitals, where you have a single large building and a large number of prescriptions, automated pharmacy has in many ways revolutionised the administration of medicines.

One of the concerns is the time lag from a dispensed medicine going from the hub out to the spoke. I hope that will be thought through, so that we do not have patients, perhaps with mobility difficulties, having difficulty getting back to collect their prescription, and that those things will be factored into such arrangements.

Another area that I have a slight concern about relates, not surprisingly, to my own area, palliative care. We know that the availability of controlled drugs is poor at times, yet they are often needed urgently. I hope that consideration has been given as to how the dispensing of controlled drugs in particular can be rapid and efficient, especially when the clinical situation has changed and new medications are required at speed for a patient to be able to remain at home, rather than ending up taking an unnecessary or inappropriate voyage to hospital, with possible admission. Those travel systems also come into it.

The last area that I hope this model will tackle is waste, because there are a lot of things that patients are prescribed but never end up taking. Those of us who have been in a house after someone has died will often have been given several supermarket bags—I will not name the supermarket—full of packs of medicines that have been dispensed. They can be extremely expensive but have not been taken. They cannot be taken back in at the moment and cannot be recycled. The schemes that recycled some of the opioids, such as diamorphine, have not continued over the years. This is an enormous financial waste to the NHS, because some of these medicines have been very expensive.

I hope that this model will free up pharmacists and incentivise them to dissuade patients from accepting prescriptions when they are not actually taking those medicines. I could spend hours relating numerous stories of patients who were either not taking their medicines or giving them to somebody else. I have even once been presented with some children trying to sell me grandmother’s pain relief at the foot of the stairs, which helped me understand why I could not get grandmother’s pain under control. There is a real problem of waste in the system. If this instrument will decrease waste without jeopardising pharmacist’ income from prescribing fees, that would be very welcome.

[Lord Scriven (LD)]

My Lords, I thank the Minister for outlining the purpose behind and need for these regulations.

On these Liberal Democrat Benches, we are of course open to innovation and efficiency in our healthcare system. We recognise the potential for modernising practices to streamline operations, to reduce burdens and, ultimately, to try to improve the delivery of medicines to patients. However, for something as sensitive and fundamental as dispensing medicines, the devil, as always, lies in the detail—as the noble Viscount, Lord Stansgate, and the noble Baroness, Lady Finlay of Llandaff, pointed out—so we must scrutinise these proposed changes with the utmost care.

--- Later in debate ---

[Baroness Merron (Lab)]

The whole point of the regulations, as well as cutting red tape, is about levelling the playing field. I understand the point the noble Lord is making, and I re-emphasise that arrangements between hubs and spokes are for them to make, rather than us to set. I am happy to look at the point the noble Lord makes and to write to him further with more detail.

[Baroness Finlay of Llandaff (CB)]

I will pick up on this because it is a concern. In her summing-up speech, the Minister spoke about the business interests of the hub and the spoke. A concern is whether you could have a hub, which will be a large, possibly even multi- national, provider that could create a monopoly. As has been recognised during this debate, in rural areas, in particular, dispensing doctors are often a small group. Pharmacy services have a relatively low turnover but are important to such communities that are a long way from other places and where the services provided by the pharmacist are particularly important. Yet, as a small spoke, they may not have the power to negotiate with a strong central hub that may well be driven by shareholders and profit. There is a little bit of me that would really like this to somehow be a not-for-profit arrangement over the whole of it, but I realise that that is not feasible.

[Baroness Merron (Lab)]

Perhaps it might be helpful to noble Lords if I refer to the Competition and Markets Authority in this regard because it noted that the proposed amendments that we are speaking of today are broadly competitive. It also acknowledged that there could be potential long-term competition risks if the market develops in such a way that pharmacy access to medicines, for example, is through an increasingly limited number of hub suppliers.

As the noble Baroness, Lady Finlay, suggested could happen, we might have only a few larger hubs emerging. I understand the concern that that could affect the availability of medicines for patients and their pricing. However, because of the recommendations from the Competition and Markets Authority, the department has committed to review the impact on competition once the hub market is sufficiently established. We will then assess whether action is needed to alleviate any barriers to the development of what, I believe, we all want to see: a dynamic, competitive hub market.

NHS and Care Volunteer Responders Service

Baroness Finlay of Llandaff Excerpts

Tuesday 20th May 2025 Lords Chamber

[Baroness Merron (Lab)]

My noble friend makes a very important point and I can certainly give her the assurance she seeks. Over 50,000 additional volunteers are recruited by NHS trusts, which they then support directly in the way my noble friend describes. Their roles are totally unaffected by the change to this programme. There are many thousands of volunteers who support the NHS directly or indirectly via other local and national voluntary sector organisations, and I pay tribute to them all.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare an interest as president of Attend. Can the Minister explain how, in the new system, the Government will work with an organisation such as Attend, which provides insurance, legal advice, financial services and networking to a whole series of agencies that provide volunteers across the country, to ensure that there are rigorously high standards and that those who volunteer are protected in their role, and that they benefit in addition to providing maximum benefit to the recipients?

[Baroness Merron (Lab)]

The noble Baroness raises an important point. I am sure there are many, like me, who have volunteered, or still volunteer, and gained as much as they gave, although they did not expect to. It is important to have standards, and to protect volunteers and everybody involved. That will be the case. A lot of local action builds relationships with local organisations, which is a very successful way of harnessing the benefits of volunteers and volunteering.