Terminally Ill Adults (End of Life) Bill
Lord Baker of Dorking Excerpts(2 days, 7 hours ago)
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Lord Baker of Dorking (Con)
My Lords, this House has debated assisted dying this century on nine occasions, first in 2003 and then in 2005. There are very few members in the House today who spoke in those debates, with the possible exception of the noble Baroness, Lady Finlay of Llandaff. She was a very devoted opponent of the Bill of those days, just as I was a devoted supporter of it. But all those debates were about Private Members’ Bills that originated in this House. What we have now is a Bill coming from the House of Commons; it is not a government Bill, but it received a great deal of debate, amendment and improvement, and then it was sent to us.
However, we do not exist as a House to frustrate the determined will of the House of Commons. Our task is to examine Bills—which they do not do themselves in a measured way today—to improve them and send them back. This has been frustrated by a relatively small group of people; just seven noble Lords has tabled nearly over 1,000 amendments. That is a tiny minority by any standard. I believe that the prolonged filibuster they embarked upon is a constitutional farrago. It is a denial of democracy and an attempt to give this House the wrecking powers that were taken away in 1912.
I congratulate the noble and learned Lord, Lord Falconer, for the very patient way he dealt with the repetitive speeches that were full of absurd exaggerations and extravagant fantasies. He did not lose his cool, and that is quite remarkable. I also thank the noble Lord, Lord Carlile, for his effective contributions towards improving the Bill. He came forward with several proposals, but he too is frustrated from implementing them currently as a result of us returning the Bill to the House of Commons in the way we received it.
I support this Bill for two reasons. First, it will reduce the suffering of many elderly people who are experiencing a prolonged death, and nothing was more eloquent than the speech that my noble friend Lord Markham made about that. We are particularly well suited in this House to debate this sort of measure because, on the whole, we are rather older than most MPs and we have experienced the deaths of friends, colleagues and relatives. Just this week, one of my closest friends, who was a Cross-Bench Peer in this House, died. I had tea with him the previous week. Robert Skidelsky was my close friend. We lived close to each other. He was a brilliant economist, but he was also a very good bridge player, and I shall miss him enormously. He is one of the lucky ones, as it were.
As I said, one reason I support the Bill is that it reduces the suffering of people when they slowly begin to lose control of their own bodies. It was very interesting to hear what the right reverend Prelate the Bishop of Newcastle said, because in previous debates the main argument was about the sanctity of life. It is only the Bishops who continue to make that argument; no one else will make the argument because what we are concerned with are the safeguards, and this Bill will reduce the suffering of people. As we slowly lose control over our own bodies, people can no longer get up and dress, wash or feed themselves, or prepare their food, or walk or run, or engage in any life whatever; they then lose control of their bowels and bladders, and it is a very unpleasant way to die. If you can get palliative care, you can anaesthetise pain, but you cannot anaesthetise indignity. This Bill allows people to die in a dignified, and sensible, way in their own homes.
Baroness Scotland of Asthal (Lab)
My Lords, I hesitate to interrupt the noble Lord, Lord Baker, but I am sure he would want the House to be aware that the Attorney-General’s guidelines have assisted in enabling prosecutors to make decisions which would obviate the need for prosecution where there is no evidence that the person assisting did it other than for love. The fact that there are so few prosecutions is something we should celebrate as opposed to criticise, because those 10 that go forward are because there is evidence that that which was done was not well done and should be prosecuted.
Lord Baker of Dorking (Con)
I understand what the noble and learned Baroness is saying, but the police have decided very clearly what their position is. Between 2009 and 2025, 199 cases were referred to the Director of Public Prosecutions by the police for assisted suicide. Of those 199 cases, 131 were not proceeded with by the Director of Public Prosecutions and were withdrawn; the police then withdrew 39 other cases. Therefore, this not a law that is operating today because juries will not convict. I would—
Baroness Scotland of Asthal (Lab)
I do not want to interrupt the noble Lord again, but I think it is right for him to know that this matter came before the Attorney-General, myself, to determine how we should address this problem. How could we make it better? How could we differentiate between those who should validly be prosecuted and those who should not? The Director of Public Prosecutions then has a duty to implement the Attorney-General’s guidelines when making a decision as to whether to prosecute or not, and they have duly done so.
Lord Baker of Dorking (Con)
I recognise that there is that power, but it is very rarely used. That is the point I have been making all the time. Juries will not convict.
This has happened before in our history. There was a time when the law decided that youngsters as young as 10 or 12 could be hanged for stealing a pocket handkerchief. That fell away because juries would not convict. Similarly, I do not believe that the present law on suicide can in fact operate effectively, and therefore it should be changed.
Lord Barber of Ainsdale (Lab)
My Lords, I have spoken only once previously in the many long hours of debate on the Bill. That was at Second Reading, when I told the story of Daniel, the much-loved son of my noble friend Lord Monks, who, in the absence of any form of assisted dying in this country and faced with intolerable suffering, starved himself to death in 2024.
Like many others around our country, I had strong hopes that the Bill would have given, for the first time, people very close to the end of their lives some choice on how to leave this world. While remaining silent in the Chamber, it quickly became very clear to me that an additional voice was certainly not needed. I have been distressed and disturbed by what I have witnessed here.
As I was coming into this place a little over a year ago now, I was given to understand that we had two central responsibilities. Our job was not to seek to displace or overturn the elected House, but to act as a scrutinising and revising Chamber. So, how well have we carried out those responsibilities? As my noble and learned friend Lord Falconer reminded us, this is a Bill of 59 clauses. In Committee, after 120 hours of debate we have managed to scrutinise only seven of those clauses. The rest of the Bill, 52 clauses, has received no scrutiny whatsoever. As to our responsibility to propose revisions for the elected House to consider, there have been a handful of entirely non-contentious matters to which revisions have been made in Committee. Of course, substantive revisions would fall to be considered and voted on Report, and we have never come even close to reaching that point. In sum, we have abjectly failed in our responsibilities as a scrutinising and revising Chamber.
It became apparent very early on in Committee that the rate of progress was utterly glacial. My noble and learned friend proposed a Motion to the House, seeking additional time if necessary, and committing the House to completing consideration of the Bill in good order to return it to the Commons. Nobody voted against it, but nobody changed the form or the length of their contributions to these debates, even by a tiny amount, to make its objective achievable. All efforts by my noble and learned friend, as he reminded us, to establish more streamlined processes, came to naught.
There has been a catch-all justification that we have heard again today, offered by some of the Bill’s opponents, that it has always been a bad Bill in need of fundamental root-and-branch reworking from top to bottom as a result of insufficient earlier work and insufficiently detailed scrutiny. I reject that view, and I regard it as deeply disrespectful and an insulting slur on the sponsors of the Bill and all those highly expert advisers who have supported the sponsors at every stage of the Bill’s preparation. It rather ignores the very detailed consideration the Bill received in the elected Chamber, in many cases, with honourable Members—
Primary and Community Care: Improving Patient Outcomes
Lord Baker of Dorking Excerpts(3 years, 7 months ago)
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Baroness Finlay of Llandaff (CB)
My Lords, like others I congratulate the noble Lord, Lord Patel, on raising this crucial debate. I declare that I am a fellow of the Royal College of General Practitioners as a GP—indeed, a medically qualified Dr Finlay—and got my fellowship before moving to hospice work. I am also a patron of the Louise Tebboth Foundation to prevent GP suicides and am president of the Chartered Society of Physiotherapy. I will focus on family medicine specialists—GPs—but we must not forget the major impact that physios and others have on conditions through direct access.
I chaired the Independent Commission on Medical Generalism for the Royal College of General Practitioners and the Health Foundation. Our 2011 report concluded that the generalist approach is essential across healthcare and that if it did not already exist it would have to be invented, while work by Barbara Starfield showed that the health of a nation depended on the quality of its primary care services. I do not believe that that has been dented by Covid.
Patients are the raison d’être of healthcare delivery. People become ill at all times of the day and night, presenting with undifferentiated conditions. Some conditions progress rapidly, in others the course is fluctuating or resolves. In our communities, many people live, work and contribute to society with a broad range of chronic long-term multiple co-morbidities. Some have rare conditions. Differentiating abnormal from the normal requires diagnostic skills and risk-assessment experience. Good primary care training is essential, providing adequate experience in paediatrics, women’s health, acute and early presentations of serious illnesses and the complexities of medicine in the elderly—and now the workload of GPs has become increasingly linked to social problems in society and mental health.
However, the problem we have is that GPs are leaving practice faster than they can be recruited. The 27,500 whole-time equivalents GPs are made up of a workforce with a headcount of around 40,000. As the noble Lord, Lord Hunt of Kings Health, pointed out, there are now 2.5% fewer GPs than in 2019 and 5% fewer than in 2015, but the average GP is responsible for 16% more patients than 10 years ago. More patients need to be seen than there are 10-minute appointments in a day, let alone time for home visits.
Seeing 40 to 60 patients a day, many of whom have complex medical and social problems, for five days a week is unsustainable. GPs become burnt out and leave. They seek work in other areas in medicine, but often in much more administrative or peripheral roles. Many GPs develop an extended role, developing expertise in some branch of medicine, such as women’s health, diabetes or hospice work, or in emergency medicine departments as part of a portfolio of clinical work. They need to carry on working but feel burnt out with the workload of routine general practice.
The GP is the first point of contact for undifferentiated complex problems. They can provide a holistic and comprehensive service for the long-term and acute care of the population they serve in their communities. An integrated approach must address the whole person: the physical, psychological, spiritual and emotional aspects which have led to the condition that has presented. Importantly, there is good evidence that, where continuity of care is in place, there are better clinical outcomes at lower cost, with greater patient satisfaction. We desperately need more GPs—incoming newly qualified GPs—but also to find ways to retain our experienced, highly skilled doctors who are leaving the profession in large numbers.
These doctors are trained family medicine specialists, and they need parity of esteem with consultant specialists in secondary or tertiary care. From that position, some will need to be able to pursue particular special interests, which will support other services such as mental health—thereby combining the family medicine specialist’s interest with some days in community practice—where integration with social care provision is essential.
There have been efforts to increase the numbers of allied health professionals in primary care to help with the shortage of GPs. But there is increasing evidence that, unless these professionals are carefully integrated into the primary care team, they cannot replace the experience and value of a GP. They need support and nurturing. The incoming chair of the council of the Royal College of General Practitioners, Professor Kamila Hawthorne, wants to create associate membership of the college for those allied health professionals who contribute to the primary care team to ensure better integration and understanding between the different disciplines in proper team working. In GP clusters that work well, all disciplines coming together has been shown to improve clinical outcomes and decrease the burden on secondary care. Change will be embraced if those delivering care can lead it and funding issues cannot be ignored in terms of the way that people are paid and reimbursed for their services.
There are other disciplines and services in the community. Hospice home care teams and Marie Curie nurses can be an essential supplement to primary care provision, but they need to be involved early. As many GPs have an interest in palliative care, I hope that the specialty will reopen to those with MRCGP, rather than allowing entry to consultant level training only to those with RCP membership, because their mature clinical experience in the community is invaluable, especially for hospice at home.
We must recognise that the diagnostic, management and risk-assessment skills of the trained GP are essential for our communities and the NHS. Community work is not easy, but it can be very fulfilling if allowed to work properly. The employment of family medicine specialists, with parity of esteem with the hospital consultant body, would allow those who wish for a much more flexible career approach to develop their special interest roles while retaining a firm foothold in family medicine in the community, with all its complexities. Working with their communities, with their own patient population and with all aspects of social care, they can be community leaders.
In the pandemic, around 30,000 doctors were granted temporary emergency registration and over 9,500 have remained licensed to practice until now. At the end of the month, they must apply to restore their registration and for their licence to practise to remain. To date, around 8,000 have not acted despite a streamlined process being in place. Will the Government request NHS trust responsible officers to be available to doctors in their area who wish to relicense?
I have not focused on pensions, but it has aggravated the problem of the loss of GPs from practising. As judges have been given an exemption from the pension cap, will the Government review the pension cap for clinicians? It would be far more cost effective than gaps being filled by expensive locums or leaving services with gaps unfilled and a population without the healthcare it needs.
More medical school places, greater flexibility around revalidation and an ability to have flexible career paths could help supply and retention. However, the problems leading to attrition must be addressed, and the scenario from dentistry is the flashing warning light in front of our eyes.
Lord Baker of Dorking (Con)
Before the noble Baroness sits down, I thank her for a very interesting, well-informed speech. She identified the pressures placed upon GPs, which are not going to be relieved easily. Would she welcome what happens in a country such as France, where many—
Baroness Bloomfield of Hinton Waldrist (Con)
I am very sorry, but the noble Lord is not on the speakers’ list.
Baroness Bloomfield of Hinton Waldrist (Con)
No, not in a time-limited debate with a provided speaking time.