NHS Corridor Care

Rebecca Paul Excerpts

Wednesday 8th July 2026 Commons Chamber

[Rebecca Paul (Reigate) (Con)]

I thank the hon. Member for Tooting (Dr Allin-Khan) for securing the debate. This is a really important topic, and I do not think there has been enough focus on it in the last few years. Her speech was very powerful, and the hon. Member for Salford (Rebecca Long Bailey) made really important points about corridor care not happening in a silo. There is a wider system of things going on, so we need to look at this more broadly.

I feel strongly about this issue because I have seen the shocking reality for myself at East Surrey hospital, in my constituency, and at St Helier hospital, which is outside my constituency but serves some of my constituents. Patients are being cared for in spaces that were never designed for clinical treatment, and staff are trying their best to do their jobs in impossible circumstances. I cannot imagine how upsetting it must be to go into hospital with a serious medical problem, only to spend hours on a trolley, surrounded by noise and footfall and without any sort of privacy, and to be denied basic dignity. In fact, I saw one example of a patient who was near automatic doors, which opened and shut every time someone walked past them. That is not dignified or appropriate in any shape or form.

How can it be right that doctors are forced to discuss private medical matters with patients in public hallways, or even to attempt examinations and treatment without the facilities that they need being close at hand? Let me be clear: all the staff I met on my visits were doing the best they could in extremely difficult circumstances. The problem was not down to their lack of commitment or compassion; it was down to a system that is operating without enough physical space to meet the excessive demand placed upon it. The previous Secretary of State, the right hon. Member for Ilford North (Wes Streeting), promised to eliminate corridor care by the next general election in 2029, and we need to understand how it will be addressed. I think we all accept that this is not an easy thing to solve, but it would be good to know what steps will be taken to address this big issue.

The crux of the issue appears to be hospital flow. Emergency departments cannot move patients into wards when beds are full, and beds remain occupied when people who are medically fit to leave cannot access the care, rehabilitation or support that they need outside hospital. Delayed discharge therefore remains part of the problem. Without sufficient social care capacity, community service and intermediate care, hospitals cannot safely discharge patients.

At St Helier, there is another fundamental issue: physical space. The hospital is trying to offer a modern service in buildings that the trust says are no longer fit for purpose. Much of the estate is older than the NHS itself, and staff contend with leaking roofs, flooding, damp, mould and buildings that are difficult to keep at a suitable temperature. Those conditions make it harder to provide safe care, and place still more pressure on staff, who are already overstretched.

One example of the type of challenge is the women’s health block, which is currently a big issue. Routine testing has identified low levels of legionella and pseudomonas in the water supply. While filters have been installed and regular testing commenced, that highlights the fact that these measures are not a sustainable long-term solution, given the age and complexity of the building’s water system. This is hugely disappointing for patients and staff, particularly considering the hard work that has gone into improving the hospital’s women’s health services.

That is why I strongly support the planned new specialist emergency care hospital in Sutton to be delivered alongside significant investment to modernise both St Helier and Epsom hospitals. The new hospital would bring together major emergency care, acute medicine, critical care and emergency surgery in modern facilities designed around the needs of patients and staff, while crucially leaving 85% of services at the existing hospital sites. This is exactly the sort of investment urgently needed to reduce overcrowding and end the indignity of patients being treated in corridors, yet the start of construction has been delayed—pushed back to 2033. I urge the Government to reconsider that timeframe, as that would be important in helping to address the challenge we face with corridor care.

[Several hon. Members rose—]

Puberty Blockers

Rebecca Paul Excerpts

Tuesday 23rd June 2026 Commons Chamber

[Rebecca Paul (Reigate) (Con)]

I frankly cannot believe that we are here again. When the Pathways clinical trial was paused earlier this year, I felt that there had finally been—[Interruption.]

[Madam Deputy Speaker (Ms Nusrat Ghani)]

Order. Forgive me—there is a five-minute time limit, which is the only way that I can incorporate all the Back Benchers who wish to contribute.

[Rebecca Paul]

Yesterday, even the Secretary of State for Health and Social Care conceded—the second one to do so—that he is “uneasy” and even “uncomfortable”. I suggest that his discomfort is nothing next to the lifelong damage that the trial will potentially do to an extremely vulnerable cohort of children, whom we should be protecting. That funny feeling in his stomach—[Interruption.] Oh, he has left. That feeling is his good judgment trying to be heard—he will not hear this if he has left—and it is not too late for him to listen to it. I agree with what one of my hon. Friends said yesterday: he is a good man who is being placed under intolerable pressure on this issue. But he needs to find his courage.

The number of children and young people presenting to the NHS with gender distress increased dramatically in the years after 2009, with an exponential rise from around 2014. What is behind the increase among Gen Z is unclear, but the reasons are likely to be multifaceted. It is speculated that the factors may include 24/7 internet access, the increased acceptance of trans identities, or even peer social and cultural influences. Over the past 20 years, groups such as Stonewall and Mermaids have called for better access to treatment and more rights for trans people. Large corporates have gone big on diversity and inclusion to boost their brands.

[Vikki Slade (Mid Dorset and North Poole) (LD)]

I am slightly concerned by the idea that trans acceptance is part of the problem. Does the hon. Member agree that trans acceptance is completely reasonable and that trans people have always been here?

[Rebecca Paul]

I am not saying that it is a negative thing; I am trying to explain why we have seen an increase in the numbers of young people with gender dysphoria. I am stating facts; we were just talking about the importance of doing so.

In 2009, only 51 patients were referred to the NHS Gender Identity Development Service for children, of whom two thirds were male. In 2016, there were 1,766 referrals and two thirds of them were female. That is quite the change. There has been an overall surge in the number of children suffering gender distress, but the increase is especially notable among girls. We also see over-representation of neurodiversity, mental health issues and trauma in this group. To put it another way, these children are much more likely to have been in care, to suffer with anxiety and depression, to be autistic and to have been abused. It is a group of incredibly vulnerable children.

GIDS was established in 1989. Its main approach to treatment at that time was therapeutic, referred to as watchful waiting. Early studies from the 1980s showed that in around 85% of cases, the gender incongruence or distress ceased in the child after going through puberty. Later studies reached a similar conclusion, with between 67% and 90% desisting after puberty. Only a small cohort of children continue to experience gender dysphoria or incongruence after puberty, and it was that extremely small group who would likely adopt a permanent trans identity in adulthood.

[Mr Andrew Snowden (Fylde) (Con)]

Recently, the Government announced that they will legislate to prevent under-16s from viewing social media. We already ban under-16s from drinking alcohol and smoking, because we believe that they should be protected from doing things now that may have negative impacts on them later in life, particularly to their health. Does my hon. Friend think that this should sit in that category of protections for children?

[Rebecca Paul]

I completely agree with my hon. Friend; a child of this age cannot possibly consent to the life-changing, irreversible changes that come from puberty blockers. We need to remember that almost all children who start puberty blockers go on to cross-sex hormones, and there is no going back from that.

We need to remember that we have already had a trial in the UK. When we started using puberty blockers in the UK after 2011, the preliminary results came out in 2015-16 and did not demonstrate psychological benefits, with some of the females actually suffering a worsening of symptoms, including a higher incidence of wanting to hurt or kill themselves. The results of the study, which were not formally published until 2020, demonstrated no statistically significant improvement in gender dysphoria or mental health outcomes. It is important to remember the early studies that told us that, in a majority of cases, going through puberty resolved gender distress. It follows, therefore, that stopping or delaying puberty using medication derails that natural desistance, essentially locking in.

[Dr Simon Opher (Stroud) (Lab)]

Speaking as a member of the political class and the medical class, may I ask the hon. Lady whether she would accept that it is better for politicians to accept advice from medical experts around medical issues?

[Rebecca Paul]

I thank the hon. Member for that excellent question. I obviously always respect and listen to different clinicians, but what is happening with this debate is that one set of clinicians with one view is being listened to. Let me remind everyone about lobotomies. Lots of very respected people came out for lobotomies; in fact, the person behind the idea won a Nobel prize. I think we would all agree that those clinicians got that wrong, so it is incumbent upon us in this House to always question. It is absolutely right that we listen to clinicians, but unfortunately we are seeing only one set of clinicians with one set of opinions being listened to here.

A Finnish study was published in April that looked at more than 2,000 adolescents and young adults who had been referred to gender services. It found that medical interventions did not reduce psychiatric problems and may even be associated with worsening mental health. How many times have we heard it said that puberty blockers offer a pathway towards improved mental health and reduced psychiatric distress for those struggling with gender identity? I have lost count. But there is hard evidence that not only says different; it says the opposite. I would be keen to understand from the Minister and the Secretary of State whether that study was taken into account before deciding to go ahead with the trial.

I want to point out that children and young people who grow up to be same-sex attracted are over-represented in this cohort, and that is something we need to think about. If we look at the case of Keira Bell, she was a lesbian struggling with her sexuality, and instead of people saying, “It’s okay to find other women attractive—there’s nothing wrong with that. You do not need to change your body,” they said, “Ah! You’ve got gender dysphoria.” They put her on puberty blockers, and then she went on to testosterone shots. She then had her breasts removed in a double mastectomy, and then she detransitioned. This is a deeply homophobic approach to healthcare. Those on the other side of the argument think they have the progressive position. I am sorry, but you are repeating mistakes that have been made historically—

[Madam Deputy Speaker (Ms Nusrat Ghani)]

Order. Obviously, I have not said anything, so I am not repeating anything. No “yous” and “yours”.

--- Later in debate ---

[Christine Jardine (Edinburgh West) (LD)]

It is a pleasure to follow the hon. Member for South Derbyshire (Samantha Niblett), who made a very effective and powerful speech. All of us here today are concerned about the safety and wellbeing of children, and we want to ensure that young people facing a crisis of identity get the support that they need and that is appropriate for them. In many cases, that will be talking therapies. We need to give children and their families time to figure out exactly what the issue is and whether they will develop out of it in time, but that is not always the case.

My concern, and I believe the concern of many here today, is for those children who do not, as the hon. Member for Sleaford and North Hykeham (Dr Johnson) put it, grow out of it as if it were some problem—children who have a genuine fear of what puberty will bring, and of what adulthood in a body that they do not recognise as theirs will mean. Those children currently feel that they have no option. If we take away the possibility of puberty blockers, where will they go? Where will they turn? Too many young people are committing suicide, and we have to acknowledge that that is the very real danger of putting up a very different type of block—a block to understanding and to helping them develop.

[Rebecca Paul]

I thank the hon. Lady for giving an eloquent speech. It is really important that we are very responsible in the way we talk about suicide, and I would like to point out that Professor Louis Appleby did a study on exactly this issue following the ban of puberty blockers. His conclusion was that we were not seeing an increase in suicides as a consequence. He also made the point that it is important not to suggest that denying young people puberty blockers causes them to commit suicide. That is a negligent thing to do, and it is important that we put that on the record.

[Christine Jardine]

I thank the hon. Lady, but I point out that that is not what I said. I said that we were leaving children without an option. I also point out that if we are going to be responsible, we should not accuse people of being homophobic because they are trying to support the transgender community. Many of those people who support the transgender community are lesbians or gay. I know this because I am the honorary president of the LGBTQ+ community within the Liberal Democrats, and there is a great feeling of community between the two. I would caution people not to call anyone who wants to support the trans community homophobic. 

These children need our support. In providing that, we should listen to clinicians and experts, such as Dr Hilary Cass, who has said, as so many Members have pointed out, that this trial will help protect children and will mean that they are less likely to be harmed. I think we should take that as our guiding principle.

My hon. Friend the Member for Mid Sussex (Alison Bennett) clearly laid out my party’s policy. I am proud of the fact that, as a women and equalities spokesperson, I was responsible for the formation of most of our policy on the transgender community. I have to say that I spoke to a great many of them, and they would be appalled if they felt for one moment that we were not going to support them, not going to support this trial or not going to stand up for them at a time when they are under increasing pressure and we are seeing the demonisation of that community.

The young children facing a crisis of identity—wondering who they are, and wondering what support they will get—are looking to us to give them that support, and that is why I will oppose the Conservatives’ motion.

--- Later in debate ---

[Stephen Kinnock]

I know that feelings on these matters are strong and heartfelt. If the Conservative party has changed its position and is putting forward its arguments with sincerity and honour, that is a perfectly acceptable position to take, but I simply remind the House of the journey that the party has been on.

[Rebecca Paul]

The Cass review also suggested a clinical trial for cross-sex hormones. On that basis, will the Government launch a clinical trial on cross-sex hormones as well?

Pathways Study: Puberty Suppression

Rebecca Paul Excerpts

Monday 22nd June 2026 Commons Chamber

[James Murray]

My hon. Friend raises an important point about the relationship between politics and clinical evidence and clinically led decisions. Being led by clinical advice and clinical evidence is a decision that I and this Government stand behind. In this case, it is a matter where in considering some of the issues raised, I have felt uncomfortable and uneasy, but that commitment to clinical evidence, particularly recommended by someone as widely respected as Dr Cass, is the basis on which we can move forward. As I mentioned in response to the Chair of the Health and Social Care Committee, because this involves children and young people, I wanted to receive extra assurances that the clinical advice was robust and that the safeguards would be as robust as possible. That is the assurance I have received, it is what I very much wanted to receive before coming here today.

[Rebecca Paul (Reigate) (Con)]

I thank the Secretary of State for his statement. No child put on puberty blockers at the earliest stage of puberty and whose natural puberty is permanently blocked will ever have an orgasm or be fertile. No child can consent to that. Around 2,000 children have already been given puberty blockers for gender distress, so there is ample information available on impact and outcomes held by gender clinics. It makes no sense to experiment on even more children while this exercise remains incomplete. Why is the Health Secretary not prioritising the completion of this important data linkage study before experimenting on more children?

[James Murray]

The hon. Lady refers, apparently with some certainty, to what she considers to be the clinical outcomes of these puberty blockers on young people. I have to say, with all due respect, that I would trust Dr Cass’s conclusion more than the hon. Lady’s, which is that there is not evidence about the risks or benefits of these medications. That is exactly why Dr Cass was so clear in recommending a trial to find that clinical evidence, because that is the basis on which we can take those decisions.

Puberty Blockers Clinical Trial

Rebecca Paul Excerpts

Monday 23rd March 2026 Westminster Hall

[Rebecca Paul (Reigate) (Con)]

The use of puberty blockers on healthy children is deeply wrong. Children given those drugs are being locked into their discomfort and put on a one-way pathway to cross-sex hormones and surgeries. All of that leads to a lifetime of sexual impairment, fertility issues, bone density loss and other catastrophic psychological and emotional impacts. No child put on puberty blockers at the earliest stage of puberty and whose natural puberty is blocked will ever have an orgasm or be fertile. That is what anyone in this room cheerleading this trial is supporting.

In December, the Health Secretary said at the Dispatch Box:

“Am I comfortable that this clinical trial has undergone the proper process and ethical approval to ensure the highest standards and supervision? Yes, I am comfortable about that.”—[Official Report, 17 December 2025; Vol. 777, c. 929.]

However, on 20 February, we found out that the MHRA had U-turned and was expressing serious concerns about the current trial. The issues it raised were not new, though, having been raised from the outset by many in this room. Making children infertile and harming bone structure are not minor points of detail, but fundamental safety flaws. That last-minute intervention raises questions about the rigour and diligence of the overall approval process. How did a trial with such potentially catastrophic health impacts make it through the research ethics committee approval process?

Having looked through the minutes of the meetings, I can see that the committee members met three times over Zoom; nine out of 12 attended the first, only five attended the second and only three attended the third. What stands out most to me is the REC’s delegation to a sub-committee of approval responsibilities for such a profoundly dangerous trial. Section 4.2.24 of the REC governance policy document indicates that sub-committees can be used when

“research proposals…present no material ethical issues”.

I am therefore staggered that it took the decision to delegate approval responsibilities in this case.

Oral Answers to Questions

Rebecca Paul Excerpts

Tuesday 13th January 2026 Commons Chamber

[Wes Streeting]

I am hugely grateful to my hon. Friend for his question and he is rightly proud of his local trust. It is absolutely right that we cannot expect the NHS to rely simply on the goodwill of staff going above and beyond the call of duty to meet the needs of patients. That is why the Government are committed to publishing a new workforce plan, to create the workforce that is ready to deliver the transformed service set out in our 10-year health plan. We are already working with health unions, both on issues around pay, as people would expect, and the conditions that people are working in, recognising, as my hon. Friend rightly does, that this is not just about doctors, important though they are, but about the entire NHS workforce that is delivering the improvements with this Government that the country is crying out for so desperately.

[Rebecca Paul (Reigate) (Con)]

One of the things that contributes to staff burnout is caring for patients in corridors. I recently visited St Helier hospital and saw that for myself, and it was very concerning and distressing. We are also seeing that at East Surrey hospital in Redhill, in my constituency. Will the Secretary of State confirm when we can expect to see the issue resolved for good?

[Wes Streeting]

The hon. Member is right to describe the appalling state of corridor care in this country. In fact, under the previous Government, not only was this allowed to emerge as an NHS issue, but it was normalised, with benign nomenclature such as “temporary escalation spaces” used to endorse that normalisation, which should never have been considered normal or acceptable. We will set out our plans shortly to publish data, so that the Government can be held to account as well as the system. I am clear that I want corridor care gone over the course of this Parliament, and I am confident that when we publish all the data for this winter, it will be better than last winter. However, I want to be honest with the House and the country: even on the best days of this winter, patients are still being treated in corridors and in conditions that I do not believe are acceptable and that we should never allow to be normalised. That is why we are committed to year-on-year improvement.

Oral Answers to Questions

Rebecca Paul Excerpts

Tuesday 21st October 2025 Commons Chamber

[Wes Streeting]

My hon. Friend is absolutely right to welcome my hon. Friend the Minister to his place. I will be honest: in effect, he has been a Minister since we came into government. We very much welcome the work that he has been putting in.

We are determined to do more on rare cancers, working with my hon. Friend the Member for Mitcham and Morden (Dame Siobhain McDonagh). All the work that she is doing, particularly on rare brain cancers, is much appreciated.

[Rebecca Paul (Reigate) (Con)]

Most young people referred to gender identity services are same-sex attracted, neurodiverse and/or traumatised. Looked-after children are also over-represented in this cohort. Is the Secretary of State really comfortable with children being given puberty blockers, which essentially chemically neuter them, for the purposes of the PATHWAYS clinical trial?

[Wes Streeting]

Within days of taking office, I upheld the judgment made by my predecessor. We need to tread carefully and be sensitive in this space. We need to take an evidence-based approach to trans healthcare in our country, and that is the approach that this Government will take.

Gender Incongruence: Puberty Suppressing Hormones

Rebecca Paul Excerpts

Wednesday 30th April 2025 Westminster Hall

[Rebecca Paul (Reigate) (Con)]

I beg to move,

That this House has considered the potential impact of puberty suppressing hormones on children and young people with gender incongruence.

It is a pleasure to serve under your chairmanship, Ms Lewell. I am pleased to have the opportunity to shine a light on this important topic, one that impacts the health and wellbeing of some of the most vulnerable children in our country. This debate must be led by science, data and evidence, not by ideology, bias or belief. I will do my best to do that today.

The number of children and young people presenting to the UK NHS with gender distress has increased year on year since 2009, with an exponential rise in 2014. What is behind the increase among Generation Z is unclear and the reasons are likely to be multifaceted. It is speculated that the factors may include 24/7 internet access, increased acceptance of trans identities, or even peer, social and cultural influences.

Over the last 20 years we have seen groups such as Stonewall and Mermaids call for better access to treatment and increased rights for trans people. Large corporates have gone big on diversity and inclusion to boost their brands, impactful TV dramas centring trans stories, such as “Butterfly”, have been widely viewed, and the public sector, from the NHS to the police, has been flying the progress flag at every opportunity. So it can be no surprise that gender identity is at the front of young people’s minds in a way that it simply was not when I was growing up.

In 2009, only 51 patients were referred to GIDS—the NHS gender identity development service for children—of whom two thirds were male. In 2016, there were 1,766 referrals and two thirds of them were female. That is quite the change. There has been an overall surge in the number of children suffering gender distress, but the increase is especially notable among girls; we also see over-representation of neurodiversity, mental health issues and trauma in this group. To put it another way, these children are much more likely to have been in care, to suffer with anxiety and depression, to be autistic and to have been abused. It is a group of incredibly vulnerable children.

GIDS was established in 1989. Its main approach to treatment at that time was therapeutic—referred to as watchful waiting. Early studies from the 1980s showed that in around 85% of cases, the gender incongruence or distress ceased in the child after going through puberty. Later studies reached a similar conclusion, with between 67% and 90% desisting after puberty. Only a small cohort of children continued to experience gender dysphoria or incongruence after puberty, and it was that small group who would likely adopt a permanent trans identity in adulthood.

Everything changed with the emergence of the Dutch protocol, which involved the use of puberty blockers from early puberty. Puberty blockers are gonadotropin-releasing hormone analogues, which supress oestrogen production in girls and testosterone in boys. They are licensed for use in children with precocious puberty—when puberty starts much too early and it is beneficial to suppress it until a more normal developmental time and age—but in the case of gender dysphoria they are used to delay or even indefinitely stop natural pubertal development and maturation, and it is important to note that puberty blockers are not licensed for that purpose.

The original rationale for using puberty blockers to treat gender dysphoria was to press pause on puberty and give children time to think, but for some the aim was also to increase the chances of a child passing as a member of the opposite sex in adulthood. GIDS started trialling puberty blockers in the UK after 2011. The preliminary results in 2015-16 did not demonstrate psychological benefits, with some of the females suffering a worsening of symptoms, including higher incidence of wanting to hurt or kill themselves. The results of the study, which were not formally published until 2020, demonstrated no statistically significant improvement in gender dysphoria or mental health outcomes.

It is also important to remember the early studies that told us that in the majority of cases, going through puberty could relieve gender distress. It follows, therefore, that stopping or delaying puberty using medication could derail that natural desistence, essentially locking in or prolonging the gender distress, rather than allowing it to naturally resolve.

One would think that, in the absence of any evidence of benefit from puberty blockers, the NHS would have stepped back from using them after the trial. Furthermore, the high numbers of autistic, traumatised, mentally unwell and same-sex attracted youth in the group of children referred should have rung alarm bells loudly, but no; instead, puberty blockers and cross-sex hormones were routinely made available to an even broader group of children, including those with neurodiversity and complex mental health presentations.

An independent systematic review of published studies on puberty blockers, of which there were 50, was undertaken by the University of York as part of the Cass review. It was found that puberty blockers do indeed suppress puberty effectively. It was also found that, given that most children progress on to cross-sex hormones after starting puberty blockers, the main objective of pausing development is not achieved. No reduction in gender dysphoria or improvement in body satisfaction was demonstrated, and there was limited evidence of positive mental health outcomes.

Worryingly, bone density in those taking puberty blockers was compromised, and height gain may lag behind normal. In the case of biological males, it can make vaginoplasty more difficult in future, due to insufficient penile growth, forcing the use of gut tissue instead. The Cass review reports:

“There seems to be a very narrow indication for the use of puberty blockers in birth-registered males…in order to stop irreversible pubertal changes. Other indications remain unproven at this time.”

I take that to mean that those drugs have been given to young girls, not because they benefit them specifically, but because they might benefit a very small group of males. Professor David Bell, a retired consultant psychiatrist at the Tavistock, and Dr Sinead Helyar, a clinical trial nurse, also warned of the potential harms in a recent article.

“Current known and potential harms of puberty blockers are multi-fold and include a reduced bone density and early-onset osteoporosis, brain swelling and concerns around impairment of future sexual functioning and ability to form emotional relationships. A recent review of the impact of suppressing puberty on neurological function highlighted that adolescence is a critical window of neurodevelopment and puberty plays a critical role in this process. The author concluded that suppression of puberty impacts brain structure and the development of social and cognitive functions, in which the effects are complex and often sex specific.”

The over-representation of same-sex attracted girls and boys in the group of children being treated with puberty blockers is particularly worrying. In a study in the Netherlands of 70 patients given puberty blockers between 2000 and 2008, 89% were same-sex attracted, and most of the rest were bisexual. The same pattern was seen in most of the other trials, with the majority of the children growing up to be same-sex attracted adults. A paper from GIDS in 2016 reported 89% of the biological girls being either same-sex attracted or bisexual.

Why would same-sex attraction be over-represented in that way? Could gender distress be symptomatic in some cases of struggling with sexuality? Is sufficient emphasis put on reassuring those young adolescents about their sexuality, to establish if the gender distress is linked or separate; or is our society’s hyperfocus on gender identity and gender conformity putting them on an unnecessary medical pathway to change their body? Keira Bell, who has now detransitioned, says,

“I became attracted to girls. I had never had a positive association with the term ‘lesbian’ or the idea that two girls could be in a relationship. This made me wonder if there was something inherently wrong with me. Around this time, out of the blue, my mother asked if I wanted to be a boy, something that had not even crossed my mind.”

The Cass review received several reports from parents of biological females that their child had been through a period of trans identification before recognising that they were, in fact, a lesbian. That begs the question: why are so many young lesbians being medically transitioned?

Before I move on to my questions to the Minister, it is important to note that almost all the children and young people who take puberty blockers go on to take cross-sex hormones. I raise that because it links the two treatments. The impact of puberty blockers cannot be looked at in isolation, because cross-sex hormones may lead to further surgeries, lifelong medication, and loss of fertility and sexual function. These are catastrophic impacts. How can a prepubescent child really understand what never experiencing an orgasm means and the impact that could have on their future relationships, or indeed what losing the opportunity to have children could mean?

It is very apparent that the lack of solid long-term data on outcomes for patients who are treated with puberty blockers is problematic. No doctor should prescribe something in the absence of strong evidence of its effectiveness and a clear understanding of the side effects. In May 2024, the previous Government temporarily banned the use of puberty blockers for the treatment of gender incongruence and gender dysphoria in under-18s, following the Cass review’s findings of insufficient evidence to show they were safe and effective, and this ban was made permanent by the current Secretary of State for Health and Social Care in December 2024. In the light of everything that I have set out today, I fully support that decision: it is sensible, has full regard to the data, and puts the safety and wellbeing of children first.

It is also important to note campaigners’ claim that suicides among young patients with gender dysphoria increased due to puberty blocking drugs previously being restricted, following the High Court decision in the Bell v. Tavistock case, has been disproved by Professor Louis Appleby’s investigation and report, published on 19 July 2024, in which he confirmed that the data did not support such assertions. He concludes that:

“The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide. One risk is that young people and their families will be terrified by predictions of suicide as inevitable without puberty blockers.”

At the same time that the Secretary of State announced the permanent ban on puberty blockers, he announced that a clinical trial would be set up in 2025 to examine the use of puberty blockers, in order to establish a clear evidence base for the use of this medicine in gender incongruence. The £10.7 million trial, called Pathways, will be carried out by a team at King’s College and is due to run until 2031. Over two years, it will track:

“the physical, social and emotional wellbeing”

of young people who want to delay puberty, and whose parents and the gender service agree with this treatment option.

I will be grateful to the Minister for an update on the trial and how she intends to ensure that children are not physically or psychologically harmed. A trial of this nature of a drug that is unlicensed for gender incongruence raises many ethical concerns. In the words of Professor David Bell and Dr Sinead Helyar:

“The first duty of any clinician inside or outside of a clinical trial is to ‘do no harm.’”

Can there ever be a situation where it is ethical to run such a trial when the harms could be significant? It is important to remember that the children who would participate in this trial are physically healthy children who stand to have worse health by the end of it. This trial is in no way similar to a clinical trial for a cancer drug, where the patient is seriously unwell at the beginning of the trial.

Secondly, approximately 9,000 children and young people were treated by GIDS over the years, which provides a plentiful supply of data about the long-term outcomes for those who took puberty blockers and those who did not. Would the Minister please clarify matters and explain why a new trial is needed, given this abundance of data? Will she please provide an update on the exercise that is currently under way to obtain more data?

Thirdly, the current trial only proposes to look at outcomes over a two-year period. To put that into context, a child who starts puberty blockers at the age of 13 will only have their outcomes followed and assessed until the age of 15. That is not long enough to understand medium and long-term outcomes. A positive result for a 15-year-old might look very different for a 25-year-old, when physical health, sexual function and fertility are likely to be more important and relevant to them than when they were 15. Does the Minister agree that two years is not a sufficient timeframe to properly evaluate the impact of puberty blockers on physical and mental health? If this trial goes ahead, will she commit to funding and ensuring that there is long-term follow-up of these children into adulthood?

Fourthly, how many children will the trial be limited to, and what criteria will be used to determine which children are eligible and which are not? Is it possible that all eligible children will be included and prescribed puberty blockers as part of the trial? How many children in total does the Minister expect to take part in the trial over its duration? How will the trial establish an appropriate control group? Fifthly, given that gender nonconformity sometimes correlates with same-sex attraction in adulthood, how will the trial safeguard those children who may simply be uncomfortable with their sexuality rather than experiencing true gender distress?

Sixthly, given the high rates of progression to cross-sex hormones following puberty blockers, will only children who agree not to progress to cross-sex hormones be accepted on to the trial, so that the impact of the puberty blockers on outcomes can be seen in isolation? If the answer is no, given the corresponding likelihood of impaired sexual function and loss of fertility, which are monumental ramifications, how will the children taking part in the trial be able to give consent?

Finally, will the Minister please provide details of other trials that have been approved for paediatric medical interventions with equivalent or similar diagnostic uncertainty, to reassure the public that moving forward with a trial in this situation has precedent? I look forward to hearing the Minister’s answers and thank everyone for attending this debate.

[Emma Lewell (in the Chair)]

I remind Members that this debate will run until five past 6. I will be calling the Front Benchers at 5.45 pm, so I ask Members to keep their contributions to five minutes.

--- Later in debate ---

[Rebecca Paul]

I will speak only briefly. I want to say a massive thank you to everyone who has spoken. To echo the words of the hon. Member for Macclesfield (Tim Roca), I appreciate the respectful and constructive tone. There have been some different ideas—not everyone is entirely on the same page—but we have all approached the debate in a way that is evidence-based and about sharing facts. It is very clear that everyone in this Chamber wants the best for our children. We absolutely share that objective.

I thank the hon. Member for Strangford (Jim Shannon) for his thoughtful contribution. We always tend to be on the same page about such issues. My right hon. Friend the Member for South Holland and The Deepings (Sir John Hayes) and I are also very much aligned in our thinking on this point. This is a really important debate. Very vulnerable children are affected by the issue, so it is important that we get it right.

I thank the spokespeople, the hon. Member for North Shropshire (Helen Morgan) and my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson), for their contributions. I also thank the Minister, who has taken a huge number of questions from me. She and her Department were very constructive in advance of the debate.

This debate is not political; it is about doing the right thing for our children. I am absolutely here to work with the Government and to support what they are doing to get us to that right position. If I can do anything to help, they should not hesitate to let me know. I thank the Minister for going through the questions, and I look forward to hearing the detail. I appreciate that some of the detail is not available yet, but will be forthcoming.

Question put and agreed to.

Resolved,

That this House has considered the potential impact of puberty suppressing hormones on children and young people with gender incongruence.

Hospitals

Rebecca Paul Excerpts

Wednesday 23rd April 2025 Commons Chamber

[Rebecca Paul (Reigate) (Con)]

I am grateful for the chance to speak in today’s debate and to be able to give voice to so many of my constituents’ frustrations about how their right to access quality healthcare has been deprioritised by this Labour Government.

Many of my constituents, especially those in the north of my constituency, are served by the Epsom and St Helier university hospitals NHS trust. To be blunt, the situation at the trust today is simply not sustainable—clinically, financially or structurally. The trust currently operates two acute hospitals, in Epsom and St Helier, with duplicate services spread across both sites. The arrangement, while a product of historical necessity, today places considerable pressure on clinical teams. Allocation of staff members between sites is challenging and service delivery is stretched. No matter how committed the staff—their dedication is beyond question—they are constantly being asked to do more with less, in buildings that are often quite literally falling apart around them.

To give just one brief example, earlier this year St Helier was forced to cancel scheduled blood tests because of widespread flooding in the phlebotomy section. We simply cannot go on like this. Indeed, time is not a luxury we have, with the estate now deteriorating faster than it can be fixed. The trust is spending millions every year simply to keep the most urgent problems at bay: patching leaks, coping with flooding, and addressing the worst outbreaks of damp and mould. I think we all agree that these are not the conditions in which 21st-century healthcare should be delivered.

That is why it was so disappointing to learn earlier this year that the planned specialist emergency care hospital in Sutton—a long-standing scheme under the new hospital programme that was carefully conceived to address the very issues I have mentioned—has been delayed to the point that work will now not even begin until 2030 to 2035, with opening coming in 2037 at the earliest.

The new hospital will consolidate emergency care into one state-of-the-art facility, delivering world-class treatment, faster access to care, and safer outcomes. At the same time, it will allow for major investment at Epsom and St Helier hospitals, helping to modernise crumbling buildings, improve planned care pathways and ensure that most services remain close to home. Under the trust’s plans, 85% of services would remain on the Epsom and St Helier sites, including out-patient care and diagnostic appointments. Local people would continue to receive the vast majority of their care where they always have done, but would benefit from shorter waiting times and access to better facilities, particularly for surgery. I passionately believe that the new hospital at Sutton is a once- in-a-generation chance to overhaul healthcare provision and ensure that my constituents receive the high-quality care they deserve in a timely fashion.

[Luke Taylor (Sutton and Cheam) (LD)]

The new Sutton hospital will sit in my constituency. In 2020, we were promised by the former Member for Sutton and Cheam that the hospital would open in 2025; indeed, he continues to have that claim on his website. Does the hon. Lady agree that the failure to deliver any new hospital in Sutton borough, whether at Belmont or St Helier, is entirely down to the failure of the previous Government to fund and bring forward these projects while they were in power?

[Rebecca Paul]

I can confirm to the hon. Member that if the Conservatives were in power, we would be delivering that hospital.

I want to be clear: the trust is ready to move forward, and clinical consensus has been secured; what is now urgently needed is commitment from the Government to drive the programme forward. After all, patients and staff alike deserve better than to spend another decade or more in facilities that are not fit for modern healthcare delivery. They deserve to know that promises made through the new hospital programme will be honoured, not quietly shelved or endlessly deferred by this Government.

I urge Ministers in the strongest possible terms to look again at the decision to delay Sutton emergency care hospital and to provide the long-term certainty the trust needs to proceed—not in 2035, but now.

Terminally Ill Adults (End of Life) Bill (Twenty-ninth sitting)

Rebecca Paul Excerpts

Committee stage
Tuesday 25th March 2025 Public Bill Committees

[Stephen Kinnock]

I think we are all moving in a direction where, if this Bill passes, we would like its delivery in England and Wales to be compatible, based on full respect for the devolution settlement and for the legislative consent motions. Divergence in the context of the devolution settlement is what the right hon. Lady is keen to achieve, and I think she is working with my hon. Friend the Member for Spen Valley to achieve that aim.

Amendment (b) to new clause 36 would provide that the Secretary of State must, by regulations, make arrangements for the provision of assisted dying services in England. The amendment would remove the provision that regulations under new clause 36 may provide that specified references to the health service in the NHS Act include reference to commissioned assisted dying services. Secondly, it removes subsection (5), which states that regulations under new clause 36

“must provide that section 1(4) of”

the NHS Act

“applies in relation to commissioned VAD services”,

which provides that health services must be free of charge unless exceptions apply. Finally, amendment (b) to new clause 36 explicitly provides that regulations made under subsection (1)

“may not amend, modify or repeal section 1 of the National Health Service Act 2006.”

If accepted, the proposed amendment may impact the provision of assisted dying services through the health service in England. The effect would be that section 1 of the NHS Act could not be amended, modified or repealed via regulations under new clause 36(1). The proposed amendment applies only to England, and the restriction does not apply to Welsh Ministers. This could result in a divergence between England and Wales in the provision of assisted dying services, as Welsh Ministers could amend section 1 of the National Health Service (Wales) Act 2006.

Amendment (c) to new clause 36 would limit the scope of the Secretary of State’s power in subsection (1) of new clause 36 to make regulations that secure arrangements for the provision of voluntary assisted dying services in England. Under this amendment, such regulations cannot authorise the provision of assistance by a body other than a public authority, even if that body is contracted by a public authority to do so. That would effectively prevent the NHS from contracting with private providers to provide assistance. The NHS regularly contracts private providers to provide NHS services. It is possible that being unable to do so here may present operational challenges. The amendment applies only to England, and the restriction does not apply to Welsh Ministers. That could result in a divergence between England and Wales in the provision of voluntary assisted dying services.

Amendment (d) to new clause 36 seeks to limit the Secretary of State’s power to amend, revoke or repeal other legislation for the purpose of making provision for assisted dying services.

[Rebecca Paul (Reigate) (Con)]

I am sorry to backtrack slightly, but I want to clarify that the Isle of Man is a Crown dependency and not part of the UK.

[Stephen Kinnock]

The hon. Member is absolutely right that it is a different situation from the point of view of devolution. Perhaps my answer was conditioned by the intervention of the right hon. Member for Dwyfor Meirionnydd, so I perhaps jumped to a conclusion.

--- Later in debate ---

[Kim Leadbeater]

The purpose of these amendments is to enhance the effectiveness and efficiency of the notification process within the context of the Bill and to ensure that the commissioner, who plays a key role in monitoring and reporting, receives the necessary information to fulfil their duties effectively. The amendments will empower the Secretary of State to make regulations that require registered medical practitioners to notify the commissioner of any events specified. This change is a critical step towards centralising the notification process and will ensure that the commissioner is directly involved in overseeing these events in a manner that supports the broader goals of the Bill.

Under the amendments, the Secretary of State will have the authority to make regulations that require medical practitioners to notify the commissioner and that grant the commissioner the power to request information. They are designed to enhance the commissioner’s ability to effectively monitor the operations of the Bill.

New clauses 38 and 39 are designed to facilitate the proper and secure exchange of information between the commissioner, various regulatory bodies and the Secretary of State in relation to the voluntary assisted dying framework. These provisions are critical to ensuring that the operation of the Bill is transparent, effective and within a secure, legally compliant framework.

New clause 38 seeks to create a structured system for the exchange of information between the commissioner and key bodies involved in healthcare regulation and oversight. This is an essential provision to ensure that all relevant parties can co-operate in the administration of the Bill and that the commissioner has access to the necessary data to fulfil their duties effectively.

New clause 39 addresses a critical issue regarding the disclosure of information under the Bill. It will ensure that information can be shared as required without compromising data protection laws or breaching confidentiality obligations; it seeks to ensure that while the Bill facilitates necessary data sharing, it will not override the existing protections for privacy and confidentiality. That is crucial both for the professionals and for the individuals involved in the processes established by the Bill.

New clauses 38 and 39 will ensure that the voluntary assisted dying commissioner can effectively share information with key bodies while maintaining strict adherence to confidentiality and data protection laws.

[Rebecca Paul]

I rise to speak briefly to amendments 172 and 173, in my name, but amendment 172 will fall if amendment 539 is voted through. The point of amendment 172 is to ensure that the commissioner has adequate data about important events. It turns a “may” into a “must”. It means that the Secretary of State must issue regulations requiring a doctor to notify the chief medical officer, or the commissioner as in all likelihood it will be, of any notifiable event.

--- Later in debate ---

[Kim Leadbeater]

I will double-check, but I am pretty confident that those reporting mechanisms are covered elsewhere in the Bill. I am very happy to confirm, but I think they are covered in clauses 7 and 8.

[Rebecca Paul]

It would be reassuring if that were the case because such data can be very useful. By making sure we get into the routine of providing it, it is there if we ever need it.

Amendment 173 provides that any regulations under the clause must be made under the affirmative rather than the negative statutory instrument procedure. In the interests of using our time well, I will not repeat the arguments that were made last week on this. However, if amendment 539 is accepted, the Bill will again defer a lot to ministerial powers and non-binding guidance and codes of practice. Under the negative procedure, Parliament is reduced to watching rather than properly participating in the decision-making process.

--- Later in debate ---

[Rebecca Paul]

It is a pleasure to serve under your chairmanship, Sir Roger. I rise to speak about amendments 518 and 520. As we have said, it is important that we understand what coercion means in a legal sense, and I am really grateful to the hon. Member for Penistone and Stocksbridge for trying to set that out, because it is not an easy task. Like her, I am concerned that defining it in this way may make it harder to prove coercion and may undermine the safeguards in the Bill.

Under the amendments, the assessing doctors and the panel are meant to look not just for evidence of coercion but for evidence of intent to induce assisted suicide, and they will have to show that the applicant is requesting assisted suicide against their will. That could make the law powerless against many kinds of behaviour that we want to prohibit.

To start with the point about intent, coercion and pressure take many forms, and they do not always involve a clear intent. Amendment (b) to amendment 518 and amendment (b) to amendment 520, in the name of the hon. Member for Lowestoft, very reasonably draw attention to family relationships. On Second Reading, the right hon. Member for Hackney North and Stoke Newington (Ms Abbott) said:

“people do not generally write letters to sick relatives urging them to consider assisted suicide and then put those letters on file. Coercion in the family context can be about not what you say but what you do not say—the long, meaningful pause.”—[Official Report, 29 November 2024; Vol. 757, c. 1030.]

But even in more blatant cases, we cannot necessarily prove intent directed towards assisted suicide. Sue Smith, a clinical psychologist, said in written evidence that coercive control often ramps up when the abused partner receives a cancer diagnosis:

“The seriousness of the cancer diagnosis may be systematically and actively denied or minimised, claims can be made by the male partner that she is attention seeking, or she is accused of making up the effects of treatment, and can be left isolated and alone when in physical need…a woman learns to doubt her reality and experience, and is extremely isolated. This can lead to heightened anxiety, hopelessness and helplessness, and abject despair, which can lead to a person wishing they were dead.”

That could be seen as coercion towards assisted suicide, but in that scenario does the abusive partner demonstrate clear intent? I am not sure the doctor or panel could demonstrate that in that instance, especially as they need to be satisfied only on the balance of probabilities that there is no coercion. If the panel think that there is a 45% chance that there is intent, but no more than that, they have to grant the application.

The harrowing story of Ryan Wellings and Kiena Dawes shows that even when coercion can be proved, proving that an abuser intends someone else’s suicide is a completely different matter. After Kiena Dawes took her own life, Wellings was convicted of coercive control and assault. The judge told him:

“from May 2020 until her death you abused, assaulted, exploited, controlled and demeaned her. When she died it is clear that she had begun to believe your lies to the effect that she was deranged, physically disgusting, friendless, worthless and an unfit mother. You had persuaded her that she had no one to turn to.”

Before her death, Dawes wrote a note saying, “Ryan Wellings killed me.” Although he was convicted on other counts, Wellings was acquitted of manslaughter. That demonstrates that coercive control, even if it is followed by suicide, does not always mean that intent can be demonstrated. It is really tricky.

Similarly, people may pressurise a relative without intending to override their will. The barrister Ruth Hughes KC, who has been quoted before, said:

“It is surprisingly easy for a relative, whilst completing a variation on ‘the classic asset strip’, to persuade themselves that they are actually acting in their aunt Dorothy’s best interests or in accordance with her wishes”.

In other words, someone can pressurise a relative into assisted suicide without intending to. Again, including intent here could actually muddy the waters.

I have a similar concern about the phrase

“against that other person’s will”.

That sounds very straightforward, but in practice it can be much less clear. Part of the effect of coercion is that people lose confidence in their own will and adopt that of others. In written evidence, many frontline workers pointed out that coercion does not always clearly appear as someone acting against their will. Janet Reiss, a specialist doctor in palliative care in Wolverhampton, says patients will not

“even necessarily be aware of being coerced”.

Dr Jennifer Hardes Dvorak, a senior lecturer at Canterbury Christ Church University specialising in medical law, states that the Bill

“does not consider how people internalise feelings of coercion and…act on this.”

If someone has internalised a feeling that they would be better off dead, that may be their will, even if we hope we could change it.

Anni Donaldson, a domestic abuse expert at the University of Strathclyde, said:

“Decades of work examining the impact of coercive and controlling behaviour has shown that ‘coercive control’ is not merely persuasion, but a complete change in the perspective of the victim so that she truly believes that she is worthless, a burden to her partner or wider family, and would not be missed should she die…Women are regularly humiliated, demeaned, and told they would be ‘better off dead’, or, that they are a ‘useless mother’, or that the children would be better off without them. This abuse erodes women’s confidence, autonomy, and self-esteem. Cut off from support, women often come to believe these lies, fearing reprisals from their partner if they report the abuse, many choose to tell no one. This long term, relentless, dehumanising process can result in a woman believing that she is ‘disposable’.”

Similarly, the writer and campaigner Sarah Ditum warns that the Bill may not protect

“the patient who, through lengthy cruelty and coercion from a partner or carer, becomes genuinely convinced that she (or sometimes he) is a burden who would be better off dead. Such a person may even refuse treatment, causing a curable disease to become terminal and placing them within the purview of the bill.”

So we might not believe that assisted suicide is in someone’s best interests, but there is no best interest test in the Bill or the amendments—just a reference to the person’s will. If a victim of coercive control truly believes they ought to die, it is not clear how the doctor or the panel can refuse their application, unless coercion can actually be proved, and proving it is not always easy, as we have just discussed.

My hon. Friend the Member for East Wiltshire has tabled amendments to remove the phrase

“against that other person’s will”.

Obviously, that is all academic now, as we are not pressing the amendment to a vote, but I would support doing that, because that phrase does more to narrow the definition than anything else.

On another point, amendments 518 and 520 refer to pressure and coercion from organisations. I do not know exactly what the hon. Member for Penistone and Stocksbridge has in mind with that. I guess an example might be the cases we have heard about in other jurisdictions where a health insurer or provider tells someone that they cannot fund a treatment but can fund assisted dying options. It could be that the hon. Lady had other things in mind there. That would possibly count as pressure under some circumstances, but it would be very hard to show that there was intent on the part of the organisation. It is not clear that the amendments help us to identify and avoid coercion and pressure in that sense.

Before I finish, I would like to point out something else that might be missing from the amendments: it is my favourite topic, the question of undue influence—my apologies to the Justice Minister, because I know we have gone over it a few times.

[Dr Tidball]

Just to put this one to bed, which is where we all need to go at this stage, I did seek advice from those that have worked in this field, and it is not a concept used commonly in the criminal law. It is instead used in the law of equity and would not be as relevant in this context. There were other, sharper elements that could make up this concept of coercion that were better and more well understood in the context of the criminal law.

[Rebecca Paul]

I thank the hon. Lady for that clarification of the information she has been given.

We have gone over the question of undue influence a few times. I promise I will not talk about it for much longer, but it is relevant, which is why I keep raising it. In a judgment that my hon. Friend the Member for Solihull West and Shirley has previously mentioned, Lord Nicholls said that undue influence includes two things. The first is

“overt acts of improper pressure or coercion”.

The second is a kind of influence that

“arises out of a relationship between two persons where one has acquired over another a measure of influence, or ascendancy, of which the ascendant person then takes unfair advantage...The influence one person has over another provides scope for misuse without any specific overt acts of persuasion. The relationship between two individuals may be such that, without more, one of them is disposed to agree a course of action proposed by the other.”

That definition suggests something broader than what is described in amendments 518 and 520, but I take the point that the hon. Member for Penistone and Stocksbridge has just clarified. The amendments suggest that somebody will actively interfere with someone else’s “decision-making autonomy” and have an intention to induce them to do something. But Lord Nicolls’s definition of undue influence is much less dramatic; it just identifies a relationship where one person’s view holds a lot of sway. For the last time—I promise—I would be grateful for the Minister’s view on that. I am sure she will talk through that point and advise on the clarification the hon. Lady has just given.

In conclusion, the amendments are completely well intended. It is helpful that the hon. Lady tabled them and that we have had this debate, and I am grateful to her for that. However, I am inclined to think that they would narrow the definition too much. My preference would be to remain with what we have, subject to the points I have raised many times on undue influence.

[Dr Tidball]

Does the hon. Member agree that it is helpful to have it on record that we have evaluated these concepts from all sides, but determined that putting them in the Bill is not the right thing to do and would be too restrictive at this point?

[Rebecca Paul]

I would not choose to have this specific definition in the Bill. There may well be another definition that I would be more comfortable with, so I cannot rule that out. However, I completely agree with the hon. Lady that this has been a helpful debate, and I really appreciate her tabling the amendments so that we could have it.

[Sarah Sackman]

Bear with me one moment, Sir Roger. I have just had a message, and I want to see whether it is relevant to what I want to say. Forgive me.

--- Later in debate ---

Brought up, and read the First time.

[Rebecca Paul]

I beg to move, That the clause be read a Second time.

The new clause would make the advertising of services by a co-ordinating and/or independent doctor by a person in the course of a business an offence with a sentence of up to two years in prison or a fine or both. As we have discussed previously, we will likely see private provision of assisted dying services, if the Bill is approved. That will create a potentially lucrative opportunity for private businesses, particularly if provision on the NHS is not consistent across the country or is overwhelmed.

“Advertising” means the techniques used to bring attention to a product or service with the aim of presenting it as something a potential customer might need or want. The overarching aim of advertising by a business is to ultimately sell more of a product or service. We must keep that overarching reason in mind when considering the amendment. It would be incredibly inappropriate for such services to be advertised on billboards, public transport or daytime telly, targeting those who may be approaching the end of their life, with ads run repeatedly along with those for stairlifts and life insurance. Such advertising could also undermine our national suicide prevention strategy by normalising suicide in certain situations. It becomes much harder to say to people that suicide is not the answer if we are content to say that it is in certain situations.

I can only imagine some of the difficult conversations that could be generated from an advert seen by a young girl or boy already battling with suicidal thoughts. How does a parent or guardian explain why suicide is not right for them? Imagine the potential impact on men, too. As we all know, suicide is a leading cause of death in men in this country. In 2022, for males between the ages of 20 and 34, one in four deaths was categorised as “intentional self-harm” or “event of undetermined intent”. That is a shocking statistic. That is why banning the advertising of such services is so important.

[Dr Neil Shastri-Hurst (Solihull West and Shirley) (Con)]

My hon. Friend is making an passionate argument. I think most of us would agree that billboards and television adverts would be egregious. I note that subsection (3) talks about “electronic form”. That could involve email correspondence between parties. How would that not be an advertisement under the amendment?

[Rebecca Paul]

I think we would be talking about an advert via electronic form, marketing a particular service. We would have to go back to the meaning of “advert” to answer that. Obviously, there are broader ways of advertising on social media and so on, which I also seek to prevent with the amendment.

That is why banning the advertising of such services is so important, so that a pro-suicide message is not inadvertently delivered to millions of people who assisted dying is not appropriate for. We have to recognise that there are vulnerable people out there who could be influenced by it. It is my view that conversations about assisted dying should happen in person, between the relevant doctor and the patient; they should not be prompted by a TV ad or something seen on a bus. Ads should not be coming up on someone’s Facebook feed every time they log on.

I hope Committee members will support this common-sense amendment. I think that for it to be properly effective, it needs to be expanded to also cover clinics or other organisations advertising assisted dying services more broadly. I very much welcome the opportunity to work with Ministers and the Bill’s sponsor to get this right, if the Committee is disposed to supporting such an amendment.

[Naz Shah]

Does the hon. Lady agree that banning advertising also mitigates the issue of advertising to young people? She mentioned young people and suicide from a social media perspective. Young people, or anybody else who has an eating disorder, may see that as an option to enable them to qualify for assisted dying. That is because, under the Bill as it stands, they would qualify for it if they were termed terminally ill due to their eating disorder.

[Rebecca Paul]

I completely agree. That is exactly what the amendment is intended to do. We are trying to prevent advertising of an inappropriate service to inappropriate groups. It makes sense, therefore, to effectively ban advertising. I think most people would agree that it would be distasteful and inappropriate to have adverts for assisted dying everywhere people look. I hope that hon. Members will consider supporting the amendment, even if that is in an amended form.

[Lewis Atkinson]

I have great sympathy with the intent behind the amendment, and I would like us to get it into a workable form. The hon. Member for Reigate may wish to confirm this, but there is a similar offence in the Surrogacy Arrangements Act 1985—the advertising of surrogacy arrangements is an offence. The important difference in the Surrogacy Act is that there are some further caveats beyond those in the draft amendment— for example, to ensure that there is not inadvertent creation of offences of the type that the hon. Member for Solihull West and Shirley mentioned. The Surrogacy Act sets out that resulting prosecutions would be carried out only with the approval of the Director of Public Prosecutions, to ensure that such safeguards were in place. Although I await the Minister’s comments, I do not think it is possible to support new clause 9 in its current form, for the reasons that the hon. Gentleman lays out.

We have set out that there will potentially be a small number of doctors providing these services. A GP—not a member of the public—would need to know where to direct their patient. I cannot see how, other than by having some form of electronic directory or email correspondence, it would be possible for such people to become available.

I am not able to vote for the new clause at this stage, but I will put it on my notepad of things on which I am keen to work with colleagues on Report, perhaps by learning the lessons from the surrogacy advice and taking advice from Minister. I think we all agree that we should not be advertising to the general public and encouraging these services.

[Kim Leadbeater]

New clause 9 specifically relates to the advertising of assisted dying services. I fully understand the intent behind it—to prevent the unethical advertising of assisted dying services. I thank the hon. Member for West Worcestershire (Dame Harriett Baldwin) for bringing the issue to the Committee’s attention. However, there are important nuances with the new clause as drafted that need to be addressed, to avoid criminalising individuals or organisations simply for providing information that is essential for those seeking access to those services. I have looked into this issue because it is an important point for the Committee to consider.

Section 4 of the Cancer Act 1939, a useful reference point, bans advertising for cancer treatment. It prevents the advertising of any treatments, regardless of whether they are evidence-based. Similarly, as my hon. Friend the Member for Sunderland Central mentioned, the Surrogacy Arrangements Act 1985 prohibits the advertising of surrogacy services. Both Acts are aimed at protecting individuals from misleading or unethical commercial activity.

The situation with assisted dying is more complex. The new clause is not about advertising unregulated or unproven services; it is actually about doctors who are offering a legal, regulated service to those who meet the criteria. I therefore have the same concerns as the hon. Member for Solihull West and Shirley.

Subsection (3) states:

“Distributing an advertisement includes transmitting it in electronic form, participating in doing so, and providing the means of transmission.”

That is particularly concerning because it could criminalise doctors involved in the process of simply communicating with their patients, such as by sending an email, if they were seen as participating in the distribution of an advert.

The intent is clear: we must prevent the unethical advertising of assisted dying services. However, we must ensure that the new clause does not inadvertently hinder access to legal services by criminalising the actions of doctors who are simply making themselves available in accordance with the law. We must not create barriers for those who need the service, nor should we penalise doctors for providing legitimate, legal services. I recognise the need to prevent the unethical advertising of assisted dying services, especially to avoid commercial exploitation or coercion, but it is essential that we carefully calibrate the clause to ensure that it targets unethical advertising practices without sweeping in legitimate and necessary actions that help people find the care they need in a manner that is lawful and respectful of their autonomy. As such, I am very happy to work with colleagues, including the hon. Member for Reigate, to look at how we can produce something to that effect ahead of Report.

[Rebecca Paul]

I thank everyone for all the very constructive points they made. I completely agree with the points raised; I think some work is needed, but I am pleased that the hon. Member for Spen Valley and other Committee members are willing to work with me and the tabling Member—my hon. Friend the Member for West Worcestershire—to get this measure into a place where it does what we want it to do, without capturing things that we do not want it to capture. I completely take the point on the concern about emails; that is not what we want to capture.

[Kit Malthouse]

My hon. Friend is making a good point, but I want to make a constructive suggestion. It might be worth our having a look at Switzerland, where advertising is actually banned but the provision of information is not. It is a fine line, but the Swiss seem to get the balance right.

[Rebecca Paul]

I thank my right hon. Friend for that point. He is absolutely right that we can learn from what other jurisdictions have done, leverage that and create an amendment or new clause that works for what we are trying to achieve, and know that it will target the advertising that we seek to target.

[The Chair]

Does the hon. Lady wish to press new clause 9 to a division?

[Rebecca Paul]

Given the spirit of it, I feel like we should. That does not prevent me from tabling it on Report—so yes, I will press it to a vote.

Question put, That the clause be read a Second time.

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[Danny Kruger]

I beg to move, That the clause be read a Second time.

This will be my last speech in this Committee, so before I speak to the important principle expressed in new clause 34, may I thank you, Sir Roger, and all your colleagues who have chaired the Committee? I also thank the Clerks, who have done a huge amount of amazing work behind the scenes, and all members of the Committee; I particularly thank the hon. Member for Spen Valley for her good faith and good nature throughout the process. I have great respect for all Committee members. A particular hero was the hon. Member for Southgate and Wood Green, who was the most popular speaker every day. [Laughter.] I am looking forward to his final speech.

I pay tribute to all those hon. Members who did not serve on the Committee but contributed to our debates by tabling amendments; I really am encouraged by many of them. I pay particular tribute to the hon. Member for York Central, who has been a very powerful influence on me and has attempted to do very good work with the Committee. I also wish to mention my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer). Perhaps in sympathy with the hon. Member for Harrogate and Knaresborough, the most liberal member of the Committee, he has attempted to create an assisted dying Bill that does justice to the principles of autonomy behind it.

My new clause reflects my hon. Friend’s conception of the Bill. His amendments would have taken assisted dying out of the NHS, and indeed out of healthcare altogether. He was right to try to do that. If we are to do this thing, we should recognise that what we are proposing to legalise is not healthcare. Indeed, new clause 36 recognises the essential incompatibility between the service proposed here and healthcare as it is traditionally understood in our country and enshrined in the NHS Act.

More than that, the foundations of healthcare in the west are contravened by the Bill. The Hippocratic oath contains the promise:

“Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.”

That is the oath that doctors take, and it has been the ethical basis of medical practice in the west for millennia. The Bill would be the final, official abandonment of that ethical tradition.

I implore the Committee to reflect on the essential principle that healthcare is the antidote to sickness, whereas this proposal for assisted suicide is the antidote to life. That is the treatment that the Bill proposes to legalise. It is entirely different from healthcare, in principle and in practice. It is therefore no surprise that so many of the professional bodies involved in healthcare regard this proposed treatment as incompatible with their professions. The BMA agrees that this should be a separate service.

I was struck by a BMJ article that appeared last November, “Reframing assisted dying through the civil law: possibilities and challenges for the UK”, which was written by a group of palliative care professionals. It sets out how, if assisted dying is to be legalised in this country, it might best be organised and delivered. New clause 34 and all that flows from it would enable us to design a better assisted suicide service than the one that the Bill would give us.

The hon. Member for Spen Valley this morning and the hon. Member for Sunderland Central this afternoon asked how it should be done, if we are to do it. My hon. Friend the Member for Reigate offered some suggestions. I will build on what she said by saying how I think the Bill should have been framed—indeed, how I and others, through the amendments we have tabled, have tried to ensure it is framed.

We have tried to match the Bill to the campaign for assisted suicide. Understandably, there is considerable public support for people at the end of their life, who are at risk of suffering a terrible, agonising death and whom palliative care cannot help, to have the right to end their life a few days or weeks early. We can argue about how many people that is. I think the number of people whom palliative care could not help if we organised our palliative care system properly is infinitesimally small—almost non-existent. However, we disagree on that, so let us assume that there are some people who will fall into that category. The campaign for this Bill is the campaign for those people to have the right to an assisted death, but that is not what we have in the Bill. What we have is a right for anybody who in the opinion of two doctors might reasonably be expected to die within six months to request and receive lethal drugs, all paid for and assisted by the NHS. That is not what the campaign has been for.

Let me suggest how, if we are to be honest to the campaign, we should design this thing: not as healthcare, but as a compassionate suicide service for people facing physical agony at the very end of their life. As we tried to ensure at the beginning of our deliberations, eligibility would be for people fearing pain, not for those feeling a burden. There would be a proper capacity test, not the Mental Capacity Act 2005 test. There would be proper, meaningful safeguards against coercion. We would have doctors and a multidisciplinary team at the right stage of the process: right at the beginning, at the first assessment. We would have all the appropriate signposting and palliative care provision as an alternative to assisted suicide. We would then have a proper judicial process to decide whether to approve the application.

As for provision, from assessment through to the final act it should not be in the NHS. It should not be provided by any profit-making providers advertising their services and receiving money for every death that they assist, which is what we have probably got with the Bill. It should be provided by non-profit organisations, should be tightly regulated and should be funded not through NHS commissioning or by the patients, but by philanthropy.

The scale of all this is to be discovered, I guess, if we pursue the Bill. It has been suggested that the lower end of the expectation is about 6,000 deaths per year. On the calculations made by the experts in the paper I cited, it would need a budget of about £10 million a year to manage a 6,000-person caseload. That is in the ballpark of what the campaign groups promoting the Bill have been spending, so I do not think that there would be any difficulty in raising that sort of money if it is what people want. After all, hospices have to raise millions of pounds every year to fund their work. I do not see why assisted dying services should not be able, and required, to do the same thing.

There was a way to do this more consistently with the campaign for assisted suicide. For the avoidance of doubt, I would have opposed that too, because even that much more honest and tightly circumscribed service would profoundly alter our society—it would send the signal that some people are better off dead, and I think it would be wrong for our country—but at least it would be honest. It would be consistent with the campaign.

I will end with the observation that what I have just described is what I think the public think the Committee is doing: designing a service like that for the small number of people at the very end of their life who are facing a terrible physical death. That is not what we have done, it is not what the Committee has approved, it is not what the original Bill said and it is not what the Bill now says as we send it back to the House. I hope that the public and our colleagues in Parliament will recognise that this Bill is not the one that they thought they were getting.

[Rebecca Paul]

I rise to support new clause 34, which clarifies that assisted dying is not a medical treatment—not only because of the principle behind it, which I have talked a lot about already, but because of the unintended results. We need to recognise that many laws, rules and regulations have been written using the word “treatment” that never envisaged assisted dying being included. Every bit of law that refers to when treatment can be given, with or even without consent, such as section 63 of the Mental Health Act 1983, will become a potential problem if assisted dying is technically viewed as a medical treatment. New clause 34 is therefore essential to protect the meaning and integrity of the current law and to protect patients in future.

In written evidence, Professor David Jones points out that there are dangerous consequences to classifying death as a medical treatment. As a general principle, he observes:

“If an effective medical treatment cannot be self-administered orally then other routes should be considered, including those administered by a healthcare professional.”

We can immediately see the problem that will arise if assisted dying is a treatment. The view that such a treatment can be administered by a healthcare professional suddenly moves us into euthanasia territory, which is clearly not the intention of the Bill. Professor Jones goes on to say:

“If a treatment effectively reduces distressing symptoms in one category of patient (adults at the end of life), then it should be considered for treating other categories of patient”.

If we substitute the word “treatment” with “assisted dying”, we get a wholly unacceptable approach that could open the way to offering assisted dying to under-18s, as in Belgium, or to people whose psychological suffering is unbearable, as we have seen in Belgium and the Netherlands with the euthanasia of people with mental health conditions. Finally, Professor Jones says:

“Where a patient does not have capacity to consent to medical treatment then doctors should provide whatever treatment is ‘of overall benefit’ to the patient.”

If we substitute the same words, we can see that once again it leaves us with a big issue.

The Bill already has requirements relating to capacity, age and physical illness, and a requirement for self-administration, but the point is that by classifying assisted dying as a medical treatment we are making those requirements less stable and introducing the potential for conflict within the existing law. We are inviting future Parliaments to question why they are there in the first place. Why arbitrarily restrict this medical treatment when we do not restrict other treatments in the same way?

If we do not rule out assisted dying as a medical treatment, we are potentially opening the Bill up for challenge by the courts when assisted dying treatment is limited to certain groups. That is one reason why the Association for Palliative Medicine has explicitly backed the principle represented in the new clause. It has said in written evidence that defining death as treatment would be

“contrary to all prior medical practice and public expectation, and laden with risks of unintended consequences.”

The Bill may look set in stone, but the law can easily be amended in future, for instance by amending a major health Bill. What we decide in this Committee could have major consequences in a few years’ time. I urge that we future-proof the Bill now by explicitly declaring in it that assisted dying is not a medical treatment, so that the issues I have set out will not arise at any point.

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[Kim Leadbeater]

We are entering deeply philosophical territory, which is welcome and has happened several times before during the Committee’s proceedings. As ever, the hon. Member for East Wiltshire has raised some interesting points, but my view is that his new clause should not be in the Bill. We all have our views on how we frame assisted dying and choice at the end of life, but I do not think that assisted dying should be defined—or rather not defined—in this way in the Bill.

[Rebecca Paul]

Will the hon. Lady give way?

[The Chair]

The hon. Member for Spen Valley is entitled to respond if she so chooses, but I think she has sat down.

Terminally Ill Adults (End of Life) Bill (Twenty-fifth sitting)

Rebecca Paul Excerpts

Tuesday 18th March 2025 Public Bill Committees

[Stephen Kinnock]

One of the fundamental principles of the Bill, which my hon. Friend the Member for Spen Valley has prioritised, is self-administration. It is not for me as a Minister to opine on that; it is simply there in the Bill. Once that fundamental principle is established, it is about defining what “assistance” means, compared with what “self-administration” means. As I was setting out, I think “assistance” can mean things like helping the patient to sit up; it does not mean actually administering the substance to the patient. It is about the dividing line between assistance and self-administration—hence the term “assisted dying”, I suppose, which is very different from the doctor actually administering the substance.

[Rebecca Paul (Reigate) (Con)]

I am going to read subsection (6)(c) again. It says:

“assist that person to ingest or otherwise self-administer the substance.”

I would interpret that slightly differently from the Minister. It talks about ingesting, which suggests the substance entering the body, so I would not suggest that sitting someone up would qualify. That in itself shows that perhaps there is some ambiguity here. The Minister has set out something that I had not read into the Bill. Will he comment further on that?

[Stephen Kinnock]

I will pretty much repeat what I have just said to my hon. Friend the Member for Ashford. There is a dividing line, as the Government see it, between assistance and administration. There is a dividing line between making the patient comfortable, enabling the procedure to take place, and the doctor actually putting the substance into the body of the patient. From the Government’s point of view, simply from the position of having a picture of the process in our mind, that dividing line is clear enough in the drafting of the clause.

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[Stephen Kinnock]

In order to ingest, there has to be self-administration. The self-administration is the precondition for ingesting the substance. That is my reading. I hope that that satisfies my hon. Friend.

[Rebecca Paul]

The Minister is being incredibly patient with our questions. The question from the hon. Member for Ashford raises exactly the point with which I am uncomfortable. To me, the phrase

“assist that person to ingest”

means something else. I am really concerned that it could be interpreted differently from how the Minister has laid it out. I want to place that on the record and raise that issue, which I believe the hon. Member was also raising.

[Stephen Kinnock]

The hon. Member’s concerns are absolutely noted. I completely understand that hon. Members are not comfortable with this, but what I am trying to do is set out the Government’s view on the workability of what my hon. Friend the Member for Spen Valley is seeking to achieve and the basic principles on which that is built.

Amendment 497, on which the Government have worked jointly with my hon. Friend, would amend clause 18(11), which states:

“Where the person decides not to self-administer the approved substance, or there is any other reason that the substance is not used, the coordinating doctor must remove it immediately from that person.”

Under the clause as it is currently drafted, there could be difficulties in relation to the duties of the co-ordinating doctor where the co-ordinating doctor does not know what the person has decided. Amendment 497 seeks to resolve that ambiguity by clarifying that the duty on the co-ordinating doctor to remove the approved substance applies where the person

“informs the coordinating doctor that they have decided”

not to self-administer the approved substance.

I turn to amendment 498. At present, clause 18(11) provides that the co-ordinating doctor has the duty to immediately remove the approved substance where the person decides not to self-administer the approved substance, or there is any other reason that the substance is not used. The amendment clarifies that the duty to remove the substance arises when the co-ordinating doctor believes that the substance will not be used. I hope that those observations have been helpful to the Committee.

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[Danny Kruger]

I hope the hon. Gentleman is right. Nevertheless, one of my concerns about the Bill is that we are leaving enormous areas of clinical practice, and regulated conduct for the professionals involved in assisted suicide, to be performed under guidance that is still to be set out and that it is the job of future Ministers to determine.

I pay tribute to the hon. Gentleman, because he has correctly identified a group of patients for whom the drafted Bill may present obstacles to the fulfilment of their wish for an assisted death. My belief is that the ability to assist will probably cover almost anybody who wants it and has found a doctor who wants to help them, but the hon. Gentleman is right that there are some groups for whom that might be more of a challenge than others. I think the answer we are going to get—it is one made by hon. Members in the debate already—is that technology will fix it, and I fear it will, because I think we are going to find ourselves in a world in which it is perfectly possible for the administration of death to be enabled through some kind of technological device, which somebody with the most limited physical mobility will nevertheless be able to activate.

I fear the insistence that we have on self-administration. Although we can all acknowledge, as referenced in the previous debate, the conceptual difference between administration and self-administration, we do have this idea that we are individuals cut off from each other and that there is an essential gap between us and other people. At the very end of life, though—in the moments that we are considering and legislating for—that distinction is void, because we are intimately connected with other people, as per the clauses that we are debating. I fear that we are going to find ourselves in a world in which a laptop will be set up and even a movement as small as the blink of an eyelid by the patient will be enough to trigger what will be called “self-administration” of the fatal dose.

I oppose this group of amendments, moved by the hon. Member for Harrogate and Knaresborough, because I do not believe in assisted suicide. I do not understand why other supporters of the Bill are not following the hon. Gentleman’s lead, and acknowledging that if we believe in autonomy and assisted suicide, of course we should enable patients to have the final act performed upon them, rather than insisting on this arbitrary distinction that it is possible to insist on self-administration in all cases.

[Rebecca Paul]

It is clear that the hon. Member for Harrogate and Knaresborough is trying to create equity, which we all understand. We need to think about the patient on the one hand, but also the doctors, nurses and medical practitioners involved. Does my hon. Friend agree that we need to think about the obligation and impact of such amendments on them?

[Danny Kruger]

Yes. We discussed this briefly this morning. There is an important consideration about the effect on medical staff involved in the administration of assisted suicide, and we have to make sure that those who do not want to participate are properly insulated from any sort of obligation, which I know is the intention of the Bill’s promoter, the hon. Member for Spen Valley. Nevertheless, I am concerned about the knock-on effect of participation in assisted suicide spreading across a practice. I agree with my hon. Friend that we have to be mindful of the impact on doctors. The more we widen the scope—as logic compels us to do, as the hon. Member for Harrogate and Knaresborough suggests—the more it is about not just discretion, but an obligation on doctors to approve.

We need to think about the conversation that doctors will be required to have with patients who are expressing that wish. If the Bill is widely drawn, as it would be if we were to accept these amendments, there is more opportunity for a doctor to feel compelled to assent to a request.

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[Dr Opher]

I thank my hon. Friend for his experience in a clinical setting. I would remind everybody that in the Bill we are trying to help people die in a comfortable way, and I do not feel it is the Bill’s job to define exactly how we treat nausea or abdominal obstruction and so on. What we would like to do here is ensure that a patient has a pain-free death, and a death that they are in control of.

[Rebecca Paul]

rose—

[Dr Opher]

I will make a little progress and will then take my hon. Friend’s intervention.

On amendment 436, all medical practitioners are required under their code of practice to record any event they come across. I feel there should be better data and I agree with the hon. Member for East Wiltshire that we need to collect data. We are actually very good at doing that in the NHS. Under clauses 21 and 22 there are provisions for the Secretary of State to collect data on complications. I am therefore not sure that particular amendment tabled by my hon. Friend the Member for York Central is necessary. I think I have covered amendment 464, from the hon. Member for East Wiltshire.

On amendment 429, about the doctor being in the same room, I totally understand the anxieties presented by my hon. Friend the Member for Bexleyheath and Crayford, but I feel that whether the doctor is there should be the choice of the family and the patient. There may be some confusion about this, but to me, what the Bill implies—I am interested to hear the Government’s opinion—is that the doctor should deliver the medicine to the patient, check that the patient is willing to take the medicine as per amendment 462 from the hon. Member for East Wiltshire, give the medicine to the patient, and then ask the family whether they want them to be there or in the next room. They need to be available, but do they need to be in the same room? I think that should be the choice of the family.

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[Stephen Kinnock]

My job and that of my hon. and learned friend the Justice Minister is to defend the integrity and coherence of the statute. The concern that we have with the word “complication” is that it is a wide-ranging term and concept, and its inclusion could potentially undermine the integrity of the legal coherence of the Bill and how it could be interpreted in terms of its implementation. I am simply flagging the risk that if the Committee chooses to accept the amendment, there could be a muddying of the waters in terms of its meaning in law.

[Rebecca Paul]

Following on from the point made by the hon. Member for Bradford West, has the Minister taken into account the guidance on private Members’ Bills? It says exactly what the hon. Member has just set out: the spirit of amendments should be taken, and it is for the Government to ensure that the integrity of the statute is respected with the final version. That is to allow a free-flowing discussion and to ensure that we capture everything we need to in the Bill, in the light of the fact that many of us are not lawyers or experts.

[Stephen Kinnock]

Absolutely, if the Committee chooses to accept the amendment, it goes into the Bill. If the Bill gets Royal Assent, it becomes the responsibility of the Government to ensure that the Bill, as passed by Parliament, is implemented in the best possible way.

The hon. Lady is right that the Government’s responsibility is to take on whatever passes through Parliament and implement it to the best of our ability. My job in this Committee is to raise concerns about risks of amendments that could potentially muddy the waters more than other amendments, or more than the Bill as it currently stands. It is a balanced judgment about whether we are better off with the Bill as it currently stands, whether the amendment would improve the Bill, or whether it could lead to concerns about the integrity of the statute if it were included.

[Rebecca Paul]

I thank the Minister for that explanation. I suggest it would also be appropriate for him to set out the changes that could be put in place in order for the amendment to work in that way. To my mind, that would give the true neutrality that he is seeking to achieve. Rather than set out why something does not work, he could set out how it could work in order to deliver the spirit of the change.

[Stephen Kinnock]

I think what I am saying is that the word “complication” contains a multitude of potential interpretations and meanings. The work that would need to be done by the Government to unpack it and understand what it means certainly could be done if the amendment passes, but the Government are saying that, as it stands, it is not clear. The drafting of the amendment is so ambiguous that it causes the Government concerns about its inclusion.

--- Later in debate ---

[Naz Shah]

I rise to speak to amendment 499, tabled by my hon. Friend the Member for Spen Valley. Let me outline what the amendment does and why I believe that it provides an inadequate safeguard. Under clause 19, the co-ordinating doctor may authorise another doctor to provide assistance—meaning that they will help the patient to take the lethal drugs. For clarity, I will refer throughout my speech to this other doctor who may step in to provide lethal drugs as the second doctor.

Under clause 18(4), the co-ordinating doctor must be satisfied of three conditions before they proceed to assist the person to take lethal drugs. Those three conditions are that the person has a clear, settled and informed desire to end their life, has capacity under the Mental Capacity Act 2005, and is not subject to coercion. Implicitly, the co-ordinating doctor can therefore end the procedure if they are not satisfied that those conditions apply. Under clause 19(3), the second doctor has the same duty as the co-ordinating doctor to be satisfied of those conditions before the assisted dying procedure can go ahead.

Amendment 499 would impose a new duty on the second doctor: if they suspected coercion, lack of capacity or lack of clear, settled and informed desire, they would have to inform the co-ordinating doctor. I suggest that the amendment does not take things far enough. It is a very serious matter if any doctor, be it the co-ordinating doctor or the second doctor, suspects coercion, lack of capacity or lack of desire. That means that a very serious mistake may well have been made, and that mistake could lead to someone having an assisted death who should not have qualified for it.

There should be several more safeguards in this part of the Bill. First, let us consider a situation where there was no previous suspicion that a patient had been coerced but where the doctor now suspects that they may have been. There should be a proper system of notification for such cases. It is true that doctors have a duty of care for patients, but it is also true that, given our overstressed, underfunded social care, health and policing systems, difficult cases sometimes fall through the cracks. The Bill should have a clear system for an authority to check back with the social care authorities and a person’s GP to make sure that steps are being taken to protect them from potential coercion. Secondly, the report that the second doctor makes in those circumstances should go to not only the co-ordinating doctor, but the voluntary assisted dying commissioner. Thirdly, when that happens, the commissioner should investigate the incident.

To repeat: if a doctor originally assessed a patient as qualifying for an assisted death, but a second doctor could not support that assessment, that is a serious incident that could lead to the assisted death of someone who should not have qualified for it. That does not mean that the co-ordinating doctor was necessarily at fault—not at all. The co-ordinating doctor will have been taking very difficult decisions under considerable stress. However, it does mean that the proper authorities should investigate the initial assessment, whether it was wrong and, if so, why it was wrong.

We see something similar with the Air Accidents Investigation Branch, which investigates not only accidents, but near misses that could have caused serious accidents. It does not assume fault when it investigates near misses. Often, it finds that there has been no human error. However, it has a statutory duty to investigate serious near misses. That is because the law passed by this House recognises that we need to understand why they happened in order to prevent fatal accidents from ever happening in the future.

For that reason, I do not think that my hon. Friend’s amendment is sufficient to fix the problems with this part of the Bill. I hope we can think about how better to address those problems, but I cannot support the amendment.

[Rebecca Paul]

I rise to speak in support of amendment 408, in the name of the hon. Member for Broxtowe. I also support amendments 499 and 210, in the name of the hon. Member for Spen Valley, and amendment 22, in the name of the hon. Member for Lowestoft (Jess Asato).

Clause 19 states that

“the coordinating doctor may authorise, in writing, a named registered medical practitioner to carry out the coordinating doctor’s functions under section 18…A registered medical practitioner may be authorised under subsection (1) only if…the person to whom the assistance is being provided has consented, in writing, to the authorisation of that practitioner”.

I support amendment 408, which adds that the person must also have been consulted.

I am sure the Committee recognises that, even where someone has basic training and the experience specified, delegating care at the end of life is something that must be done with great care, given the vulnerability of patients. If a co-ordinating doctor has guided someone through this profound and significant process, there are some intrinsic risks that come with delegating the administration of the final approved substance to someone else. I concede that there will be situations where a substitute may be required, but it will not be the doctor that the patient has trusted, confided in and relied on.

A new doctor will of course do the final checks for capacity and consent, but they do not necessarily have any specific detailed knowledge of the patient and may be unable to pick up less obvious cues that someone who knows the patient may be better able to. That gap matters, and history shows that it can lead to problems. The risks of delegation are well documented. If we take the Mid Staffordshire NHS foundation trust scandal in 2005 to 2009, detailed in the Francis report, consultants often delegated tasks to junior staff or nurses without adequate supervision, which contributed to poor care and an estimated 400 to 1,200 excess deaths. Patients suffered from neglect, untreated infections, dehydration and medication errors. That was partly because delegated staff lacked the training or authority to act decisively, and consultants failed to monitor effectively.

In surgical contexts, delegation can also falter. A 2006 Daily Mail report highlighted NHS payouts exceeding £1 million for wrong-site surgeries, where consultants delegated preparatory or operative tasks to trainees or assistants, who then misidentified sites—for example, operating on the wrong leg or tooth. Those errors often stemmed from inadequate briefing or supervision, pointing to a systemic delegation risk. We have to be really aware of this.

Those examples suggest that when consultants delegate, whether to junior doctors or other practitioners, including their peers, things can go wrong if communication breaks down, or if the replacement lacks equivalent expertise or is simply not aware of some of the detailed information. In order to manage some of the risks better, patients must be consulted about who takes over their care, and not just asked to consent after the co-ordinating doctor has decided what will happen.

[Dr Shastri-Hurst]

Given that valid consent requires a voluntary and informed decision, can my hon. Friend set out why that would not involve being consulted on the matter in any event?

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[Rebecca Paul]

I would like to think that that would naturally happen, and we have had lots of conversations where we have said, “In reality, of course this conversation would happen.” But I always like to be belt and braces, and I would like to have these things covered in the Bill. If Committee members are confident that these things would happen anyway, I am not sure there would be any detriment to accepting this amendment.

I want to finish with a question for the Ministers. I have been worried—perhaps unnecessarily—about the lack of photographic identification in this process, and I can see a situation where allowing another doctor to provide assistance could create a risk. Although it might be less of a risk in someone’s home, because it would probably be clear who the person is, I am worried about a doctor in a hospital or clinic being substituted in at the final hour with no photographic verification of the person. At the point where they assist the patient to take the approved substance, how can the doctor be sure that it is the appropriate person if they have not had any involvement with the patient before? I accept, given some of the deep sighs I can hear, that that may be a rare occurrence, but it is worth thinking about. The simple inclusion of a photographic ID check would address some of that risk. I will not go over old ground, but I have been worrying about that.

[Naz Shah]

I rise to support amendment 22, in the name of my hon. Friend the Member for Lowestoft. Before I carry on, I am happy to give my hon. Friend the Member for Spen Valley the opportunity to say whether she will accept the amendment, because my hon. Friend the Member for Lowestoft has had a hat-trick of amendments being accepted around training on coercion.

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[Danny Kruger]

I entirely agree. The regulations need to specify not only what drugs may be approved, but, as the hon. Gentleman suggests, how they should be stored and transported. I would expect that to be part of the package of regulations under the Bill.

As I have stated, I do not accept that we are talking about healthcare here; nevertheless, we are using products that are comparable to health products. The MHRA would need to significantly adapt its work in order to identify the most effective drug to cause what we currently perceive as harm—namely, the death of a patient. I recognise that that would be a significant change of remit and work for the MHRA, but we need to do it. One of the reasons that we need regulation of approved substances is to help ensure that falsified versions of the drug—drugs that do not have a licence for use in assisted dying—cannot enter the market. Such drugs may not be effective and could cause distress to those ending their lives and their families. I would be grateful if the Minister could clarify whether, in his view, clause 20 is sufficient to establish the necessary regulatory regime, or whether further legislation will be needed.

We had evidence from Greg Lawton, and other pharmacists, who wrote to the Committee to suggest that the approved substances would not legally come within the definition of a “medicinal product”, so medicines law, the protections associated with medicines and the MHRA licensing process might not apply. If that is the case, what do we do about it? We need a new licensing regime to ensure that the MHRA is able to properly regulate the substances, or, potentially, another regulatory agency would need to be established to do the job.

The Committee needs to make sure that there is a process that applies to approved substances used for assisted dying. It is not necessarily the case that a product licensed for treating a medical condition could not be used to bring about death—it is not the case that we cannot use any drug that is currently used for genuine health treatment—but it would not be being used as a medicine, so medicines law may not apply to its use for that purpose. There is an ambiguity, and I would be grateful for clarity on it.

The amendments that I am supporting would ensure that the MHRA had approved the drug for the specific purpose of ending someone’s life, and that there was scientific consensus that the drug would be effective for that purpose. The MHRA, in the marketing authorisation for the approved substance, would define the dosage of the drug required to bring about death. It would also ensure that specific considerations and warnings were placed in the product licence.

For example, some patients have allergies to certain drugs. If they decide to end their own life, that should be brought about as a result of the effect of the drug, not an unintended allergic reaction to it. Some patients would not be able to take drugs orally and might need to have the drug administered through a tube into the stomach, so different formulations would need to be available. Some drugs may need to be administered by injection. Patients may be unable to do the injection themselves, as we have discussed. Even if the patient is physically capable, injection techniques require proper training, and that needs to be considered when licensing drugs for assisted dying if the patient is responsible for self-administration.

There will be further considerations when deciding what drugs can be used. Patients will have a right to know what to expect. If they take the drug orally, how long will they have to wait before they die? Will they lose consciousness first? If so, how long will that take? Could there be some side effects or reactions after taking the drug, such as seizures or choking, that the family or carers will have to deal with? Can the drug be taken at home—that relates to the point that the hon. Member for Ashford made—or must it be used in a clinical setting? We have suggested that it could be used at home, so questions about transportation arise. Is a combination of drugs required? If so, in what order should they be taken? What happens if the patient passes out before taking the entire concoction of drugs? Has the drug formulation been optimised for the purpose of assisted dying, so that it reaches maximum blood levels as quickly as possible?

All these sorts of questions are appropriate for medical regulators. The MHRA could ensure that the patient information leaflet, and the warnings associated with it, given with the drug when it is prescribed prompt doctors to think about what drugs are most suitable for the patient and to provide information to the patient about what to expect.

Parliament must have oversight. It must bear responsibility for the kinds of deaths that it approves. Both Houses of Parliament should approve the statutory instrument. To inform that decision, the Secretary of State should provide all relevant information on the likely time to death, and on complications and side effects. When the state is creating a regime that will end lives, there must be maximum transparency and accountability, yet the Bill provides that this will be done by a negative statutory instrument. In other words, Parliament will get a say on the regulations only if the Leader of the Opposition prays against them—that is the process for a negative SI. That is the only circumstance under which the Government would make time for a debate and a vote on a negative SI. Given that this is an issue of conscience, I find it inconceivable that the Leader of the Opposition would want to take a position on it and so pray against it to trigger a proper debate. I think it is highly likely that Parliament would never get a say on this crucial issue because of the use of the negative procedure.

That situation has been recognised repeatedly as being unacceptable. When Lord Falconer introduced his Assisted Dying Bill to the House of Lords in 2014, it too provided for a negative SI power on this matter. The highly respected House of Lords Delegated Powers and Regulatory Reform Committee—we do not have an equivalent Committee in the Commons, but it sits over Parliament—said that it did not consider either the power or the procedure in the Falconer Bill to be appropriate, yet that is the procedure that we are being presented with here.

In 2021, when Baroness Meacher introduced her Assisted Dying Bill to the House of Lords, the Delegated Powers and Regulatory Reform Committee again issued a report, in which it said:

“In the interests of clarity and transparency on such important issues of public policy, the matters that are in due course to be dealt with under clause 4(7) by negative regulations should in our view be spelled out in detail on the face of the Bill from the outset. Accordingly, the Bill should contain a definitive list of medicines, and details of the manner and conditions under which such medicines are to be dispensed, stored, transported, used and destroyed. The power to amend such matters should be a matter for regulations subject to the affirmative procedure.”

We then come to Lord Falconer’s 2024 Assisted Dying for Terminally Ill Adults Bill, which he withdrew following the introduction of this Bill by the hon. Member for Spen Valley. That Bill in part took on that feedback from the Lords Committee. Although it did not provide a list of medicines, it did at least provide that the power to specify the drugs would be through the affirmative procedure.

The Hansard Society, which is non-partisan and neutral on assisted dying, has issued a critical report on this power. It says:

“MPs may wish to enquire why Kim Leadbeater has chosen not to adopt the scrutiny procedure set out in the 2024 bill, but has preferred that proposed in the 2014 and 2021 incarnations of the bill, despite the advice to the contrary of the Delegated Powers Committee.”

I would be grateful to learn from the hon. Lady why she has chosen this procedure.

It might be objected that the list that I am requesting might need to be modified quickly and that the affirmative procedure—having a parliamentary vote—would be an obstacle to doing that. The Hansard Society anticipated that objection. It said that

“this could be addressed by making provision for the use of the ‘made affirmative’ procedure in urgent cases where the Secretary of State wishes to remove a substance from the approved list and is of the opinion that it is necessary to do so immediately in order to prevent adverse medical events or failed assisted deaths. This would mean Ministers could act expeditiously but Parliament would have to debate and approve – albeit retrospectively – the change in the list. Whilst not perfect it would provide more opportunity for oversight than that offered by the negative scrutiny procedure.”

It seems to me that there is no justification for this vital matter to be regulated under the negative procedure. Too much power and responsibility is being given to Ministers subsequent to the passage of the Bill— if that is what happens. My amendment 467 would ensure that Parliament has a meaningful say, through the affirmative procedure, and that a report is published as part of that process setting out the expected efficacy of the drugs that will be used. I hope that the Committee will support it.

[Rebecca Paul]

My hon. Friend the Member for East Wiltshire eloquently covered most of the things I would have said.

We have probably not spoken enough to date about the impact on pharmacists, but we are getting to the point in the Bill where it is really important that we take on board the written evidence and feedback that we are hearing from them. The Royal Pharmaceutical Society said:

“In dispensing a prescription, a pharmacist assumes a proportion of the responsibility for that prescription and therefore must be assured that all legal requirements are in place and that it is entirely appropriate for the patient. The link to the clinical assessment of eligibility criteria is essential and therefore the prescriber should always be one of the assessors. In addition to the usual practice of checking that the prescription fulfils the necessary legal requirement, pharmacists must have full access to the patient’s diagnosis and assisted dying care plan.”

That raises a few valid and interesting points that we need to take on board to ensure that pharmacists can do their jobs in line with the regulations and laws they are subject to, which are ultimately there to maintain patient safety.

I support amendment 466, tabled by my hon. Friend the Member for East Wiltshire, which would ensure that the Secretary of State must be of the opinion that there is scientific consensus that the drug is effective without causing pain. I am of the view that the Secretary of State is probably the right place for that responsibility to sit. One reason for that, which my hon. Friend spoke about, is that I am not sure that the MHRA is the right regulating body for that. I am no expert on this, and I am open to hearing the debate, but the MHRA’s remit covers medicines and healthcare products, so there is a question about whether legally the responsibility falls to it. If it does not, do we set up another body, or do we adjust its remit so that it is covered? I have reservations about doing anything that would merge assisted dying into normal healthcare, but I have laid that out many times over the weeks, so I will not go over that.

My understanding is that, on top of all the things my hon. Friend set out, the MHRA’s role is to give marketing authorisation for the promotion and advertising of medicine. Once that has been given, reams of regulations and compliance must be done, including in respect of the labelling of medicine. I believe it would have to be put on packaging that a medicine could be used for assisted dying. We need to get clarity on that from experts in the field, so that we fully understand it. If that is the case, how do we feel about making it clear that said medicines, potentially out in the market, could be used for assisted dying? I suggest there could be some significant downsides to such clear labelling. That is something for us all to think about. I wanted to raise those important points.

[Naz Shah]

I rise to speak in support of amendment 465, tabled by the hon. Member for East Wiltshire. It is a pleasure to follow the hon. Member for Reigate, who has made some powerful contributions. As we have heard, the amendment states that a drug may be approved under the Bill only if it has been approved by the Medicines and Healthcare products Regulatory Agency for that purpose.

--- Later in debate ---

[Naz Shah]

I rise to speak to amendment 439, tabled by my hon. Friend the Member for York Central, which would amend clause 21 such that the relevant body would provide the chief medical officer and the commissioner with the full set of documents relating to a person who had undergone assisted dying. The relevant body would be the co-ordinating doctor if that person were a practitioner with the person’s GP practice. If the co-ordinating doctor did not meet that condition, the person’s GP practice would have the responsibility of sending those documents.

Those documents would be the person’s full medical records, court records and all documentation relating to assessments and procedures relating to the person’s assisted death. I note that “court record” refers to the Bill before we agreed to the amendments and new clauses that replace the High Court procedure with a panel system. We should be able to slightly tweak the wording to reflect that when we tidy up the Bill. That is what the amendment does. Let me say a little about why it does so and how it would make the Bill stronger.

The key aim is to ensure proper public oversight of any assisted dying scheme. The Bill creates the role of the voluntary assisted dying commissioner, who will look at and report on the workings of the system, appoint panel members and be the final court of appeal, so to speak. Those are far too many powers to give to one person, but if we are giving the commissioner a duty to report on how the system works, they should have the best possible information. It is only right that the information also be sent to the chief medical officer for England or for Wales, as appropriate; they are both very senior public officials and experienced doctors.

My hon. Friend the Member for Spen Valley has tabled amendment 382, which, to quote the explanatory statement,

“provides for monitoring, investigation and reporting functions under Clause 34 to be carried out by the Voluntary Assisted Dying Commissioner (instead of the Chief Medical Officers for England and for Wales).”

I will have more to say on that amendment when we come to it, but removing the chief medical officer from the monitoring, investigation and reporting functions is not a good idea.

What use could the commissioner and the chief medical officers make of the data provided under amendment 439? Let me give some practical examples. If there were reported instances of a person experiencing discomfort or pain as a result of taking the medication, that would be of interest to the CMO and the assisted dying commissioner. It could trigger a further exploration of the titration of medication used in the procedure. As another example, let us think about what could happen if a family raised concerns about a person receiving assisted dying despite lacking capacity or being coerced. The CMO and assisted dying commissioner could use the information provided to investigate those allegations.

The amendment will ensure that the assisted dying commissioner and the chief medical officer receive detailed qualitative as well as quantitative data on people who have received assisted deaths. It is an important step towards making sure that the assisted dying scheme receives proper, well-informed scrutiny. In turn, that scrutiny will make it less likely that the scheme will allow abuses or ignore serious problems. I urge hon. Members to support the amendment.

[Rebecca Paul]

I will be very brief. I rise to ask a few questions about clause 21 as a whole. Following our debates on various amendments, I am aware that family and those close to the patient could not be involved in the process, although potentially for understandable reasons. I appreciate that we are not here to deal with the whole operational piece, but we should think about it. For example, what happens with notifying next of kin after death, bearing in mind that “next of kin” has a different meaning after death? That is when we start to get into legal considerations, such as who the executor is—and this could be the first time that they are hearing about it. What would be the process for that, given that the person has potentially died on their own at home with the doctor?

What is the process for handling the next stage? Is there anything that we need to include in the Bill to make it a clearer, simpler and easier process? Who will the medical certificate of cause of death be given to for registration of the death? While all that is going on, what will happen to the body? At that point, we may not have family members to take care of that. Those are some questions arising from clause 21 that are worth reflecting on.

[Stephen Kinnock]

The amendments relate to clause 21, which applies where the person has been provided with assistance to end their own life in accordance with the Bill and has died as a result. Throughout this process, we have worked with my hon. Friend the Member for Spen Valley. Amendments 379 and 500 have been mutually agreed on by her and the Government, so I will offer a few technical and factual comments.

Amendment 379 would require that, where a person has been provided with assistance to end their life and has died as a result, the co-ordinating doctor must provide the voluntary assisted dying commissioner with a copy of the final statement under clause 21 as soon as practicable. That links to the commissioner’s role in monitoring the operation of the Bill, as set out in new clause 14. Amendment 500 sets out the information that must be included in the form of a final statement, which is to be set out in regulations in accordance with amendment 214.

The effect of amendment 439 would be to introduce a new requirement for the relevant body, defined as either the co-ordinating doctor or the person’s GP practice, to provide full medical records, court records and all documentation related to assessments and procedures relating to bringing about the death of the person in accordance with the Bill to the chief medical officer and the voluntary assisted dying commissioner. The amendment is broad, and it is not clear whether doctors would be able to comply with the duties fully.

For example, GPs do not normally have access to court records, and would need to request them to provide them to the chief medical officer and the commissioner. Currently, a decision to share court records is made at the discretion of the judiciary in most cases. As such, any statutory burden to disclose court records agreed by both Houses would require consultation with the independent judiciary. Depending on the type of record, there could also be data protection considerations.