Terminally Ill Adults (End of Life) Bill
Lord Kamall Excerpts(1 day, 17 hours ago)
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Baroness Coffey (Con)
My Lords, I tabled Amendments 56 and 57. Amendment 57 is to do with
“acting for the primary purpose of avoiding physical pain”,
while Amendment 56 is about someone
“acting for their own sake rather than for the benefit of others”.
The two amendments are distinct, although they are linked somewhat because, to some extent, the issue of physical pain—or avoiding it—is a clear-cut way of limiting the scope. I accept that my noble friend Lord Markham does not think that the scope should be limited in this way; indeed, many others may well think the same. I also bear in mind what the noble Baroness, Lady Royall, said about the fact that people are dying anyway. However, this is about a new way of accelerating death rather than the situation that we have at the moment, including, for example, “Do not resuscitate”; as I say, I am relieved that we no longer have the Liverpool care pathway.
Without revisiting the entire palliative care debate, one thing I was struck by in the words of noble Lord, Lord Stevens of Birmingham, is that element of choice—that is, whether this is a real choice and can be considered objectively, in terms of the primary purpose being avoidance of pain. If palliative care were widely available—I know that there are people who feel that palliative care may still not be enough—Amendment 57 would still allow for that.
Where the second element comes in—I appreciate that noble Lords may feel, “We’re back here again talking about coercion”—is in relation to motivation. I was struck somewhat by what the noble Baroness, Lady Whitaker, said, which was almost, “I don’t want to be a burden—my children know this—so let’s just get on with it”. However, this issue keeps coming back, I am afraid.
I thank the noble Lords who signed my amendments; one of them, the noble and right reverend Lord, Lord Harries of Pentregarth, has left because we have gone past 3 pm. I was motivated to table them by the debate in the name of the noble and learned Lord, Lord Falconer of Thoroton, in this Chamber on 7 November 2014, with the same Peer, going back to this understanding of what “voluntary” is. Back then, the noble and learned Lord referred to the aspect of people not wanting to be a burden. I intend to quote him, if that is okay; I appreciate that he may not have the Hansard to hand. Another Peer asked the noble and learned Lord, “How do you know?” The key thing is that, although that Bill was admittedly about a judge-led process, it was also about conducting
“in-depth discussions with the patient and the other doctors”
where the voluntary bit had to be voluntary, with
“he or she … not being forced into it either by coercion or by the sort of guilt that we referred to earlier”.—[Official Report, 7/11/14; cols. 1955-56.]
The “earlier” was that feeling of being a burden. So, my question for the noble and learned Lord, I guess, is: has something changed? Is it just that society has moved on and that autonomy is now more important than our concerns, which are still there, around why people want to accelerate the end of their life even though they know that it may come quite soon?
I am still concerned with making this issue clearer. Most of the stories that have led to the debates and Bills that we have had have been about pain and suffering; that is why, to be candid, I prefer Amendment 57, to avoid the issue highlighted in Amendment 56.
Lord Kamall (Con)
My Lords, this has been another rather long but interesting debate. It is important that noble Lords who wanted to speak had their voices heard. It touches on something we touched on very early. Noble Lords will remember when we debated another version of motivation and talked about coercion. A number of noble Lords put forward amendments to talk about encouragement. In that debate, we saw how difficult it was to distinguish between encouragement and coercion, to say whether encouragement is a form of coercion, and to legally define something such as encouragement.
Now we have the very same issue with motivation. In some ways, as the noble Baroness, Lady Cass, said, motivation is the internal version: it is self-encouragement or self-coercion, not wanting to feel a burden. We have debated what it means to feel like a burden. It is important that we understand the motivation. As the noble Baroness said, professionally, doctors need to do that to understand what help or assistance that patient could be given. It could be, if this Bill passes, that they are allowed or helped to progress to assisted dying, but it could be that they are offered something else that they feel very comfortable with that gives them a bit longer to live and to have that quality time that the noble Baroness, Lady Fox, talked about having with her family. When I was a Health Minister, one of the things that I learned about palliative care from the noble Baroness, Lady Finlay, when I first spoke to her was that people who live longer, even though they may have wanted their life to end “now”, appreciated that extra time with their family, once they entered palliative care, to close those unclosed things, to make up with friends and family they may have fallen out with, and to bring closure to their life before they went. It is important that we recognise that. I do not want to go back into the whole debate about palliative care, but it is important that it is seen as an option to give that closure to people, even if they do not want it and they decide, “I’ve made my mind up”. That is probably a more informed choice.
We need to be very careful about trying to define exactly what the one word that sums up the debate is. If it is about choice and only choice, pretty soon after the Bill reaches the statute book, people will say, “I only have 12 months to live. Why can’t I have the same choice as people who have six months?” Surely it is about not just choice or suffering but a combination of factors. That makes it incredibly difficult for the lawyers, but also for the medical people, to determine. We need to unpick some of that.
Noble Lords who have spoken on this group have picked up a number of issues: people feeling like a burden, mental health disorders, disabilities, and remembering that not all disabilities are visible. On that point, I welcome back the noble Baroness, Lady Campbell of Surbiton—I should know her title because she lives down the road from me; next time she sees me on the high street, she will probably prod me on that. There are also financial considerations, self-motivation and avoiding physical pain. The Bill does not require a specific motive as part of the eligibility criteria. Obviously, the whole Bill is about eligibility—the first few words are about who is eligible to seek assisted death services or terminally ill adult services—but it would be helpful if the noble and learned Lord, Lord Falconer of Thoroton, could expand on the thought process behind his very tight definition of “eligibility”.
I must say to noble Lords who have teased the noble and learned Lord a little bit about things that he may have said in the past that we are all entitled to change our mind when we learn new facts or hear a different view. I do not see it as a weakness in an argument if someone changes their mind when they have heard new facts. I find myself defending the noble and learned Lord, but I do not think we should be too harsh. I should remind people that I am personally very torn on this Bill, and I have not made up my mind. I am waiting to see the outcome of this debate before I make up my own mind about how I vote on this.
We also heard about dignity. I teach at a Catholic university, and dignity is a very important concept in Catholic social teaching. But what is dignity? It can be subjective. One person could be told that they have to wear incontinence pads for the rest of their life, and someone else could be told, “I’m sorry, you can’t walk for the rest of your life”, but other people have quite a full life even if they face those challenges or find themselves disabled. It is really difficult to define dignity; in many ways, it is subjective.
I have read many of the papal encyclicals about all this. By the way, I am a Muslim teaching at a Catholic University; in many ways I am the diversity, if you like. It is important that we consider what we really mean by dignity. We all think we know what it means, but we all have a different perspective on what it is.
A point that has come up many times in the debate is that we hear the words “pain” and “suffering”, but they are not in the Bill. We have to ask the noble and learned Lord, the sponsor of the Bill, about the thought process behind why he decided not to put “pain” and “suffering” in the Bill so that we can all understand, given that many noble Lords have asked that question about pain and suffering, why they are not explicitly there.
I ask the Minister this very carefully. A number of times during Committee, we have put questions to the Government but they have constrained themselves as to what they answer. It is important that the Government tell us what the implications would be if the Bill were to pass into law and what that would mean for resources in the department and for decisions that the Department of Health may have to make, as well as what it might mean for other departments of government. That is important. We cannot just say, “I’m going to confine myself to these few clauses”, because this will have implications. Some will say that it may have implications for wider society—a society that allows people to take their lives earlier or encourages death. It changes the sort of society we live in. Many people will welcome that and will say it is a society of choice, while others will say, “No, we don’t want to live in that sort of society”. We have to remember the implications of this Bill.
I ask the Minister to set out the Government’s considered view. I know that the Minister will say that some of these amendments as drafted are not legally sound—we understand all that—but these are probing amendments. This is a Committee stage and the amendments are not meant to be completely technically sound. We need to know, if they were to pass and were to be tidied up by the government lawyers or the officials, what that would mean for the workability of the wider health and care system and not just in respect of these issues that we are debating or the individual clauses in the Bill. We need to have a clear view of how this will change things and of the challenges that any Government will face when a new Bill comes in. That would be helpful.
I will stop there. I have asked a few questions to the noble and learned Lord, Lord Falconer of Thoroton, about the motivations for some of the decisions that he made in drafting the Bill, but also to the Minister speaking on behalf of the Government to answer the very real implications for resources, et cetera, not only in the Department of Health and Social Care but more widely across government.
Baroness Merron (Lab)
My Lords, I, too, welcome back to the Chamber and to this House the noble Baroness, Lady Campbell. It is a pleasure to see her back with us and I thank her and other noble Lords for their contributions in this group of amendments.
I once again make it clear that I will keep any detailed comments limited to amendments on which the Government have major legal, technical or operational workability concerns. It is important to remind your Lordships’ House of that. I say to the noble Lord, Lord Kamall, that the Government are doing only what any Government would do, which is to be scrupulously neutral, as your Lordships would expect us to be, and to handle it in that way. If Parliament passes the Bill into law, of course we will ensure its safe and effective implementation, but until that point I am afraid that I will be sticking scrupulously to what the role of any Government would be. I am sure that the noble Lord understands.
Amendment 30, tabled by the noble Baroness, Lady Foster, was spoken to by the noble Lord, Lord Weir, and Amendment 30ZA, in the name of the noble Baroness, Lady Lawlor, seek to prevent a terminally ill person in England or Wales from being eligible for an assisted death if they are motivated by certain specified factors. These amendments would introduce uncertainty around definitions and concepts, such as what constitutes “adequate housing”. They would also create an internal inconsistency in the Bill, as they are not reflected in later provisions that set out the assessment process. Drafting difficulties and internal inconsistencies are likely to result in confusion on eligibility, and significant further consequential amendments and policy development would be needed to produce predictable legal effects.
The Government also have some further practical operational concerns, which I will note for the Committee’s consideration. The amendment’s exclusion of those
“substantially motivated by… a disability”,
while excluding terminal illness from “disability”, would be potentially complex to operationalise. It may also be that somebody has multiple motivations. It is unclear how these could be separated or who would be able to make a final judgement.
Noble Lords
Lord Kamall (Con)
My Lords, I have been very clear throughout this debate that any noble Lord who wants to speak and participate should be allowed to do so.
Lord Kennedy of Southwark (Lab Co-op)
As I said earlier, it is absolutely fine to break mid-group on these amendments.
Baroness Hayter of Kentish Town (Lab)
While that is absolutely a legitimate thing to discuss, and I would always defer to doctors on that, it makes no difference to this part of the argument of whether we call it dying. The noble Lord may well want to raise the question of whether we can ever be sure that someone is dying, although I have to say that I cannot be the only one who has been with someone where it is jolly clear that they are not going to live till the end of the week. There are times when you absolutely know that someone is going to die. While he may well be right that there are other cases, that is not the issue of this word. This word in the Bill is to give to the public the understanding that we are talking about whether there is a way of helping either the final timing or the way of those final days. We are not talking about someone who just decides to commit suicide for some other reason; we are talking about people who are dying from some sort of terminal illness.
Lord Kamall (Con)
My Lords, I remind the Committee that I am one of those who are still balancing the arguments on the overall Bill, and where I get put off some arguments is when people heckle those who are trying to make a point. I do not think it helps their cause. On the other side of the argument—I am trying not to sound as if I spend my life sitting on the fence—those who speak much longer than they need to in making a point also make it difficult to support some of the points that are being made. On future Committee days, I would like to see a bit more mutual respect between the different sides of the debate, with shorter points made but also less heckling of those who want to make a point. It is important, if we are going to say that we are doing our job in scrutinising the Bill, that everyone who wants to make a valid point, relevant to the amendments, is allowed to make it.
I thank my noble friend Lord Frost for tabling the amendments in this group. I recall that at Second Reading my noble friend Lord Moylan spoke about the importance of language. Language is important, especially clarity of language, so I understand my noble friend’s intentions in tabling these amendments. One could argue that there is a distinction to be made between the terms “assisted dying” and “assisted suicide”. “Assisted dying” on its own, before you even consider the Bill, does not necessarily mean consent on the part of the person whose life is being ended. The Bill introduces that element of consent, but “assisted dying” on its own does not mean consent, whereas it could be argued that the term “assisted suicide” conveys some form of intent—that it is a person seeking to end their own life, they want to do so and are not being assisted to die, regardless of whether or not they want to die. That may seem to be a philosophical point, but it is important that there is a distinction between assisted dying and assisted suicide. As the Official Opposition, we have no collective view, but it is a legitimate challenge by my noble friend to the language of the Bill, seeking clarity or, as the noble Baroness, Lady Fox, said, transparency.
Noble Lords have argued that people in this country should be able to access the services that people can access from Dignitas in Switzerland. However, Dignitas is described as offering physician-assisted suicide. Looking at the Dignitas website—not because I have lost the will to live after trying to get through a day of debates, but to look at the language—I see that it uses the phrase:
“Legal assistance for suicide with DIGNITAS”.
So we have to ask ourselves: if we are trying to be consistent with Dignitas, why is it okay for Dignitas to use the language of “suicide” but, when people want that same service in this country, we cannot use that language?
Baroness Hayter of Kentish Town (Lab)
That is exactly because it will take people who are not dying. This is not what this Bill does.
Lord Kamall (Con)
That is a fair point to be made. It is why the question was asked, and I thank the noble Baroness for answering it.
I thank my noble friend Lord Frost for provoking this debate, because there are still other arguments for using the phrase “assisted suicide”, particularly in terms of clarity. I look forward to the consideration of the arguments made by my noble friend Lord Frost from the noble and learned Lord, Lord Falconer, and the Minister.
Baroness Merron (Lab)
My Lords, I will be very brief. The amendments tabled by the noble Lord, Lord Frost, do not present significant workability concerns. As noble Lords will be aware, the amendments have not had technical drafting support from officials. Therefore, further revision and corresponding amendments would be needed to provide consistent and coherent terminology throughout the Bill.
Rare Cancers Bill
Lord Kamall Excerpts(1 day, 17 hours ago)
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Lord Kamall (Con)
My Lords, I begin by thanking the noble Baroness, Lady Elliott of Whitburn Bay, for introducing this Bill in such a clear and moving manner. I thank all noble Lords who have spoken in this debate and echo the sentiments that they expressed. It is pretty clear that many of your Lordships from all Benches, if not all who spoke, welcome this Bill—as did Members in the other place.
I also thank Dr Scott Arthur, who introduced the Bill in the other place. If noble Lords have not already done so, I strongly encourage them to read Hansard on the Second Reading debate in the other place from 14 March last year. Just like the debate today, it contained many powerful and personal contributions sharing the devastating impact on patients and their loved ones. I particularly thank those noble Lords who have shared their own experiences, however difficult and emotional it may have been. I could sense a few tears being shed around the House.
I also have a personal story. I lost my mother-in-law and, despite growing up in an era of Les Dawson jokes about mothers-in-law, I loved her very dearly. Sadly, she died from a cancerous brain tumour a few years ago.
The noble Baroness, Lady Elliott, has clearly and persuasively set out the purpose and content of the Bill, but it is important to look at its three important tasks. The first is to place a legal duty on the Secretary of State for Health and Social Care to promote research into rare cancers, driven by a national cancer specialty lead for rare cancers. As was mentioned by two of the experts in this House, the noble Lords, Lord Kakkar and Lord Patel, and by my noble friend Lord Randall, a role—a specialist lead—to drive this forward is really important. An example was given of the effectiveness of specialist leads in other areas.
The second task concerns the importance of improving access to clinical trials, particularly through the use and better sharing of data. From some of the stories that we have heard today, people cannot believe that we are still not sharing some of that data, which should be available.
The third task is the requirement for the Government to conduct a UK-wide review of the regulatory framework for orphan medicine and products used to diagnose, prevent or treat cancers.
These three objectives are sensible and laudable, but how do we deliver them? How do we move from aspiration to implementation? As the excellent briefing from the Library makes clear, we are dealing with a stark reality because rare cancers, despite the name, account for almost half of all cancer diagnoses in the UK each year. My noble friend Lord Blencathra made the point that there are over 200 rare cancers and he referred to how many people they affect, yet they are often harder to diagnose and treat than the most common cancers. There are many reasons for this, a few of which were explained today.
Patient populations are smaller and more dispersed, which makes recruiting sufficient numbers for clinical trials very difficult. That point was made by my noble friend Lord Moylan and the noble Lord, Lord Mendelsohn, and it was addressed in the review by my noble friend Lord O’Shaughnessy. Another reason is that there are fewer commercial incentives to develop new treatments compared to medicines that may be used more widely.
I apologise for not declaring my interests at the beginning: I am a professor of politics and international relations at St Mary’s University in Twickenham, and I am helping to open a new medical school there. I am also teaching a module to MBA students on healthcare policy and strategy. I also have an academic link to the University of Buckingham, although not to the medical school there, but I just want to make sure that I have covered all bases.
As an academic, I was looking at some of the papers around this. A 2024 paper by Danielson, Prime and Larter found that the cancers that are most common in teenagers and young adults are different from the cancers that are common in children and older adults. Their survival rates for the same cancers can differ. This shows how incredibly difficult it is to tackle this issue. Crucially, the Teenage Cancer Trust reports that cancer treatments can be less effective for young people, as there is less research and fewer clinical trials for this age group.
The range of rare cancers—my noble friend Lord Blencathra said that there are more than 200—is vast. There are blood cancers, cancers of the female reproductive organs, head and neck cancers, pancreatic cancers, brain cancers and many more besides. That shows what a complex and challenging problem this is, but it should not be an excuse for inaction. As all noble Lords have said, the call for action is now.
By introducing this Bill, the noble Baroness, Lady Elliott, is shining a light on an issue that too often receives insufficient attention. She is proposing a measured, thoughtful and practical set of steps to make medical progress. Quite often, at the Dispatch Box, whether in government or opposition, we hear about government aspirations rather than firm steps, but this is a very practical proposal to the Government.
In discussing progress, we should acknowledge the extraordinary work of all those campaigners and charities who play their role in different ways, with some funding research, some advocating, and some supporting families and loved ones, as the noble Baroness, Lady Morgan, acknowledged. I thank them for their engagement with the Bill but, more importantly, for their tireless efforts on behalf of those living with cancers.
Although we are supportive of the Bill, it would be helpful to understand the view both of the Government and of the noble Baroness, Lady Elliott, on a few issues. The first issue, raised by a number of noble Lords, is funding. Although the Bill places an important duty on the Secretary of State to promote research into rare cancers, it does not seek to ring-fence or guarantee specific funding. Could the Minister say a little about how the Government envisage this duty being reflected in future funding decisions, and how we ensure that rare cancers do not continue to lose out when resource is allocated? I should declare that we understand the challenge of trying to fund all this research. Of course, it would also be interesting to learn of the view of the noble Baroness, Lady Elliott.
Secondly, on clinical trials, one of the challenges that patients and clinicians frequently raise is simple. As my noble friend Lady Browning said, not all clinicians are aware of all relevant trials, particularly where those trials are highly specialised or geographically distant. Could the Minister share the current thinking of the department on what steps could be taken to improve awareness and signpost rare cancer trials, especially for clinicians and patients in rural or remote areas? Related to that, even where new treatments or trials are available, access is often concentrated in a small number of specialist centres. Could the Minister comment on the thinking in the department on ways to address these disparities in access, so that patients are not disadvantaged simply because of where they live?
Turning to the proposed review of the regulatory framework, could the timeframe be cut to less than three years, and what are the implications of doing that? Looking at the issue of medicinal products, on the three-year timeframe, do the Government or even the noble Baroness, Lady Elliott, have any views on whether the period of three years could be shortened, given the urgency that many noble Lord have raised? Also, would the proposed review include consideration of NICE’s pricing and appraising processes, and will it consider wider societal impact, as we debated last week? Many stakeholders have highlighted the difficulty of balancing affordability with price points while supporting innovation in rare cancers. It would be really helpful to understand those points.
Finally, although the Bill rightly focuses on rare cancers, many of the issues it seeks to address, such as delayed diagnosis, limited research, small patient populations and a need for specialist care, also affect people living with other rare conditions. Could the Minister say a little about how the Government are thinking more broadly about rare diseases, and whether the lessons learned from this Bill might inform wider policy in this area? We also heard about a few other issues thrown in by noble Lords. One is timelines; another is the abolition of NHS England. I know this point was raised in the other place. What is the Government’s thinking on that issue?
The Bill is thoughtful and important, commands broad support across the House, and addresses an area of clear and long-standing need, but it does so in a careful and proportionate way. It reflects the voices and experiences of patients and families who too often feel overlooked, particularly those affected by rarer and less well understood cancers, which we should remember, despite the name, account for 47% of all cancers. This alone is an important and welcome development, and I commend the Bill’s sponsors for that. The questions I pose are not intended to delay; they are intended to be constructive, to understand how the Bill would operate in practice, how ambitions could be turned into reality, and how principles might inform and provoke wider thinking across government. I hope that my questions will be seen as constructive. Once again, I thank the noble Baroness, Lady Elliott, for her leadership on this Bill, and I look forward to working with her and supporting its progress through the remaining stages.
Vaccine Health Technology Assessment
Lord Kamall Excerpts(1 week, 2 days ago)
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Lord Kamall (Con)
My Lords, I thank the noble Baroness, Lady Ritchie of Downpatrick, for securing this timely and important debate and for the eloquent way in which she laid out her argument. We saw the value of vaccines during the Covid-19 pandemic. Millions of people rolled up their sleeves, with the impact not just on patients and hospitals but on the wider economy. I thank my noble friend Lord Bethell, who was a Minister during that time, given some of the challenges Ministers faced in making sure that we found the vaccine solution and then were able to roll it out. That rollout was a turning point that allowed restrictions to be lifted and our country to try to get back to normal, but we know that we are still feeling the effects in some places, and some people are still feeling them.
When respiratory illnesses such as flu and Covid strike, people are forced to stay off work and children miss school. I thoroughly recommend the excellent briefing by the House of Lords Library; in fact, I may well use it in my teaching. At this point, I probably should declare my interest. I am a professor of politics and international relations at St Mary’s University in Twickenham, and I will be teaching an MBA module on healthcare policy and strategy this semester. The excellent Library briefing quotes the Office of Health Economics, which estimates that such absences cost employers around £850 per employee annually. As the noble Lord, Lord Rennard, said, that amounts to about £44 billion across the UK.
The Royal College of Paediatrics and Child Health suggests that reducing vaccine-preventable illnesses helps children to stay in school more consistently, improves access to education and supports better educational outcomes overall, as the noble Baroness, Lady Goudie, alluded to. In the Lancet, Professor Philippe Beutels wrote about the “peace of mind” that vaccination can bring, particularly for the clinically vulnerable. Knowing that you or your loved ones are protected matters enormously, yet this assurance is often overlooked in formal evaluations.
But there is a challenge. Taking account of wider societal and economic benefits within the current health technology assessments is not straightforward and is often subjective. We should also be aware of any unintended consequences, whether for healthcare budgets or for the cost of vaccine development. We will have read of the example of Portugal, when the argument was that it increased productivity so the pharmaceutical company said, “In that case, you can pay more for the vaccines given the wider societal impact”.
At the moment, vaccines are assessed in a more focused way. NICE and the Joint Committee on Vaccination and Immunisation largely operate from what is known as a health sector perspective. Health technology assessments focus on the direct impacts on the healthcare system, with wider societal and economic effects considered only in exceptional cases. NICE’s economic evaluations usually look only at the cost to the NHS and care services. While savings within the health system, such as short hospital stays, can be counted, the wider impacts such as productivity or keeping people in work are explicitly left out. The case for capturing some of these wider benefits within health merits careful consideration, as my noble friend Lord Bethell laid out.
While recognising concerns about broadening the criteria and the unintended negative consequences, as in the Portuguese example, there is also a practical challenge. We simply do not have enough good-quality data on the wider social and economic impacts of vaccines. As an academic I know, and others will know, that the quality of data really matters. You can make whatever argument you want if you have data that is too subjective or if it is contested, but neither is that an argument not to contest the data or some of the theories that come out. This is hardly surprising, given that these impacts are not currently captured as part of the health technology assessment and there is no agreed way of measuring these wider effects. Estimating the socioeconomic impact is inherently difficult, particularly for complex areas such as the role that vaccines play in reducing AMR, for example, or even putting a value on unpaid work, such as caring for family members. Once again, the noble Baroness, Lady Goudie, mentioned this.
There are and will be debates over what should be included and how; whether and how different factors should be weighted; and how far across society and the economy we should go. On many of these points, scientific consensus would be difficult. In measuring these effects, there will also be a challenge in ensuring that the data collected is robust and reliable. Achieving data of sufficient quality and certainty is itself a challenge.
The Office of Health Economics pointed out the siloed nature of public sector budgets, as the noble Lord, Lord Rennard, mentioned. This leads to a focus on clinical outcomes and healthcare alone. NICE has asked why, if health technology assessments were expanded to take account of the impacts on other sectors, those other sectors should not also routinely assess the health impacts of their own policies. Without that wider responsibility, there is a risk of the burden all falling on NICE or on the health part of government, when it is actually a wider societal gain. Finally, considering the broader challenge set out by the noble Baroness, Lady Ritchie, we should recall that in 2022 the NICE review judged that expanding this work further
“would be disproportionate to any expected benefits to the quality of NICE decisions”
given the flexibility that already exists to take “relevant wider effects” into account.
It is clear that this debate is important but also on a balanced issue. It raises serious questions about the wider benefits of vaccination, not always considered by current health technology assessments, but also exposes some of the methodological and resource challenges. This should not be an excuse for a lack of action or for not investigating these ideas in more detail.
One crucial point should not be overlooked: the benefits debated today, economic, social and clinical, can be realised only if people actually get vaccinated in the first place. I was concerned, as I am sure the Minister was, to see that by the end of week 50 of 2025, only 36% of pregnant women and only 39% of under-65s in clinical risk groups had received the flu vaccine. Within the NHS, as of late October—I hope that the Minister has more up-to-date figures—fewer than three in 10 nurses working in secondary care had received the flu vaccine. This sends the wrong message to patients but also puts patients’ health, and even lives, at risk. Given the concerns over the flu outbreak this winter, we should consider why these vaccination rates are so low.
I really want to ask the Government about their strategy, so I shall end by asking some quick questions. Can the Minister explain why the vaccination rates are so low? What are the primary reasons? Is it about communications, access or convenience? What assessment has been made of each of these factors? What assessment has the Department of Health and Social Care made of the wider benefits of achieving high vaccination coverage, especially among school-age children? We know that this can be a sensitive topic at times, but has the department considered the broader societal and educational impacts?
Can the Minister also set out whether any work is under way within the department to ensure that the wider assessments we have debated today are carried out more regularly? Has it looked into that in more detail? Given that the NICE 2022 review concluded that the current system already has sufficient flexibility to consider wider impacts on an ad-hoc basis, is the Minister aware of whether such assessments have been used more regularly since then, and does the department judge them to be a helpful and effective part of decision-making? These are really important questions that I think we need answers to, but I close again by thanking the noble Baroness, Lady Ritchie of Downpatrick, and all noble Lords who contributed today. I also thank the Minister in advance for her response.
Puberty Suppressants Trial
Lord Kamall Excerpts(4 weeks, 2 days ago)
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Lord Kamall (Con)
My Lords, I begin by thanking the Government for their sensitive language in handling this delicate issue. I recall the noble Baroness, Lady Cass, telling the House that puberty blockers are currently licensed only for much younger children with precocious puberty or older adults with certain cancers. Trials are therefore needed to determine whether they are safe for adolescents with gender incongruence and to understand the interaction with the different processes of puberty. I understand that children taking part in the trials must have their parents’ consent, but can the Minister clarify two points that are clearly raising concern? First, what is the maximum and minimum age of children taking part in these trials? Secondly, what assurances can the Government definitively give that children taking part in these trials will not experience fertility issues or loss of sexual function or any conditions that are irreversible later in life? I also wish all noble Lords, staff and officials a merry Christmas, happy Hanukkah, happy new year and, as our American cousins say, happy holidays.
The Parliamentary Under-secretary of State, Department of Health (Baroness Merron) (Lab)
My Lords, I am grateful to the noble Lord for acknowledging the sensitive language. This is indeed a sensitive issue. For all the division and divided opinion that I know there is, there is also a determination—including across the House, I am sure—that we get this right. The clinical trial is just part of the PATHWAYS study. With regard to the clinical trial, it is extremely unlikely that anyone under the age of 11 will qualify as a potential participant and it runs up to the 16th birthday, so I hope that that is helpful. Can the noble Lord remind me of his second question?
Lord Kamall (Con)
What assurance can be given so that any health developments under these trials are not irreversible?
Baroness Merron (Lab)
I thank the noble Lord. Before participants enter the trial—and it is an extremely high bar, as it should be; there will be at least 226 participants required, but that is not a target and there will be no drive to get up to that number—certainly any possible impacts such as those the noble Lord describes will be fully discussed and mitigations will be explained and made available, particularly in terms of fertility. I absolutely take the point that the noble Lord raises.
Women’s Health Strategy
Lord Kamall Excerpts(1 month ago)
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Baroness Merron (Lab)
The noble Baroness is absolutely right, and we are taking every opportunity to find the right ways to communicate with women about their healthcare. If I had to give a big message, it would be, “Don’t not put up with it”. That is a basic challenge to get across, because so many women do put up with health challenges when they should not. Many women’s health challenges have become normalised—“It’s just part of life, it’s your age” and so on—and I am very keen that, in the renewed women’s health strategy, we will take on that myth and also take on the services to match that.
Lord Kamall (Con)
My Lords, I thank my noble friend for this Question and pay tribute to her consistent championing of women’s health issues. I also thank her for discussing the particular concerns behind this Question with me. I am sorry to return to gynaecology, but the Royal College of Obstetricians and Gynaecologists has raised concerns that cervical screening coverage remains well below NHS targets. Cancer Research says that low attendance is particularly evident in particular groups: the youngest as well as the oldest age group, and women from poor socioeconomic and ethnic minority backgrounds. Can the Minister update the House on how we can reach those women and encourage them to come forward for screening, particularly by working with local charities and community organisations that understand their communities far better?
Baroness Merron (Lab)
This is a very important point. The 10-year health plan restated the aim of eliminating cervical cancer by 2040 through the improved uptake of cervical screening and HPV vaccination. To the specific point, which is such an important one, in June—not many months ago—we announced that screening providers can offer home testing kits to underscreened individuals in the exact groups that the noble Lord refers to. I believe this will help tackle deeply entrenched barriers that keep some people away from life-saving screening. I am sure the whole House will reflect on the wise words and advice of His Majesty the King in imploring us all to take up the screening opportunities that there are. I certainly agree with that.
NHS: Winter Preparedness
Lord Kamall Excerpts(1 month ago)
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Lord Kamall (Con)
My Lords, I want to ask the Minister about two cohorts in respect of which there are concerns about vaccination levels. The first is front-line health workers. Is the Minister aware of what percentage have been vaccinated and what action is being taken to improve the uptake of vaccinations, particularly among those front-line health workers? I know that there are stories and concerns expressed in the press about the rate of vaccination. On the second cohort, will the Minister tell the House which socio-economic or ethnic groups have the lowest update? What targeted plans does the department and NHS England have to increase uptake rates in these groups?
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
First, we have started earlier and done more than ever before to prepare for the winter pressures. The good news is that the flu vaccines are working well to protect people against severe disease, and they are certainly working well in comparison to how they used to. In fact, we are the first country in the world to show vaccines working this well. On the uptake of vaccinations, 60,000 more NHS staff have been vaccinated this year than last year, which is extremely welcome. We have delivered over 17 million flu vaccines, which is tens of thousands more than we had delivered this time last year. We have a particular programme of communication and support and availability to those groups which are less likely to take up vaccinations. Vaccinations are our best line of defence against RSV and flu. I will be pleased to provide more detailed information to the noble Lord.
Resident Doctors: Industrial Action
Lord Kamall Excerpts(1 month ago)
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Lord Kamall (Con)
My Lords, the announcement of further industrial action by resident doctors is obviously deeply concerning. These strikes, which we now know will go ahead after all, will have a serious impact on the capacity of our health service to function at precisely the time of year when demand is at its highest. Resident doctors make up almost half the medical workforce, and NHS leaders have already warned that action will cause significant disruption.
We on these Benches agree with the Secretary of State for Health and Social Care when he says that the BMA has clearly chosen to strike when it will cause maximum disruption, causing untold anxiety at the busiest point of the year. We agree with Rory Deighton, the acute and community care director of the NHS Confederation, who warned that, with the winter now upon us and rising levels of flu and staff sickness, pressure on services will be intense, with the likely consequence of
“thousands of cancelled appointments and operations”.
The impact of these strikes is compounded by the fact that NHS England has warned that it is bracing for an unprecedented flu wave this winter. In London alone, there are three times as many people hospitalised with flu compared to last year, with an average 259 hospital beds occupied each day, compared to just 89 a year ago. It is in this context that the CEO of the NHS described the BMA’s decision to strike in the run-up to Christmas as
“cruel and calculated to cause mayhem”.
There is a wider concern, shared by patients and families across the country. When the Government caved in to the BMA last year with an unconditional 29% pay settlement, noble Lords on all Benches warned that this would only incentivise the BMA to come back year after year with more demands. At the time, the Secretary of State brushed off these concerns and criticised those who raised this obvious observation, claiming that there would be no further strikes, no more cancellations and no more disruption. While we agree with the Health Secretary that this action by the BMA is cynical, strong words alone will not keep operating theatres open or ensure that patients receive their care in a timely manner. Appointments will still be postponed or cancelled, operations will be postponed and patients will suffer.
Now that the BMA membership has rejected the latest offer and is pressing ahead with further strikes, will the Minister lay out the Government’s plan? What additional resources have been made available to mitigate the serious disruption that these strikes will inflict? Given the combined pressures of flu and RSV, what steps are being taken to ensure that those who are eligible for vaccination actually receive it?
It appears that we are stuck in a downward spiral. Strikes are threatened, offers are rejected, strikes happen, misery is inflicted and then it is threatened all over again. If the Government do find a way of ending the threatened action, will they please do a couple of things? Will they make sure that it is conditional on updating work practices, to ensure that we have a more efficient health system? Many people who work in the health system know that some practices are out of date and have not moved on since the 1940s. Will they make sure that it does not incentivise the BMA to pocket any settlement and return next year threatening more strike action? The very uncertainty surrounding future militancy by the BMA is deeply damaging. It should be a matter of grave concern to the Government that the public seem not to have any confidence in the Government’s ability to keep doctors at work and keep the health service functioning.
As part of this, does the Minister recognise that the Government’s Employment Rights Bill risks making matters significantly worse next year? Will they think again about their rejection of minimum service levels to protect patients in the future? Finally, we know that the OBR has said that the cost of industrial action is a major risk to health spending. What estimate have the Government made of the cost of strike action in December, and will costs be paid using existing NHS budgets? As we know, the Chancellor often says there is no more money.
We are clear that these strikes must end and that the behaviour of the BMA is indefensible, but we must remember that it is not Ministers, unions or negotiators who will bear the cost of this action; it is patients and their families and loved ones. They deserve better. I am sorry to say that we are not yet convinced that the Government are on top of this and working to end the threat of these damaging strikes now and avoid incentivising future strikes in future years. I really hope that the Minister can reassure noble Lords that the Government have a plan.
Lord Scriven (LD)
My Lords, I thank the Minister for putting the Statement before us, but do so with a measure of frustration—a feeling shared by countless citizens. This frustration with the ongoing and deeply damaging resident doctors dispute is directed at both parties, the Government and the British Medical Association leadership. We are witnessing a breakdown in negotiation, a failure of common sense and, critically, a failure of duty towards the patients who rely on the National Health Service.
First, let me address the actions of the Government. The manner in which this dispute has been handled is, frankly, not best practice. We have seen periods of silence followed by 11th-hour media interventions by the Secretary of State. This pattern suggests not a serious negotiation but a high-stakes, last-minute political gamble, PR approach. The way the reported details of the last-minute offer were put before the public and resident doctors serves only to deepen this suspicion. This approach disrespects the process and the professionals involved. Given that the issues addressed in the Government’s 11th-hour offer have been known since the general election, why did the Government choose a high-stakes, last-minute intervention, rather than presenting the offer within a calm, realistic timeframe that could have facilitated constructive consideration by resident doctors?
Further, I must express my dismay at the tone sometimes employed by the Secretary of State. Using rhetoric that seeks to divide resident doctors from the public is counterproductive. This dispute will not be solved through grandstanding but through respect and meaningful compromise. The Government must reflect on their tone and timing.
However, the frustration I feel over the Government’s handling is matched in equal measure by my frustration over some of the tactics and demands employed by the BMA leadership. The pursuit of this round of strike action, especially scheduled at the most challenging time of the year, is, in my view, deeply irresponsible. The BMA has a singular responsibility that transcends typical union negotiations. Their members are the direct custodians of people’s health. We are currently grappling with two severe pressures on the NHS: the rising tide of flu and the deliberate scheduling of this strike to coincide with the Christmas period. To choose this time, when hospital rotas are already thin and the NHS is under maximum strain, is totally unacceptable. It shows a disregard for the welfare of the most vulnerable patients. We on these Benches wish to thank the consultants, those resident doctors who decide to go into work, and the other dedicated staff who will keep our NHS safe during this unnecessary strike, for doing the right and decent thing.
The core demand pushed by the BMA leadership is full pay restoration. While I acknowledge the significant financial pressures facing resident doctors, a demand for full restoration to a prior decade’s real-terms value is neither achievable nor reasonable in the present economic climate. By focusing the entire dispute on this single maximum pay demand, the BMA leadership is allowing the Government to ignore the far more crucial systematic issues that genuinely plague resident doctors and threaten the future of the NHS workforce.
This failure is a stain on both parties. The Government must return to the table with a genuine commitment to a multi-year funded plan that addresses the systematic non-pay issues, and the BMA leadership must immediately reassess the morality of its current strike schedule and shift its focus from an unrealistic pay demand to achievable reforms in training and conditions.
I have two further questions for the Minister. The recent offer included a promise to create up to 4,000 extra speciality training posts. However, the BMA leadership has claimed that these posts are simply being cannibalised or repurposed from existing locally employed roles. Will the Minister confirm categorically that these 4,000 places represent genuinely new, funded training opportunities that increase the total number of doctors retained in the NHS career structure and are not merely a reclassification of existing roles?
Given that the pay restoration demand is deemed unachievable, how will the Government—outside of pay—guarantee fundamental reforms to the working time directive enforcement, the quality of training rotations and the rota planning to ensure that resident doctors are used efficiently for patient care and for the development of their skills, thereby making a medical career in the NHS sustainable and attractive?
Our healthcare system cannot afford this deadlock. I urge both sides to put down their political weapons, swallow their pride and focus on the real-world issues before the consequences become truly tragic.
Terminally Ill Adults (End of Life) Bill
Lord Kamall ExcerptsFriday 12th December 2025
(1 month ago)
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Lord Kamall (Con)
As I set out last week and will repeat if noble Lords will forgive me, I completely agree with what the Government Chief Whip said about noble Lords ensuring that they speak to the amendments and do not give Second Reading speeches, but, at the same time, I think it is important that all noble Lords who want to speak to an amendment are given the opportunity to do so.
I thank the noble Baroness, Lady Finlay of Llandaff, for her amendment in this group. It seeks to ensure that someone who currently is or has recently been deprived of their liberty will not be eligible under the Act. This amendment refers to the Mental Capacity Act 2005, which is also the Act underpinning capacity for the purposes of this Bill. I appreciate the underlying logic behind the amendment, which has opened up a valuable discussion of who exactly should have access to assisted dying services. I am sure that all noble Lords would agree, whatever their position, that there should be robust provisions and safeguards in the Bill and that it should be available only to those who are suffering from terminal illnesses who are of sound mind, so that we do not inadvertently open it up to those with issues related to their capacity.
I am also grateful to the noble Baroness, Lady Berger, for her contribution in place of the noble Baroness, Lady Keeley. It is very important that, given the backlog in the system, not just those who have DoLS but those who have made an application for DoLS are deemed not to have capacity when seeking to end their lives. It would be very interesting to hear the Government’s perspective on this and that of the noble and learned Lord.
These questions all fundamentally ask whether the Bill is right to use the Mental Capacity Act 2005 as the basis for defining capacity. I am very grateful to the noble and learned Lord, Lord Falconer of Thoroton, for offering to meet those who have tabled these amendments. That is very constructive and helpful and should be acknowledged. I also look forward to hearing the noble and learned Lord’s responses to some of the issues that have been raised.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I am grateful to noble Lords for their contributions on this group. To echo the comments of my noble friend the Chief Whip, the Government remain neutral on the principle of assisted dying and on the passage of this Bill. Whether the law in this area should change is a matter for Parliament. As before, any comments that I make will focus on amendments where the Government have major legal, technical or operational workability concerns.
This group relates to deprivation of liberty and eligibility for seeking an assisted death. I thank the noble Baroness, Lady Finlay, and my noble friend Baroness Keeley for tabling the amendments in this group. Amendments 16 and 114, tabled by the noble Baroness, Lady Finlay, seek to prevent individuals who have been deprived of their liberty within the last 12 months under the Mental Capacity Act being eligible for an assisted death. In the case of Amendments 16A and 114A, tabled by my noble friend Lady Keeley, someone would be ineligible as a result of an application for deprivation of liberty having been made, irrespective of the outcome of that application.
Noble Lords may wish to consider that the amendments would introduce a departure from the Mental Capacity Act framework by linking a lack of capacity in one area—capacity to consent to care and treatment arrangements that amount to confinement—to lack of capacity in another area, that being capacity to make the decision to end one’s life. Amendments 16A and 114A go further and would make a person ineligible on the basis that only an application for deprivation of liberty had been made. This may result in a situation where the application was unwarranted, but that person would still be ineligible for assisted death.
Regarding the European Convention on Human Rights—
Lord Kamall (Con)
The question that a number of noble Lords are concerned about, when discussing this amendment, is that the Mental Capacity Act was passed in 2005. Of course, the guidance has been updated, but it might be helpful to those in the Committee who are concerned that this Act is 20 years out of date to talk about any guidance that has been updated, so that it is not seen as out of date—if that makes sense. This is just to clarify that we are not dealing with an Act that was set in stone in 2005, as things have changed since then.
Baroness Merron (Lab)
I am grateful to the noble Lord and feel that this would probably be a very appropriate point to move on to my noble and learned friend.
Lord Kamall (Con)
I have never been so popular; it will not last, I know.
I thank the noble Baroness, Lady Grey-Thompson, for her amendments. I pay tribute to her for her sincere and long-standing commitment to protecting the most vulnerable in society. If we cast our minds back to Second Reading, many of the contributions made and concerns raised were regarding those who are the most vulnerable in our society. I remember at Second Reading being particularly touched by the words of the noble Lord, Lord Rees—he is not in his place now—who raised concerns about the vulnerability of some ethnic-minority communities, particularly those from disadvantaged communities as well.
Let us quickly rush through some of the points. On Amendment 22, which would make prisoners ineligible for end-of-life services as envisaged by the Bill, I completely understand the underlying principle. Many have spoken, rightly, about the vulnerability of prisoners. While for some it might seem wrong, as the noble Lord, Lord Farmer, has suggested, that a prisoner who has a terminal illness may have a way of cutting short their sentence by means of this Bill, as my noble friend Lady Coffey alluded to, others may say “Good riddance”. I also recognise the argument that prisoners with a terminal illness should be treated with the same compassion and care at the end of their lives as other terminally ill people subject to the Bill, as my noble friend Lord Markham recognised.
We also have to recognise some of the concerns over moral hazard. I do not know how large the incidence of this would be. Would it really encourage those who are terminally ill to commit crime? No studies have been done, but I am open to that concern. There is also the idea about higher levels of suicidal ideation, as raised by the noble Baroness, Lady Fox. These are really important points that we have to take account of.
The right reverend Prelate and my noble friend Lord Deben spoke about the pressure of reducing the prison population, while the noble Lord, Lord Carter, spoke about the higher rate of suicide among male prisoners. These are all reflections that should give us cause for concern, and things we should take account of as we consider what we will do between Committee and Report.
I thank the noble Baroness, Lady Grey-Thompson, for raising the issue of those who are pregnant. As the noble Baroness said, this was not debated in the other place, so I am grateful that the noble Baroness was able to give us the opportunity to debate it. I am also grateful to the noble Baroness, Lady Berger, for sharing statistics about expectant mothers. It was important that we heard those stats. I cannot begin to imagine the difficulty an individual in those circumstances may face. I understand the concern that it does not seem right that the safety of an unborn child may be endangered under the provisions in the Bill. I also understand that there might be precedence in other legislation. I wonder what the noble and learned Lord’s reflections on that are, given his expertise.
I note the amendment tabled by the noble Lord, Lord Farmer, on access to this for those who are awaiting trial. Once again, I would be very interested in the noble and learned Lord’s legal experience on whether that seems relevant and should be within this Bill. During the debates on the Mental Health Bill, my noble friend Lady Berridge was assiduous in spotting gaps in legislation or inconsistencies between different Acts. My noble friend has done the same thing here by raising concerns over the vulnerability of those with education, health and care plans. I think this needs further consideration.
I also thank the noble Baroness, Lady Grey-Thompson, for her amendments relating to those who are homeless or who live in insecure and temporary accommodation. I welcome the experience of the noble Baroness, Lady Gray. I still remember a conversation I had with one homeless charity that we are all one or two unlucky events or bad decisions away from homelessness. I heard from homeless people who told me that they had a great job and a great family life and that everything was going their way. They lost their job, which then led to them losing their marriage. After incidents of sofa surfing and testing the patience of their friends, they ended up homeless. It could happen to anyone. It is important that we do not dismiss the homeless as people who cannot be bothered or are idle. It could happen to anyone. Any noble Lords who have met those in homeless communities will know that some people had been incredibly successful but, after two or three bad decisions or unlucky things that happened in their life, they suddenly found themselves homeless. They are also judged by the way they look when they are homeless.
I remind all noble Lords that the Bill relates only to those who are suffering from a terminal illness and those who have been given an expectation that they will not live for longer than six months. We have to be very careful that, although we have sympathy for the homeless and prisoners, the Bill relates only to those who have a terminal illness. I know there are concerns that the Bill may be widened beyond that, but that is the debate at this stage. We should be quite clear that we are focusing on those with a terminal illness. So, much like on the question of prisoners and others, I recognise the arguments on all sides, but this is an opportune moment, not only because of time but because of the noble and learned Lord’s legal experience, to hear his reflections—after the Minister, obviously.
Baroness Merron (Lab)
I am most grateful.
My Lords, I thank all noble Lords for their contributions to the debate on this group. As is my consistent introduction, my remarks will focus only on issues where the Government have major legal, technical or operational workability concerns. Many of the points that follow relate to the European Convention on Human Rights. These are risks that I am raising to inform noble Lords’ decision-making, as I said on the first group. I wish to be clear that the underlying policies are a matter for Parliament. I say to noble Lords who referred to my ministerial colleagues in the other place that it is the role of Ministers, whether in your Lordships’ House or in the other place, to flag the risks to the Bill, including potential legal challenges. As I said, policy decisions remain a matter for the sponsors. Decisions in this regard rest with Parliament.
I begin with Amendment 22, tabled by the noble Baroness, Lady Grey-Thompson, and Amendment 30C, tabled by the noble Lord, Lord Farmer. These amendments would make prisoners, a defendant on remand, a defendant on bail or those detained by a hospital order ineligible for assisted dying services, even if they have a terminal illness and meet all other criteria. Aside from the right to liberty—Article 5—the ECHR requires that prisoners, a defendant on remand or a defendant on bail should have the same rights as those who are not. The rights engaged by this amendment are Article 8 on the right to respect for private and family life and Article 14 on prohibition of discrimination. Noble Lords may wish to note the risk that making these groups ineligible for assisted dying would, on the face of it, lead to a difference in treatment, which would need to be objectively and reasonably justified in order to comply with ECHR obligations.
Likewise, making ineligible hospital in-patients who are under a hospital order would lead to a difference in treatment. Without sufficient justification for the discriminatory treatment, this may be a breach of the ECHR, which could lead the courts to issue a declaration of incompatibility.
The noble Baroness, Lady Grey-Thompson, has also tabled Amendments 24, 458, 308 and 347. The purpose of Amendments 24 and 458 is to exclude those who are pregnant from accessing assisted dying, while that of Amendments 308 and 347 is to make persons who are homeless, or living in supported or temporary accommodation, ineligible for assisted dying services. As I have previously noted, the reasons for this difference in treatment would need to be adequately justified to avoid the risk of a successful challenge under the ECHR.
Wheelchair and Community Equipment Strategy
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Lord Kamall (Con)
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for securing this valuable debate. I also thank all noble Lords who have shared their own valuable experiences. I also welcome the noble Baroness, Lady Gerada—I hope I have pronounced that correctly—who, in her maiden speech, shared her valuable background, which we know will contribute hugely to this House.
At its heart, this is a discussion about people’s freedom, dignity and independence. Wheelchairs are, for many, the difference between participating in daily life or being excluded, by enabling people to leave their homes, to see loved ones and to access work and education. However, the reason for today’s debate is that the current system faces serious problems. NHS England’s 2025 wheelchair quality framework recognises this, while the APG for Access to Disability Equipment describes the system as being “in crisis”.
We welcome and acknowledge NHS England’s initial steps to improve wheelchair services, such as a national wheelchair dataset and personal wheelchair budgets. These steps are welcome and should be acknowledged, but data from the British Healthcare Trades Association shows that only around 80% of users received a wheelchair, or a much-needed modification, within 18 weeks, which is below the 92% national target, while people with complex needs can wait significantly longer. A delay in receiving a wheelchair is not simply an inconvenience or a statistic; it is a barrier to living a fuller life.
Also, we find that where a person lives determines how their wheelchair services are assessed, whether they qualify, their level of support, how clearly the process is explained, and what kind of equipment they ultimately receive. NHS England’s own national dataset shows significant regional variation between integrated care boards in meeting the 18-week standard. There is also a wide variation in eligibility criteria. In north Bristol, the threshold for regular use is at least 4 times weekly, on a regular basis. In Oxford, regular use is defined as at least three days per week. In Wirral and west Cheshire, regular use is worded as “more often than not”. For powered wheelchair assessment, we find that in west Suffolk a person must demonstrate indoor need and appropriate home accessibility, get GP clearance and pass a driving assessment, while north-west London uses a tiered categorisation system of need, with detailed thresholds and criteria for the effects that denying access to certain items could foreseeably have.
When noble Lords discussed this topic last month, the Minister said that
“integrated care boards are responsible for the commissioning of local wheelchair services based on the needs of the local population”.—[Official Report, 24/11/25; col. 1089.]
I appreciate the need for such flexibility, reflecting local populations, but could the Minister tell the House whether the Government believe there should be better co-ordination on eligibility and communicating the criteria, and what plans they have for achieving this?
The noble Lord, Lord Hunt, shared an article from Paul Sagar about his home experience. While he was on his hospital bed, distressed and worried about his future, he was phoned by the wheelchair service when he was obviously unable to speak. He assumed that he would be called back. Instead, a letter was sent to his home address: an upstairs flat which he would never access again. I thought that showed just how Kafkaesque a situation some users find themselves in. What is the recourse for patients where local ICBs offer such poor and unempathetic services? What is the accountability mechanism for that and, while respecting local differences, what is the department’s thinking on making them accountable for allowing such poor services? Do the Government have any plans for regular reviews of wheelchair service providers to make sure that they are all meeting standards?
I appreciate that noble Lords have asked a lot of questions, but I hope the Minister, who we know cares deeply about patients, will appreciate that we see this not as a party-political issue but as one which all Benches can agree touches directly on people’s independence, dignity and everyday lives.
Terminally Ill Adults (End of Life) Bill
Lord Kamall ExcerptsFriday 5th December 2025
(1 month, 1 week ago)
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Lord Kamall (Con)
My Lords, I hesitate to rise as I want to ensure that everyone feels that their voice has been heard in this debate. We do not want to make law on a basis on which people look back and say that we did not properly debate a particular issue. If all noble Lords who wish to speak in this debate have spoken, I am very happy to make my contribution, but if there are any other noble Lords who wish to make their point, I should give way.
Well, that answers that question; I tried my best. I want to make that point clear. It is really important that everyone who feels they want to speak can do so, but I also say to noble Lords, including my noble friends, that it is also important to respect the rules and conventions, to speak to the amendments and not to repeat Second Reading speeches or make wider debates. I hope we can get that appropriate balance. I have taken time making those points, so I will try to be brief.
I pay tribute to the noble Baroness, Lady Berger, especially for the way in which she delivered the Select Committee process that preceded our deliberations in Committee. The evidence submitted to that committee will be invaluable to noble Lords as we continue our work to scrutinise the Bill.
Without making a long speech, I will reflect on the specific amendments on changing the minimum age. I was talking to a noble and learned friend about this, and he said that, frankly, the law around age is a mess—and that has come out in some discussions. Sometimes we are speaking from our own experience. My two children are in their 20s, and I wonder whether they would really have the capacity to make this decision. But at other times, I sit in awe of them and the decisions they make. They express maturity way beyond 20 years, and, in fact, more maturity than much older people.
It very much depends on the individual in these cases. We have to look at whether there is a way to achieve that right balance; otherwise, we will just be making another age limit. You can join the Army at 16 but you cannot serve in combat until you are 18. The Government are talking about reducing the voting age to 16, but then we are hearing debates on neurological competence and capacity. It is important that we understand and express these points.
The point that came out for me in this whole debate about neurological development is that there is no such thing as “the science”. Science is contestable. We heard this from noble Lords who are experts in their field. We must be very careful about saying that “the science says this”. It also has implications for other decisions.
I turn to a couple of points which may already be treated in the Bill. I want to check the understanding of the noble and learned Lord, Lord Falconer of Thoroton, on what is in the Bill. The noble Baroness, Lady Hollins, asked: what happens if a new treatment is available? Clause 2 says
“which cannot be reversed by treatment”,
which probably takes care of that point, but I would like the noble and learned Lord, Lord Falconer, to share his interpretation and say whether it addresses her concerns. The noble Baroness, Lady Hayter, said that we should think about these young people who will be suffering and in pain, yet nowhere in Clause 2 are the words “pain” or “suffering”. We must be very careful to read what is in the Bill when we are making these points.
I welcome the intervention by the noble and learned Lord, Lord Falconer, that while he is quite clear about 18, he is sympathetic to the idea of cognitive development and maturity between 18 and 25, and there might be some discussion. Who knows—I cannot speak for the noble and learned Lord, who has looked into this issue very deeply—but perhaps in those discussions he may be persuaded. He is saying 18 at the moment, but clearly he is open to enhanced measures for those aged between 18 and 25. That is something that I hope the whole Committee will welcome.
There are many other points that I could make, but it is important to hear from the Government and what the noble and learned Lord believes in response to the points that have been raised.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I am grateful to noble Lords for their contributions to this debate on the age of eligibility for those who are provided with assistance under the Bill. I have made it clear previously, and reiterate, that I will keep my comments limited to the issues on which the Government have major legal, technical or operational workability concerns.
The amendments tabled by the noble Baronesses, Lady Berger, Lady Lawlor and Lady Hollins, seek to raise the age at which an individual would be eligible for the provision of assistance under the Bill. The points that I wish to raise here relate to the European Convention on Human Rights. There are potential risks that I am raising to inform the decision-making of noble Lords, but the underlying policies are rightly a matter for Parliament. Under the convention, the amendments in this group could give rise to legal challenge; for example, that excluding people who are under 21 or 25 from accessing assisting dying may not be justified under Articles 2 or 8 of the EHCR, or that this amounts to unjustified discrimination under Article 14.
Noble Lords will be aware that differential treatments, such as raising the age of eligibility, may be lawful if it is possible to persuade the courts to agree that the age limit is justified, necessary and proportionate. There would need to be a reasonable justification for restricting access to assisted dying to people aged either 21 and over or 25 and over. Noble Lords will want to consider this in relation to these amendments.