Terminally Ill Adults (End of Life) Bill (Twentieth sitting)

Stephen Kinnock Excerpts

Committee stage
Tuesday 11th March 2025 Public Bill Committees

[Danny Kruger (East Wiltshire) (Con)]

It is a pleasure to serve under your chairmanship once again, Sir Roger. I am looking forward to this week’s debating.

I want to draw the Committee’s attention to further evidence that has come in since the debate got under way. Since we started the Committee, we have had more than 400 pieces of evidence, so I apologise for not having got to this earlier, but it is relevant. I do not want people who have submitted evidence to us to feel that their submissions have fallen into a black hole and are not being considered, and I think this is significant evidence. We are talking about the necessity of a proper period of reflection, which is acknowledged in the Bill—it is understood that it is inappropriate for people to be able to request and receive an assisted death in very short order. The debate is about the extent of that reflection period. I am supporting amendments that suggest that we need slightly longer in some cases.

I want to refer to two pieces of the evidence that has come in. One is from six palliative care doctors who wrote that

“our experience is that many patients experience a period of adjustment to ‘bad news’ and may say that they cannot live under these conditions. However, after a period of reflection and adjustment, the majority come to find peace and value in their altered life circumstance, in a way they would not have believed possible. This may often take many weeks and sometimes short months. It is our profound concern that the two ‘periods of reflection’…would not allow time for this adjustment. This is even more so the case where these periods of reflection are reduced for patients predicted to have an even shorter prognosis. It is thus a reality that patients and their families may miss out on a period of life they would have valued by seeking to end their lives prematurely, and these days, weeks and perhaps even months will never be regained.”

The other piece of evidence is from Tom Pembroke and Clea Atkinson, who are experts in hepatology and palliative care in Cardiff. They raised the problems of the seven-day reflection period where there is alcohol misuse. I do not think this topic came up in last week’s debate, but it is worth acknowledging because liver disease is the most common cause of death for people in middle age. It is also worth noting that liver disease disproportionately affects the people who are most disadvantaged in our society. These experts say:

“Prognostication in advanced liver disease is challenging as management of the underlying causes, including abstinence from alcohol, potentially reverses advanced liver failure…The neurocognitive and depressive effects of alcohol misuse disorder frequently requires more than seven days to resolve following abstinence. Advanced liver disease frequently manifests with hepatic encephalopathy which can affect the ability to make informed decisions.”

Their concern is that

“A seven-day review period is not sufficient to ensure that there is an enduring wish to die which is not influenced by alcohol misuse.”

Considering the prevalence of alcohol misuse in our society, the extent to which so many people tragically die of it and the difficulties in prognostication, I suggest to the Committee that there is a particular argument to be made for extending that short period at the end for the expedited process that is being considered. I beg the Committee to consider accepting the amendment.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship again, Sir Roger.

Amendment 301 would prolong the first period of reflection, after which point the independent doctor can conduct the second assessment. In the original draft of the Bill, the first period of reflection is seven days, but the amendment would extend that period to 14 days. That means 14 days would have to pass between the time that the co-ordinating doctor has made their statement following the first assessment, and the independent doctor carrying out the second assessment.

Amendment 317 would increase the duration of the period of reflection before a person may make a second declaration from 14 days to 28 days. It relates to cases where a person’s death is not reasonably expected within one month of the date of the court’s declaration.

Amendments 314 and 315 would increase the duration of the second period of reflection before a person may make a second declaration, in cases where a person’s death is reasonably expected within one month of the date of the court’s declaration, from 48 hours to seven days. They would also introduce a requirement for a mandatory immediate referral for urgent specialist palliative care. The requirement would be introduced into the definition of the second period of reflection. It is unclear what impact it would have on the duration of the period of reflection. The amendments do not say who should be responsible for making the referral or where it should be recorded. The drafting is also ambiguous as to what happens if a person does not consent to such a referral or care.

I hope these observations are helpful to the Committee in considering the Bill and the amendments put forward by various Members. Whether these amendments should form part of the Bill is a matter for the Committee to decide.

[Kim Leadbeater (Spen Valley) (Lab)]

I have nothing to add on this group of amendments. I am confident that the Bill as drafted already includes significant periods of reflection. Bearing in mind that we are putting dying people through a very lengthy process already, I remain confident that the periods of reflection are adequate as set out in the Bill.

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[Lewis Atkinson]

Yes, I do. I recognise the importance of independent assessment for prognosis and capacity. However, particularly with the issue of coercion, healthcare is a team sport, as anyone who has worked in healthcare knows. The more information and the more viewpoints we can get in those instances, the better. One of the strengths of the Bill is the team sense around it, which we will further in the amendments to clause 12 that we will come on to in due course.

I will finish briefly on amendment 460. I do not see the loophole that has been described. I think we would all want someone to be able to cancel their first declaration, and they are more likely to do so if they feel they have the option of going back and making a future first declaration. My worry with amendment 460 is that, by removing the word “particular”, it suggests that people are only able to make one first declaration in the course of their life. With the periods of reflection built into the Bill, which Members spoke about earlier, if someone changes their mind, they should cancel their first declaration. They are absolutely free to do so and the Bill, as currently drafted, makes good provision for that. To me, amendment 460 would remove the ability for that person to come back to that decision at a later point and go through the assessment process again. While I understand the motivations behind amendment 460, I am cautious about it for those reasons.

[Stephen Kinnock]

Amendment 348 seeks to add an additional requirement to clause 8(5). This would mean that, where the independent doctor is satisfied that the requirements under clause 8(2) have been met, they must

“inform the person’s usual or treating doctor and, where relevant, the doctor who referred the person to the independent doctor, of the outcome of the assessment.”

Some elements of amendment 348 duplicate requirements that already appear in the Bill, such as the requirement in clause 8(5)(b) for the doctor to inform the co-ordinating doctor of the outcome, including providing a copy of the statement.

The amendment would also overlap with the requirements in clause 16 for the co-ordinating doctor to make entries in the person’s medical record that must include the original statement or declaration. Where the co-ordinating doctor is not with the person’s GP practice, they must also give notice to a registered medical practitioner with the person’s GP practice of the outcome of the assessments.

Amendment 303 seeks to prevent a person from seeking multiple second assessments from different independent doctors. It places a requirement on the independent doctor to confirm

“that no other practitioner has undertaken a second assessment for the same person.”

This amendment creates the risk of a medical practitioner inadvertently committing an offence if there is no centralised record-keeping. It may also have the impact of preventing the person seeking assistance from obtaining a second opinion, as provided for in clause 10. Under the amendment, as drafted, it is unclear how this is intended to interact with the possibility of an independent doctor’s becoming unable or unwilling to continue to act as the independent doctor following the second assessment, when an alternative independent doctor may therefore be required.

On amendment 458, as the Bill stands, clause 10 provides that if, following the second assessment, the independent doctor refuses to make the statement confirming that they are satisfied that matters in clause 8(2)(a) to (e) are met, the co-ordinating doctor may refer the person to a different registered medical practitioner who meets the requirements of clause 8(6), and is able and willing to carry out an assessment mentioning clause 8(2). The effect of the amendment is to restrict the circumstances in which the co-ordinating doctor can make a referral under clause 10(1) to a different registered medical practitioner to only when there has been a material change of circumstances. It is not clear from the amendment who is required to establish that there has been a material change in circumstances and/or how that will be proved. That may cause some uncertainty for the co-ordinating doctor.

I now turn to amendment 459. Clause 10 provides that if, following the second assessment, the independent doctor refuses to make the statement that they are satisfied that the person meets the criteria in clause 8(2)(a) to 8(2)(e) when conducting the second assessment, the co-ordinating doctor may, if requested to do so by the person who made the first declaration, refer that person to a different registered medical practitioner who meets the requirements of clause 8(6) and is able and willing to carry out an assessment of the kind mentioned in clause 8(2).

The effect of the amendment is that, where such a referral is made to the registered medical practitioner under clause 10(1), the co-ordinating doctor is required to provide them with the report by the independent doctor setting out their reasons for refusal. If the new registered medical practitioner reaches a different conclusion from the original independent doctor, they must produce a report setting out why they disagree. The two reports must be made available to any subsequent decision maker under the Bill, and to the commissioner. This additional requirement for reports on the reasons for refusal or differences in opinion may make the process of seeking assistance longer and add to capacity demands on co-ordinating and independent doctors.

Turning to amendment 460, clause 10(3) provides that if, following the second assessment, the independent doctor refuses to make the statement mentioned in clause 8(5), the co-ordinating doctor may make one referral for a second opinion. The effect of the amendment is to remove the word “particular” from clause 10(3), which says that only one second opinion may be sought

“In consequence of a particular first declaration made by a person.”

The amendment is unclear and could have several possible effects in practice. For example, it could have the effect of limiting the circumstances in which a referral can be made under clause 10(1) to the first time a person makes a first declaration.

I hope that these observations were helpful to the Committee.

[Kim Leadbeater]

I associate myself with the Minister’s comments regarding the other amendments in the group; however, I listened carefully to the debate on amendment 459 and the points made by the hon. Member for Richmond Park, my hon. Friend the Member for Stroud and the Minister. My view on that amendment has changed: I do think independence is really important in the doctor’s opinions during the normal process that the Bill sets out. However, it is a really fair point to make that if the independent doctor refuses the patient, there needs to be transparency about that, and it is important that everybody involved in the process can see how that decision has been made. That is a really valid point. It is a good example of how this Bill Committee is operating, and should be operating, in that we have been listening to different views and opinions.

I take on board the Minister’s point on capacity. We need to be aware of that. We will hopefully debate the third layer later today. That layer may be a panel of experts who are there to oversee the full picture of the patient journey. For them to see what has happened with the doctors that they have interacted with is very important. Therefore, I am minded to support amendment 459.

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[Naz Shah]

The hon. Member for East Wiltshire makes an important point. Where are the opportunities? When doctors are doing the assessment.

The other issue that speaks to me is the question of internalised bias. We will have professionals with subconscious bias or affirmed bias. They will be clinicians who have chosen or agreed to take part in the process; fundamentally, the majority of clinicians will not take part in this process because of their beliefs. It changes the relationship between doctor and patient from a societal perspective.

I know that a number of times I have been stopped during a process and asked a different question, and at times that opportunity for reflection—even without the pressure of knowing I have only six months to live—is of benefit to me. I am sure that others would benefit from it, too, particularly because the decision is so momentous. For that reason, I will certainly support amendment 468.

I thank my hon. Friend the Member for Spen Valley for tabling amendment 201. I have mixed views on it. I appreciate what my hon. Friend the Member for Luton South and South Bedfordshire said about medical records, especially when it comes to women and their past, but I also appreciated what my hon. Friend the Member for Ashford said about his experience from a mental health perspective.

I am still thinking about the amendment and I am not sure whether I will support it or not, but further thought needs to be given to the subject. There are the issues of mental health and women’s rights, but another issue applies, too. If someone has experienced trauma in childhood but that trauma has come out much more recently, even though it does not necessarily affect the decision at hand—whether to choose an assisted death—is there some kind of historical post-traumatic stress disorder that would then need to be explored? I do not have the answer, but I look forward to hearing the comments of my hon. Friend the Member for Spen Valley on that point. I would value hearing whether she has thought about that and what her understanding of it is.

[Stephen Kinnock]

As I have mentioned before, the Government have worked closely with my hon. Friend the Member for Spen Valley on some mutually agreed amendments, including amendments 201, 422 and 433. The amendments that the Government support aim to ensure the legal robustness and operability of the legislation, should it pass, and I will offer a technical explanation for them.

Amendment 201 will clarify the wording in clause 9 on the doctor’s assessment. It provides that the duty on an assessing doctor to examine a person’s medical records applies only to records that appear relevant to the doctor. The effect of the amendment is to make clear as part of the assessment process that the assessing doctor is required only to review medical records that are considered by the doctor to be relevant to the person’s request to seek an assisted death.

Amendment 422 would add an additional requirement on an assessing doctor to make inquiries of professionals who are providing or who have recently provided health or social care to the person and make such other inquiries as the assessing doctor considers appropriate. This applies to—

[The Chair]

Order.

Dental Patient Charges Uplift

Stephen Kinnock Excerpts

Tuesday 11th March 2025 Written Statements

[The Minister for Care (Stephen Kinnock)]

The Government ambition is to make sure that everyone who needs a dentist can get one. On Friday 21 February 2025, we launched the roll-out of the extra 700,000 urgent dental appointments promised by the Government in their election manifesto. Integrated care boards have been asked to start making these extra appointments available from April 2025, and they will be available to NHS patients experiencing painful oral health issues, such as infections, abscesses, or cracked or broken teeth. Appointments will be available across the country, with specific targets for each region. These targets are more heavily weighted towards those areas where extra appointments are needed the most.

Through the golden hello scheme, integrated care boards are supporting practices across England in recruiting NHS dentists to posts that they have previously struggled to fill. This recruitment incentive will see up to 240 dentists receiving payments of £20,000 to work in those areas that need them most for three years. As of 10 February 2025, in England, 35 dentists have commenced in post and a further 33 dentists have been recruited but are yet to start in post. A further 249 posts are currently advertised.

To rebuild dentistry in the long term, we will reform the dental contract with the sector, with a shift to focusing on prevention and the retention of NHS dentists. On 7 March 2025, we announced investment of £11.4 million to implement the manifesto commitment of a national, targeted supervised toothbrushing scheme for 3 to 5-year-olds. The investment will be focused on around 505,000 children living in the 20% most deprived communities across England. Following public consultation, we also announced the expansion of community water fluoridation across the north-east of England, reaching an additional 1.6 million people. At the same time, we will not wait to make improvements to the current system where these can increase access and incentivise the workforce to deliver more NHS care. We are continuing to meet the British Dental Association and other representatives of the dental sector to discuss how we can best deliver our shared ambition to improve access for NHS dental patients.

We have launched a 10-year health plan to reform the NHS. A central and core part of the 10-year health plan will be our workforce and how we ensure we train and provide the staff the NHS needs to care for patients across our communities. We have taken necessary decisions to fix the foundations of the public finances at autumn budget. This enabled the spending review settlement of £22.6 billion extra investment in resource spending for the Department of Health and Social Care from 2023-24 out-turn to 2025-26.

On 10 March 2025, the National Health Service (Dental Charges) (Amendment) Regulations 2025 were laid before Parliament to increase national health service dental patient charges in England in line with inflation from 1 April 2025.

NHS dental patient charges provide an important revenue source for NHS dentistry and are typically uplifted on 1 April each financial year. The charges will be uplifted by 2.39% in 2025-26, aligning with the forecast GDP deflator value. Dental patients will benefit from the continued provision that this important revenue supports.

From 1 April 2025, the dental charge payable for a band 1 course of treatment will rise by £0.60, from £26.80 to £27.40. For a band 2 course of treatment, there will be an increase of £1.80 from £73.50 to £75.30. A band 3 course of treatment will increase by £7.60 from £319.10 to £326.70.

Details of the revised charges for 2025-26 can be found in the table below:

Terminally Ill Adults (End of Life) Bill (Nineteeth sitting)

Stephen Kinnock Excerpts

Wednesday 5th March 2025 Public Bill Committees

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mrs Harris. The amendments have been tabled by my hon. Friend the Member for Spen Valley in consultation with the Government. This reflects the Government’s role in ensuring that the Bill is legally robust and workable. The amendments relate to the regulation-making powers and bring together various provisions about procedure and requirements for regulations and consultation.

I will address the amendments in two groups, starting with new clause 8 and its consequential amendments 187, 199 and 211. The new clause contains a duty to consult before making regulations; it is intended to consolidate three subsections that contain duties to consult before making regulations, as set out in the original draft of the Bill under clauses 5, 8 and 19. In addition to retaining the existing duties to consult before making regulations in clauses 5, 8 and 19, the new clause requires the Secretary of State to consult before making regulations under clauses 7, 13 and 21, and brings together these requirements under a single duty.

The new clause would place an additional requirement on the Secretary of State to consult the Equality and Human Rights Commission, as well as such other persons that the Secretary of State considers appropriate. The latter group must include persons with expertise in matters relating to whether persons have capacity or have been coerced, unless it would not be appropriate to consult such persons.

I turn to amendments 233, 188, 192, 215 to 219, 222, 225, 226, 212, 213, 200 and 206. There are provisions throughout the Bill, as it is currently drafted, about the procedure for making regulations. All regulations, except for those made under clause 5(3)(a), clause 8(6)(a), clause 30(3) and clause 32, are required to be made under the negative procedure. Amendment 233 would bring together the various provisions about the procedure for making regulations into a single clause, clause 39, thereby removing repetition in the Bill. The amendment seeks to achieve that by replacing subsections (3) to (5) in clause 39 with the following:

“(5A) The Secretary of State may not make a statutory instrument containing (whether alone or with other provision) regulations under section 5(3A), 8(6A), 30(3) or 32 unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.

(5B) Any other statutory instrument made by the Secretary of State containing regulations under this Act is subject to annulment in pursuance of a resolution of either House of Parliament.”

The amendment would require that any regulations made under those provisions must be laid before, and approved by, a resolution of both Houses of Parliament. This procedure, the draft affirmative procedure, will apply to regulations setting the training, qualifications and experience of both the co-ordinating and the independent doctors, establishing a code of practice and securing arrangements for the provision of assisted dying under the Act. Any other statutory instrument made under powers within the Bill will remain subject to the negative procedure.

As I have said, the Government have taken a neutral position on the substantive policy questions. These comments relate to the legal and regulatory side of the Bill, and I hope that my observations are useful to the Committee.

[Kim Leadbeater]

I have nothing further to add.

Amendment 187 agreed to.

Amendment made: 20, in clause 5, page 3, line 25, at end insert—

“(4A) Regulations under subsection (3)(a) must specify that training in respect of domestic abuse, including coercive control and financial abuse is mandatory.”—(Daniel Francis.)

This amendment would require the registered medical practitioner acting as the coordinating doctor to have undertaken training on domestic abuse, including coercive control and financial abuse.

Amendment made: 188, in clause 5, page 3, line 28, leave out subsection (6).—(Kim Leadbeater.)

This amendment is consequential on Amendment 233, which contains a single set of provisions about the procedure for regulations under the Bill.

Clause 5, as amended, ordered to stand part of the Bill.

Clause 6

Requirement for proof of identity

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The Bill does that overall. It takes us clearly through a journey from the initial discussion to the final act. There is a chronology to the process, naturally enough, and the Bill reflects that. I am therefore unclear why we have this amendment 419, which I think is essential and important—I wish it were stronger, as I said earlier—but I am unclear why it is here. Why is it a subsection in a clause dealing with regulations for forms of identity? I am concerned about the amendment and why it is in the place it is. I will be grateful for clarification from Ministers or the promoter about why it is there.

[Stephen Kinnock]

This group of amendments refines the requirements related to the first declaration, clarifying the witnessing process, identity verification and regulatory obligations. I will take the amendments in turn.

In executing our duties to ensure that the legislation, if passed, is legally robust and workable, in this group the Government have worked with my hon. Friend the Member for Spen Valley on amendments 189 to 191 and 419. Amendment 189 would clarify the requirement for proof of identity when making a first declaration. It would adjust the wording to make it clear that proof of identity must be provided before a person signs a declaration, ensuring no ambiguity about when the requirement applies.

As with amendment 189, amendment 190 clarifies the requirement for proof of identity when making a first declaration. This amendment would make it clear that a person must provide two forms of proof of identity before signing the declaration, rather than simply at the same time. That ensures that both the co-ordinating doctor and the witness have received the necessary proof before the declaration is signed.

Amendment 191 ensures that the co-ordinating doctor can witness the first declaration only if they are satisfied that the person has provided two forms of proof of identity. The doctor must therefore first be satisfied that the required proof has been given to them and to the witness before proceeding with witnessing the signing of the declaration.

Amendment 419 requires that, before witnessing the first declaration, the co-ordinating doctor must be satisfied that a preliminary discussion has taken place, whether that was conducted by the co-ordinating doctor or another registered medical practitioner. The co-ordinating doctor must also have made or seen a written record of the preliminary discussion.

Amendment 291 adds to the requirement around proof of identity when making a first declaration. It requires that one of the forms of ID provided to the co-ordinating doctor and witness be photographic. The person must also provide proof of residence at this stage of the process. I note we would expect this type of issue to be considered by the Secretary of State when making regulations about forms of proof of identity that are acceptable, as already provided for in clause 6(3). Requiring a person to provide proof that they have been resident in the UK for at least 12 months appears to impose a different residency requirement to other parts of the Bill. Specifically, “being resident” is a looser test than being “ordinarily resident”, in clause 1, and “in the UK” is broader than “in England and Wales”, also in clause 1. In consequence, our assessment is that this amendment may make the Bill less legally coherent.

[Rebecca Paul (Reigate) (Con)]

I want to raise a question on photo ID. My apologies, I probably should have spoken sooner. Thinking this through as we have debated, I think photographic ID is important to avoid mistaken identity and fraud, and to make sure everything works as it should. With respect to this process, would the Minister normally expect photographic ID to be an acceptable or appropriate form of identification?

[Stephen Kinnock]

Yes, I believe so. Photographic ID would be the standard to which we would aspire. I do not know whether there was anything else under her question? I think the answer is yes.

[Sojan Joseph (Ashford) (Lab)]

Could the Minister clarify whether the requirement for one year of residency in the UK means that a foreign citizen studying at a university here would be able to consider assisted dying?

[Stephen Kinnock]

I thank my hon. Friend for that intervention. We have the term “ordinarily resident” in the UK in clause 1. Obviously if the Committee sees fit to accept the amendment it would change to “resident”, which is a looser term. This matter would also be one for the Home Office, as the custodian of our rules and regulations on immigration, but my sense would be that if we stick with “ordinarily resident” then someone who is not ordinarily resident in the United Kingdom would not qualify for assisted dying.

As the Bill currently stands, the Secretary of State has the power but not the obligation to set these requirements in regulations. This amendment would remove this discretion and require the Secretary of State to specify what forms of ID must be provided.

Amendment 293 ensures that regulations on acceptable forms of proof of identify must be approved by both Houses of Parliament before coming into force, by requiring these regulations to follow the affirmative rather than the negative procedure. As I said earlier, the Government’s position is neutral, but I hope my observations—

[Kim Leadbeater]

This is a thought based on the comments by the hon. Member for Reigate. The issue of photographic ID is worth giving consideration. Photo ID is used in multiple settings for different reasons. My slight concern is that some of the people we are thinking about with this Bill would be older and I think of some of my own family members who no longer have driving licences, passports or potentially any form of photographic ID. I would be concerned this could be a barrier for terminally ill people. Considering we are making this a robust process, which I totally agree with, I would be concerned that might present an issue.

[The Chair]

Order. I have asked for interventions to be short and not speeches.

[Stephen Kinnock]

I thank my hon. Friend for that intervention. She makes a very good point. It is definitely something that needs to be explored, to ensure that people are not being excluded for the reasons she set out. It is a different example, but when voter ID was introduced a special ID card was created by the Government to cater for exactly the situation she set out. We have to find a way of ensuring that people are not excluded because of that technicality. She makes a valid point.

[Kit Malthouse (North West Hampshire) (Con)]

Scanning back through my experience of the health service, I do not remember ever having to show my ID, whatever the procedure or medical service. I do not remember showing ID to witness the birth of my children or my wife having to show her ID. I am not sure that is common in the health service. Why would we introduce it for this? I can go in and have a heart bypass and not be asked to show my ID. My assumption is that often people will have been—

[The Chair]

Order. I have asked for interventions to be short.

[Stephen Kinnock]

This section of the Bill covers the issue of ID and says that proof of ID is required. I am simply responding to the requirements of the Bill. I am more than happy to have a debate about ID cards and all sorts of other issues more broadly—

[The Chair]

On another day.

[Stephen Kinnock]

I look forward to having that debate on another day. Unless other colleagues want to intervene, I will now sit down, to the delight of the Chair.

[The Chair]

I call Kim Leadbeater, who now has the opportunity to say anything she likes.

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[Sojan Joseph]

I agree. It highlights the point that the impact assessment will be very important here, to see from where the resources are being pulled to provide this. The Committee should acknowledge amendment 296.

[Stephen Kinnock]

These amendments introduce requirements on the timing within which the co-ordinating doctor must carry out a first assessment once the first declaration is made by a person. I will turn first to amendment 296. As currently drafted, clause 7(1) requires that the co-ordinating doctor must carry out a first assessment

“as soon as reasonably practicable”

after a person has made a first declaration. Amendment 296 would require that after the first declaration is made, the co-ordinating doctor must arrange a mutually convenient time and date for the first assessment to take place, but it removes the stipulation that the assessment must be carried out as soon as reasonably practicable. The amendment would also require the date and time agreed not to jeopardise the care of other patients. The effect of the amendment may be to lengthen the period between the first declaration and the first assessment, in some cases.

Amendments 127 to 141 seek to ensure that the assessments, declarations and statements made throughout the Bill are finalised and recorded within 10 working days of being started. The amendments achieve this by inserting the term “within 10 working days” in place of

“as soon as reasonably practicable”

in clauses 7, 8, 16, 17, 21 and 22. This would put in place a time-bound limit that the medical practitioner must adhere to when carrying out the first and second assessments, when recording information in medical records at various stages, including the High Court declaration, and when recording other matters in medical records.

Our assessment suggests that in most circumstances, although it would depend on the facts of a particular case, the requirement to do an action as soon as practicable would generally amount to a requirement to do the action sooner than in 10 working days’ time. In terms of the operational effects, having a set timeline may give greater certainty to individuals seeking assistance. However, it may limit doctors’ discretion to set the timeline based around the patient’s wishes. These are matters for the Committee to weigh up and consider.

[Kim Leadbeater]

That has been a very useful discussion. I have nothing to add.

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[Dr Opher]

I am grateful that you have not intervened as well, Mrs Harris. You did say that I am allowed to call you “you”.

I will finish on this serious point. Amendment 6 has much power, and we would all agree that if the first or second doctor has doubts, they must—not may—refer to a psychiatrist. Expecting every patient who requests assisted death to have a psychological or psychiatric assessment is simply not necessary, and it would not improve the safety of this Bill.

[Stephen Kinnock]

rose—

[Lewis Atkinson (Sunderland Central) (Lab)]

rose—

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[The Chair]

I call the Minister.

[Stephen Kinnock]

Thank you so much, Mrs Harris—I will try again.

Although it is up to Parliament to pass or reject this Bill, the Government remain committed to ensuring its legal robustness and workability. For that reason, we have worked closely with my hon. Friend the Member for Spen Valley, and we have mutually agreed some amendments, including amendments 370 and 202. This group of amendments relates to the assessment process for determining a person’s ability to make a first declaration. I will take them in turn.

As the Bill stands, the co-ordinating doctor is responsible for ascertaining whether, in their opinion, a person applying for assistance to end their own life has met the eligibility criteria in clause 7(2), as part of the first doctor’s assessment. Amendment 347 would change the co-ordinating doctor’s role from ascertaining whether, in their opinion, the criteria in clause 7(2) are met to instead ensuring that steps have been taken to confirm that those criteria are met. Its practical effect would be that the co-ordinating doctor could rely on the assessment of other, non-specified, persons to confirm that the eligibility criteria have been met.

Amendment 294 provides that the co-ordinating doctor, in ascertaining whether, in their opinion, the criteria in clause 7(2) are met, would be required to base that assessment on evidence that has been provided. It does not specify who would provide the evidence, what types of evidence would be considered acceptable or whether the co-ordinating doctor could disregard evidence if they consider it appropriate to do so. It could create uncertainty for the co-ordinating doctor in carrying out the first assessment.

Amendment 14 would require the co-ordinating doctor, when making the first assessment, to take into account an additional report. The report would be made by a qualified person and would cover duress and/or coercion, communication needs and capacity. It would be informed by an interview between the specialist and the person applying for assistance to end their own life. The specialist must have expertise in psychiatry or other qualifications set out in regulations. There are various exclusions aimed at avoiding conflicts of interest.

Amendment 15 would similarly require that the independent doctor, in making the second doctor’s assessment, takes the report into account. Amendments 16 to 19 are consequential to amendment 14.

In practice, the amendments would represent a change at the medical assessment stage from requiring two professionals to requiring three. They also represent a departure from usual practice for professionals applying the Mental Capacity Act 2005. The requirement to interview the person and write a report that must, in all cases, address capacity may amount to an assessment of capacity in itself. That would undermine a core principle of the Mental Capacity Act, which is the presumption of capacity.

In addition, the test of capacity set out in the amendments is more limited than the test of capacity under the Mental Capacity Act. It covers only capacity to understand information, not capacity to retain, use or weigh it.

Amendment 284 would require the co-ordinating and independent doctors to, in all cases, refer the person seeking assisted dying to a psychiatrist for an assessment of their mental capacity. Although that is set out in the explanatory note from my hon. Friend the Member for York Central, the amendment does not specify the type of assessment that is required. Putting aside specification of the type of assessment, the overall intention of the amendment is that, in order to be eligible for assisted dying, a capacity assessment would always be required, irrespective of whether there is a proper reason to doubt that the person has capacity. That would differ from the Mental Capacity Act, under which capacity is presumed unless it is established that the person lacks it.

Amendment 6 would require the assessing doctor to refer all cases where there is doubt about mental capacity for an assessment by a doctor who is an expert in psychiatry. This is a power, as currently drafted, but the amendment would make it a duty. Requiring, rather than permitting, the assessing doctor to make a referral when capacity is in doubt would remove their discretion on whether to refer a person to a doctor who is an expert in psychiatry. Instead, it would be required in all cases where there is doubt about capacity.

Terminally Ill Adults (End of Life) Bill (Eighteenth sitting)

Stephen Kinnock Excerpts

Committee stage
Wednesday 5th March 2025 Public Bill Committees

[Naz Shah]

Thank you, Mr Dowd.

I come back to the issue of potential coercive control, which is what amendment 20 addresses. As I have outlined, there are patients who could be in that position. Given the examples that I have put before the Committee, I argue that the amendment, although it is brilliant in getting us to a better place than where we started out with the Bill—I am pleased that my hon. Friend the Member for Spen Valley has indicated that she is happy to discuss strengthening the safeguards—does not go far enough, for the very reasons that I have outlined, and no doubt will outline further when speaking to other amendments.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd. As I have said, the Government remain neutral and my role is not to offer a Government view on the merits of the amendments, but to provide a factual explanation of their technical and practical effect to assist the Committee in its scrutiny.

The Government remain committed to ensuring the legal robustness and workability of all legislation, so I have worked closely with my hon. Friend the Member for Spen Valley on some amendments. Where changes have been mutually agreed by my hon. Friend and the Government, I will offer a technical, factual explanation and rationale for the amendments. Those include amendments 185 and 186 in this group. The Government remain neutral on the Bill and do not have a position on assisted dying.

This group relates to the necessary training, qualifications and experience of the co-ordinating doctor. As drafted, clause 5 gives the Secretary of State the power to specify the training, qualifications and experience required for a registered medical practitioner to act as a co-ordinating doctor, but there is no legal duty for the Secretary of State to do so. Amendments in this group either seek to change that power to a legal duty, or would introduce specific training, qualifications and experiential requirements for a registered medical practitioner to act as a co-ordinating doctor.

Amendments 185 and 186 tabled by my hon. Friend the Member for Spen Valley would introduce a duty on the Secretary of State to make regulations regarding the necessary training, qualifications and experience of the co-ordinating doctor. Giving the Secretary of State a duty rather than merely a power would ensure certainty as to the training, qualifications and experience that the registered medical practitioner must have in order to act as a co-ordinating doctor. The Secretary of State’s duty in this respect would include making provision in regulations about training for co-ordinating doctors relating to assessing capacity and assessing whether a person has been coerced or pressured by another person. Amendment 186 would also enable the Secretary of State, subject to the specific training requirements already mentioned, to delegate the determination of the training, qualifications and experience needed for a co-ordinating doctor to a person specified in the regulations. That would allow that determination to be delegated to a body or bodies with appropriate expertise, in line with other aspects of training for healthcare professionals.

--- Later in debate ---

[Danny Kruger]

Will the Minister clarify that point? Is he suggesting that because fewer doctors might be eligible or willing to conduct the preliminary assessment, we should not require it at that early stage?

[Stephen Kinnock]

What we are trying to say is that the important thing here is to ensure that, when the Secretary of State brings the regulations forward, the hands of the Secretary of State are not tied too tightly, so that the Secretary of State is able to bring together the right people, to deliver the right training, to achieve the outcomes that are required through the regulations. Our assessment is that this amendment would, in essence, narrow the pool of people available to do the training. That would seem to pre-empt the idea behind doing this through regulations, which is to ensure that there is up-to-date training that is responsive to where we may or may not be two years down the line from the Bill having its commencement. It is about having that flexibility and that ability to build capacity.

Amendment 340 would place the Secretary of State under a duty to make regulations requiring a co-ordinating doctor to have specific and up-to-date training relating to reasonable adjustments and safeguards for autistic people and people with a learning disability. I note that amendments 185 and 186, if passed, would impose a duty on the Secretary of State to specify the training, qualifications and experience that the co-ordinating doctor will need.

The consequence of this amendment would be to require the Secretary of State to introduce a further requirement on the co-ordinating doctor—to have undergone training relating to reasonable adjustments and safeguards for autistic people and people with a learning disability. In considering whether the amendment is required, I note that the Health and Social Care Act 2008 requires that all CQC-registered health and adult social care providers ensure that their staff receive specific training on learning disability and autism.

Amendment 427 would impose an obligation to take all reasonable steps to ensure that the co-ordinating doctor is proficient in the Welsh language if services or functions under this legislation are to be provided to an individual in Welsh in Wales. The amendment does not make it clear who would be obliged to ensure that those steps were taken, or who would assess and enforce whether the “fluent proficiency” standard was met.

[Liz Saville Roberts]

What the Minister is referring to is the appropriate authorities, because areas related to training and regulation of registered practitioners in Wales are devolved to the Welsh Government. I will be touching on that later, but I would beg him to approach the amendment in that spirit.

[Stephen Kinnock]

I know that we are coming on to the question of appropriate authorities and I absolutely see and understand the spirit in which this amendment is suggested. The challenge is just about the potential for it to lead to operational issues, such as a reduced pool of registered medical practitioners who are able to carry out the function of a co-ordinating doctor under this legislation.

[Liz Saville Roberts]

That is exactly why the amendment includes a reference to “all reasonable steps”. It is with that in mind. This is reflected in other legislation where similar concerns have been expressed.

[Stephen Kinnock]

I thank the right hon. Lady for that. We go back to the point about the true significance of the 2011 Welsh Government Measure, which sets a basic foundation for the duty of the Welsh Government to ensure that Welsh language provision is provided through the Welsh NHS. There is absolutely no debate about that point; that is nailed on. The question is simply how we ensure, if we are to amend this Bill along the lines that the right hon. Lady suggests, that that does not create a lacuna or confusion in the system. I think we need to sit down and discuss that, to ensure that whatever we propose is watertight.

It may be helpful to note, as in discussion of amendment 413, that regardless of this amendment, under the Welsh Language Measure of 2011 the NHS in Wales has a statutory duty to deliver its services to the public in both Welsh and English. That legislation gives the Welsh language official status in Wales, and the Measure states that individuals in Wales should be able to conduct their lives through the medium of Welsh if they choose to do so. The Welsh Government’s active offer for health is intended to support all staff across NHS Wales to provide a service in Welsh for patients without their having to ask for it.

Under amendment 20, regulations made by the Secretary of State on the necessary training, qualifications and experience of the co-ordinating doctor would be required to include mandatory training relating to domestic abuse, including coercive control and financial abuse. Amendments 185 and 186, tabled by my hon. Friend the Member for Spen Valley, would require that regulations made by the Secretary of State on the necessary training, qualifications and experience of the co-ordinating doctor covered training related to assessing capacity and whether a person has been coerced or pressured by another person. But I note that, as my hon. Friend the Member for Spen Valley has said, she is minded to support amendment 20, which clearly would ramp up the requirement, as previously discussed.

As I have said, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed, but to clarify the intent of the Bill, we have worked with my hon. Friend the Member for Spen Valley in relation to amendments 185 and 186, which would place the Secretary of State under a duty to make regulations regarding the necessary training, qualifications and experience of the co-ordinating doctor. That would include specific training on assessing capacity and assessing whether a person has been subject to coercion or pressure.

I hope that that explanation and those observations have assisted the Committee. I thank hon. Members for their attention.

[Kim Leadbeater]

I rise to speak first to my amendments 185 and 186, which would make important changes to impose a duty on the Secretary of State to make regulations about the training, qualifications and experience required to act as the co-ordinating doctor, as the Minister says. Moving from “may” to “must” would make it a legal requirement that such training take place and would thereby strengthen the Bill. In its present form, the Bill gives the Secretary of State that power to make such regulations but does not legally require him or her to do so.

Amendment 186 would ensure that regulations must include training about

“(a) assessing capacity;

(b) assessing whether a person has been coerced or pressured by any other person.”

Colleagues will appreciate that it is difficult for me to resist the temptation to put the entire training manual in the Bill—we all want to show the thorough approach that has been taken—but doing so would not make for good, clear legislation and can be limited in terms of flexibility and future-proofing. However, given the importance of the matters of capacity and coercion, I felt that it was important that this level of detail be specified in the Bill, because those issues have been at the heart of so many of our deliberations on this hugely sensitive and important issue.

My hon. Friend the Member for Bexleyheath and Crayford, who tabled amendment (a) to my amendment 186, has made a compelling argument, as always. Like my hon. Friend the Member for Penistone and Stocksbridge, I have some concerns that the amendment would limit the number of disabled people who are covered and that it would not cover people with mental disorders, but I understand the concerns around autistic people and those with learning disabilities.

I am also mindful, given that people with Down’s syndrome will typically have some form of learning disability, that amendment (a) may help to address some of the concerns that were expressed yesterday about ensuring that the Bill meets their needs and takes them into consideration. I take on board the Minister’s comments about the Health and Care Act 2022, but I am minded to support the amendment and work with my hon. Friend the Member for Bexleyheath and Crayford and others as necessary to make any further changes as the Bill progresses.

--- Later in debate ---

[Danny Kruger]

I absolutely agree with the right hon. Lady. There is a whole set of challenges, including in England, in respect of the impact assessment and the Bill’s commencement. Nevertheless, my suggestion is that we strengthen her proposal to empower Welsh Ministers to proceed. We should respect the devolution settlement and reflect what she describes as the “correct and rightful powers” of the Welsh Parliament to ultimately decide whether this law were to come into effect in Wales.

[Stephen Kinnock]

Amendments 144 to 171, tabled by the right hon. Member for Dwyfor Meirionnydd, relate to the powers and duties vested in the Secretary of State under the Bill. The purpose of the amendments is to change all references throughout the Bill from “Secretary of State” to “appropriate authority”. Amendment 169 defines “appropriate authority” as the Secretary of State in relation to England and as Welsh Ministers in relation to Wales. I note the intent of the promoter of the Bill, my hon. Friend the Member for Spen Valley, that the Bill’s provisions extend and apply to both England and Wales.

The amendments would mean that all the powers and duties vested in the Secretary of State are instead shared between the Secretary of State where they relate to England and Welsh Ministers where they relate to Wales. I would like to put on the record the Government’s continued commitment to devolution and to working with the devolved Governments. Having taken a neutral position on the Bill and the matter of assisted dying, the Government are still committed to working with the Welsh Government to resolve legal and technical issues and discuss constitutional matters that might arise thoughtfully and amicably.

With regard to the phrase “appropriate authority”, the challenge is that in each case throughout the Bill the appropriate authority would be determined by the devolution position of the clause in question—what is the underlying question that the clause seeks to address, and is that a reserved or devolved matter? I have discussed this with parliamentary counsel and others, and the concern is that a blanket provision of this nature may well be premature at this stage. Until we have finalised and determined the constitutional nature and impact of each clause, putting a blanket provision in place may run counter to that process.

[Liz Saville Roberts]

I have a simple question: in relation to the Sewel convention, if not now, when? We should have clarity on these points. I hope the Minister will forgive me if this is slightly longer than an intervention, but he gives me no option in the here and now but to withdraw the amendments, because I will not push them to a vote if it is likely to be lost. However, these are serious questions. How does this respect the Sewel convention? As a Back-Bench MP, I am not in a position to answer that, and I would have expected the Government to provide clarity on these points earlier than Committee stage. I assure the Minister that I will push this issue on Report if we do not have a satisfactory resolution on the Sewel convention.

[Stephen Kinnock]

It is, of course, the right hon. Lady’s prerogative to press amendments as and when she sees fit. I am simply flagging that terminology such as “appropriate authority” risks tying the hands of the legislative process in a way that could have perverse outcomes. A clause that should be the lead responsibility of Welsh Ministers could instead end up in the hands of Secretary of State due to the lack of clarity or relative vagueness of the term “appropriate authority”.

The Government’s suggestion is to work through each clause and be specific about the lead responsibility in each case—is it the Secretary of State or Welsh Ministers? We are open to discussing whether it is better to do it that way or with the terminology “appropriate authority”; we are simply flagging that there are risks associated with that term.

[Liz Saville Roberts]

Before the Minister sits down, will he commit to engaging with me on this issue to identify the specific needs in the spirit of what I have bought forward?

[Stephen Kinnock]

Yes, absolutely, and before Report. Let us ensure that we do that, and that parliamentary counsel is in the room. I am not a constitutional lawyer, so we definitely need people in the room who can speak to these issues. Of course, it also needs to be done in close dialogue with colleagues in the Welsh Government, particularly given what was said earlier about the need for a legislative consent motion.

--- Later in debate ---

[Stephen Kinnock]

Amendments 360 and 361 introduce requirements on the co-ordinating doctor. Amendment 360 would insert an additional condition into the definition of a co-ordinating doctor and would require a co-ordinating doctor who receives financial payment for providing assisted dying to make an annual statement declaring publicly their total turnover from providing the service, the number of people they have assisted and any other information specified in regulations.

The related amendment 361 would require that any regulations specifying the information to be made available must be subject to the affirmative procedure. It is not clear whether the amendments are intended to apply to both private and NHS providers. It could create difficulty if the requirement were to apply to NHS providers, as a doctor is unlikely to know the total turnover from providing an assisted dying service.

As the Bill’s promoter, my hon. Friend the Member for Spen Valley has said that her intent is to ensure that the assisted dying service is available as an integral part of the NHS. Officials are working on amendments to later clauses to establish the operating model for her consideration.

[Rebecca Paul (Reigate) (Con)]

Does the Minister not think the word “remuneration” refers to the amount of income received specifically by the doctor, rather than by any organisation or company?

[Stephen Kinnock]

As my hon. Friend the Member for Stroud has just said, the picture is very complex because there are tariffs for services. Doctors receive a tariff for each service across the entire panoply of everything they do, particularly general practitioners who provide a very wide range of services. They are remunerated on the basis of a tariff that is negotiated in the GP contract between the Department of Health and Social Care and, primarily, the BMA. When a doctor operates in that environment, it is difficult to pick out their turnover from a particular service.

As my hon. Friend the Member for Stroud said, picking out an individual doctor and saying how much money they have made from a particular service, whether assisted dying or any other service, would put a particular focus on that doctor. We are drawing a distinction here with what the tariff could and should be, which we will need to discuss alongside the operating model in later clauses. Moving from being transparent on the tariff to saying, “That doctor over there made this much money from providing this service,” is a whole new ball game.

[Danny Kruger]

I am grateful to the Minister for raising a number of points, including the extraordinary revelation that we are about to find out how the Bill will operate in practice, with amendments yet to be developed even though we have been debating the Bill for a couple of weeks.

The difference between the tariff and a doctor’s income is fine, but if the tariff is to be clearly specified—no doubt it will be—how could it be complicated to determine how many tariffs a particular practice has received? I recognise that there is a separate question about whether it is appropriate to reveal that, but why is it difficult to identify how many individual tariffs a particular practice has received?

The Minister has described the tariff income, but my other concern is about the sponsorship, gifts, hospitality and fees of all sorts that the pharmaceutical companies are always trying to administer. Will he address the question of whether that should be transparent as well?

[Stephen Kinnock]

The challenge in the hon. Gentleman’s amendment is the term “total turnover.” A GP would have to extrapolate from the service provided to a whole range of other costs that may apply—for example, the share of the overhead they pay into their primary care network, the share of admin costs or the rent on their building. The definition of total turnover is the entire cost and entire revenue from the tariffs. As officials have made clear, this additional level of complexity would be an onerous task, although not necessarily impossible.

Total turnover is one side of this issue; the other, much more salient point is the quantum leap between having transparency on a particular tariff and pointing at a specific doctor and saying, “You over there—you did this much work on that much tariff, and that’s how much money you made for it.” There is a big difference between the two.

[Naz Shah]

I also do not like the idea of doctors being identified in such a way, as they have with abortion clinics, but I am trying to understand how we will protect these services. If it is an NHS provision and specialty, with doctors in certain practices signing up to provide services for assisted dying and becoming either the primary or the secondary doctor, by definition those will be the practices to which people will refer. That will become common knowledge, just as it is for musculoskeletal or podiatry services, for example. In this instance, there would be an assisted death service, and there would clearly be practices that do not provide it. How would we then protect the doctors? How will the Government respond to all these concerns?

--- Later in debate ---

[Stephen Kinnock]

If we are specifically talking about the amendments tabled by the hon. Member for East Wiltshire, he is saying that the total turnover from providing this service should be publicly available—it should be published—so I assume he thinks it should be on a website that everybody can see.

My hon. Friend the Member for Bradford West is asking about the knowledge that, if someone wishes to seek an assisted death, they can go to a particular practitioner or service. That is baked into the Bill, and clearly those doctors who wish to opt into the service will be doing so with their eyes open—they will know that they are providing that service. We must ensure that doctors feel protected if there is a sense of risk.

It would of course be deeply regrettable if there were to be threats or risks to doctors, but the evidence from other countries suggests this has not led to some of the deeply unfortunate things we have seen around abortion clinics, for example. It does not seem to have led to that, but of course we as a Government always need to be vigilant in monitoring all our services to ensure that our excellent medical professionals are getting the support they need.

[Rebecca Paul]

I thank the Minister for that useful explanation. Does he agree that the setting of the tariff will be key, because it could either incentivise or disincentivise the provision of the service?

[Stephen Kinnock]

I agree. Like any other aspect of what doctors and general practitioners do, this service is based on remuneration. They are professionals and should be remunerated as such, so the tariff will be important. It is also important that we do not jump ahead into defining the operating model. As I said, officials are working on this with the Bill’s promoter, and it will be made clear when we get to the relevant clauses.

[Kim Leadbeater]

Hopefully the Minister and other colleagues are reassured that, if the Committee agrees to the introduction of the voluntary assisted dying commission, monitoring will be very intense and reporting will be very robust. That might allay some of the fears that have been raised today.

[Stephen Kinnock]

As I have repeatedly said, the Government are neutral on the fundamental question of the Bill, but we are absolutely committed to ensuring it is workable should it receive Royal Assent. The role of the commission will be pivotal in ensuring that the Bill is workable and that all the necessary monitoring and regulation mechanisms are in place.

Terminally Ill Adults (End of Life) Bill (Seventeenth sitting)

Stephen Kinnock Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the following:

Amendment 285, in clause 4, page 2, line 28, leave out paragraphs (a) to (c) and insert—

“(a) the person’s diagnosis and prognosis, in consultation with a specialist in the relevant illness, disease or medical condition,

(b) any treatment available and the likely effect of it, in consultation with a specialist in the provision of such treatment,

(c) any palliative, hospice or other care, including symptom management and psychological support, in consultation with a specialist in palliative care.”

This amendment ensures that a specialist carries out the assessment of the patient, the treatment options available and the palliative care options available, since these may not be known to a doctor coordinating an assisted death.

Amendment 343, in clause 4, page 2, line 28, at end insert

“, including any relevant probabilities and uncertainties surrounding the person’s diagnosis and prognosis.”

This amendment would make clear that the doctor conducting an initial discussion is required to discuss the probabilities and uncertainties of any estimates of how long a person may have to live.

Amendment 344, in clause 4, page 2, line 29, at end insert

“, including the risks and benefits of such treatment, potential side effects, and the impact of the treatment on the person’s quality and length of life.”

This amendment would make clear that the doctor conducting an initial discussion is required to discuss the impact of any treatment available.

Amendment 275, in clause 4, page 2, line 30, leave out “any available” and insert “all appropriate”.

Amendment 108, in clause 4, page 2, line 31, at end insert

“and offer to refer them to a registered medical practitioner who specialises in such care for the purpose of further discussion.”

This amendment would require the doctor who has an initial discussion with a person about assisted dying to offer to refer them to a specialist in palliative, hospice or other care.

Amendment 183, in clause 4, page 2, line 31, at end insert—

“(and, accordingly, such a preliminary discussion may not be conducted in isolation from an explanation of, and discussion about, the matters mentioned in paragraphs (a) to (c)).”

This amendment emphasises that the initial discussion mentioned in subsection (3) may not be conducted without also explaining and discussing the matters mentioned in subsection (4).

Amendment 425, in clause 4, page 2, line 31, at end insert—

“(4A) Where a person indicates to a registered medical practitioner their wish to seek assistance to end their own life in accordance with this Act, they must be referred to a multidisciplinary team to explore options for relevant care and support.

(4B) The Secretary of State may by regulations specify the requirements for the multidisciplinary team under subsection (4A).

(4C) The regulations must include a requirement for the multidisciplinary team to include all of—

(a) a registered medical practitioner or registered nurse,

(b) a person registered as a social worker in a register maintained by Social Work England or Social Work Wales, and

(c) a practising psychiatrist registered in one of the psychiatry specialisms.”

Amendment 53, in clause 7, page 4, line 8, at end insert—

“(ca) has relevant and available palliative care options.”

This amendment would mean that someone is only eligible for assistance in ending their own life under this Act if they have relevant and available palliative care options.

Amendment 54, in clause 7, page 4, line 17, leave out “(g)” and insert “(h)”.

This amendment is consequential on Amendment 53.

Amendment 426, in clause 7, page 4, line 26, at end insert—

“(4) The coordinating doctor may not take the steps set out in subsection (3) unless they receive confirmation from a multidisciplinary team that the person has had a meeting with that multidisciplinary team as specified in section 4.”

Amendment 286, in clause 9, page 5, line 36, leave out paragraphs (a) to (c) and insert—

“(a) the person’s diagnosis and prognosis, in consultation with a specialist in the relevant illness, disease or medical condition,

(b) any treatment available and the likely effect of it, in consultation with a specialist in the provision of such treatment,

(c) any palliative, hospice or other care, including symptom management and psychological support, in consultation with a specialist in palliative care.”

This amendment ensures that a specialist carries out the assessment of the patient, the treatment options available and the palliative care options available, since these may not be known to a doctor coordinating an assisted death.

Amendment 424, in clause 40, page 23, line 37, at end insert—

“‘preliminary discussion’ means a discussion of a kind mentioned in section 4(3);”.

This is a drafting change.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd.

When we broke at 11.25 am, I was talking about amendment 108. Clause 4(4) sets out that a registered medical practitioner who conducts the preliminary discussion on assisted dying must, as part of that discussion, explain and discuss

“the person’s diagnosis and prognosis…any treatment available and the likely effect of it…any available palliative, hospice or other care, including symptom management and psychological support.”

Amendment 108 would supplement that with a requirement for the registered medical practitioner also to offer to refer the person to a specialist in palliative, hospice or other such care for the purpose of further discussion.

The amendment would add an additional level of specificity to the preliminary discussion on palliative, hospice or other care, but would not in itself place a duty on the registered medical practitioner to make such a referral, or on the person to accept it. In considering whether the amendment is required, the Committee may wish to note that the General Medical Council’s good medical practice already requires doctors, when providing clinical care, to refer a patient to another suitably qualified practitioner when this serves their needs.

As the Committee is aware, the Government have worked with my hon. Friend the Member for Spen Valley on several amendments to ensure that the Bill is legally and operationally workable and reflects her policy objectives. Amendments 183 and 424 are two such amendments.

The purpose of amendment 183 is to emphasise, not change, the existing provisions in the Bill that provide that the preliminary discussion held with the person by a registered medical practitioner must not discuss assisted dying in isolation. Rather, the discussion must reference the matters contained in clause 4(4), including

(a) the person’s diagnosis and prognosis…any treatment available and the likely effect of it…any available palliative, hospice or other care, including symptom management and psychological support.”

Amendment 424 seeks to clarify the meaning of “preliminary discussion” in clause 40, to align that with the description of the discussions in subsections (3) and (4) of clause 4. It is a drafting change. As per subsections (3) and (4), a preliminary discussion takes place between a person seeking the provision of assistance in accordance with the Bill and a medical practitioner, about the requirements that need to be met for such assistance to be provided. The preliminary discussion must include

“the person’s diagnosis and prognosis…any treatment available and the likely effect of it…any available palliative, hospice or other care, including symptom management and psychological support.”

Amendment 425 would introduce a requirement that a person seeking assistance under the Bill is referred to a multidisciplinary team to consider support and care for the person. The Secretary of State may provide regulations to determine what kind of professionals should make up such a team, but the amendment would require that at a minimum each team should include a medical practitioner or nurse, a social worker and a psychiatrist. The obligation to refer to the multidisciplinary team would apply each and every time

“a person indicates to a registered medical practitioner their wish to seek assistance to end their own life in accordance with this Act”,

so there could be multiple referrals. Finally, I note that the amendment might have wider resource implications, including for social workers.

Together, amendments 53 and 54 propose changes to clause 7—rather than clause 4, which we have been considering so far today—the effect of which would be that in carrying out the first doctor’s assessment, the co-ordinating doctor must, in addition to the other requirements, be satisfied that the person has relevant and available palliative care options. As such, the amendments would mean that people are eligible for assistance to voluntarily end their own lives only when they have relevant and available palliative care options. The amendments would create an additional criterion, which may reduce the number of people able to receive an assisted death, linked to the availability of palliative care services to any given individual.

Amendment 426 would prevent the co-ordinating doctor from finalising the first assessment process until they had received confirmation from a multidisciplinary team—as set out in amendment 425—that the person seeking assistance to end their own life had met with the multidisciplinary team. The Committee may wish to note that under the amendment there would be no requirement on the multidisciplinary team to provide that confirmation in a given timeframe. That might lead to delays in the co-ordinating doctor being able to make their statement and onward referral.

Amendment 286 would remove the requirements in paragraphs (a) to (c) of clause 9(2) and insert three new requirements. The three new conditions require the assessing doctor, for both the first and second assessment, to consult specialists in relation to the person’s diagnosis and prognosis, any treatments available and the likely effect of those treatments, and any palliative, hospice or other care, including symptom management and psychological support.

The Committee may wish to note that, as drafted, amendment 286 might have some unintended consequences. That is because by replacing clause 9(2)(a), (b) and (c), it would remove the words

“explain to and discuss with the person being assessed”

at clause 9(2)(b). Consequently, the amendment would remove the requirement for the assessing doctor to have a discussion with the person about the factors currently set out in clause 9(2)(b). The assessing doctors would also not be required to examine the person and their medical records, and to make other inquiries as they consider appropriate.

The amendment could also lead to a significant loss of essential discussion between the assessing doctors and the person seeking assisted dying. The removal of clause 9(2)(b) would eliminate the requirement to explain and discuss the diagnosis and prognosis, treatment options and palliative care. Additionally, the amendment would remove the requirement to discuss the person’s wishes in the event of complications arising in connection with the self-administration of an approved substance, which may be seen as important for fully informed decision making.

I thank the Committee for its attention.

[Kim Leadbeater (Spen Valley) (Lab)]

I will try to keep my comments as brief as possible because we have had another very thorough discussion. First, my amendment 424 is, as the Minister said, a simple drafting change in clause 40 that confirms that “preliminary discussion” means a discussion as per clause 4(3).

Amendment 275 from my hon. Friend the Member for Sunderland Central would, in many circumstances, broaden the scope of the conversation that the doctor would have with the patient, and I am happy to support it.

I am also happy to support the very sensible amendment 108 from my hon. Friend the Member for East Thanet (Ms Billington). It is perfectly acceptable to ask the doctor to offer to refer the patient to a specialist, as they would probably do in most cases anyway, but the amendment is for clarity.

I refer colleagues to the comprehensive comments on my amendment 183 earlier in proceedings, and also to the support of the British Medical Association. Following Second Reading, I listened carefully to Members’ concerns about the possibility of doctors only discussing assisted dying with patients. Even though the Bill states that that cannot be the case, for the avoidance of any doubt the amendment emphasises that the initial discussion mentioned in clause 4(3) may not be conducted without also explaining and discussing the matters mentioned in subsection (4). Accordingly, such a preliminary discussion may not be conducted in isolation from an explanation of and discussion about the matters mentioned in paragraphs (a) to (c) of that subsection—that is, doctors cannot discuss the option of assisted dying in isolation but only in conjunction with discussion about all other available and appropriate treatment.

Indeed, Andrew Green of the BMA told us that

“some patients find it very difficult to bring up sensitive subjects with their doctors, even when those are the most important thing on their mind.”

He asked us to

“please do not pass legislation that makes it harder for doctors to understand their patients.” ––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 42, Q24.]

That concludes my remarks.

--- Later in debate ---

I will not press the amendments to a vote, but I think they would be a step in the right direction. Would that address my concerns? Unfortunately not. It still leaves a lot to be desired.

[Stephen Kinnock]

This group of amendments focuses on language and literacy barriers, including discussion of the use of interpreters and translations. If amendment 414 is agreed to, a registered medical practitioner who conducts a preliminary discussion with a person will first have to ensure the provision of adjustments for language and literacy barriers, including the use of interpreters. It may be helpful to note that, in all areas of practice, registered medical practitioners must uphold the standards in the GMC’s “Good medical practice”, which includes the provision of adjustments for language and literacy barriers.

The purpose of amendment 413 is to require medical practitioners in Wales who are conducting the initial discussion outlined in clause 4 to

“discuss with the person their preferred language of Welsh or English.”

It may be helpful to note that under the Welsh Language (Wales) Measure 2011, the NHS in Wales has a statutory duty to deliver its services to the public in both Welsh and English. The Measure, which gives the Welsh language official status in Wales, states that

“persons in Wales should be able to live their lives through the medium of the Welsh language if they choose to do so.”

The Welsh Government’s active offer for health is intended to support all staff across NHS Wales to provide a service in Welsh for patients, without their having to ask for it.

Technically, I would note that the amendment does not require the medical practitioner to conduct the initial discussion in the person’s preferred language, or to refer the person to another medical practitioner who can conduct it in the person’s preferred language, if they are unable to do so themselves. I have discussed that point with the right hon. Member for Dwyfor Meirionnydd and am more than happy to have a further discussion about how her amendment might work. The concern that I simply flagged was that we have the 2011 Measure and, as with so many of these things, there is a law of unintended consequences. An amendment that may be designed with the best possible intentions could end up disrupting the system and causing confusion or uncertainty, which I am sure she would not want. As with all these things, that is the challenge.

[Liz Saville Roberts]

We have raised already in the Committee the need for an impact assessment. I have also raised with the Minister the need for an impact assessment in Wales. The fact that we are having this conversation shows that there is an element of uncertainty about exactly whether it is necessary for this provision to be included in the Bill. I am concerned that it could be in a code of practice; I share the concern expressed by the hon. Member for Bradford West that we do not know how such codes of practice will operate, or whether we will have any say over how they operate. However, as the Minister has come to this in a spirit of co-operation, I hope that we will find some clarity. If it appears that it is better for Welsh language speakers that such a provision be set out in the Bill, I hope that he will agree in that respect.

[Stephen Kinnock]

I am happy to have that discussion, to better understand how it might all work in practice.

If amendment 415 is agreed to, it will mean that an assessing doctor making an assessment under subsection (2) must first ensure the provision of adjustments for language and literacy barriers, including the use of interpreters. As with amendment 414, the Committee may want to note the existing standards that all medical practitioners must uphold, which include requirements for the provision of adjustments for language and literacy barriers.

Amendments 416 and 417 would amend clause 30, which states that the Secretary of State may issue codes of practice on a number of matters, including on arrangements for ensuring effective communication and the use of interpreters. The amendments would impose a duty on the Secretary of State to issue one or more codes of practice in connection with arrangements for ensuring effective communication, including the use of interpreters, and to do so within six months of the passing of the Act. The requirement to issue any such code of practice within six months may prove unworkable. Under clause 30, it would be necessary to consult on the code of practice, make regulations to allow for the code of practice to come into force, have the regulations approved by both Houses of Parliament and then issue the code of practice, all within a six-month period after the passing of the Act.

As I have said, the Government will continue to remain neutral on whether or how the law in this area should change. As I have made clear, that is a matter for the Committee and for Parliament as a whole. However, I hope that these observations are helpful to members of the Committee in considering the Bill and the amendments tabled to it.

[Kim Leadbeater]

On amendment 413, from the right hon. Member from Plaid Cymru—with apologies, I will not embarrass myself by trying to pronounce the wonderful name of her constituency—I am very sensitive to issues around devolution. We have had many conversations about it, which I am very happy to continue. The Minister has confirmed, as I understand it, the issue around the Welsh language, in that it would be covered by the Welsh language legislation, which states that individuals in Wales

“should be able to live their lives through the medium of the Welsh language if they choose to do so.”

I am very supportive of that. I am also happy to continue those conversations, where necessary, with the Minister.

I turn to amendments 414 and 415. I think several Members of the Committee have had the same message from my hon. Friend the Member for Ipswich, who was clearly struggling to get here on time. I, too, would be happy to move them in his name. They seem very sensible amendments, and I am happy to support them. Along with the GMC’s “Good medical practice”, which sets out the principles, values and standards of professional behaviour expected of doctors, it is a belt-and-braces approach to an issue that is very important, for reasons that several hon. Members have set out.

I cannot support amendments 416 and 417, however, because the timeframe that they would impose would not fit with the rest of the Bill. In reference to the two-year implementation period, that would just not be workable or possible.

--- Later in debate ---

[The Chair]

Order. I remind the hon. Member to keep to the issue that we are discussing, because if he or any other Member does not, and goes beyond the scope of what they really should be sticking to, I will take a much less lateral approach in future. I say that gently and with the best intention.

[Stephen Kinnock]

I will speak to this group of provisions as one, given that amendments 71 to 80 are consequential on new clause 4. The purpose of these provisions is to create a new statutory body—the assisted dying agency—which has the purpose of co-ordinating requests from people to be considered for assisted dying. The provisions provide for various functions and duties of the agency, including assigning a co-ordinating doctor and an independent doctor to a person seeking assistance to end their own life.

The agency would be responsible for accepting referrals, replacing registered medical practitioners with the roles of assigned co-ordinating doctor and assigned independent doctor, and receiving and recording declarations, statements and cancellations made by co-ordinating doctors, independent doctors and those receiving assistance under the Bill.

That would be a change from the current provisions in the Bill, which place a number of those duties on the individual co-ordinating doctor and independent doctor. One effect of the proposed new clause is that a new agency would have to be established by the Government. If it passed, we would have to work to assess how that might be possible in practice.

I hope my brief remarks are helpful to Committee members in considering the Bill, the amendment and the new clause.

[Kim Leadbeater]

I have nothing to add, other than to agree with the hon. Member for East Wiltshire; I do not think any of us on the Committee are keen on the implementation of the assisted dying agency.

--- Later in debate ---

[Stephen Kinnock]

This series of amendments relates to the various discussions and assessments that registered medical practitioners, co-ordinating doctors and independent doctors will have with individuals seeking assistance to end their life in accordance with the Bill. In particular, they seek to amend the requirement for recording information about those discussions. As I have done throughout, I will limit my remarks to comments on legal and practical impacts of amendments. In executing our duty to ensure that the legislation, if passed, is legally robust and workable, the Government have worked with the hon. Member for Spen Valley on amendments to the Bill, including new clause 19 in this group.

Amendment 345 would require the registered medical practitioner, following a preliminary discussion with a person, to record and document in that patient’s medical records the discussion and any information provided to the patient, and it would require them to provide a copy to the patient.

Amendment 288 adds an additional requirement on the registered medical practitioner who conducts an initial discussion with the person on the subject of an assisted death to record all efforts to dissuade a person from ending their own life in the person’s medical records, and subsequently to make those records available to the medical examiner. As drafted, it is not clear whether the wording “all efforts” is intended to include efforts made by the registered medical practitioner alone, or to include efforts made by others that could be reported to the registered medical practitioner. Further clarity would be needed to establish the practical implications of the amendment. The amendment does not require this information to be recorded at a specific time. I would also note that, operationally, medical examiners are not involved in scrutinising all deaths. Some deaths are investigated by coroners. Clause 29 will consider inquests and death certifications in relation to assisted death.

Amendment 297 requires a full written transcript to be produced for any consultations that occur as part of the first assessment undertaken by the co-ordinating doctor. That would potentially add some operability challenges and, if passed, we would want to explore those further. For example, there could be situations in which the person seeking assistance does not want there to be a written transcript. Further clarity is also required on whether the amendment intends to capture only consultations between the co-ordinating doctor and the patient, or whether it also intends to capture conversations with relevant persons other than the person seeking an assisted death.

I turn now to amendment 295. As the Bill stands, if, having carried out the first assessment, the co-ordinating doctor is satisfied that the person being assessed has met all requirements in clause 7(2), the co-ordinating doctor must:

“(a)make a statement to that effect in the form set out in Schedule 2, and sign and date it,

(b) provide the person who was assessed with a copy of the statement, and

(c) refer that person, as soon as practicable, to another registered medical practitioner who…is able and willing to carry out the second assessment”.

Amendment 295 seeks to add an additional requirement for the co-ordinating doctor to

“collate all evidence provided regarding the condition of the patient in a document to be provided to the Medical Examiner and the…Chief Medical Officer after the person has received assistance to die”

in accordance with the Bill. The aim of the amendment is to ensure that the documentation will be available when required by the medical examiner.

[Naz Shah]

The Minister referred to a patient not wanting to keep a written record. How does that fare if there is a potential issue of negligence later on? Is that not a requirement of every NHS service that we provide? For example, in the case of a kidney donation where an independent assessor was needed, the details would have to be kept. I am just a bit confused. I wonder if the Minister might comment on that.

[Stephen Kinnock]

The challenge we found with amendment 297 is that it is not entirely clear what would happen if the person were to say expressly that they did not want a written record. That eventuality is not baked into the Bill as it is currently drafted, so I think it would require a lot of thinking through—again, we are back to the law of unintended consequences—about the impact the amendment would have in certain circumstances if, for example, someone were to say expressly that they did not want a written record. That is the question: the impact of the amendment is not clear.

[Naz Shah]

If that is an issue, then it is my understanding, being new to Bill Committees, that it is not because the provision is poorly drafted, but because the outcome is not clear. Can the Government not clarify that on Report or Third Reading? I have heard nothing from the Government, even where they are supportive of amendments, about going away and looking at them. There is none of that conversation coming from the Government. Perhaps the Minister will comment on that.

[Stephen Kinnock]

As my hon. Friend knows, there will be an impact assessment on the Bill once it has cleared Committee. The Government’s impact assessment would be based on the Bill as it cleared Committee, so it would include the amendment we are discussing, if it were to pass. As things stand, I cannot tell her what the impact of the amendment would be in the event that it passed, because that has not been thought through from all the different angles, including if someone were to expressly say that they did not want a written transcript.

I turn to amendment 300, which would require a full written transcript of the second assessment as a record of the conversation. This goes further than the requirement that the Bill currently places on the independent doctor, which is to make a statement in the form in schedule 3. As with amendment 297, further clarity is required on whether the amendment is intended only to cover consultations with the patient, or whether conversations with other individuals should also be transcribed.

Amendment 302 would require the independent doctor to provide details of the way in which the second assessment was conducted alongside a written transcript of any consultation to the relevant chief medical officer and the person’s GP.

[Naz Shah]

The Minister is being very generous with his time. I want to understand the idea that someone might say that they do not want a written transcript, when everybody in our country who uses the NHS has a written medical record. Why, in this instance, are the Government of the view that we should stray from normal practice?

[Stephen Kinnock]

I think it reflects the fact that, as the Committee has agreed, we are in uncharted territory on a whole range of issues here. I think it is best to think through the implications of every amendment. If it passes, every clause of the Bill will have to be assessed for its potential impact. I have other questions about amendment 297 in my notes. Does it intend to capture only the consultations between the co-ordinating doctor and the patient, or does it intend also to capture conversations with relevant persons other than the person seeking an assisted death? That is not clear from the amendment. What I am saying is that it poses more questions than it answers.

[Kim Leadbeater]

I might be wrong, but my understanding is that a patient could ask for access to their medical records at any point. On the basis that new clause 19 requires the doctor to record a preliminary discussion, presumably, if a patient wanted to see that record, they would be able to.

[Stephen Kinnock]

I agree with my hon. Friend on that point. As I stated at the start of my comments, officials have worked with her on new clause 19, which I think goes a long way to clearing up many of the points that have been raised, including hers.

[Juliet Campbell (Broxtowe) (Lab)]

rose—

[The Chair]

Order. The Minister is in the middle of responding to a particular question. Will Members wait until he has done so before standing up to ask a question on a question, please?

[Stephen Kinnock]

Thank you, Mr Dowd. I have answered the question from my hon. Friend the Member for Spen Valley and am happy to take another intervention.

[Juliet Campbell]

Throughout the debate, we have spoken consistently about things that happen normally within medical practice, but the amendment we are discussing would move us away from ordinary practice. Could the Minister explain why we would do that?

[Stephen Kinnock]

As I have set out, officials have looked at amendment 297 and raised a couple of flags or questions about it. One is what we have discussed about the transcript. The other is that it is not clear whether other people should be included in the consultation. I do not think it is so much about departing from common practice as about the questions that the amendment raises. As always, the Government are neutral. The Government trust that if the Committee, in its wisdom, sees fit to pass the amendment, it will be workable, but as things stand it raises a number of questions. That is all I am flagging.

[Naz Shah]

The Minister is being generous with his time. I am even more confused now. Originally, the Minister suggested that a patient might not want a transcript, but in response to the question from my hon. Friend the Member for Spen Valley, he mentioned that under new clause 19 people will have access to their written records. That appears to be a contradiction. I just want to nail this down. What will it be? If a patient does not want a written record, we would not have a written record to access, so that contradicts the Minister’s response. I want to understand exactly what the Minister is suggesting.

[Stephen Kinnock]

The Government have worked with my hon. Friend the Member for Spen Valley on new clause 19. The Government’s view is that if the Committee accepts it, then that new clause will provide the level of robustness and resilience that the system requires. The Government are not convinced that, on its own, the amendment that my hon. Friend the Member for Bradford West is talking about would provide the level of robustness and resilience we would be looking for. As things stand, the choice has been made to work with my hon. Friend the Member for Spen Valley on new clause 19, and we are satisfied that that would provide us with the operational integrity we need.

Amendment 302 would require the independent doctor to provide details of the way in which the second assessment was conducted, alongside a written transcript of any consultation to the relevant chief medical officer and the person’s GP. The independent doctor would be required to maintain a copy of that record to provide to the relevant medical examiner.

As I have mentioned, in executing our duty to ensure that the Bill, if passed, is legally robust and workable, the Government have worked with my hon. Friend the Member for Spen Valley on new clause 19. The new clause would require a practitioner to include a record of a preliminary discussion having taken place under clause 4. The record of the preliminary discussion must be included in the person’s medical records. Where the medical practitioner is a member of the person’s GP practice, they must make such a record in the person’s medical records as soon as practicable. Where the medical practitioner is not a member of the person’s GP practice, they must, as soon as practicable, provide a written record of the preliminary discussion to a medical practitioner at the person’s GP practice, who will then be required by the new clause to include it in the person’s medical records as soon as practicable.

The Committee may wish to note that amendment 424 would add a definition of “preliminary discussion” to the Bill that would make it clear what discussion medical practitioners would be required by law to record.

That concludes my remarks on this group. I thank the Committee for its attention.

[Kim Leadbeater]

I rise to speak briefly to my new clause 19, which refers to the recording of the preliminary discussion. It would require the practitioner to include in the medical records of the person in question a record of a preliminary discussion under clause 4. The initial discussion with the patient is very important and, as such, should be recorded in their records. I hope that colleagues agree and will support the new clause.

--- Later in debate ---

[Stephen Kinnock]

Amendment 412 would remove the duty in clause 4(5) on a registered medical practitioner who is unwilling or unable to conduct the preliminary discussion to, upon request, refer the person to another practitioner whom the first practitioner believes is willing and able to conduct that discussion. Guidance for medical professionals requires that, where a practitioner objects to performing a procedure, they must refer the patient to a practitioner who can meet their needs.

Amendment 341 removes the duty on a registered medical practitioner who is unwilling or unable to conduct the preliminary discussion to, upon request, refer the person to another registered medical practitioner whom they believe is willing and able to conduct that discussion. The amendment requires the registered medical practitioner who is unwilling or unable to conduct the preliminary discussion with the person to instead ensure that the person is directed to where they can obtain information and have the preliminary discussion.

New clause 13 would introduce a requirement for the Secretary of State to create, via regulations, an independent information and referral service for individuals who are, or may be, eligible under the Bill for assisted dying services. The accompanying amendment 338 would require a registered medical practitioner who is unwilling or unable to conduct the preliminary discussion to direct the person, upon that person’s request, to another registered medical practitioner or to the information and referral service, as set out in the new clause. The effect of this amendment is to remove the obligation in clause 4(5) for the registered medical practitioner to refer the person to another registered medical practitioner whom the first practitioner believes is willing and able to conduct the initial discussion. This amendment would make it more likely for a person seeking assistance to be referred to someone who is unwilling or unable to help. In addition, these amendments could carry an operational impact, as the new service would need to be designed and brought into existence.

Amendment 287 would mean that, if the first practitioner is unable or unwilling to conduct the preliminary discussion, they must, upon request, refer the person to a registered medical practitioner who is qualified to undertake the preliminary discussion. They must also set out palliative medicine options to provide the patient with appropriate end-of-life care, including referring the person to a palliative medicine expert. This amendment removes the duty in clause 4(5) to refer to a practitioner whom the first practitioner believes is willing and able to conduct the preliminary discussion.

As with previous amendments, this language could make it more likely for a person seeking assistance to be referred to someone who is unwilling or unable to help. It is not clear what

“qualified to undertake such a preliminary discussion”

is intended to mean. In addition, the term “palliative care expert” is not a defined term. Palliative medicine is a designated speciality of the General Medical Council and a doctor can apply to be entered on to the GMC specialist register for this speciality, provided they have the specialist medical qualification, training or experience. I hope these observations are helpful, and I thank the Committee for its attention.

[Kim Leadbeater]

I rise to speak to amendments 341, 338 and 412 together, and I welcome the debate on these important amendments. Choice is one of the key tenets of the Bill, primarily—but not exclusively—for terminally ill adults with a limited time to live. Choice is also very important for medical practitioners, and I am very respectful of, and acknowledge the importance of, conscientious objection for doctors. When it comes to assisted dying, I believe that they should also have choice. Indeed, the Bill is written so that they can choose not to participate in the process for any reason. That is the BMA’s view, and I agree with it.

The BMA has a position of neutrality on assisted dying, and there are a range of views within medical professions, as there are within all groups of people. That is why I have adopted its position of an opt-in model for the purposes of the Bill. Nevertheless, the process must remain patient focused at all times, and that means enabling them to have a discussion on such an important matter. It would not be right to rely on online advice or even the best-designed written materials. As we have already established, doctors are used to having sensitive and compassionate discussions with people who are terminally ill, and there can be no substitute for that. While a doctor may not wish to participate themselves, and I fully respect that, they still have a responsibility towards their patients, and that should include ensuring that they can speak to a properly qualified medical practitioner at such a difficult time.

I understand that the BMA and others would not be comfortable with the word “refer”, which I understand to have a special meaning within medical practice. The GMC guidelines use different language. They talk about where a doctor has a conscientious objection, in which case they are advised that they must make sure that arrangements are made for another suitably qualified colleague to take over their role. The BMA’s guidance says that patients must be able to see another doctor, as appropriate, and that it need not always be a formal procedure. It is not, however, sufficient to simply tell the patient to seek a view elsewhere—I agree completely.

The BMA supports amendment 341, which says that a doctor

“must ensure that the person is directed to where they can obtain information and have the preliminary discussion.”

I am therefore happy to support the amendment today and, if it were to need further adjustment, I am very happy to consider alternatives based on existing best practice. I would be very happy to meet with the hon. Member for Sleaford and North Hykeham, who is herself a doctor, to discuss her thoughts and draw on her considerable medical experience.

--- Later in debate ---

[Stephen Kinnock]

As amendments 125 and 126 are consequential on new clause 7, I shall speak to them as a whole and not in turn. The purpose of the amendments appears to be twofold. First, they seek to restrict the role of medical practitioners who can hold an initial discussion to those who have completed training. That training would be specified by the Secretary of State in regulations and would make them eligible to be listed on the register of assisted dying medical practitioners.

Secondly, the amendments seek to apply the same principle to the co-ordinating or independent doctor. In addition, they would place a duty on the Secretary of State to make regulations that would create the register to sit outside or alongside the current system of registration of medical practitioners and set out the training requirements to be eligible to be listed on the register.

Both sets of regulations are to be subject to the affirmative procedure, and the Secretary of State must consult such persons as they consider appropriate before making them. The regulations making provision for the relevant training requirements must be laid within six months of the passing of this Act. The regulations establishing the register must be laid within 12 months of the passing of the Act.

Although the purpose of the amendments is clear, our assessment suggests that the drafting would not achieve the desired effect, because the register would include only those doctors who have not undertaken the specified training or who have opted out of the assisted dying service. Additionally, the suggested timeframe for laying regulations is unworkable, given the need to work with regulators and the proposed duty to consult. There are also significant operability concerns regarding the creation of a new register for a subset of registered medical practitioners.

I hope that the Committee has found those observations helpful. I thank Members for their attention.

[Kim Leadbeater]

I have nothing to add.

--- Later in debate ---

[Lewis Atkinson]

I accept that that is a risk factor, but it is by no means determinative. Therefore, that risk factor has to be considered in the round with other risk factors such as levels of family and social support. As set out, the amendment does not distinguish between someone receiving a terminal diagnosis by themselves without any support network, and someone who expects to receive a terminal diagnosis at the end of a very long illness. As a point of principle I do not accept that we should mandate psychosocial interventions or that people must receive a level of healthcare in order for them to access other options related to their care—let alone the practicalities, which I have laid out, about when the provision would apply in relation to diagnosis and the fact that it is an intervention, which is in no way an assessment or any such thing.

[Stephen Kinnock]

I have made it clear throughout the debate that I am not offering a Government view on the merits of amendments. My remarks are focused much more on the legal and practical impacts of amendments, to assist Members in undertaking line-by-line scrutiny.

The amendments were tabled by the right hon. Member for South West Wiltshire. They would create a further eligibility requirement of the person seeking assistance under the Bill. Amendment 271 and 272 would limit those eligible to seek assistance to end their own life, in circumstances where their terminal diagnosis was received less than six months prior to the date on which the person signs the first declaration, to those who have received a psychosocial intervention. This would be subject to any exceptions provided for by the Secretary of State in regulations. Amendment 271 does not define what is meant by “received a psychosocial intervention” in relation to their diagnosis.

The term “intervention” is usually employed in the health service to mean the provision of support or treatment. This is different from, for example, an assessment that a clinician might undertake to assess whether an intervention may be required. While there is not a standard definition of psychosocial intervention, we understand it to mean psychosocial interventions such as cognitive behavioural therapy. The amendment could create uncertainty as to what type of treatment a person will need to undergo to satisfy the requirement. If a person who would otherwise seek assistance to end their own life under the Bill is unable to, or does not wish to, receive a psychosocial intervention, unless an exemption applies, they may need to delay starting the assisted dying process until at least six months has elapsed from their terminal diagnosis. That could be challenging in circumstances where the terminal diagnosis has a prognosis of six months or less.

The amendment would also introduce a requirement for people in certain contexts to undergo an intervention that could undermine a person’s autonomy in making their own treatment decisions. Were the amendment made, it would confer a regulation-making power on the Secretary of State to create exceptions to the proposed provisions on psychosocial intervention. Regulations made using this power would be subject to the affirmative procedure. It would also give the Secretary of State the power to issue a code of practice in connection with the form of the psychosocial intervention required.

If the Committee decides to accept the amendment, further consideration would be needed on Report to ensure that it is operationally deliverable, and my earlier comments about the definition of psychosocial intervention and other comments would have to be clarified. The Government would, of course, stand ready to assist were the amendment to pass.

As I said earlier, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed—as I have made clear, that is a matter for this Committee and for Parliament as a whole. However, I hope that these observations have been helpful, and thank the Committee for its attention.

[Kim Leadbeater]

I have nothing to add, other than to associate myself with the comments of my hon. Friend the Member for Sunderland Central and those of the Minister.

Question put, That the amendment be made.

--- Later in debate ---

[Dr Shastri-Hurst]

That would satisfy me. The reason I say that is because at the moment the wording is too broad and ill-defined. The question is: is this about the closeness and proximity of a relationship? The suggested wording that my hon. Friend just put forward would be much closer to that and much clearer, and more akin with the language of medical registration. When someone turns up in A&E, they are asked to give the name of their next of kin. That defines the closeness, the proximity and the permanency of that relationship.

If my hon. Friend was perhaps to consider withdrawing this amendment and tabling it again in an alternative form, or rewording it, that would certainly be something that I would be open to supporting. I have outlined why, as the amendments currently stand, I cannot support them.

[Stephen Kinnock]

Although it is for Parliament to decide whether to progress the Bill, this Government remain committed to ensuring the legal robustness and workability of all legislation. For that reason, the Government have worked closely with my hon. Friend the Member for Spen Valley, and some amendments have been mutually agreed upon by her and the Government: in this group, those are amendments 184, 418, 420, 195, 209, 220, 421, 203, 204, 207, 208 and 214.

This group of amendments replaces the forms set out in the schedules to the Bill, with the requirement for the forms to be set out in regulations by the Secretary of State. The amendments also make provision about the content and form of the first and second declarations, statements and reports.

Amendment 184 provides that the form of the first declaration must be set out in regulations made by the Secretary of State, as opposed to in schedule 1 as currently drafted. Operationally, using regulations will allow for consultation in relation to the form and content of the declaration. It will also provide flexibility to tailor or update the content of the declaration.

The effect of amendment 289 would be to limit those able to act as a second witness to a first declaration to registered clinicians, though that term is not defined in the amendment. In normal usage, “registered clinician” is broader than “registered medical practitioner”, so practically the amendment may lead to a wide range of registered healthcare professionals being able to act as a witness to a first declaration under the Bill.

--- Later in debate ---

[Kit Malthouse]

Just to be clear, a number of the amendments the Minister mentioned are in my name; I have now withdrawn them, albeit they would not have been voted on until later stages. I have withdrawn them in favour of the amendments tabled by the hon. Member for Spen Valley, which broadly do the same thing.

[Stephen Kinnock]

I thank the right hon. Gentleman for that clarification, because I had heard he was withdrawing but I thought perhaps he meant he would not push him amendments to a vote.

[Kit Malthouse]

No, no. I formally withdrew those amendments earlier today.

[The Chair]

Order. As far as I am aware, they are still on the amendment paper, but let us not get too technical at this particular stage.

[Stephen Kinnock]

I will therefore speak to amendment 208, which provides

“that the form of a statement by the coordinating doctor following the making of the second declaration is to be set out in regulations”

as opposed to the current position, where it is set out in schedule 5 of the Bill. This would have the effect of providing flexibility to update the content of the form of the statement if required later.

Amendment 214 provides

“that the form of a final statement is to be set out in regulations”

as opposed to in schedule 6, on the face of the Bill. This would have the effect of providing flexibility to update the content of the form if required later.

Amendment 404 would mean that, following court approval, the person seeking assistance must confirm, in a second declaration on the form set out in schedule 4, whether or not they have informed their family of their wish to be provided with assistance to end their own life. From a practical perspective, the amendment does not specify how a family would be defined. This may create uncertainty as to who the person would need to inform or how to determine that they have no family. It requires the form of the first declaration, set out in schedule 1, to capture whether a person seeking assistance to end their life has: informed their family of their wish to be provided with assistance to end their life and taken their family’s opinion into consideration; or decided not to inform their family of their decision; or has no family to inform of their decision. It is not clear how the term “family” would be defined. It is also worth noting that the amendment would conflict with amendment 184, which removes schedule 1 to the Bill. I hope those observations have been helpful to the Committee, and I thank Members for their attention.

Amendment 184 agreed to.

Amendment made: 418, in clause 5, page 3, line 12, at end insert—

“(2A) Regulations under subsection (2)(a) must provide that the first declaration contains—

(a) the following information—

(i) the person’s full name and address;

(ii) the person’s NHS number;

(iii) contact details for the person’s GP practice;

(b) the following further declarations by the person—

(i) a declaration that they meet the initial conditions for eligibility (see subsection (2B));

(ii) a declaration that they have had a preliminary discussion with a registered medical practitioner, that they were aged 18 or over when they had that discussion, and that they understand the information referred to in section 4(4)(a) to (c) that was provided during that discussion;

(iii) a declaration that they are content to be assessed, for the purposes of this Act, by medical practitioners;

(iv) a declaration that they are making the first declaration voluntarily and have not been coerced or pressured by any other person into making it;

(v) a declaration that they understand that they may cancel the first declaration at any time.

(2B) In subsection (2A)(b)(i) ‘the initial conditions for eligibility’ are that the person making the declaration—

(a) is aged 18 or over,

(b) is ordinarily resident in England and Wales and has been so resident for at least 12 months, and

(c) is registered with a general medical practice in England or Wales.” —(Kim Leadbeater.)

This amendment makes provision about the content of regulations under subsection (2)(a), which will set out the form of the first declaration.

Amendment proposed: 277, in clause 5, page 3, line 12, at end insert—

“(2A) A person may not make a first declaration under subsection (1) until 28 days have elapsed, beginning with the day they received a diagnosis of the terminal illness.”—(Naz Shah.)

This amendment would mean a person could not make the first declaration until 28 days from the day they received a diagnosis of the terminal illness.

Question put, That the amendment be made.

Terminally Ill Adults (End of Life) Bill (Sixteenth sitting)

Stephen Kinnock Excerpts

Committee stage
Tuesday 4th March 2025 Public Bill Committees

[The Chair]

I remind the Committee that with this we are discussing the following:

Amendment 8, in clause 4, page 2, line 16, leave out from “practitioner” to end of line 20 and insert

“shall raise the subject of the provision of assistance in accordance with this Act with a person who has not indicated to that or another registered medical practitioner that they wish to seek assistance to end their own life”.

Amendment 124, in clause 4, page 2, line 16, leave out from “practitioner” to end of line 20 and insert

“shall discuss assisted dying with a person unless that matter is first raised by that person.”

The amendment prevents a registered medical practitioner from discussing the provision of assistance under the Act unless that matter is first raised by that person.

Amendment 319, in clause 4, page 2, line 20, after “person” insert

“who has attained the age of 18”.

Amendment 339, in clause 4, page 2, line 20, after “person,” insert

“, unless that person has a learning disability or is autistic, in which case—

(a) the person must be provided with accessible information and given sufficient time to consider it; and

(b) at least one of a—

(i) supporter, or

(ii) independent advocate;

must be present for the discussion.”

This amendment would require that, if the person is autistic or has a learning disability, they must be given accessible information and sufficient time to consider it. Additionally there must be at least either a supporter or independent advocate.

Amendment 368, in clause 4, page 2, line 20, after “person” insert

“, unless that person has Down syndrome, in which case the registered medical practitioner must be acting in accordance with any statutory guidance issued by the Secretary of State under the Down Syndrome Act 2022 to meet the needs of adults with Down syndrome.”

Amendment 320, in clause 4, page 2, line 21, after “person” insert

“who has attained the age of 18”.

Amendment 270, in clause 4, page 2, line 25, at end insert—

“(3A) Before conducting a preliminary discussion under subsection (2) the registered medical practitioner must ensure that the person has no remediable suicide risk factors which pose a significant risk to their life.”

This amendment requires that the doctor ensures that there are no remediable suicide risk factors before proceeding to the initial discussion about assisted dying.

Amendment 276, in clause 4, page 2, line 31, at end insert—

“(4A) A medical practitioner must not conduct a preliminary discussion with a person under subsection (3) until a period of 28 days has elapsed, beginning with the day the person had received a diagnosis of the terminal illness.”

This amendment would mean a doctor could not conduct a preliminary assessment until 28 days from the day the person received a diagnosis of the terminal illness.

New clause 6—Advance decision of no effect—

“An advance decision, made pursuant to sections 24 to 26 of the Mental Capacity Act 2005, which stipulates that the maker of the decision, having become incapacitated, wishes to be provided with assistance to end their own life in accordance with this Act, shall be null and void and of no legal effect.”

The new clause prohibits an individual from making an advanced directive for voluntary assisted death in the eventuality he or she were to become incapacitated at a future date.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Efford.

As I have stated previously, my remarks on behalf of the Government on these amendments will provide a factual explanation. I shall not offer a position on how the Committee should vote, as that remains a matter of conscience. The overarching theme of the amendments relates to the requirement on how and when a medical practitioner may raise the matter of assisted dying.

Clause 4(2), as drafted, provides that nothing prevents a medical practitioner from using their professional judgment to decide when to raise the subject of assisted dying. Amendment 278 seeks to prevent a doctor from raising the subject of assisted dying if the person has a recorded advance decision in their medical records that states that in future they will not want assisted dying.

The Mental Capacity Act 2005 enables a person with capacity to make an advance decision to refuse a specified form of treatment in future, should they lack capacity. A person who has lost capacity under the Mental Capacity Act would not be eligible for assisted dying under the Bill. Where such an advance decision is in place, the effect of the amendment would be to prevent the doctor from raising the subject of assisted dying, unless the person indicates to the doctor that they wish to change their previous decision, that they wish to seek assistance under the legislation and that they have the capacity to do so.

Technically, amendment 278 appears unnecessary, because advance decisions under the Mental Capacity Act are not relevant to assisted dying. That is because advance decisions are about refusing treatment at a time when a person no longer has capacity, and assisted death would be available only to those who have capacity.

As drafted, clause 4(1) states:

“No registered medical practitioner is under any duty to raise the subject of the provision of assistance in accordance with this Act with a person”.

but clause 4(2) specifies that they may do so if, in exercising their professional judgment, they consider it appropriate. Amendment 8 would prevent a registered medical practitioner from raising with a person the subject of provision of assistance under the Bill, unless the person has indicated to that practitioner or to another registered medical practitioner that they wish to seek assistance to end their own life. The effect would be that any conversation on assisted dying will need to be patient-initiated, and not at the discretion of the medical professional within a wider conversation about end-of-life care.

The effect of amendment 124, as with amendment 8, would be to prevent a registered medical practitioner from raising with a person the subject of provision of assistance under the Bill. That would mean that the person will need to indicate to a registered medical practitioner that they wish to seek assistance to end their own life before an initial discussion can take place. The effect would be that assisted dying can be discussed only if the patient has initiated the conversation.

The Government’s assessment of amendment 319 is that, as drafted, it would not prevent the subject of an assisted death from being discussed with a person who is under 18. There is already a requirement that, to be eligible for the provision of assistance under the Bill, a person must be aged 18 or over at the time that they make their first declaration under clause 1(1)(b).

Amendment 319 would impose additional requirements on the approach that a medical practitioner must make if raising the subject of assisted dying with a person who has a learning disability or is autistic. It would require the person to be provided with accessible information and given sufficient time to consider it. It would further require that they must have a supporter and/or independent advocate present for the initial discussion. The amendment would require that a person with autism or a learning disability must have a supporter or independent advocate present for the discussion, even when they have capacity or are high-functioning. Autism is a spectrum disorder, meaning that autistic people have diverse and varying needs, so the effect of the amendment would vary among individuals.

It is already the case that all registered medical practitioners, in meeting their professional standards, are expected to communicate information clearly and effectively. That includes allowing sufficient time for the individual to consider and process the information provided. For example, the General Medical Council’s “Good medical practice” states that all GMC-registered clinicians

“must take steps to meet patients’ language and communication needs”

to support them to

“engage in meaningful dialogue and make informed decisions about their care.”

Amendment 368 would require registered medical practitioners, when deciding if and when it is appropriate to discuss assisted dying with a person with Down’s syndrome, to act in accordance with the Down Syndrome Act 2022. The Act requires the Secretary of State to issue guidance to relevant authorities on what they should be doing to meet the needs of people with Down’s syndrome. Although this work is being taken forward as a priority by the Department, no statutory guidance has yet been published under the Act.

The relevant authorities in scope of the Act are institutions such as NHS trusts. The Act does not provide for guidance to be prepared for individual doctors. The relevant authorities must have due regard to the statutory guidance, which enables them a degree of discretion in following it, but the amendment would require medical practitioners to act in accordance with the guidance. It might therefore create uncertainty as to how a doctor can comply with their obligations under the Bill.

[Danny Kruger (East Wiltshire) (Con)]

I hear what the Minister says—the guidance does not exist and there is concern that the amendment may therefore induce some confusion—but would the answer not be to put a commitment into the Bill that the Secretary of State will issue guidance on how the 2022 Act could be applied in the context of the Bill?

In the light of our conversation at the Committee’s last sitting, I put on the record my intention to press the amendment if the Minister cannot give a commitment now to introduce an amendment later that the Secretary of State will introduce statutory guidance to ensure that proper care is taken of people with Down’s syndrome in accordance with amendment 368.

[Stephen Kinnock]

The challenge is the dissonance in how the guidance under the Down Syndrome Act, which is currently very close to publication, is directed towards authorities such as trusts, but there is no coverage around individual doctors. At this stage, without seeing a clear distinction between the two or how it would work for individual doctors, the Department’s concern is that it could create confusion as to the obligations on individual medical practitioners under the 2022 Act. I am obviously open to conversations about how to clear that up, but the lacuna between the authorities and the individual doctors is the problem being flagged by the Department.

[Kim Leadbeater (Spen Valley) (Lab)]

I take the Minister’s comments on board. Will he agree to a conversation with me and with the right hon. Member for East Hampshire (Damian Hinds), who tabled amendment 368, to take the discussion forward?

[Stephen Kinnock]

I am happy to have conversations with the hon. Lady and other hon. Members, but as things stand it is not clear to the Department or to me how the proposal would work in practice.

[Kit Malthouse (North West Hampshire) (Con)]

I apologise for having arrived ever so slightly late, Mr Efford. In the Minister’s view, is it conceivable that he or any future Minister—or, indeed, the current or any future chief medical officer—would not consult with groups representing those with Down’s syndrome in drawing up the various guidelines on the Bill?

[Stephen Kinnock]

Extensive consultations have taken place with all the key groups and advocacy organisations on Down’s syndrome in the drafting of the guidance. The guidance is very close to publication; once it is published, it will form the basis of a further consultation. It is an iterative process.

[Kit Malthouse]

Perhaps I was not clear. I meant the guidance on this Bill. Although the Minister may not necessarily be able to say what will be in it, is it conceivable that the CMO, in drawing up guidance as a requirement under the Bill, would not consult Down’s syndrome groups? My point is that, given what has been expressed and the desire of the Committee, I cannot see that a CMO would not talk to Down’s syndrome groups in any event.

[Stephen Kinnock]

I thank the right hon. Gentleman for that clarification and apologise for my misunderstanding; I thought he was referring to the guidance that we are currently working on under the terms of the 2022 Act. Yes, absolutely: the Bill currently specifies a two-year commencement period, within which a whole range of operationalisation work will need to be done. All of that will need to be consulted on; we will not do it all in an ivory tower from Whitehall or Westminster.

[Danny Kruger]

It is welcome that a commitment has been made to meet my right hon. Friend the Member for East Hampshire, who tabled the amendment, but a commitment to consult is not the same thing as specific protections in the Bill for people with Down’s syndrome. What we really need is a commitment in the Bill that there will be statutory guidance. There will be opportunities for that later, so we may not need to press the amendment to a vote, but if we cannot have a commitment, we must press it.

[Stephen Kinnock]

It is absolutely the hon. Member’s prerogative to press the amendment to a vote if he so wishes. As things stand, because of the baseline, which is the GMC guidance that I have just read out, we constantly go back to the Government’s position that the current corpus of guidance, regulations, advice, training, expertise and professional judgment is, in essence, satisfactory to the Department. We believe in and rely on the professional judgment of the experts in the field. That remains our fundamental position.

The effect of amendment 320 would be that the safeguards in clause 4(4) in respect of the preliminary discussion apply only where the person seeking assistance is aged 18 or over. The amendment would not prevent a discussion with a person under 18. As the Committee will be aware, there is already a requirement that, to be eligible for the provision of assistance under the Bill, a person must be 18 or over when they make their first declaration under clause 1(1)(b).

Amendment 270 would make it a requirement for a registered medical practitioner to ensure that there are no remediable suicide risk factors before proceeding to the initial discussion about assisted dying. The amendment does not state what is to happen if the practitioner considers that there are remediable suicide risk factors. As the Committee will be aware, we rely on medical practitioners to make judgments in relation to their patients that draw on their training, experience and expertise. We would expect the judgment and skill of a medical professional to be brought to bear where there are remediable suicide risk factors.

Amendment 276 would mean that a person is unable to have a preliminary discussion or make a first declaration to be provided with assistance to end their own life until 28 days after receiving a terminal diagnosis. The amendment would add an additional pause into the process for a person who has received a terminal diagnosis in the preceding 28 days. The 28-day pause would apply regardless of the patient’s prognosis, even if they had only one month left to live, for example.

New clause 6 would ensure that an advance decision to refuse treatment under the Mental Capacity Act 2005 cannot be used to seek assisted dying. Our analysis suggests that the new clause is not necessary, because an assisted death is available only to those with capacity, whereas advance decisions provide for a person to be able to refuse treatment at a future time when they have lost capacity. If a person still has capacity, they may be eligible for an assisted death. If they do not have capacity, they will not be eligible, irrespective of whether they have made an advance decision.

That concludes my remarks on this group of amendments. As I say, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could change. However, I hope my comments and observations are helpful to Committee members in considering the Bill.

[Rebecca Paul (Reigate) (Con)]

I appreciate the opportunity to speak briefly, Mr Efford. Many other speakers have already made excellent points in support of the amendments, so I will not repeat them, but I would like to put on record one pertinent point.

During these proceedings, there has been a tendency by some to speak as though assisted dying were another type of treatment or healthcare option being offered by medical practitioners, rather than a completely different and separate offering. I have grave concerns about that. The legal norm, and GMC guidance, is that patients should be offered all reasonable medical treatments. A medical treatment can be defined as something that combats disease or disorder. It is fundamentally about healing, relief of symptoms, recovery and cure. Straightaway, we have a conflict. Assisted dying ends the life of a person. It is not a treatment in the normal sense—

--- Later in debate ---

[Dr Tidball]

I will make progress.

In reply to a question from me about those who are seeking assistance, Dr Jane Neerkin, a consultant physician in palliative medicine, said:

“For them, it is about trying to regain some of that control and autonomy and being able to voice for themselves what they want. That is what I tend to see that people want back at the end of life.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 201, Q263.]

Importantly, amendments 183 and 275 would strengthen clause 4 to ensure that we avoid a situation that gives those with the most social capital more choice, while leaving those who might otherwise be unaware of all other options available to them without that choice. If the Bill is passed by Parliament without them, it will exacerbate health inequalities rather than abating them.

Together, the amendments expound and elaborate on the need for discussion of all appropriate palliative and other end-of-life options available to someone with a six-month terminal illness. I commend them to the Committee.

[Stephen Kinnock]

The amendments would make changes to the discussion between the medical practitioner and the patient. They are largely focused on clause 4, on the initial discussions, but several are thematically linked or related to later clauses.

Amendment 342 would impose a requirement on the registered medical practitioner to conduct a preliminary discussion with a person where that person has indicated that they wish to seek assistance to end their own life. As it stands, the Bill allows registered medical practitioners to opt out should they not wish to hold that conversation with someone, although they have an obligation under clause 4(5) to refer an individual to another medical practitioner for that discussion.

The amendment would remove that discretion and thus remove the opportunity for a medical professional to opt out of having the preliminary discussion. That may conflict with the principle set out in clause 23 that no registered medical practitioner or other healthcare professional is under any duty to participate in the provision of assistance. Our analysis suggests that in removing discretion as to participation, the amendment could interfere with an individual’s rights under article 9 of the European convention on human rights, on the freedom of thought, belief and religion, and article 14, on the prohibition of discrimination.

Amendment 285 would require the registered medical practitioner who conducts a preliminary discussion with a person on the subject of an assisted death to discuss with them, in consultation with a specialist, the person’s diagnosis and prognosis, any treatments available and their likely effects, and any available palliative, hospice or other care. The amendment would therefore require additional registered medical practitioners or other specialists to be consulted as part of the preliminary discussion under clause 4(4). The additional time required for consultation with specialists would be likely to lengthen the period over which a preliminary discussion can take place.

I also note that clause 9, “Doctors’ assessments: further provision”, will already require the assessing doctor to make such other inquiries as they consider appropriate in relation to the first and second assessments.

[Naz Shah]

The Minister’s point speaks to what my hon. Friend the Member for Stroud and I have spoken about in relation to the amendment, so I wonder which bit he supports. The Minister says that there will be extra time, but my hon. Friend pointed out that doctors do this routinely, so the objection is only that it will be on the face of the Bill. I just want to understand the Minister’s position on that.

[Stephen Kinnock]

If I understood the point that my hon. Friend the Member for Stroud was making, I think it was that the basic provisions in place enable doctors to carry out their work based on their experience and expertise, whereas the amendment would require additional registered medical practitioners or other specialists, so that would be in addition to what my hon. Friend was talking about.

I turn to amendment 343. As the Bill stands, a registered medical practitioner undertaking a preliminary discussion with a patient is required to discuss the person’s diagnosis and prognosis. The amendment would require a registered medical practitioner also to discuss any relevant probabilities and uncertainties of a person’s diagnosis and prognosis. It would put an additional legal requirement on what needs to be discussed during the preliminary discussion with the patient. In considering whether the amendment is required, the Committee may wish to note that all doctors acting in accordance with the General Medical Council’s “Good medical practice” are expected to discuss uncertainties about diagnosis and prognosis, and potential risks and uncertainties about treatment.

Under clause 4, the registered medical practitioner conducting the preliminary discussion must discuss any treatment available to the patient and the likely effect. Amendment 344 would require the registered medical practitioner conducting the initial discussion to discuss, as part of the conversation on the treatments available, the risks and benefits of such treatment, potential side effects and the impact of the treatment on the person’s quality and length of life. As with amendment 343, the Committee may wish to note, when considering whether the amendment is required, that all doctors acting in accordance with “Good medical practice” are expected to discuss the risks, benefits, uncertainties and the likelihood of success of treatment with a patient.

Amendment 275 would change the wording of clause 4(4)(c) to “all appropriate palliative hospice and other care”. That would require a registered medical practitioner who conducts a preliminary discussion with a person on the provision of an assisted death to explain and discuss palliative and hospice care on the basis of appropriateness for the individual, not on the basis of the care that is available. Clause 4(4) sets out that a registered medical practitioner who conducts the preliminary discussion on assisted dying must, as part of that discussion, explain and discuss the person’s diagnosis and prognosis, any treatment available and the likely effect—

[The Chair]

Order.

Early Support Hubs

Stephen Kinnock Excerpts

Tuesday 4th March 2025 Written Statements

[The Minister for Care (Stephen Kinnock)]

The Minister for Patient Safety, Women’s Health and Mental Health, my noble Friend Baroness Merron, has made the following written statement:

Nothing says more about the state of a nation than the wellbeing of its children. That is why the Government made a clear commitment in our manifesto to improve the mental health of young people through specialist support and earlier intervention. We continue to make progress on delivering these manifesto commitments, such as access to specialist mental health professionals in every school, as part of our drive to reform the NHS through our 10-year health plan and create opportunities for young people through mission-led Government.

Today, I wish to inform the House that the Government are providing continued top-up funding in 2025-26 for 24 early support hubs in England and running an evaluation of the support that they deliver, backed by £7 million.

Building on a shared outcomes fund project being delivered in 2024-25, this means that over 12,000 children and young people will continue to have access to innovative early mental health and wellbeing support at an early stage.

In our manifesto, we committed to providing open access mental health support for children and young people through Young Futures hubs. Working with the Home Office, the Department for Education and colleagues across Government, our hope is that the evidence and insights collected through the early support hubs evaluation will support the delivery of Young Futures hubs, alongside best practice and learning from other initiatives. This learning will inform our ambitions for community mental health and wellbeing support for children and young people, and ensure that they have access to the kinds of support they need.

As well as providing mental health support in every community, we are also continuing work to recruit 8,500 new mental health workers to cut waiting times and ensure that people can access treatment and support earlier.

I know that we still have a long way to go to ensure that all young people are provided with access to the mental health support they need. However, today’s investment marks a step in the right direction to support children and young people’s mental health.

Terminally Ill Adults (End of Life) Bill (Thirteenth sitting)

Stephen Kinnock Excerpts

Committee stage
Tuesday 25th February 2025 Public Bill Committees

[The Chair]

I have received a manuscript amendment from the hon. Member for East Wiltshire that he wishes to move. As the hon. Gentleman knows, a manuscript amendment requires a very high bar and exceptional circumstances. I do not believe that exceptional circumstances are present, and he will be aware that further amendments can be proposed to the clause for consideration on Report. That is my decision on the matter.

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Dowd. Although it is for Parliament to progress any Bill, the Government have a responsibility to make sure that legislation on the statute book is effective and enforceable. For that reason, the Government have worked with my hon. Friend the Member for Spen Valley; where changes have been agreed mutually between her and the Government, I will offer a technical, factual explanation of the rationale for those amendments. That applies to amendment 181 in this group.

This group of amendments is linked to how the Bill’s definition of a terminal illness applies to those with a mental disorder or disability. Amendments 399 to 401 would remove the term “medical condition” from the Bill’s definition of a terminal illness, so that only those with an inevitably progressive illness or disease would be able to request to end their life, rather than, as under the current drafting, those with a “disease or medical condition”.

The amendments could narrow the scope of those who may access assisted dying services. However, clinical advice suggests that the use of the terms has changed over time, may not be used consistently and remains debated in both medical and lay circumstances. Removing the term “medical condition” may lead to disputes or protracted debates about whether a particular condition is or is not a defined disease or illness, despite there being medical consensus around whether it will lead to death within six months.

[Danny Kruger]

I am grateful for that clarification, but it rather concerns me. Can the Minister elucidate exactly which conditions might fall into the category of medical condition that would not be captured by “illness” or “disease”? Does he accept the point that I made in my speech—that the interpretation of the law by the court will be that the phrase expands the definition of a terminal illness beyond illness or disease, as it is in the current law? What are the new conditions that will be captured by the term?

[Stephen Kinnock]

What the hon. Member will have picked up throughout this debate, on every day that we have met, is that the Government are concerned about adding or taking away terminology that delivers clarity, stability and familiarity.

I have to say that I am quite torn on the hon. Member’s amendment 399, because I absolutely see where he is coming from. It is one of those situations in which my position as a Government Minister is made somewhat more complex by my personal view that his amendment is perfectly reasonable. My instinct—speaking personally as a Member of Parliament, rather than as a Government Minister—is that the remaining terms in the Bill, if we removed “medical condition”, would continue to cover the waterfront or spectrum of conditions. It is possible that this is a case in which there has been an overabundance of caution on the part of the Government. I am delivering the Government’s position, but I want the hon. Member to know that that will not necessarily determine how I vote if this amendment does go to a vote.

[Danny Kruger]

I was going to remind the Minister that he is, in his strange Jekyll and Hyde personality, speaking as a Minister but voting as a Member of Parliament, so if he has given the Government’s view that my amendment is not acceptable, but he personally thinks that it is, I hope that he will vote for it.

[Stephen Kinnock]

It is a well-made case; I am still reflecting on it, because of the somewhat complex nature of my role on this Committee, but I am inclined to support the hon. Member’s amendment.

Amendment 11 also seeks to amend clause 2(3). Our assessment of the effect of this amendment is that a person who has a mental disorder and/or a disability may not qualify under the Bill as terminally ill, even if they have an inevitably progressive illness and can be reasonably expected to die within six months. There might be concerns from the point of view of the European convention on human rights and the Equality Act if the amendment were passed as currently drafted, because its effect would be to exclude people from the provisions of the Bill if they had a disability or a mental disorder. That may not be the intention of the hon. Members who tabled the amendment.

I turn to amendment 181. In executing our duty to ensure that the legislation, if passed, is legally robust and workable, the Government have advised my hon. Friend the Member for Spen Valley in relation to the amendment. It clarifies that a person who seeks assistance to end their own life based only on a mental disorder or a disability, or both, would not be considered terminally ill for the purposes of the Bill. Such a person would therefore not be eligible to be provided with assistance to end their own life under the Bill. Someone who has a disability or a mental disorder, or both, and who also already meets all the criteria for terminal illness set out in the Bill would not be excluded by the amendment, as drafted. The amendment therefore brings important legal clarity to the Bill.

Amendment 283 sets out that a person who has one or more comorbidities, alongside a mental disorder within the meaning of the Mental Health Act 1983, would not be considered terminally ill by virtue of those comorbidities alone. The reality of modern healthcare is that many patients, not least those towards the end of life, will be dealing with several conditions or comorbidities. The term “comorbidity” in a clinical context can sometimes be used to distinguish the main problem that someone has experienced experiencing from additional but less serious problems, but it can also be used by those specialising in one or more other aspects of a patient’s care to distinguish their area of focus from other issues.

In the context of the Bill, the essential test is whether any morbidity, comorbidity or otherwise, meets the requirements in the Bill. Although it is unlikely that a terminal morbidity would be thought of as a comorbidity, it is not inconceivable that it might be, for the reasons that I have set out. The phrasing of the amendment, notably the term “alongside”, potentially increases that possibility. The effect might be that a condition that would otherwise be considered terminal would instead be considered a comorbidity alongside a mental disorder. The amendment would prevent a person with a mental disorder who would, but for the amendment, have been considered terminally ill from accessing assisted dying services under the Bill.

As I have said, the Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed. However, to ensure that the legislation works as intended, we have advised the sponsor in relation to amendment 181, to further clarify the Bill such that only having a disability and/or mental disorder does not make a person terminally ill and eligible for assistance in accordance with the Bill.

[Jack Abbott (Ipswich) (Lab/Co-op)]

Most of the discussion on amendment 181 has centred on the word “only”. Just to get clarification on this point, would someone with an eating disorder who was later diagnosed with a terminal illness still be able to access an assisted death, if that were required under the amendment?

[Stephen Kinnock]

My answer to that question is yes. My understanding is that so long as the terminally ill, six-month criteria are met, that person would qualify for assistance under the Bill.

[Jack Abbott]

Just to be absolutely clear for everyone in the room, and in case I was not specific enough, if that terminal illness is a result of the eating disorder, rather than, say, of that person also being diagnosed with a terminal illness such as cancer, would they be covered under amendment 181?

[Stephen Kinnock]

My understanding is that amendment 181 is clear that the qualification for accessing assisted dying has to be based on the definitions in the main body of the Bill. If passed by the Committee, the amendment will make it clear that an eating disorder does not qualify for access to that service. There has to be another, clear definition that does qualify under the terms set out in the main body of the Bill.

[Kit Malthouse (North West Hampshire) (Con)]

I just want to illustrate to the Committee that people with eating disorders, certainly as they come towards the end of their life, are already subject to quite assertive action by the state. For example, over the past few years, generally, where hospitals have detected that an individual is effectively trying to starve themselves to death, they have applied to the Court of Protection and got orders for forcible treatment. In that application, it is determined that that person does not have the mental capacity to make decisions about their own medical care.

I do not want the Committee to labour under the illusion that people with anorexia or other eating disorders are going to wander up and suddenly ask for an assisted death. If there has been a detection that they are trying to get themselves eligible by effectively causing organ failure by starvation, the system would have intervened well before then, effectively to force them to be treated.

[Stephen Kinnock]

The right hon. Member makes an excellent point. I think it goes back to our basic view that there are some amazing health professionals in our healthcare system who do fantastic work. Eating disorders are a truly tragic condition and, of course, there is all sorts of support in place. It is not always perfect or exactly how we would want it to be, but I think it would be a false move for the Committee to think that this is an either/or situation. This is a both/and situation. Of course it is not always perfect, but I think we should pay tribute to our amazing health professionals, who look after all sorts of people with all sorts of conditions, including eating disorders.

[Dr Marie Tidball (Penistone and Stocksbridge) (Lab)]

Does the Minister agree that the language of clause 2(1)(a)—

“cannot be reversed by treatment”—

is reassuring? Indeed, the written evidence from Professor Emily Jackson notes:

“Someone with a condition that is not inevitably progressive, or which could be reversed by treatment, would be ineligible under the Act.”

That covers the case raised by my hon. Friend the Member for Ipswich.

[Stephen Kinnock]

My hon. Friend makes an excellent point. She brings us back to the fundamental point made in the Bill, which is that it has to be “an inevitably progressive illness”. Eating disorders do not fall under that definition: that is very clear. I hope that that explanation and the observation that I have made on the other amendments are helpful to members of the Committee in their consideration.

[Kim Leadbeater]

I will keep my comments brief, because we have had a very thorough discussion today. I will first speak briefly to amendment 123, tabled by my hon. Friend the Member for Broxtowe. Amendment 123 would change “an inevitably” progressive disease to “a typically” progressive disease. [Interruption.] Is that the next grouping? Oh, I am peaking too soon—my apologies, Mr Dowd.

I will come back to my hon. Friend the Member for Broxtowe, but let me turn to amendments 399, 400 and 401, on the exclusion of “medical condition”, which the hon. Member for East Wiltshire submitted a few days ago, before the end of the recess. I looked at them over the weekend and was very interested to hear his reasoning for them today. This is the purpose of the Committee; I have listened carefully to what the hon. Gentleman has said, and he has made some valuable points. All along, I have taken the view that this legislation must not only be the strongest anywhere in the world, but be very clear in its intentions and leave no room for ambiguity regarding who is entitled to request assistance under its provisions.

I am very comfortable with the definition of terminal illness in the Bill, but across the world—I have done lots of research into this, as I know other colleagues have—some jurisdictions use the term “medical condition” or, actually, just the term “condition”, and others do not. Many in Australia do, but in New Zealand, for example, which has a similar law to what is being proposed here, “medical conditions” do not feature, nor do they in a number of states in America.

While I do not necessarily think that it would definitely be problematic to include the term “medical condition”, I appreciate the argument that the hon. Gentleman has made. We have to be as cautious as possible to ensure that the Bill achieves its purpose but does not create a lack of clarity. That point has been very well made.

The advice that I have received from officials is that, as the hon. Gentleman suggested, “medical condition” does not have a clear legal definition and could therefore be seen as imprecise. That does worry me. The purpose of the Bill is clear—it is in the title. It is to give choice to terminally ill adults at the end of life. They must have a clear, settled and informed wish, and be expected to die within six months, in circumstances that are inevitably progressive and cannot be reversed by treatment. The hon. Gentleman has, I believe, helped to make that even clearer, and I am grateful to him for doing so.

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[Lewis Atkinson]

I do, and I thank my hon. Friend for bringing my attention to that; I was struggling to put my hands on it.

In my view, clause 2 does a difficult job very well in tightly drawing eligibility criteria so that the Bill does what it says on the face of it—that it allows access for terminally ill adults, at the end of their life. By having a six-month prognosis, rather than anything else, it allows individuals to put their lives in order and have the best last months of their lives possible. I therefore speak against the amendments and in favour of the clause as drafted.

[Stephen Kinnock]

As usual, I will make brief remarks on the legal and practical impact of amendments, while emphasising that the Government continue to remain neutral on the Bill and on assisted dying more broadly. This series of amendments, which I will take in turn, seeks to change the definition of “terminally ill”, either widening or narrowing the cohort of people able to access assisted dying services.

Amendment 123 would change what it is to be “terminally ill” for the purposes of the Bill from having an “inevitably” to a “typically” progressive illness, disease or medical condition that cannot be reversed by treatment. That would widen the pool of those able to access assisted dying services by reducing the level of certainty that a doctor must have that the illness, disease or medical condition in question is progressive—from one that is “inevitably” progressive to one that is “typically” progressive.

Amendment 9 seeks to amend the definition of “terminally ill” such that it would not include a person who has an inevitably progressive illness, disease or medical condition that can be reversed, controlled or substantially slowed by treatment. The effect of the amendment is that such a person would not be eligible for lawful assistance to voluntarily end their own life. Should the amendment be accepted, the effect would be to restrict the eligibility for assisted dying services to a narrower category of patients than is currently set out in the Bill. The amendment may make assessment of a person’s prognosis and eligibility under the Bill more extensive, as it would be likely to require an assessment of a broader range of treatment options.

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[Naz Shah]

I apologise to my hon. Friend the Member for Sunderland Central; I was actually incorrect. The girls did not have capacity, so he was correct. However, in the cases that went before the court, those nine girls did not have capacity yet the judge made a decision that they should not be force-fed to keep them alive, and they should be allowed to die. Perhaps the Minister could comment on how the amendment would not meet that criteria. Would it fix that loophole?

[Stephen Kinnock]

I thank my hon. Friend for her intervention. I am just talking about the amendment to reduce the time from six months to one month. I will come on to the issue of eating and drinking in a second.

As amendment 282 would reduce the time within which the person is expected to die from six months to one month, it would also limit the number of people with a terminal illness who would be eligible for assisted dying under this legislation. Furthermore, there may be very challenging workability issues in delivering a service within one month, given the other time-dependent safeguards elsewhere in the Bill.

Amendment 51 would remove the requirement for the patient to have a six-month prognosis to be defined as “terminally ill”. If agreed to, it would expand the pool of people eligible for lawful assistance to voluntarily end their own life beyond those with a life expectancy of six months or less. In other words, it would remove the timeframe requirement of when death can be reasonably be expected.

Amendment 234 would widen eligibility to include cases of neurodegenerative diseases, illnesses or medical conditions where a person is reasonably expected to die within 12 months. Matters such as this are for the Committee, and ultimately for Parliament, to decide, but it is clear that the effect of the amendment would be to broaden the number of people eligible for lawful assistance to voluntarily end their own life under this legislation.

Amendment 10 would provide that, if treatment exists for a person’s progressive illness, disease or medical condition that alters the overall prognosis of that person’s condition, they are not terminally ill and would not be eligible for assisted dying services.

Amendment 402 would exclude a person who would not otherwise meet the definition of “terminally ill”—namely, being diagnosed with an inevitably progressive illness with six months or less to live—if that person meets that definition as a result of stopping eating or drinking. The effect of the amendment would be to prevent a person from being defined as “terminally ill” as a result of their own actions of stopping eating or drinking, or both. The Government’s analysis suggests that this may also exclude people who are terminally ill under the definitions of the Bill and who are, for various reasons, unwilling or unable to eat or drink. For example, it may include those with conditions such as oesophageal cancers, which could result in their being unable to eat or drink.

Furthermore, it is unclear whether someone who is on intravenous fluids or being fed through a feeding tube would be considered to have stopped eating or drinking under the amendment. I think that addresses the concern expressed by my hon. Friend the Member for Bradford West, but she is welcome to intervene again if she would like to. The amendment could therefore lead to uncertainty over the person’s eligibility for assistance under the Bill.

The Government have taken a neutral position on the substantive policy questions relevant to how the law in this area could be changed. Questions around the definition of terminal illness and who should be eligible to access voluntary assisted dying under the legislation are matters for the Committee and for Parliament as a whole. However, I hope that these observations are helpful to the Committee in considering the Bill and the amendments tabled by various Members.

[Kim Leadbeater]

Colleagues will be pleased to know that, despite my copious notes, I do not intend to speak for very long, because I believe we have had a very thorough and robust debate on these issues. The Minister makes a valuable point on amendment 402, which I do not think anyone else raised. Coincidentally, it relates to the person in the Public Gallery this morning, whose mum had a horrible form of cancer and had to have her tongue removed. She would have stopped eating or drinking, but it was not a choice; it was an inevitable result of her condition. She would have been excluded from having an assisted death, which I am sure is not the intention of my hon. Friend the Member for Bradford West.

We have had an excellent debate and covered a lot of ground. I do not intend to add anything more on this group of amendments. I will only say that if we get a move on, we might be able to get through clause 2 before we close at 5 o’clock.

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[Lewis Atkinson]

I rise to speak briefly in opposition to the amendments. When the chief medical officer gave oral evidence to the Committee, the hon. Member for Richmond Park asked him:

“Is it possible to come up with a list of illnesses that are terminal that would qualify under the legislation?”

The response was very clear:

“If I am honest, I think it would be extremely difficult.”

It is difficult in both directions, because some illnesses or diseases can be terminal, but are not necessarily terminal. People can live with prostate cancer for many years. Setting out in the Bill a list of specific diseases or illnesses that would be eligible risks achieving exactly the opposite of the amendment’s intention. To quote Professor Whitty again:

“Equally, there are people who may not have a single disease that is going to lead to the path to death, but they have multiple diseases interacting…I therefore think it is quite difficult to specify that certain diseases are going to cause death and others are not, because in both directions that could be misleading.”––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

Further to the point that the hon. Member for East Wiltshire made about on judicial oversight, my understanding is that giving power to the Secretary of State to make a list that includes only some diseases is absolutely inviting action through the courts on the reasonableness of why one disease is on the list while others are not. We would end up in much more of a legal quagmire than we otherwise would. The safeguards that we have talked about, as to eligibility criteria, terminality and capacity, are in the Bill as drafted. Those are the safeguards that we need. A list would further muddy the water and would create confusion.

[Stephen Kinnock]

I have some brief comments to make. Amendments 12 and 13 seek to further define a terminal illness for the purpose of the Bill; I will set out some details about their effect. The amendments would add a requirement that a list of a terminal illnesses for which people are eligible to seek assistance under the Bill be specified in regulations made by the Secretary of State. The effect would be that only a person who has an illness, disease or medical condition listed in regulations, and who meets the other eligibility criteria, would be eligible to be provided with lawful assistance to voluntarily end their own life.

I draw the Committee’s attention to the chief medical officer’s oral evidence given on 28 January, which was well articulated by my hon. Friend the Member for Sunderland Central. The CMO said that multiple diseases may interact, making it

“quite difficult to specify that certain diseases are going to cause death and others are not”.––[Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 32, Q5.]

It is also the case that many illnesses, diseases or conditions that may be terminal in one case may not be so in another. Committee members may therefore wish to consider where a focus on specific illnesses or diseases, rather than on the facts of an individual case, could aid clinicians in their decision making.

The amendments also include a discretionary power for the Secretary of State to make regulations that expire after 12 months in order to make temporary additions to the list of illnesses that meet the definition of terminal. It is not clear what types of illnesses, diseases or medical conditions are intended to be captured in such regulations. I hope that those observations on the purpose and effect of amendments 12 and 13 are helpful to the Committee in its considerations.

[Danny Kruger]

I sense that the wish of the Committee is probably not to accept the amendment, so I do not propose to press it to a Division, but we have just heard quite clearly, in response to the amendment, that the Bill is essentially permissive. Once again, we have declined to put clear parameters around the eligibility for this new law. We have heard specific conditions mentioned so many times in the course of the debates over the preceding months. It is a shame that we are not prepared to state those conditions clearly in the Bill, with the opportunity for Parliament to amend them over time.

I end by echoing a point that the hon. Member for Spen Valley made about the importance of good data. I hope that if the Bill passes, we will have the best data collection in the world. I am afraid to say that data collection is not good in other jurisdictions. Nevertheless, it is possible to see how often in Oregon, Australia, Canada, and Europe, albeit in a minority of cases, conditions that most people would not recognise as deserving of assisted dying, including anorexia, arthritis, hernias and diabetes, are listed as causes of death. Indeed, so is frailty, as I discussed earlier.

My fear is that if we pass the Bill, we too—if we do data collection properly—will have a shameful appendix to the annual report showing that people have had an assisted death for reasons that most people would regard as inappropriate. I will leave it there. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment made: 401, in clause 2, page 2, line 5, leave out “, disease or medical condition” and insert “or disease”.—(Danny Kruger.)

This amendment is consequential on Amendment 399.

Amendment proposed: 402, in clause 2, page 2, line 6, at end insert—

“(2) A person who would not otherwise meet the requirements of subsection (1), shall not be considered to meet those requirements as a result of stopping eating or drinking.”—(Naz Shah.)

This amendment means that someone who is not terminally ill within the meaning of subsection (1) cannot bring themselves within that definition by stopping eating or drinking or both.

Question put, That the amendment be made.

Cardiovascular Disease: Prevention

Stephen Kinnock Excerpts

Thursday 13th February 2025 Westminster Hall

[The Minister for Care (Stephen Kinnock)]

It is a great pleasure to serve under your chairship, Mr Mundell. I am indeed starting with an apology. I am very embarrassed by the fact that the debate was put by my officials in my diary as starting at 3.30 pm, and it is completely unacceptable that I arrived late. I apologise to you, Mr Mundell, and to the hon. Member for Strangford (Jim Shannon). It is a very embarrassing situation, and I am not happy about it at all.

I thank the hon. Member for Strangford for securing this debate on such an important issue and for the vital work he does as the chair of the APPG on vascular and venous disease. For their excellent contributions, I also thank my hon. Friend the Member for Dudley (Sonia Kumar), who spoke powerfully on the basis of her extensive real-world experience and expertise, my hon. Friend the Member for Ilford South (Jas Athwal), who spoke so movingly about his family and personal experiences, and the hon. Member for Mid Sussex (Alison Bennett), who spoke passionately about the shocking health disparities that blight our country, caused by 14 years of Tory neglect and incompetence.

Before I begin my remarks, I want to pay tribute to people working in local government, our NHS staff and GPs up and down the country for their efforts to find, treat, and manage people at risk of cardiovascular disease—also known as CVD. As hon. Members will know, health is a devolved issue, so my remarks will be limited to matters in England; however, I am happy to pick up on many of the broader points that the hon. Gentleman for Strangford has made.

The last Labour Government made significant progress on reducing premature deaths from CVD through the introduction of big-hitting interventions such as the ban on smoking in public places and increases in statin prescribing. However, as the hon. Member for Strangford said, among the many appalling findings of Lord Darzi’s report, there is clear evidence that progress on CVD stalled, and even went into reverse in some areas, between 2010 and 2024. That is why it is this Government’s mission to invest in the health service, alongside fundamental reform to the way that healthcare is delivered. We will build a health and care system fit for the future by moving from sickness to prevention, hospital to home, and analogue to digital. Tackling preventable ill health is a key part of these shifts.

As part of our 10-year health plan, we are committed to helping everyone to live a healthy life for longer, and as the hon. Gentleman also outlined in his remarks, too many lives are cut short by heart disease and strokes. In 2022, one quarter of all CVD deaths in the UK occurred among people under the age of 75. Tackling CVD is not just the right thing to do for patients; CVD is also having an impact on growth. People with CVD are more likely to leave the labour market than people with poor mental health, and we must dispel the fiction that people with CVD are always old and infirm. Around one in three people who have a heart attack, one in four people who have a stroke, and two in five people with coronary heart disease are of working age.

The hon. Gentleman referred to premature deaths, and we know from the most recent figures that I have, from 2023, that in England alone over 130,000 people died from CVD and over 30,000 people died before they turned 75. The best estimates show that the annual cost of CVD to the NHS is a staggering £8.3 billion, with knock-on effects of £21 billion to the wider economy. This is a huge challenge, which is why we are meeting it with great ambition: to reduce premature deaths from heart disease and stroke in people under 75 by one quarter within a decade. The Under-Secretary of State for Health and Social Care, my hon. Friend the Member for West Lancashire (Ashley Dalton), will be spearheading our work in this area, and will also be picking up on many of the issues that the hon. Gentleman raised in his speech.

We know that around 70% of the CVD burden is preventable and due to risk factors such as living with obesity, high blood pressure, high cholesterol and smoking—all of which can be reduced by behaviour changes, early identification and treatment. In England, the NHS health check is a free check-up for people between 40 and 74. The NHS health check is a wide-reaching programme delivered by local authorities in England. This CVD prevention programme aims to prevent heart disease, stroke, diabetes, and kidney disease—and also dementia for older patients. 

In the very short period of time that I have left, I just wanted to say that the hon. Member for Strangford called for the introduction of Lp(a) tests. As I understand it, lipoprotein(a) measurement is not currently recommended by NICE guidance, and there are no treatments available that specifically target Lp(a).  Instead, our focus is to improve the uptake of lipid-lowering therapies for prevention of CVD and to treat people with established CVD to NICE treatment targets. We will look closely at new tech and innovation and the essential role they will play in reducing health inequalities.

[Jim Shannon]

I apologise, but at the end of my speech I asked for three things. I asked whether there would be a willingness to meet me and representatives from the Lp(a) taskforce to discuss the essential steps that are needed, and that—

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[David Mundell (in the Chair)]

That is not technically a point of order, but I am sure the Minister has heard what you have had to say. I am sure he and, indeed, the hon. Member for Glasgow South West (Dr Ahmed)—who was here from the start—will have noted all the points that Mr Shannon raised. If the points that Mr Shannon raised at the end—and indeed earlier, in his contribution before the Minister spoke—were unaddressed, I am sure that the Minister will write to him.

[Stephen Kinnock]

I absolutely will. I would be happy to complete my remarks, but I do not know that would work, given that Mr Shannon has made his second contribution.

[David Mundell (in the Chair)]

I will make the determination that Mr Shannon’s contribution was an intervention—although an excessively lengthy one, which he will not repeat at the conclusion of the debate.

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[Stephen Kinnock]

This has been an interesting debate on so many levels. I thank you for that clarification, Mr Mundell.

I was just talking about the fact that around 70% of the CVD burden is preventable, and that the causes include obesity, high blood pressure, high cholesterol and smoking. All those factors can be reduced by behaviour changes, early identification and treatment. In England, the NHS health check is a free check-up for people between 40 and 74. It is a wide-reaching programme delivered by local authorities in England. This CVD prevention programme aims to prevent heart disease, stroke, diabetes and kidney disease, as well as dementia for older patients. It engages over 1.4 million people a year and, through behavioural and clinical interventions, prevents around 500 heart attacks or strokes annually.

I agree with the hon. Member for Strangford that the National Audit Office report shows that there is still so much more to be done. That is why we have asked officials to be more ambitious, developing policy proposals for how that programme can go even further. In the meantime, we are focused on delivering a new digital NHS health check, available through the NHS app, so that people can assess, understand and act on their CVD risk at home. We want to make it easier for people to access that programme, especially our constituents who have caring or childcare responsibilities, or cannot easily get to their GP surgery during opening hours. The creation of a state-of-the-art national digital NHS check service will improve access to this lifesaving check.

The hon. Member was right to mention diabetes as a key risk for CVD. Each year, the NHS health check identifies 22,000 people with high blood sugar who are referred on to primary care for further assessment and management. GPs can refer people at risk of developing type 2 diabetes into the Healthier You NHS diabetes prevention programme. The programme has been highly effective: some 35,000 people have been referred to it by their GP, and over 20,000 have started the programme since September 2020. For people who complete that programme, it can cut the risk of developing type 2 diabetes by 37%. For those who already have diabetes and are overweight or obese, the NHS type 2 path to remission programme is available. This joint initiative between NHS England and Diabetes UK aims to support eligible people with type 2 diabetes to achieve clinically significant weight loss, improve blood glucose levels and reduce the need for diabetes-related medication. A recent study found that almost a third of patients with type 2 diabetes who completed the programme went into remission.

Around half of heart attacks and strokes are a result of high blood pressure. A third of adults have high blood pressure and, worryingly, almost a third of these conditions are currently untreated, meaning that over 4 million people do not know that they have high blood pressure. It is often referred to as the silent killer, as high blood pressure is largely symptomless. The tragedy is that the treatment is so cheap and effective. We could prevent around 17,000 heart attacks and save more than £20 million in healthcare costs alone over three years just by treating 80% of patients on target.

The hon. Member for Strangford also mentioned high levels of cholesterol as a key risk factor in CVD. For every three NHS health checks delivered, one person is found to have high cholesterol, and there are well-known health inequalities in CVD affecting underserved communities in England. Addressing undetected and poorly managed high blood pressure and raised cholesterol is key to preventing CVD and reducing health inequalities.

There are effective drug treatments. Statins are readily available and very cheap. They can reduce an individual’s risk of CVD in four to six weeks. If we improve treatment rates for people with CVD to 95%, more than 18,000 CVD events, such as heart attacks and strokes, may be prevented over three years. We will look closely at how we can get that done. The hon. Member for Strangford called for the introduction of Lp(a) tests. As I mentioned, that is not currently recommended by NICE guidelines. I have taken account of his other remarks, including his request for a meeting and engagement with system partners. The Minister for Public Health and Prevention will take all those requests on board. She is the right person for him to meet, given that she leads in this policy area.

Smoking costs health and care services £3 billion a year—resources that could be freed up to deliver millions more appointments, scans and operations. The cost of smoking to our economy is even greater, with around £18 billion lost in productivity every year. Smokers are a third more likely to be off work sick, which is why we introduced the Tobacco and Vapes Bill: the biggest public health intervention in a generation. It will break the cycle of addiction and disadvantage, and put us on track towards a smoke-free UK. That will make a real difference in constituencies where smoking contributes to the cycle of poverty and ill health. We are also supporting local stop smoking services with an additional £70 million this financial year.

Today’s debate has shown what a challenging and complex area this is. The shadow Minister, the hon. Member for Hinckley and Bosworth (Dr Evans), raised a range of issues. I will ask the Minister for Public Health and Prevention to write to him on all his points, many of which I think would be best dealt with in correspondence.

[Jas Athwal]

The Minister makes powerful points. Does he agree that we should consider a wider, holistic approach, taking into account planning and advertising—for instance, children going to school and having access to the proliferation of chicken shops and fast-food shops, and being exposed to, on average, 13 to 15 junk food adverts? That would help to limit the number of heart diseases later down the line.

[Stephen Kinnock]

My hon. Friend is right that prevention should focus on as early as possible in the life of our young people. Bad habits form at early ages. That is not helped by the behaviour of some aspects of our economy, and the way in which products are advertised. It is essential that we move to a model of prevention that is a partnership between the Government, our communities and business. We are taking action against the advertisement of certain products before the 9 o’clock watershed. We are also cracking down on energy drinks, which are really pernicious in terms of the amount of sugar, caffeine and other deeply unhealthy components they contain.

My hon. Friend is right that we are genuinely all in this together. We need that partnership with the private sector, and a change in mindset around healthy and nutritious food. That needs to be put into schools through community health, and through working with parents and communities to change the habits of our country. We have a gargantuan challenge ahead of us, but our Government are absolutely committed to facing it, and that prevention strategy will be at the heart of our 10-year plan. It is one of the key shifts from sickness to prevention.

That leads me to my closing remarks. We have seen today what a challenging and complex area this is. It is a challenge that requires sustained action on a number of risk factors, but I assure colleagues that this Government will leave no stone unturned in getting premature deaths from heart disease and stroke down by a quarter for people under the age of 75 within the next year.

In my contribution, I have sought to demonstrate our commitment to getting on with the shift from sickness to prevention with our cast-iron commitment to expanding NHS health checks, the shift from hospital and community by making it easier for people to get checks at their convenience and at home, and the shift from analogue to digital through an innovative and expanded digital service. I once again thank the hon. Member for Strangford for securing this important debate, and thank all hon. Members across all parties for their excellent contributions. Watch this space: we will continue to work on this issue with focus and at pace.

Telecare National Action Plan

Stephen Kinnock Excerpts

Tuesday 11th February 2025 Written Statements

[The Minister for Care (Stephen Kinnock)]

The digital phone switchover is a necessary upgrade to our underlying national digital infrastructure as the old analogue landline network is becomingly increasingly unreliable. The safety of telecare users throughout the switchover is the Government’s utmost priority. That is why I am pleased to publish a joint telecare national action plan with the Minister for Data Protection and Telecoms, the hon. Member for Rhondda and Ogmore (Chris Bryant), setting out the steps that stakeholders need to take to safeguard telecare users during the digital phone switchover.

The digital phone switchover means that traditional analogue devices, such as telephone handsets and telecare units that are currently connected to the analogue landline network, will need to be reconnected to the digital network. There is a risk that the process of migrating telecare users to digital landlines will disrupt their telecare services. Telecare users must be protected during the digital phone switchover and every effort must be taken to avoid these risks.

Our action plan is predominantly aimed at communication providers, local authorities, housing providers, third sector organisations and commercial providers. It demonstrates the Government’s commitment to working with the telecare and telecommunications industries and ensuring that telecare users’ safety is put first during the switchover. Officials have worked closely with stakeholders to develop and agree the actions set out in this plan.

This telecare national action plan sets out the actions that the Government expect to see delivered. The actions are set out against the following outcomes:

No telecare user will be migrated to digital landline services without the communication provider, the user or the telecare service provider confirming that the user has a compatible and functioning telecare solution in place;

Use of analogue telecare devices is phased out to ensure that only digital devices are being used. DHSC will be working with stakeholders over the coming months to set a deadline for this;

Telecare users, their support networks and their service providers understand what actions they need to take to ensure a safe migration to digital phone lines; and

Stakeholders identified within the plan collaborate to safeguard telecare users through the digital phone switchover.

The Government are committed to improving adult social care for those who draw on it, helping people to stay independent in their own homes, joining up services and improving the quality of care. The Government recently announced an independent commission into adult social care led by Baroness Louise Casey as part of their critical first step towards a national care service. While the Casey commission carries out its work, the Government are getting on with the job of reforming the system and have announced immediate actions to improve adult social care services. This includes the development of new national standards and trusted guidance for technology in social care. The new standards and guidance will make it easier for providers, commissioners and people who draw on care and support to identify the technologies that will work best for them.

The transition to digital telephone networks will lay the foundations for a next generation of telecare services that will support more personalised and early preventive interventions, and support the Government’s reforms to adult social care. The plan includes examples of where local areas have utilised the opportunities presented by the digital phone switchover to advance the use of technology within their social care provision.

Given the complexity of the issue, it is possible that additional necessary actions might be identified. We will review progress against the telecare nation action plan every six months and identify new actions as needed. A copy of the telecare national action plan will be deposited in the Libraries of both Houses and will also be published on www.gov.uk.

[HCWS434]