Live Debate: Lords Chamber

Lords Chamber

Friday 12th December 2025

(began 3 hours, 51 minutes ago)

10:07

Legislation: Space Industry (Indemnities) Bill – third reading

My My Lords, My Lords, I My Lords, I should My Lords, I should like My Lords, I should like to My Lords, I should like to notify the House of the retirement with effect from today of the noble Lord, Lord Hodgson of Astley Abbotts, pursuant to section one of the House of Lords Reform Act, 2014, on behalf of the House. I should like to thank the noble Lord for his to thank the noble Lord for his much valued service to the House.

Third Reading of the Space Industry (Indemnities) Bill Baroness Anelay of St Johns. My Lords, I beg to move that this bill be now read a third time.

10:08

Baroness Anelay of St Johns (Conservative)

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The question is that this bill be now read a third time, as many be now read a third time, as many of that opinion will say. Content, not content. The contents have it.

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I beg to move that the bill do now pass. I congratulate John Grady now pass. I congratulate John Grady MP, who introduced the bill in the House of Commons, where he secured all party support. And my Lords, I thank all those who supported the Bill in this House as it made its way through its Second Reading. Every member who attended the and participated in the Second Reading supported the bill. I am also grateful to the noble Lord, the Minister, for responding in constructive detail, both during the debate itself and subsequently in a letter to all Second Reading participants, in which he answered the detailed questions posed by my noble friend Lord Moylan, the opposition transport spokesman.

The minister's hard working experts, who may well be in the box today, I see no doubt had an expert hand in all that. My Lords, the bill amends the 2018 Space Industry Act to provide legislative certainty that spaceflight operators will not face unlimited liability when operating from the UK. As a consequence, the bill should strengthen investment in the UK's space sector. This is important, my Lords, for both the economic growth and the defence of the United Kingdom. My Lords, I beg to move.

10:09

Viscount Stansgate (Labour)

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The question is that this bill do now pass. we all know there's very important business ahead. But I do want to congratulate and thank the noble Lady Baroness Anelay for her work Lady Baroness Anelay for her work on this bill, and having brought it to the stage where it is poised on the brink of the statute book, and as someone who in the past has piloted a private member's bill through to its final stages. I know very well that the private member's bill procedure can indeed change the law of this country.

As to the bill itself, it literally changes one word from May to must. And as a member of your Lordships Committee on the UK's engagement with space, I'm not here to talk about our report. Interesting though it was act now or lose out. But the fact is that this bill will unlock future investment and a space economy for the future. And the UK could be very well placed to play a very active part in it. So in conclusion, I want to say that to thank all those involved and to say that I wish this bill very well in the future.

Well done. Well said. the future. Well done. Well said.

10:10

Lord Moylan (Conservative)

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My Lords. This is the second bill this week which effectively transfers risk or cost away from private investors onto the taxpayer or the fare payer. In order to help put Britain on the path to industrial success in the future, it's all a long way. I might say to the noble Lord, the Minister who supports this bill from the days of the railways, when private money, without government support, without without any transfer of risk, sometimes private investors losing their funds built our great railway network.

But it turns out that this is necessary for our success in space. And so we support this bill. And we congratulate my noble friend, Lady Ainley of Saint John's, for bringing it forward and bringing it to a successful conclusion. And like her, I wish to thank not only the Minister for his friendly and open engagement, but also his civil servants who have been supportive in this.

10:12

Lord Hendy of Richmond Hill, Minister of State (Department for Transport) (Labour)

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My Lords, I would like to thank all noble Lords for their contributions to and support for this Bill. I would like to offer particular thanks to the noble Baroness, Baroness, for steering the Bill, this this bill through this House, and to John Grady for bringing forward the short, this short but important bill. In the other place, the government recognises that the question of liability and insurance is of utmost concern to the space sector and the value that the industry places on having legislative certainty on this matter and the concerns it has raised about the use of the word may.

In section 12 two of the Space Industry Act. I'm therefore grateful to the noble Baroness for this bill, which, by amending section 12 two, will meet a key request from the sector.

10:12

Lord Kennedy of Southwark (Labour)

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The question is this bill do now >> The question is this bill do now pass. As many of that opinion will say, content, not content. The contents have it.

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contents have it. My Lords, before we move on to the fourth day of committee, I will make a statement about proceedings as I did for the previous three sitting Fridays. I hope again this will help planning and is in line how we business has proceeded previously. Firstly, it's important to thank the staff of the House, those on duty today in their various roles and those who have been working in preparation for today's proceedings. The whole House greatly values your work and

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we thank you for all you do. Hear, hear. The Government Whips office have circulated the updated groupings circulated the updated groupings list. Our noble friend Lord Falconer of Thoroton, as he has previously, has set a proposed previously, has set a proposed target for today's debates. As was the case in previous week weeks, I expect the House to rise at a convenient point around 3 p.m. in line with usual procedures and in line with usual procedures and in line with the companion, we maintain the typical flexibility to rise slightly before or slightly beyond that point to include the group we are debating.

I do think that having only considered six groups of amendments in three days, committee there should be looking to make more progress today. Ultimately, this remains in the hands of the house and not me in my role as Government Chief Whip. I expect to return to the despatch box this afternoon between 230 and 3 p.m. to advise the House further. I do though, want to make a few other points before we begin the Committee stage consideration of this bill. In doing so, I fully accept that not everything I say is accepted by the whole house.

But please accept my intentions are good to show the house in the best light, and to enable the House to deliver effective scrutiny of these important issues before us. I have many times before at this Dispatch Box as Government Chief Whip and from the opposite as Opposition Chief Whip, made reference to the companion and now, following its guidance, is of great assistance to the House and to their own all noble Lords in undertaking an important work every day. I make that same point today for the advice of the companion.

It will help us all to better debates today's and better proceedings today. In that light, it's important to remind ourselves that this is Committee stage, and noble Lords should address their remarks to the amendments under consideration and not make long Second Reading speeches going way beyond the substance of amendments being debated. This is all set out in the companion on page one. 43.8 .81. Also, we do not accept interventions on interventions. That is not the House of Lords way.

Please refrain from attempting to do this. I've asked the government whip on the bench to intervene to stop this practice if it begins. If any noble Lord does make an intervention on another noble Lord, I refer the noble Lords to the companion. Specifically. Page 60.4 .29, which makes clear interventions should be a brief question of clarification only and not another speech. Also, when pressing or withdrawing, amendments to noble Lords should be brief. This is set out in The Companion on page one.

43.8 .82. I expect, as I believe all noble Lords do, that despite sincerely held views and differences of opinion, we will always conduct ourselves with courtesy and respect for each other and show the public watching our debates. The House of Lords in the best possible light. So, as I said before, please refrain from doing anything that will bring that into question. As I've said previously, the acoustics are excellent in this chamber and the microphones are very sensitive and overlords should not be holding conversations in the chamber or making remarks that they would not like to be broadcast live.

If you wish to speak to another noble Lord, please retire to the Prince's Chamber, the Royal Gallery, the peers Lobby, the Long room with the Peers guest room and then return with your conversations ended. These are good places to have conversations and regular use. On most other days after every city. Friday's debate on this bill I have noble Lords with very different views contacted me in the preceding days, expressing their frustration with other noble Lords sitting near them who seem to talk constantly to the annoyance and convenience of others.

Please bear this in mind. As I said, have your conversations outside the chamber. This is a private member's bill, and the noble Lord in charge of the bill is my noble friend, Lord Falconer of Thoroton. It is not a government bill and it is not the government Ministers on the frontbench in charge of the Bill. It is not a government bill. It will not become a government bill. The government remains neutral. That position is not going to change, my Lords. I not going to change, my Lords.

I have said it time and time again. This will not change. Having made This will not change. Having made the opening remarks, which again are said to assist the House, I think we should now move on to think we should now move on to debate the issues of substance before us.

10:18

Business of the House Lord Kennedy of Southwark (Labour)

Very briefly, I am extremely

10:18

Baroness Hayman (Crossbench)

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grateful to the noble Lord, the Chief Whip, for what he said in forcing. The companion is obviously a prime responsibility of the whip and the bench and the government whips, but it does extend further. And would he confirm that any of And would he confirm that any of the whips can intervene and point out when the companion is not being out when the companion is not being applied for to? And that actually applies to any member of the House as well? Yes.

10:18

Lord Kennedy of Southwark (Labour)

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When the noble spoke. I remember the Countess of Mar who would actually regularly get up and correct noble Lords when they were getting things wrong. The noble is absolutely right. We should all follow the companion. We are all responsible for a self-regulating house, and we should do that to ensure we have good debates, sink debates, and get make good progress.

10:19

Legislation: Terminally Ill Adults (End of Life) Bill - committee stage (day 4)

Has to be again in committee on the terminally ill adults end of life bill. Lord Falconer of Thoroton I beg to prove. Thoroton I beg to prove. >> That the House do now again resolve itself into a committee upon the bill. >> The question is that the House

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The question is that the House now do now again resolve itself into a committee upon the bill, as many of that opinion say. Content, many of that opinion say. Content, not content. The contents have it. In clause one, amendment 16 Baroness Finlay of Llandaff. Baroness Finlay of Llandaff.

10:19

Baroness Finlay of Llandaff (Crossbench)

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Amendment 16 and one one for proposes that anyone who is currently or was in the year preceding their first declaration, deprived of liberty under the Mental Capacity Act, and will be considered to lack capacity for the decision to seek assisted death. Amendment 16 a amendment for extend this to those on whom an application has been made but not necessarily completed. Given the data. There is good reason that these amendments from the noble Lady Baroness Keeley should be considered.

The Mental Capacity Act 2005, section four requires that decisions made on behalf of individuals who lack capacity are made in their best interests and with the least restriction of freedom. This amendment can only probe the eligibility assessment process because we're at a transition point from the overloaded deprivation of Liberty Safeguards or Dole system, possibly to liberty protection safeguards. Implementation of the 2019 Mental Capacity Amendment Act with the concomitant refresh of the MCA code to incorporate Liberty protection safeguards.

Guidance is planned for early next year, but no firm date has been set. Deprivation of liberty safeguards authorise arrangements that restrict liberty in hospitals and care homes for those aged 18 or over, when necessary, for care and safety in their best interests, and there is no other way to look after them. A standard authorisation under section four can be given by local authority, valid for up to one year to a hospital or care home. After a series of six assessments within a 21 day period.

Forby allows for an urgent seven day deprivation of liberty, renewable once to sustain life or for vital acts pending a Court of Protection decision, or while the standard process is underway. Urgent dols applications arise from acute crises. In 20 2324, 58% of applications were urgent. Temporary incapacity in acute hospital settings is often due to acute delirium in cardiovascular events, infection, or medication effects. Of course, when a person improve and regain capacity, the dolls became inapplicable.

But my Lords, the system is completely overloaded. There were over 334,000 applications in England alone in 20 2324, taking an average of 144 days for assessment. Only 44% were fully assessed and only 19% were completed within the required statutory 21 days. And this goes to the heart of the problem, as local authority records are not integrated with health records, neither the panel nor the assessing doctors in this bill will always have details of applications and outcomes.

Different medical record systems exist in different trusts. Access to GP records is variable absence or very limited because some GP practices have not signed to give access by trusts to their GP records. There is no access to social care clinical information systems, no information sharing between social care and medical records, and no access to the details of safeguarding information held by local authorities. Although police callouts may trigger the GP being notified, a callout has occurred. No details are given, meaning there is no access to police records of actually what went on.

Even when psychiatry asks, such information is not readily given from the police. National computer Network will come on later to discuss whether a panel can access this information, as it may be a clear pointer to domestic abuse, and without a requirement to even interview the family. How will anyone know what's gone on? Hence the amendment. The very fact that an impairment of capacity serious enough to precipitate a dols application has occurred should act as a yellow flag when eligibility is being assessed.

Although relatively small numbers, the 20 2324 data shows that 3% of fully assessed Dols applications were rejected, but it's noticeable that half were due to change in circumstances and a fifth because the criteria were not fulfilled. So I expect to be told that this amendment, intended to protect vulnerable adults, has adverse implications for individuals with temporary hospital related incapacity, potentially restricting autonomy because they'd had a previous episode of seriously impaired capacity. But individuals with irreversible conditions, such as advanced dementia or lifelong severe cognitive impairment, may remain ineligible long term, which aligns with the safeguards intent.

I am grateful to my noble friends Baroness Butler-Sloss and Baroness O'Loan who supported this amendment, and to the noble Lady Baroness Keeley, whose amendment to my amendment intends to increase safety by capturing the larger number, comprising 56% of applications that had not been completed. I anticipate the noble Lord, the Minister, saying that this amendment poses legal difficulties for those who lack capacity when it was temporary, but serious enough to to prompt dols as it creates a statutory presumption rather than case by case assessment for anyone with adult or LPs history.

I hope, therefore, that this short debate will mean that a previous impairment of capacity will act as a yellow flag, an indicator that risk may be elevated when an application is assessed. It is known that an episode of impaired capacity serious enough to trigger restricted liberty can signal further episodes of delirium in over a fifth of people, or be the first pointer to dementia. I hope this will encourage recognition by the noble Lord, Lord Faulkner, of the need to re-examine the balance of safety where unrecognised implications and indications of impaired decision making could all too easily lead to an excess of poor assessments and

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inappropriate assisted deaths. I beg to move. Amendment proposed clause one,

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Amendment proposed clause one, page one, line ten. At end, insert the words as printed on the marshalled list as an amendment to amendment 16, amendment 16 a Baroness Keeley.

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Baroness Keeley. I am speaking to amendment 16 A and 114 A, which have been tabled

10:26

Baroness Berger (Labour)

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and 114 A, which have been tabled by the noble Lady Baroness Keeley, and these amendments address the fact that for the last ten years there has been a substantial backlog of applications for deprivation of liberty safeguard assessments, and this is a backlog which grew after there was a Supreme Court ruling in 2014 on the Cheshire West. Following that ruling in 2014, the criteria for what constituted a deprivation of liberty assessment led to a surge in applications for dols assessments.

Back in 20 1314, there was just around 13,000 assessments. This grew to over 332,000 applications in 2023 2024. The last reported backlog of Deprivation of Liberty Safeguards assessments back in October of this year was more than 123,000 applications. That is more than 123,000 cases where a person so lacks capacity in one area that an application for deprivation of Liberty Safeguards assessment has been made. But our overstretched social workers and local authorities have not been able to process these applications.

I hope we can all agree that people whose incapacity for basic decisions is so severe that they are deprived of their liberty, or have an application made for deprivation, deprivation of their liberty, are the most vulnerable members of society, and the protection of people who lack capacity is a solemn duty. The state looks after their interests because they cannot. Amendment 1616 a 114 and 114 A provide a fundamental safeguard to protect this group by excluding them from making a life and death decision, both when they have been deprived of their liberty in the last 12 months, or particularly, what these amendments are seeking to achieve is while they are waiting for that assessment to be made, to deprive them of their liberty.

In conclusion, and in considering these amendments, that in addition to the delays that have been outlined just now by Baroness Finlay, we must also reflect that our current social care workforce has struggled so much with the backlog of assessments, as I've described, that the last government was not able to implement the changes to the Deprivation of Liberty Safeguards assessments that were contained in the Mental Capacity Amendment Act of 2019. And it's worth pointing out that this bill is seeking to create a new and additional role for social workers on the panels, and it is in that context that I hope that members will the noble Lords will consider these amendments.

10:29

Baroness Butler-Sloss (Crossbench)

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Amendment proposed in paragraph CAA leave out been and insert had CAA leave out been and insert had an application to be. >> The reasons given both by the

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The reasons given both by the noble Ladies, the Baroness Finlay and the Baroness Berger. I support all these amendments. I wonder if your Lordships, particularly the whips, would forgive me if I go slightly wider very briefly. I'm one of the oldest members of this House. I don't like the bill, but I am here. Like other noble Lords, to try and make it work. It needs scrutiny, it needs improvement. But we must get it to Third Reading. If we don't, there is a very real danger that the reputation of this house, which not only I, but all your Lordships care about deeply, will be, or possibly will be irreparably eroded.

I listened this morning to the today programme, where there was in many ways I agree every word of what the noble Lady Grey-thompson said. But that was the perception that we are being unreasonable. My Lords, what can we do? Perhaps by not expecting to be entitled, by exercising self-restraint, by dealing with the amendments relatively briefly, if someone has already spoken on the point that you're going to make, don't make it. Because we really must get to Third Reading.

Would you forgive me for having saved all that? Yes.

10:30

Lord Falconer of Thoroton (Labour)

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My Lords. >> My Lords. >> Could I act immediately upon the words of the noble and learned Baroness Butler-Sloss? Could I Baroness Butler-Sloss? Could I respond briefly to what the noble Baroness Baroness Finlay and my noble friend Baroness Berger has said? They are basically referring to the problem of people who lack capacity and have had their liberty deprived, because the lack of capacity is so severe that they cannot be trusted to be free. That normally takes place in the setting of a hospital or a care home, but can also take place in the setting of a private home.

And it's then that the Cheshire East cases come into play. What the noble Baroness Baroness Finlay said that should be a yellow flag if your lack of capacity is so serious that your liberty is taken away, then that does indicate that there is something very seriously wrong. The principle of the Mental Capacity Act 2005 is that you should look at capacity on a case by case basis. There will be cases where your liberty is taken away, where you wouldn't necessarily lack the capacity in relation to very serious issues.

And can I take sorry, I should have made a declaration before. Apart from receiving money from Mr. Bernard Lewis to pay for an assistant, and apart from having the Dignity in Dying paper, a publication of some printing that went around to the peers. My wife was a designated family judge until very recently and sat in the Court of Protection, and I should disclose that amongst the sorts of cases that come before the courts, and they will come before the courts, not come before a local authority, is people who desperately do not want to leave their home.

They eventually have to have an order from the Court of Protection, meaning that they have to leave. And sometimes it's accompanied by deprivation of liberty order. Many of those people, even though they are moved somewhere else, still would have the capacity to make a decision in relation to assisted dying. How do we deal with the perfectly legitimate points that Baroness Finlay is making? And I've had the opportunity, and I thank the Baroness Finlay for this, having a discussion with her.

The answer is there should be some form of enhanced protection to deal with what she says is a yellow flag. And could I suggest to the House that I speak to those who are interested, including the Baroness Berger and the Baroness Keeley, who sadly can't be here today so that we can see what form that enhanced protection could take. And I hope in the light of what I've indicated,

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we can move on to the next amendment. My Lords, I would like to make

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My Lords, I would like to make some comments in this group and in response to what the noble Lord has just said in its recent briefing. just said in its recent briefing. For peers, it's the view of the Royal College of Psychiatrists that assessors should be required to assessors should be required to take all practical steps to work with professionals involved in a person's health and social care,

10:34

Baroness Hollins (Crossbench)

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person's health and social care, and to talk to a relative, carer or nominated friend, including by accessing medical notes from both primary and secondary care. The Royal College has expressed concern that a consideration of suicide protection duties are being bypassed by the Bill in its current form, due to unmet need not being formally assessed. A previous Dols is relevant to consideration of current capacity to decide what to end one's life. What would the mechanism be for reliably ensuring information that there has been a dols before it gets to the assessors and the panel? Having mentioned the Royal College of Psychiatrists, I would like to make a short statement because the college has asked me to respond to allegations about the college leadership made by Baroness Murphy on November the 14th, during the first day of committee.

The president, doctor, Lady Smith, wrote to Baroness Murphy asking her to withdraw her allegations as they are inaccurate. But although the noble Lady was present in the chamber the following week, no clarification was provided. And as a past president myself, I beg leave to set the record straight. The college's recommendations on the bill are, in fact, based on 18 months consideration by a Cross College working group involving membership surveys, debate with members on proposals before other jurisdictions, and discussions with colleagues in other jurisdictions where assisted dying is practised.

The president is clear that Doctor Annabelle Christ, the appointed college lead for the bill, has accurately represented their views when giving formal evidence to both houses with the Bill before the Lords. The Royal College of Psychiatrists is focusing on how to make it safer for people with mental health and learning disability needs, and better aligned with the responsibilities of psychiatrists. And I felt that in light of the discussion on dolls, this was an appropriate statement to make.

10:36

Baroness O'Loan (Crossbench)

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To amendment 16, and I'm supportive of amendment 16, a 114 114 a because the very general definition in clause one of a terminally ill adult who has the capacity to take their own life does not contain any consideration of those who have been deprived of their of their liberty under section four of the Mental Capacity Act. My Lord, it's an unfortunate reality that many of those detained in hospitals or care homes are detained because they lack the capacity to make a decision about their own care or treatment.

And in such circumstances, it's surely axiomatic. As the noble Baroness Baroness Finlay has said, that there should be very careful consideration of cases involving individuals subject to dols, even assessing as the noble Lord, Lord Faulkner has said, even assessing the capacity, for example, of someone with dementia or another neurological condition can be profoundly difficult, not just because of the frequent fluctuating of capacity and the extent to which any identified capacity enables the making of a particular decision. It's the case that a medical practitioner or social worker who meets a person for the first time may be misled as to the capacity which that person actually has.

As the Royal College of Psychiatrists noted in their written evidence, an assessment of the person's mental capacity to decide to end their own life is an entirely different to other assessments of capacity and more complex determination, requiring a higher level of understanding. The noble and learned Baroness Butler-sloss in 1977, in the case of re MB, said the grave of the consequence of the decision, the commensurately greater the level of competence required to take the decision. Capacity assessment. My Lord, is not a precise science.

The unique context of this bill makes taking a cautious approach appropriate. It's common sense that there is a likely correlation between incapacity in one area, which is so extreme that the state must deprive the person of their liberty and incapacity to decide whether or not to end one's own life. People whose incapacity for basic decisions is so severe that they're deprived of their liberty are the most vulnerable members of society. I want to give your Lordships a very brief example. I was aware of a woman in her late 80s who had been assessed and was subject to a dols.

She objected to it, appealed against it intellectually, enormously able, possessed of considerable social skills despite her dementia. She was able to persuade those dealing with her appeal that she had capacity, despite the very real concerns of her family, who knew the extent of her incapacity. The doors was lifted. She went back to her own home, she was found playing golf in her pyjamas. At 2:00 in the morning she was going to the supermarket at 4 a.m. she was leaving the door unlocked all night for her husband and cooking his dinner every night.

He had died some 20 years previously. My Lords, that lady was my mother. She certainly wouldn't have understood a suggestion that she should opt for assisted death. The dolls were subsequently reinstated, and that is not an unusual situation. If the noble Lord, Lord Faulkner, rejects these amendments, how does he consider that such vulnerable individuals can be protected from making this final decision, although they may not understand exactly what they're doing?

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And I think that what the noble Lord lady is saying is extremely interesting. But the noble Lord has interesting. But the noble Lord has already said that he would seek a meeting with Baroness Finlay with. With all noble Lords who are With all noble Lords who are interested in this. So it's not that he's rejecting the amendment. My Lords, he is willing to enter a

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discussion. For her intervention. I think it's very helpful, but we don't know what the outcome of that know what the outcome of that meeting will be. And I think I have the right to make my remarks. Thank you. Chair.

10:40

Baroness Berridge (Conservative)

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I rise to speak to the amendments in this group, and I didn't lay one in my name about a group of people who were also group of people who were also subject to deprivation of liberty safeguards. I am pleased to hear the noble and learned Lord repeat his offer of a meeting, which was made last Friday, and I was disappointed not to receive an invitation to a group meeting to discuss the various groups of vulnerable people who may need additional conditions. Had there been that meeting, I would not be taking up time today, nor in the later group where I specifically offered to withdraw amendments had a meeting taken place.

My Lords, there is another group of people under deprivation of liberty safeguards that are not under the Mental Capacity Act. And these are young people who are under the High Court jurisdiction of deprivation of liberty safeguards called High Court Dols. And I want to thank the president of the Family Division for ensuring this research available on this group and the Children's Commissioner, who has visited very many of them. These young people are so troubled that their liberty needs to be restricted, but they can't be currently detained under section 25 of the Children Act in a secure children's home.

That's for a variety of reasons. One, we ran out of places, but also some of them were such that in such a situation that they couldn't even bear the communal, secure environment like that. I also didn't learn amendment because under the Children's Schools and Wellbeing Bill, these young people are being brought possibly under the statutory jurisdiction of the Children Act, but not all of them. There were 1280 applications last year made, and around 90% of them were granted. So this is not, as I think was originally envisaged, a handful of young people.

Are any of these young people also ill? Is the noble, our noble Lords content that at 18 years old and one day they have assisted suicide rates with them? Are they also happy that if a child has been under mental health treatment, but is also physically ill at 18 years and one day they come under the jurisdiction of this bill? The same, of course, applies to those detained and in a young offenders institution. Sadly, due to the private member's bill process, I don't believe there's been any consultation or white paper or pre-legislative scrutiny to flush out the details and data that we need in order to properly legislate.

So I'm grateful to the Children's Commissioner for attending the Select committee, but I was surprised that the public Bill Committee in the House of Commons did not hear from her. In addition to the issues of 18 years old and one day, some of whom are still under the jurisdiction of the Children's Commissioner until they are 25, and of course, under the jurisdiction of the local authority. I don't think it's wrong to say that there will be enormous societal change that will affect children, so I'd be grateful to know whether now or in the meeting that the noble and learned Lord has promised, whether he's aware of this group of children and what meetings he has had to establish, how many there are who would be affected at 18 years old, how many are in this group, and how they can be protected by additional conditions and safeguards?

10:43

7 Lord Harper (Conservative)

My Lords, I rise briefly to ask the. the. >> noble and learned Lord, Lord Falconer, a question actually in response to his very welcome response to his very welcome response to Baroness Finlay's opening speech. And that is, once he's had those conversations, if he is persuaded that there do need to be, and he did set out a range of protections that there may be if he's persuaded that there do need to be some protections. Can I ask whether he is planning to bring forward his own amendments? Would he would he be prepared to bring forward his own amendments at Report stage to put those protections and assurances on the face of the legislation? Or is he going to do what the I think it's the delegated Powers Committee is referred to as what is effect disguised legislation, which is only putting it in codes of practice and guidance.

I know speaking just for myself and but I think this would be shared widely, that if we're going to have those protections, it's better if they're on the face of the bill. They can't be watered down and they can be properly enforced. And I think if after he's had those conversations with those that are interested, he would then indicate to all noble Lords, that's of course, the disadvantage of having private meetings is you're then you're not able to tell other people if he wants proceedings to go faster and he wants to to bring forward his own amendments that report and prevent other people or prevent the need for other people to do so.

Then obviously, if he can indicate once he's had those conversations that he will be willing to bring forward his own amendments, put those protections on the face of those protections on the face of the legislation, then I'm sure that will be most welcome. And perhaps if you could indicate his thinking if you could indicate his thinking on that today, that would be of help to the House. help to the House.

10:45

Lord Harper (Conservative)

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I don't know whether or not it's convenient just to. Sorry.

10:45

Lord Kamall (Conservative)

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I'll help. No, no. Lord Pack. No. >> Completely understandable. I just, as I said last week, I want to repeat this. If noble Lords will forgive me, I completely agree. forgive me, I completely agree. What the what? The Chief Government Chief Whip said to ensure that noble Lords do speak to the amendments and not give Second Reading speeches. But at the same time, I do think it's important that all noble Lords who do want to speak to an amendment are given that opportunity to do so.

I thank the noble Baroness of the amendment to this group. And just to be clear, and my understanding of this amendment is that it seeks to ensure that someone who is currently, is, or has recently been deprived of their liberty would not be eligible under the act. This amendment makes reference to the Mental Capacity Act 2005, which is obviously also the act underpinning capacity for the purposes of this bill. So I appreciate the underlying logic behind the amendment. I think it opened up a valuable discussion of who exactly should have access to assisted dying services.

And it is important, I'm sure all nobles would agree, whatever their position, that there are robust provisions and safeguards in the bill, and that is only available to those who are suffering from terminal illnesses of sound mind, and that we do not inadvertently open it up to those with issues related to their capacity. I am also grateful to noble Baroness Keeley's contribution as well. Or in place of Baroness Keeley, who is not in her place, because I thought that was very important that someone given the backlog in the system, it's important that it's not just those who have dols, but those who have made an application for Dols.

I think it'd be very interesting to hear from the government, the government's perspective on this, as well as the noble Lords perspective is and they are deemed not to have capacity when seeking to end their life. These are, I think, all these questions ask a fundamental question of whether the Bill is actually right to use the Mental Capacity Act 2005 as the basis for defining capacity, and I am very grateful to noble and learned Lord, Lord, Lord Falconer of Thoroton for offering to meet those who tabled amendments.

I think that's very constructive and very helpful and should be acknowledged, but I also look forward to hearing the noble Lords responses to some of the issues

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raised. My Lords, I'm grateful to noble

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My Lords, I'm grateful to noble Lords for their contributions on this group and to echo the comments of my noble friend, the Chief Whip. Government does remain neutral on the principle of assisted dying and on the passage of this bill. Whether or not the law in this area should change is, of course, a matter for Parliament. And as before, any comments I make will focus on amendments where the government has major legal, technical or operational workability concerns. My Lords, as we have heard, this group relates to deprivation of liberty and eligibility for seeking an assisted death.

And I thank the noble Lady Baroness Finlay and also my noble friend Baroness Keeley for tabling the amendments in this group. Amendment 16 and one, one for tabled by the noble Lady Baroness Finlay seek to prevent individuals who've been deprived of their liberty within the last 12 months under the Mental Capacity Act, from being eligible for an assisted death in the case of amendment 16 A and one one for A, tabled by my noble friend Baroness Keeley, someone would be ineligible as a result of an application for deprivation of liberty having been made irrespective of the outcome of that application.

Noble Lords may wish to consider that the amendments would introduce a departure from the Mental Capacity Act framework by linking a lack of capacity in one area, capacity to consent to care and treatment arrangements that amount to confinement, to lack of capacity in another area, capacity to make the decision to end one's life. Amendment 16 A and one one for A. Go further and make a person ineligible on the basis that only an application for deprivation of liberty has been made.

This may result in a situation where the application itself was unwarranted, but that person would still be ineligible for assisted death. I also wish to raise points relating to the European Convention on Human Rights. Rights.

10:49

Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)

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10:56

Lord Falconer of Thoroton (Labour)

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own knowledge of the working of the act, that's an absolutely valid point to make. Could I could I repeat what I said earlier that we need to discuss this? Can I deal with the interventions after I'd made my intervention? First of all, Baroness O'Loan, she rightly identifies the risks that arise. That is why I think what the Baroness Finlay is saying is right. We need to build in some form of enhanced protection. As far as Baroness Berridge is concerned.

This, this, this amendment is limited to Dols under the Mental Capacity Act. It does not include any exercise of the inherent jurisdiction of the courts of somebody whose liberty is being taken away. The Baroness Berridge is very welcome, and I will give her notice of any meeting that we have to come and discuss that with us. As far as the noble Lord Lord Harper is concerned, how one provides the protection and it's got to be effective will depend, first of all, on the discussions that take place.

I would envisage putting forward an amendment or maybe agreeing that somebody else put forward amendment. The extent to which it will involve the Minister having powers, I cannot tell you, but it will be something that we will discuss as far as what the noble Minister. My, my, my, my noble friend Baroness Merron has said, the points that she was making about discrimination relate to a situation where people who had a deprivation of liberty order in the past, or even those who had one now, were excluded altogether from the right to an assisted dying.

When the nature of the Mental Capacity Act is, it should be done on a case by case basis. What I am proposing we discuss is how do you provide enhanced protection rather than excluding? I hope in the light of what I've said, the noble Baroness Baroness Finlay and the noble Baroness Baroness Berger, on behalf of Baroness Keeley, would amendment.

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Okay. Pick the point up that the noble

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Pick the point up that the noble Lord Lord Pannick said. I agree with what he said, that a court is unlikely to interfere with unlikely to interfere with important social and economic policy that's been decided by Parliament, but I think that rather Parliament, but I think that rather reinforces the point I made about why it's important these protections are on the face of the

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legislation. I'm grateful to those who contributed to this discussion. I did make clear at the beginning that I was probing, and I'm most

10:58

Baroness Finlay of Llandaff (Crossbench)

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grateful to particularly the noble Lady Baroness Hollins, for pointing out that one of the difficulties for assessors is knowing how reliable the information is that reliable the information is that they are able to access. It would seem that we do need to have some way to make sure that people who could be particularly at risk could be particularly at risk should have an enhanced level of assessment for in the protections relevant to them. Sorry, should I

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not be speaking now? Yes. Of course. Okay. I'm sorry, I apologise.

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Okay. I'm sorry, I apologise. I was simply. Being told by the whips that Baroness Berger had to withdraw her Baroness Berger had to withdraw her amendment first. And I apologise for the discourtesy.

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Hoping to sum up. And then I would willingly hand over to the noble Lady Baroness Berger to withdraw the amendment. I think withdraw the amendment. I think that that we do need to make sure that the face of the bill makes it clear that there is a level of particularly enhanced assessment for several groups of people. This will only be one, but people who are, for whatever reason, particularly vulnerable. And I hope that the number of meetings that we have will include everybody who has a concern over this going forward to to Report stage.

I do think it is of concern, though, that the code of Practice for the Mental Capacity Act has still not finished being updated, and I do hope that next year we will see an updated version, because the one that's currently in place has actually, in some ways, a little bit out of date, given the model, the the modern world we live in. But with all that, if the noble Lady would like to withdraw her amendment, I would be delighted to withdraw mine.

11:01

Baroness Berger (Labour)

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My Lords, just in advance of withdrawing the amendment, I just would like to put on record just the magnitude of this issue. There the magnitude of this issue. There were, in the last recorded year, were, in the last recorded year, 141,925 people that had the deprivation of liberty standards. So deprivation of liberty safeguards the dolls standard authorisations granted, and only 3% of the applications that were fully assessed and completed were not granted. 97% of those applications were granted. I've listened very closely to what my noble friend has said, and I look forward to the meetings that we will have further to our deliberations today and I, on that basis, withdraw the amendments.

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Is it your Lordships pleasure that this amendment be withdrawn? Amendment by leave withdrawn. Amendment 16. Is it your is it your Lordships pleasure that this Lordships pleasure that this amendment be withdrawn? Amendment by leave withdrawn in clause one

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by leave withdrawn in clause one amendment 17. Lord Beith to. Speak. To amendment. 17 309 A in the

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To amendment. 17 309 A in the name of Lord Beith. Beith, which I have supported, and Lord Beith

11:02

Baroness Fraser of Craigmaddie (Conservative)

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sends his sincere apologies that he cannot be here today. I will also speak to amendment 62 in my name, and I thank the noble and learned Lord Faulkner for his discussions with both Lord Beith and myself on with both Lord Beith and myself on how this Bill affects Scotland. These amendments are probing These amendments are probing amendments. They seek to establish the scope of the Bill firstly with regard to residents of England who regard to residents of England who who may find themselves availing of Scottish Health Services.

Amendment 17 and 309 a remove an anomaly in the bill under which some residents in England, close to the Scottish border, will be excluded from its scope because they are registered with a Scottish GP. This is relatively common in border areas, as it may be that a Scottish GP is closer than the nearest English practice, or it may reflect a desire to stay with the same practice after moving house. And the BMA have identified cross-jurisdictional protection for doctors supporting their patients in shared care arrangements across borders as a gap in this bill that they would like to see addressed at Committee stage.

The Scottish Ambulance Service have also requested further clarity on what paramedics should do or not do across border areas. How does the noble Lord and learned Lord plan to address these issues? But my amendment 62 is about whether the remit of the bill extends, perhaps unwittingly, to Scottish doctors as it probes whether any Scottish GP, whether or not you are registered with them, can undertake preliminary discussions. The amendment refers to section three on page one of the bill and the steps taken under sections eight, ten, 11 and 19.

Section eight refers to the preliminary discussion, the initial request for assistance and first declaration. So that is done by the terminally ill person who under Lord Reay must be in England and Wales. But sections ten and 11 are about the role of doctors. So my reading of section of subsection one three, which was inserted in the other place, is that steps eight, ten, 11 and 19 must be taken when the terminally ill person is in England or Wales.

But steps ten and 11 only by doctors in England and Wales, not sections eight. The initial request for assistance, or 19 confirmation of the request for assistance. The second declaration. They could be undertaken by any GP and as such the Bill, as it stands, would permit discussions to be undertaken by GPS in Scotland, even though they would not be regulated under this Bill. Is this what the sponsors of the bill intended? I believe there would be a number of consequential issues that might need to be addressed, depending on the territorial extent of the bill.

For example, can the Noble and Leonard Lords say whether the recording required of the preliminary discussion in clause seven would work for Scottish GPS? And given the very separate record keeping of NHS Scotland and NHS England, which he and I have discussed, and the considerable challenges of cross border data sharing in the context of health, particularly in primary care and the separate Scottish legal context. Where does that leave the offence of destruction of documentation in clauses 35 and 36, if the preliminary discussion is undertaken by a Scottish GP? If the intention is that Scottish GPS can undertake these discussions, then can I ask the sponsors to clarify this for the record? But if if this is the intention, then can the noble and learned Lord consider whether the territorial extent needs to be clarified in other areas of the bill? And if it is not the intention, then does the noble and learned Lord consider that further amendments need to be tabled to ensure that this loophole is closed? Perhaps he could take us through the provisions relating to Scotland in this response and clarify.

I believe that when parts of the Bill were extended to Scotland at Report stage, the sponsor did not have time to explain why they were needed or what they did. The hon. Member for Glasgow West asked whether the bill sponsors had had any conversations with Scotland's Lord advocate and the Scottish Government, and the hon. Member for Spen Valley was only able to confirm that she had taken legal advice from government officials to ensure devolution is respected. She stated that conversations had already started and would continue where legislation that affects other jurisdictions needs to be amended.

So could the Minister confirm for us what guidance the government has provided regarding the provisions relating to Scotland and their necessity? As this House is well aware, the Scottish Parliament is currently going through its own stages on an assisted dying private Member's Bill in Holyrood. So we are facing the very real possibility of a two tier system in Britain, something which the former Prime Minister, Gordon Brown, has highlighted as being extremely concerning. There is currently a sharp divide between what has been proposed for Scotland and what we have before us here.

The amendments in this group do not affect in any way what happens in Scotland. But like the former Prime Minister, I am very concerned that we could find ourselves in a situation where people are moving between the two jurisdictions. At the very least, I would have expected there to be intensive consultation between the two parliaments. The Scottish Cabinet Secretary for health has written a number of letters to the lead Committee on Assisted Dying in the Scottish Parliament, in which he acknowledges that the Scottish and UK government officials must continue to hold discussions on the legislative competence issues.

Is the Minister able to say more about these discussions? Are they confined to legislative competence or do they extend to to issues such as delivery timescales, the regulatory framework of medical practitioners across the UK, and the intention to give Scottish Ministers the authority to determine approved substances to use. All of which Mr. Grey has highlighted as concerns, and are indicative of the problems of having potentially different systems north and south of the border. It seems to me, in conclusion, my Lords, that matters are moving and changing at pace, both with additions to this Bill and the Scottish Bill.

And if things are done in piecemeal or with haste, we are in danger of the assisted dying becoming another deposit return scheme. Although you can't return from being dead. The deposit return scheme, my Lords, was an example of the two parliaments wanting to implement something that needed careful consultation and co-operation across the UK, legislating separately, both totally within their devolved areas. But in the case of Scotland ending up with a bill that could not be implemented because of the cross-border issues that had not been fully acknowledged and addressed.

Addressing these issues and getting clear answers from the bill's sponsors and the Minister are what these group of amendments are about and I believe are essential. My

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Lords, I beg to move. Amendment proposed clause. One, page. One, line 11.

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One, line 11. After England.

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Insert Scotland. Voice speech on amendment 17. In mystery, particularly in relation to the Scottish Ambulance Service,

11:09

Lord Shinkwin (Conservative)

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to the Scottish Ambulance Service, which my little friend Baroness Fraser of Craigmaddie has mentioned briefly in her speech, and I do so as someone who can remember just about all of my journeys in ambulances, some in agony after a fracture, some with the blue light flashing, others more sedate. But what marked them all was the sense that however much pain I was in, I was nonetheless safe. The ambulance crew were in control of the situation.

Karen, competent and consistently professional. That is my abiding memory. Based on first hand experience. So my thoughts. I am concerned, as I understand, is the Scottish Ambulance Service, that there is currently no guidance on this specific issue, even though its absence has significant practical implications. Simply put, from an ambulance, frequent travellers perspective, but not this amendment. Ambulance crews or other healthcare professionals might well not feel fully in control of the situation.

And that's just not where you want to be as a potential patient needing urgent emergency care. Surely emergency services operating across Scotland England boundary not only need but desire. Clear guidance. For example, what exactly is a paramedic meant to do if they are called out because an assisted death. Which of course Tando and indeed has done on occasion in other jurisdictions where such legislation has been implemented. Badly wrong, leaving the individual seriously injured but very much alive.

It does happen. My voice. Yet the bill, as far as I can see, is silent on this point, which is not much use to a paramedic desperately wanting to provide care when an emergency response is requested due to complications such as choking or vomiting. My Lords, I'm not aware of this having been triggered in the impact assessment or of John Grady having received an answer when he raised this very issue at Report stage. In the other place.

So I'd be very grateful if the noble Baroness Vere Minster to share with the House in her closing remarks what work has been done by the government to evaluate and address such an important cross-border issue?

11:13

The Lord Bishop of Norwich (Bishops)

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My Lords, I rise to support the amendments 17 and 309 A proposed by the noble Lord. Lord, be so ably explained by the noble Baroness, Lady Fraser, and in standing I declare an interest in that. My wife is a GP and a medical examiner. So this bill has had much discussion at home, but also having spent ten years living in Northumberland with friends who live along the Scottish border, many of those living near enough the border have chosen very deliberately to be registered with the Scottish GP, because then they receive free prescriptions.

So this does arise to me a number of questions to the noble and learned Lord. Because if you live on the Scottish, on the English side of the border, say at Cornhill on Tweed, and your GP is in Coldstream, the the sense of continuity of care that GPS give to their patients is so vitally important for that GP patient relationship. Indeed. This House was reminded yesterday in the excellent maiden speech of the noble Baroness, Lady Gerada, when she said that continuity seeing lives unfold across time gives general practice its unique moral and social power.

It allows us to see people as whole human beings, not as isolated organs or diagnoses. So I'm I'm interested in this probing amendment to discover more about how that continuity of care that is, is so essential in primary health can can be continued, but also how those GPS operating in Scotland, if this bill is proposed and and a bill comes forward within the Scottish Parliament, of course, they are likely to be very different in their approaches. So I'm keen to understand from the noble and learned Lord what discussions have taken place to give this House confidence that Scottish GPS will receive the required training in any system that might be in place for for their patients who who live just across the River Tweed.

My second question around supporting these probing amendments is about access to to healthcare. For those living along the the English Scottish border. If you live in Berwick upon Tweed, you may sometimes choose to attend the Borders General Hospital in in Melrose, which I think is 37 miles away. Or you have the other choice of of going down the A1 that's not yet been dualled to the Cramlington Hospital, over, over 50 miles away. And and whilst in Berwick there is the excellent Berwick Cancer cars that volunteers help patients to get to places.

I can fully understand how this is utterly exhausting for people and people living in remote parts of the borders. Faced with that length of drive, when they're not feeling well, when they're needing to get to appointments, perhaps at Cramlington, 55 miles away, could have a greater sense of wanting to seek to end their lives because of the stress, the just sheer exhaustion that there comes with travelling such distances for cancer treatment or other treatments for terminal illness. So I ask the noble and learned Lord, what consideration has been given to those living in remote parts of the English Scottish border?

11:17

Lord Harper (Conservative)

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My Lords, this is a very sensible group of probing amendments, and it's a pleasure to amendments, and it's a pleasure to follow the right reverend Prelate. The reason why I rise to speak is the issues raised in this group about the difference between where somebody resides and where their GP is registered, is exactly analogous to the situation between England and Wales, which I raised on an earlier group of amendments, but to which I have not received a satisfactory set of answers.

So let me just remind the noble and learned Lord, and then he can hopefully respond in a positive way. There are two issues raised. I think. One is about the difference between, as I said, where you reside and where your GP is registered, and there are significant number of people both along the England Scotland border, but also on the England Wales border, where their place of residence is not the same as where their GP is registered. And it's very important, therefore, in the legislation, that it's clear that your the rules under which you access assisted suicide are governed by where you live, not where your GP is registered.

And that's very important both for the reasons that the noble Lady Baroness Fraser set out, because between England and Wales there will be sorry between England and Scotland there will be two very different potentially legal situations. But as we know from the earlier debate, although this bill covers England and Wales, the detail of how an assisted suicide service is going to work in Wales, the rules around that are going to be set by the Welsh Senate, not by the UK Parliament.

And it's very important, therefore, that it's only people in Wales that the Welsh rules apply to who are therefore governed by a body to which that's democratically accountable to them, not people who live in England, because there will be a massive democratic deficit there. So I think it's very important. The noble Lord is clear about how that's going to work. The final question I would ask him, and he I think he set out in response to the debate we had on England and Wales, he said, I think that he and his the hon.

Member for Batley and Spen had had some detailed discussions, I think, with the devolved governments, but I wasn't clear from those, from his responses whether the conversations had covered this point. And obviously it needs to cover both the views of the devolved governments, but also the UK government, for which for these purposes is actually only the English government. But we need to understand how this is going to work in practice. And as I said in conclusion, this has got to be got right now in primary legislation, because if we don't get it right now, somebody is going to have to spend months and years clearing up the mess afterwards, which is one of the things that I have to do.

When I was the member of Parliament for the forest of Dean in dealing with the cross-border issues that hadn't been properly thought through then. So I think this is a very, very valuable set of amendments, and I was pleased that I think it was last week that the noble and learned Lord himself acknowledged when Lord Beith spoke about it briefly, that these issues were valid, ones that needed proper answers. And I look forward to hearing them now.

11:20

Lord Deben (Conservative)

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Could I just the practical about >> Could I just the practical about this, because of a point which the noble Baroness mentioned, which was noble Baroness mentioned, which was the parallelism with the issue that got into terrible trouble and the deposit return scheme? I declare an interest as the chairman of Valpak, and we had to work through that. So it's burnt into me. How extremely damaging it was, because it wasn't decided beforehand. And I know that we are talking about much greater issues here, but this is and I hope the noble peer will will accept this is a really serious issue because it did bring about enormous cost, vast misunderstanding, and it ended up by destroying what the Scottish Government wanted to do.

And therefore it is a very dangerous precedent, and I'm sure that the noble Lord will want to make absolutely sure that we don't have a repetition of something which cost vast sums of money, both in the private and the public sector, and something that has undermined an important measure ever since. My Lords, this group.

11:22

Earl Howe (Conservative)

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Of amendments. Deal covers two >> Of amendments. Deal covers two distinct but connected questions. The first question posed by amendment 17 is, in my judgement, a very helpful one, because the answer will clarify the role or lack of role played by a person's GP in the process being pursued by that person in seeking an assisted death. Reading the provisions of the bill seems to me that the involvement of a person's GP in that process, although very likely, is not legally necessary, provided that the patient fulfils all the conditions set out in clause one.

One clarification from the noble and learned Lord would be very helpful. The second question posed by my noble friend Lady Fraser's Amendment 62, is also one that I hope can be answered very simply by the noble and learned Lord. Am I correct that it is implicit in clause five that the preliminary discussion between the patient and the registered medical practitioner need not involve a doctor physically situated in England and Wales, and need not be face to face. Equally, am I correct that it is unnecessary to state in clause three B that the steps set out in clauses eight and 19 must be taken by persons in England and Wales, because clauses eight and 19 because clauses eight and 19 already explicitly provide for this.

11:23

Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)

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My Lords, let me start by thanking noble Lords for their contributions in this debate. I contributions in this debate. I will, as I've said previously, keep my comments limited to the amendments on which the government has major legal, technical or operational workability concerns. Turning first to amendment 17 and 309, a in the name of the noble Lord, Lord Beith, introduced by the noble Lady Baroness Fraser, amendment 17 is a probing amendment which seeks to establish whether people who are registered with the GP in Scotland, but live in England would be excluded from eligibility for an assisted death.

Under the Bill. Noble Lords may wish to note that amendment 17 has limited effect as it only amends clause one, which is largely descriptive, without further amendments to clauses ten and 17, which contain duties to assess eligibility criteria, amendment 17 will not impact these criteria and will introduce conflicting provisions. Amendment 309, a amends the correspondent eligibility corresponding eligibility criteria in clause ten to include a person registered as a patient with a general medical practice in England, Wales or Scotland.

It does not amend clause 17, which contains the assessment by the panel. Therefore, both amendments 17 and 309 would require further consequential amendments to ensure that the bill is coherent. This would include amendments to ensure that data recording obligations and the associated criminal offences apply to Scottish GPS. These consequential amendments are likely to require consultation with the Scottish Government, as the noble Lady Baroness Fraser referred to, in line with guidance for private Members Bills. I thank the noble Lady Baroness Fraser for amending a for tabling amendment 62.

The purpose of this amendment is to establish why the bill only requires the actions set out in clauses ten and 11, to be undertaken by people in England and England or Wales, and not the preliminary discussion under clause five. Our understanding is that the reference to the preliminary discussion, clause five, is not mentioned in clause one three, because clause 53 already requires that a person wanting to have a preliminary discussion must be in England and Wales, amendment 62 would require steps under clauses eight and 19 to be taken by persons in England or Wales.

As drafted, the Bill requires that most of the steps in clauses eight, ten, 11 and 19 will already have to take place in England and Wales. In addition to the above, amendment 62 has the effect that when the Secretary of State makes regulations under clause 19, the Secretary of State must be in England and Wales at the moment they sign the regulations. This could lead to the regulations being improperly made and challenged. Should the Secretary of State not physically be in England or Wales at the time of signing the regulations? This does raise a practical issue of workability, as I'm sure the noble Lady understands with regard to the points raised by the noble Lady Baroness Fraser and the noble Lord Lord Shinkwin, relating to Scotland and guidance that the government has provided to the sponsor, as I'm sure that noble Lords will understand, and I have reiterated, we are providing technical and workability support to the sponsor in relation to devolution issues, including those that have been raised.

This is an

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evolving situation which will continue throughout the passage of the bill. I'm grateful to everybody who's

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I'm grateful to everybody who's taking part in short debate. Could I pay particular tribute to the noble Baroness Baroness Fraser of Craigmaddie, who discussed the issues with me yesterday and was incredibly clear in the way that incredibly clear in the way that she raised them today, and she also raised the noble Lord, Lord Beith's concerns. And can I deal with three

11:28

Lord Falconer of Thoroton (Labour)

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concerns. And can I deal with three issues? First of all, where does the GP practice have to be to satisfy the eligibility requirements? Secondly, does the clause five conversation have to take place within England and Wales GP or can it take place with the Scottish GP? Thirdly, how are we going to deal with the clashes between Scotland and England? Because I am aware, because the Baroness Fraser of Craigmaddie told me about the deposit return scheme and how that went wrong and I am conscious of that as an issue.

First of all, the noble Lord, Lord Beith's amendment, he is saying, can the GP to whom you have to be a member of the practice, be in Scotland? The answer to that is no. Under the Bill at the moment, the Bill is clear that you have to be in a GP practice in England or Wales. Everybody has said to me it is perfectly normal for a person living in England, in the border areas, to have a GP in Scotland, so why can't we change the bill to say your GP could be in Scotland? Because that's a reflection of how people actually live.

I'm sympathetic to that. But the Baroness Fraser of Craigmaddie legitimately makes the point. If that happens, then I will need to make various other changes. For example, and this is a point that the Baroness Fraser of Craigmaddie made. If you look at clause seven of the bill, where there is a preliminary discussion, it's got to be sent to the GP. The GP has got to keep a proper record of it in his or her records. How can I enforce that unless I expand the provisions of the Bill to allow Scottish enforcement, for which I would need Scottish agreement? My view in relation to the noble Lord Lord Bates point is, let's see if we can make it work, but it will require discussions with Scotland.

The second point, which is the point made in the Baroness Fraser of Craigmaddie amendment, is can the are preliminary discussion take place in England? And my noble friend Baroness Merryn said it's intended that it should only take place in England and not be with, for example, a Scottish GP. The way the Bill is drafted, it says specific things have got to take place in England and Wales. As it happens, that doesn't include clause five. And then if you look at clause five, it says in clause five three you've got to make your request from England and Wales for a preliminary discussion, which might involve a request to somebody in Scotland.

So I think the point that the Baroness Fraser is making is an entirely legitimate point. Again, speaking for myself, I don't see why the conversation can't take place with somebody in Scotland, but that will give rise to particular difficulties about enforcement. So I need to take away what the Baroness Fraser has said and think about what is the answer to all of those problems. And it is a classically appropriate probing amendment because it raises quite thorny issues, not little as far as the noble Lord Lord Harper is concerned, we're dealing with a slightly different issue in relation to the England Wales border issues.

What the noble Baroness and the other peers who have raised issue have raised is the question of eligibility, whether your GP practice is in on one side or other of the border doesn't matter for eligibility. Whether you live one side or the other of the border doesn't matter. The noble Lord, Lord Harper, then raised the issue of what will the arrangements be for delivery of the NHS in relation to assisted dying? One side of the border and those are legitimate issues, but they are not raised by this bunch of amendments and will fall to be discussed under clause 41 and 42.

So perhaps I could postpone answering that till then. As far as the noble Lord Lord Shinkwin points, which one is very sympathetic to? Again, I don't think the question of how you deal with somebody in distress in the circumstances he raised, is a real issue in relation to the cross-border issues and in relation to the right reverend Prelate. I think I've answered the questions that he raised because he's raising effectively the same issues that the Baroness Fraser of Craigmaddie has raised.

So in the light of that, I would invite the amendment.

11:33

Baroness Fraser of Craigmaddie (Conservative)

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Thank you. I'd like to thank all noble Lords who took part in this debate, and I would like to thank debate, and I would like to thank the Minister for, you know, her words. I think we all want to ensure that this bill is coherent and we all want to we all appreciate it's an evolving situation, and there might be consequential things that need to happen down the line. I just fear that the interactions with Scotland seemed to me as something that has been very hastily done.

We had our debate on Wales on the first day of committee, but I do agree. I feel Scotland is different, both with health and justice being devolved and the fact that there is a Bill going through the Scottish Parliament at the moment. So I, I have the permission of Lord Beith to withdraw his amendment. And on the assurance that we can continue to monitor this evolving situation, to ensure that things are indeed

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coherent. I beg leave to withdraw. Your Lordships pleasure that this amendment be withdrawn. Amendment by leave withdrawn. Amendment 18 not moved. Frontbench. Amendment 18 not moved. Frontbench. Not moved. Not moved. We now come to the next group of amendments in

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to the next group of amendments in clause one. Lord Rook amendment 19. My Lords, I rise to speak briefly to my amendment. Amendment briefly to my amendment. Amendment 19. This adds a modest, but I believe, an important safeguard to

11:34

Lord Rook (Labour)

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clause one by ensuring that a person seeking an assisted death has been registered with a GP has been registered with a GP practice in England or Wales for at least 12 months, and has had at least two contacts with that least two contacts with that practice in that period, whether in person, remotely or through a home person, remotely or through a home visit. These are minimal thresholds. They do not obstruct genuine applicants. They simply ensure that applicants. They simply ensure that before someone seeks the assistance of the state in ending their life, there is at least some continuity of care.

The importance of which the right reverend Prelate, the Bishop of Norwich, has already stressed this morning. To this end, a real relationship with the primary care system is important and prevents a terminal decision becoming subject only to a paper exercise. The bill already requires 12 months of ordinary residence, but ordinary residents, as we discussed in the last day of committee, can be, legally speaking, a somewhat elastic concept. A single GP registration can, in practice, be little more than having your name down on a list.

The government's own Equality Impact Assessment notes that access to GP services is uneven, that continuous continuity of care is declining, and that patients in deprived or rural areas often struggle to obtain timely appointments. Lord Darzi independent investigation into the NHS discovered that more than 1300 GP practices have closed since 2015, while the average full time GP now has responsibility for more than 2200 patients. In such a landscape, it is simply unrealistic to assume that every person approaching the end of life will have a meaningful GP relationship without a safeguard, such as the one I proposed in this amendment.

This amendment gives the residency requirement real substance. 12 months of registration and two GP contacts do not create a barrier, but they do provide a more objective basis for assessing doctors to know that the person has not merely appeared in the system at a moment of crisis. It also increases the chance that some medical history exists. Notes of previous consultations, indications of distress, relevant family context, and prior diagnoses are all crucial in understanding whether a wish to die is stable or situational.

Now this matters because, as we have discussed already and at some length, the bill places extraordinary weight on two clinicians making difficult judgements about a prognosis, about mental state, and about possible coercion. Clause 12 allows them to seek information from the person's GP, but this safeguard only works if a relationship with that GP actually exists. As a number of noble Lords have mentioned, this House has been served well by the Bill's own Select Committee, and in that your Lordships heard repeatedly that continuity of care is one of the most reliable protections against misjudging capacity or missing signs of procedure.

Doctor Michael Mulholland of the Rcgp stressed that continuity is not a luxury, but central to safe clinical judgement. Professor Catherine Stillman explained that earlier access to palliative care often changes patients perception of their suffering, which again relies on a clinician who knows the patient and without any medical history, without any prior interactions with clinicians. Life and death decisions are being made without the proper safeguards, and this is not safe for patients, and it is not safe, and it's not fair to doctors.

We also heard extensive evidence on access difficulties. Caroline Abrahams of Age UK told the select committee that the single biggest practical improvement older people want is simply being able to see their GP. Many cannot. She noted that significant numbers of older people near the end of life have no contact at all with their GP, not because they don't want it, but because the system does not provide it. A report cited in the Equality Impact Assessment on the bill found that 2 in 3 older people in Wales struggle even to make suitable appointments.

If access to GP care is already fragile, the Bill must not assume a relationship that does not exist. There is also the risk recognised multiple times already in this Committee stage of doctor shopping. We see it in pain management, in cosmetic procedures, even in end of life discussions, when someone is desperate, frightened or grieving, they simply will go from clinician to clinician until they find the answer they feel they want and need. Expert witnesses, including psychiatrists and geriatricians, told the select committee that major emotional shifts commonly occur around diagnosis, around transitions in care, or around family crises.

These are precisely the moments when a single assessment by an unfamiliar doctor is most likely to misread a temporary situation, or wish to die as a settled and autonomous choice. My Lords, international evidence reinforces the point. Australian states, often cited as models, have tightened their systems after discovering patterns of people travelling to access assisted dying without any real connection to those local health services. Canadian doctors regularly highlight the difficulty of assessing capacity and voluntariness when clinicians had no longitudinal knowledge of the patient, contributing to public concern over several high profile cases.

We need not make those mistakes. The DHSC and the MoJ impact assessments underline that assisted deaths must be documented and monitored, and that clinicians require access to historical records to make safe judgements. But the true quality and veracity of these records relies on real and consistent engagement with a primary care provider. The select committee also heard from social workers and safeguarding experts, who emphasised that subtle coercion is almost impossible to detect in a single clinical encounter.

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I'm very grateful to the noble Lords giving away. I just wonder what he feels a GP should do in that circumstance where he doesn't approve of assisted dying. Is that

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approve of assisted dying. Is that a problem, do you feel? With the greatest respect, that's not the conversation I'm trying to have here. The trying to have here. The conversation we are trying to have here is the necessity that someone who is going through that process has a continuity of care and has a continuity of care and relationship with that GP, and we are suggesting that someone who is after a state assisted end of life process has the opportunity to see that GP on a number of occasions so their judgement can be made in the in the context of continuity of care, not in kind of one appointment.

My Lords, this amendment does not block access to pick up the noble Lords questions. It does not frustrate autonomy. It simply ensures that assisted dying does not begin from nowhere. It grounds a grave decision in a minimal but essential relationship with the health service that is charged with safeguarding the person in question. Supporting autonomy requires a supportive context. It requires knowing whether a request reflects a settled conviction, a moment of despair, untreated depression, or pressure that the patient feels unable to articulate.

These things cannot be reliably assessed in isolation. Above all, care is relational. If Parliament is to contemplate legislation under which the state may participate in deliberately ending life, then the very least we must insist upon is that such decisions take place within the context of real and primary medical relationships, not on the periphery of the system. This amendment strengthens residency safeguards, improves the evidential foundation for clinicians, reduces the risk of doctor shopping, and respects the seriousness of what the bill proposes by rooting it in genuine and consistent care.

I commend the amendment to the House.

11:42

Baroness Jay of Paddington (Labour)

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Opposed in clause one, page one, >> Opposed in clause one, page one, line 12. At end, insert the words as printed on the Marshall List.

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as printed on the Marshall List. My Lords, I was simply going to ask the noble Lord before he sat ask the noble Lord before he sat down, having cited the doctor, Michael Mulholland, as a great authority in relation to his evidence to the Select committee. Whether he also accepts what Doctor Mulholland said to the select committee, which was that as GPS, we are very used to providing holistic care and trying to understand where the patient is coming from in lots of different

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situations. To respond to the noble Lady. I absolutely agree with that. And the reason why the doctor is able to do that is because he gives consistency and continuity of care. consistency and continuity of care. He doesn't see patients on one occasion on one big issue, but actually is able to travel with them in a longitudinal relationship, and that gives him the ability to make those decisions.

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make those decisions. To. Sorry, it's my first time I stood up.

11:43

Baroness Gerada (Crossbench)

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So as a GP myself, I understand the sentiment behind this amendment and I understand the power of continuity. And in fact, what was continuity. And in fact, what was my maiden speech was yesterday. But modern general practice works in teams. Modern general practice works in multidisciplinary teams. Nurse prescribers, pharmacists, physician associates. We also work with our other members, especially with those at the end of their life. Palliative care teams, oncology teams. So I also understand the need to have a GP involved.

I think it's rather reductive. We deliver continuity in today's world through our medical record, which actually is a complete record of the individual we have from cradle to grave. So I would actually say it is with the primary health care team that the individual has a relationship rather rather than an individual. And then just on a point of clarification, the average patient over the age of 75 actually consults with their GP team to the primary health care teams around ten times per year.

So I don't recognise the figure that most of those elderly people at the end of their life have no access to the GP. We reach out to our elderly patients and we try and deliver the best possible care we can to them, especially when they're approaching the end of their life.

11:45

Baroness O'Loan (Crossbench)

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And I put my name to amendment 220, in the name of the noble 220, in the name of the noble Baroness Barran Foster, who is not able to be here today. I am sympathetic to amendments 21 and 29, and to the process devised by noble Baroness Lawlor in her amendments 30 265 and four four Lord Reay my Lords, a huge range of clauses seven, eight, ten, 12, 15, 19, 20, 23. 24, 28, 29, 30. All refer to the applicant's GP practice and the importance of keeping a GP informed.

Clause 12 two F includes a provision for the assessing doctor to recommend that the patient in the applicant informs their GP practice. These amendments also refer to the very relevant information, which may be available from those who are close to the person seeking assisted death. My Lords, there is an assumption that the GP knows the patient and that the patient has an ongoing supportive relationship with the UK GP practice. And notwithstanding what the noble Baroness, Baroness Gerard has just said, that is actually no longer the case for many people.

Many patients now see different clinicians on each visit. Locum and temporary staffing arrangements reduce the possibility of a GP being familiar with temporary, with the patient's condition, or with the context in which they live. Home visits have almost disappeared. People in need of care often have to go to A&E, since doctors no longer visit as they once did, and a major theme in UK and international data on GPS is declining continuity of care, particularly where people live in poverty or deprived areas.

The Government Equality Impact Assessment notes that such people have experienced poorer quality healthcare, have a higher patient to GDP ratio, have worse continuity of care, and are more likely to struggle with navigating the healthcare system. My Lords, amendment 20 in my name provides. It is not enough to be registered with the GP, but there must be an established relationship between the GP and the patient. The GP must be able to certify that they have good knowledge of their personal circumstances, having seen the patient at least four times in the year and made at least one home visit in the last 12 months.

As I said, my Lord, the reality today is many sick and elderly people don't have the relationship they might like with their GP. It's a thing of the past. Moreover, when a person moves into a residential or nursing home, they're often required to change the GP who attends that facility and who may only have seen them on a few occasions, if at all. A GP who doesn't know a patient may not have the ability to make the necessary assessment. My Lords, the Select Committee heard evidence highlighting the very real inherent difficulties in detecting coercion, pressure and complex capacity issues.

Making someone feel that they're a burden doesn't normally happen by direct coercion, but is more likely to occur over a period of time, and the National Care Forum stated that our members are concerned that some of the people they support may sadly already see themselves as burden. This can be financial, or just because they're now reliant on those who once relied on them. The concern is that this makes them vulnerable to deciding for this reason alone, or as a result of exploitation.

Doctor Annabelle Price, of the Royal College of Psychiatrists, said in her evidence that coercion is everybody's business and is difficult to confidently rule out. It needs to be thought about throughout the process, not just at the scrutiny at the end of the panel. Professor Patel, president of the Royal College of Physicians, said in his evidence that the involvement of the family within decision making is important and that I feel that the complex decision making is hard. It has to be shared.

So, my Lords, amendment 220 provides a mechanism to allow GPS to consult with those who have a close interest in the applicant's welfare when there are concerns about safeguarding capacity and undue influence. Such concerns, regrettably, do often arise. Family members and close contacts may possess information which could be vital for a robust assessment, and which is otherwise unavailable to the assessing medical practitioner. Professor Katherine Sleeman said complex capacity assessments conventionally require triangulation with input and information from the family.

This amendment allows access to professional records, including police and local authority records. As medical practitioners may be unaware, for example, of existing domestic abuse situations which have been reported to the police but haven't actually made their way back to the doctor, where you've got a patient or an elderly person. My Lords, it should never be the case that the first time that somebody found out that a family member has been granted a request for assisted dying is when they're asked to go to the mortuary to view the body.

Anybody with any experience of the situation in which a patient dies by suicide will know the terrible shock and trauma which ensues for surviving family and members. The reality is that by extending the concept of autonomy to this extent, there can be a terrible impact on the ability to function of those who love the person who has died. Autonomy in this context can cause serious medical problems for those who are left behind. Autonomy, to the extent provided for in the bill, doesn't ensure sufficient protection for a vulnerable.

Sorry pardon with the noble Lady.

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Except because she's. Been quoting from some of the evidence given to the Select evidence given to the Select Committee, of which I was a member, that we were not able to hear either from people who were dying on the select Committee, or indeed from the families who had been from the families who had been through what she's talking about, and that we were absent. We we lost that. And on the particular point that. And on the particular point she raises about the first time a family may know about it, could she also just reflect that the evidence was that actually most families try and discourage somebody from taking their own life, rather than the other way round?

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My Lord, I thank the noble Lady for her intervention. It is, of course, the case that the Select Committee was very truncated in its Committee was very truncated in its ability to hear evidence. That was a decision of the House, and the fact that we would have preferred to hear evidence from others was to hear evidence from others was not possible.

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So I, if I may, as a member of the select committee, actually, it was a decision by the Select committee not to hear from terminally ill people. It wasn't to terminally ill people. It wasn't to do with the time available. It was to do with that committee, the majority of which were opposed, did

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not want to hear from terminally ill people. I can't comment on the deliberations of the committee. I

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deliberations of the committee. I think there are others here who possibly can. For the record, noble Lords, I

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For the record, noble Lords, I inform the House that there was only one vote taken at the Select Committee. The vote was whether or Committee. The vote was whether or not the committee should receive written evidence, and in fact, the vote was taken and the committee did not receive written evidence, did not receive written evidence, which is a great shame, because we would have heard from so many groups that people are raising in their contributions today. So for the record, there was only one vote taken.

There were many witnesses that people on all sides wished to hear from. It was a deep regret that we were truncated, and we had those three weeks in order to have those 13 panel sessions. If we'd had more time, we'd been able to hear from many other groups. But for the record, only one vote was

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taken, and that was not to take written evidence. I thank the noble Baroness for intervention, which very helpful. intervention, which very helpful. My Lords, all I was trying to say was that we are aware of situations and many situations in which people are subject to coercion and where are subject to coercion and where there are financial and other interests which cause people to be subject to pressure, to think that perhaps they're a burden, etc. etc. perhaps they're a burden, etc. etc. and the autonomy which currently exists in the bill in terms of decision making, where there's no decision making, where there's no access provided for, sorry, no provision for access to police and other records, medical records doesn't ensure sufficient protection for vulnerable individual who's making an application for assisted death.

And that, my Lord, is why these amendments are important so that the GP, who is faced with dealing with the situation and all those involved, can have access to other documents. Thank you, my Lords. I would like just to speak about the fact that I'm currently a patient in a very minor way at an excellent medical practice where the nurses

11:53

Baroness Butler-Sloss (Crossbench)

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know me well. There are five GPS. I've met two of them briefly, but they don't really know me. And what I would say is I have huge sympathy with this, these amendments, but I think it's unrealistic. And over the years I've been in this excellent practice, I have never excellent practice, I have never got to know a GP, certainly to an extent of more than twice. But since there are five and I'm extremely well looked after, I don't see any problem with it.

But the idea that you should know your GP, or rather that your GP should know you, I just don't think that happens across the country. And listening to what the noble Lady, the Baroness Gerada said, I mean, this is really the reality. I look another place sits down. Could she possibly accept that there are situations in which patients A can't get access to GPS? B when they do get access to GPS, have GPS who have huge patient loads, which means that they can't see the patients, and that while she may be in a very privileged position having five GPS, many doctors practices don't have that number and people quite simply do not get access to the doctor.

I'm not fabricating anything as I excuse me as I say this, and I would ask her to reflect on the fact that it is established in the government's equality impact assessment, that there are problems with access. Well, yes, I entirely agree, and this is the basis of what I'm saying. I think it would be admirable if anyone who was seeking assisted dying actually had had the opportunity to be known by the local GP. All I'm saying is, I mean, if I'm lucky, but I don't actually know my GPS.

And of course I accept what the noble Lady says. Baroness O'Loan there are many people who never meet their GPS who never have access. This is why it seems to me

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that what is required cannot be achieved. That's all I'm saying. My Lords. Should we not hear Lords.

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Should we not hear Lords. Who have tabled, who have tabled the amendments before we before. Before. All I'm pointing out is we should hear.

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should hear. Oh, my Lords, can we follow the normal courtesies of the House, normal courtesies of the House, please? If the noble Lady wasn't here at the beginning of this group of amendments, she cannot participate in this group of amendments. And I urge noble Lords to reiterate in terms of where we were and move forward.

11:56

Lord Winston (Labour)

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My Lords, my Lords, the noble >> My Lords, my Lords, the noble Lady Baroness O'Loan actually destroys her own argument because access to GPS, unfortunately, is still a major problem. And in that respect, I would like to respect, I would like to congratulate the noble Lady Baroness Gerada, who gave a fantastic maiden speech yesterday explaining the role of the GP. The ideal situation, but the fact of the matter is, in this chamber there will be a number of people who, quite rightly, absolutely deplore or disagree or disagree with assisted dying as they have every right to do so.

It's also true that in my practice many years ago, I saw patients who had requested termination of pregnancy and certainly in more than one case, but one particular patient I remember very clearly several years after the Abortion Act had been agreed to and had started, I saw a patient who who came into the hospital, having been refused referral for a GP because he disapproved as he was entitled to do so of abortion. She did not get a referral.

She ended up going to an illegal practitioner in the East End of London, and she ended up with infection of the uterus, and she was in bed for several weeks with septicaemia, septicaemia. She didn't actually die, but her laparotomy required her, the uterus, tubes and most of her pelvis to be removed. That is the risk, and it's always going to be the case that individual GPS have the absolute right to decide how they might handle a particular difficult ethical issue. But of course, the problem here is that these vary from patient to patient.

We have to understand that. And just simply relying on the GP in this way seems

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to me to be deeply flawed. My Lord. I think you interviewed after I shut down, but I would like to ask the. And it's very regrettable that he had a patient in an abortion he had a patient in an abortion situation. We are not in this group discussing the doctor's wishes or otherwise and his views about otherwise and his views about abortion. But I'd like to ask the noble Lord, the Minister, because we're sort of I hear mutterings here.

What provision says that you can't intervene in a debate where you have not been present, perhaps at the very, very first moment of the debate, what is the section in the companion that provides for that?

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Return to the amendment as we are discussing them? Actually, I are discussing them? Actually, I wanted to commend the sponsors of the bill in the sense that when I the bill in the sense that when I read the bill, multiple clauses read the bill, multiple clauses refer to the applicant's GP. But there is an assumption of an there is an assumption of an ongoing relationship with that GP. If there isn't, then we can come back to that. I had assumed that

11:59

Baroness Fox of Buckley (Non-affiliated)

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was it, that it was an ongoing relationship and the noble Lord relationship and the noble Lord Lord Rook has raised some of the real challenges to why that might not be realistic. The problem for not be realistic. The problem for me is if there is no assumption of an ongoing relationship, but just an ongoing relationship, but just simply a visit to a GP, it seems to me to be completely meaningless. You go in for a ten minute meeting You go in for a ten minute meeting with a GP transient, patchy at They're unlikely to be able to make any kind of clinical, as I think the noble Lady Baroness Sloss referred to not seeing a GP, but how pleasant it was.

I thought I would do a little bit of lived experience here, which is I've been in the same GP practice for 25 years. I've never seen the same GP, I've seen locums, I've seen temporary staff, I've seen physician associates who I thought were GPS and found out afterwards they weren't. No problem at all, you might think, but they've had no familiarity with my conditions. In many instances I've had to say, would you please read my notes as they looked elsewhere and the consequences of this and I don't usually the consequence of this has been misdiagnosis and not in a very positive way, any kind of a reasonable intervention in serious conditions.

That is what life is like for many people. When the noble Lady Baroness Gerada, who by the way, I am delighted to welcome to this house and I know her maiden speech described the ideal GP, which she may well embody. I wish I knew more of them. I have friends who are GPS, but it's not the real life experience of most people in this country. Even the noble Lady, Baroness Gerada said. We all work in harmonious teams and that she doesn't recognise the scenario of elderly people who can't get to see their GP.

Well, actually that statistic was from Wales and if you know anything about the Welsh NHS, let me tell you I'm surprised any of them get to see a GP. The truth of the matter is the truth of the matter is, is, is that there's no point. The bill, as I was commending the sponsor of the bill, saying, well, it's all all right because you'll get to see a GP if you just wander in and see a GP for a short consultation.

That is not what this holistic notion of a GP who can really act as somebody who can be a safeguard, who can really understand all that's going on in your life, which is what I, by the way, when I read the bill, I had assumed and was flattering the the sponsors of the bill for wanting. I was then going to ask them, but the real, real life's not like that. I actually think there's a serious danger if it's just a question of going to see a GP without continuity of care, that it just becomes a tick box exercise.

It just mentioning the word GP to give it some kind of medical authenticity, authenticity, but it's of no real consequence. But I do have a degree of sympathy with the question, and if I can ask the to be even handed, especially the noble Lady Baroness O'Loan, who spoke very well on her amendment 20 but when I read her amendment, I thought, who on earth is ever going to have access to? I mean, home visits are mentioned in a number of the amendments.

Home visits. Who's ever had a home visit recently? I mean, these are a thing of the past, and I know we're all getting on, but honestly, and I, I just think that I'm confused because I want the bill to embody a sense of the GP being important, but that

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requires continuity, continuity of care. I would. Just like.

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Just like. To remind the noble Lady and I thank her for giving way, but we are talking about people who are terminally ill. We're not talking

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terminally ill. We're not talking about the general population. Right to.

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Right to. I was just I was. I was just finishing. I was just

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I was just finishing. I was just finishing because it it relates to this. I appreciate that once given a terminal diagnosis, that might be true, but not necessarily. By the way, let me tell you, that is the honest reality of the situation. And so there's that. But I but what I'm saying is, is that we've got a moral dilemma here. GPS are being called on as though they're important to this bill. But if they're just passing and you haven't got continuity of care, then actually they've been treated with contempt.

On the other hand, the demand that you have to have continuity of care before you can ever be offered assisted dying seems unrealistic in today's modern health service, in truth.

12:04

Baroness Lawlor (Conservative)

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12:13

Lord Deben (Conservative)

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Registered practitioner in Suffolk for many years. I don't have a particular one because that is not how the local system works. So I really do say that we are not in a sensible position, if that is what we ask. But Lord Rook has got an important point, which I don't want us to lose because of the suggestion that all people have the kind of National Health Service which we would all wish to be true. I do think we have to take his point rather differently.

I was surprised that Lord Winston suggested that what the proposition is, is that the for some way or another, that the general practitioner or the team, because I quite understand it, is in normal circumstances, the team, the team could in some way stop the application. The point really is, and I do ask the House to think this seriously. The point really is that if someone has a general practitioner, it is important that that person and his or her team is in fact informed of this request in case they are able to contribute to a sensible decision.

And the fact that this is assumed in the Bill. I

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think as as well. Okay. As I think that that is

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As I think that that is absolutely put forward by by Lady Fox, the fact that it's assumed in this doesn't prevent us, perhaps from insisting that at least they should have the opportunity. And if should have the opportunity. And if we do that, I think we do a very valuable thing. And I do give way to the noble Lord.

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to the noble Lord. I thank the noble Lord. It isn't an assumption. It's actually on the face of the bill that if the coordinating doctor is not the GP of the person seeking the assisted death, then under clause 3B2 the GP, the coordinating doctor has to write to the GP practice to make

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them aware of that request. I agree with that. But the point of Lord Rook's particular amendment is that it ties together also a is that it ties together also a period, a period of someone being in the National Health Service. Now, in the National Health Service. Now, I agreed with the comments made by the lawyers about how you talked the lawyers about how you talked about not normally resident, rather than the whole issue about other words, but it does seem to me that the noble Lord who introduced this bill might consider that this particular amendment will give some confidence to those who had a concern, because it does mean that normally resident has been underlined by the fact that someone has in fact, been in a general practice of the National Health Service, and I don't think it does.

I can't see any harm that it does, given there's a year in any case. But what it does do is to underline what the noble Lord reminds us of the idea that this should be part of the normal way in which people are dealt with. I don't like this bill very much, but what I do think is our job is to make it work, and in order to make it work, it is more valuable to fix it within the National Health Service as we have it, and not to try to invent a service which we might well like to have and which I can.

I'm old enough to remember when we did have it. All I would say is, let's not pretend when things aren't as they ought to be.

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Great, great, great. Thompson. If a patient is at the end of their life in any practice in the NHS, that patient will be discussed at a multidisciplinary team meeting. That patient will be put onto an That patient will be put onto an end of life pathway. That patient will have a named clinician within that practice to do their caring. that practice to do their caring. This includes, as it would be I suggest, for assisted dying. So there's absolutely no way that a there's absolutely no way that a patient unless extraordinary situation.

And I take the point about Wales. Wales has a desperate problem with GPS. It's not the GPS problem, but that would be the normal way. That's how our contract is. That's how we want to care for our patients. So there is no way that somebody and we would know because it would come and we would code it on the notes, that every single person consulting with that patient would know that this patient was an assisted dying choice, and then they would get the care that I've just described with respect to the arbitrary 12 months, 24 months, many patients at the end of their life choose to move.

They choose to move to the place that either with their loved ones. Many of them, by the way, choose to do something at the end of their life, like go abroad to the countries that they may have been, may have come from, and come back right towards the end of their life. So to put an arbitrary barrier of 12 months, 24 months, I think, isn't putting the patient first. It's putting an arbitrary time limit first.

12:18

Baroness Falkner of Margravine (Crossbench)

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I wondered, first of all, whether the Minister in winding up would advise us what the companion would advise us what the companion says about peers making speeches on the same amendment over several the same amendment over several points of the passage of that amendment. I just wanted to say that it's a pleasure to follow Lord that it's a pleasure to follow Lord Deben speaking to Lord amendment, because I think it's there is a lacuna in clause 11D, which doesn't, by requiring the registration with a GP, doesn't cover the practical point of what happens to people who have lost contact with their GP, not for any other reason than having been taken because they were so ill.

Perhaps with cancer. And cancer is the main, main illness with which these people who might be seeking assisted dying would engage, may have taken take being taken into care, in private care, those who are lucky enough to do so. And it is an increasing proportion of the population of the United Kingdom who now uses private care, not least because employers provide that as part of a package. So coming to continuity of care and Lord amendment, which is a light touch amendment to clarify and strengthen clause 1D, if we must have it in the bill.

I just want to share with the House, very briefly, a practical experience of what it means to have advanced cancer, and the interaction with the GP. My GP practice having failed to diagnose me over six months, and I mentioned this in my Second Reading debate, slipped away the moment I engaged with private care. Although every single consultation with a private practitioner is sent to the GP, nevertheless, between August the 30th, when I was first diagnosed, and this September, late this September, I had no contact whatsoever with my GP practice, I'm told I finally was invited to come in and I was told that I had fallen between the cracks.

Must have been a pretty large crack to have lasted 14 months. So my question to the noble and learned Lord, when he's winding up on this debate, is what consideration has been given in in having clause 1D on the face of the Bill as to the relationship of the private oncologist who is treating that patient. And I noticed in the equality impact assessment, 66% of the people who sought assisted dying in the two jurisdictions quoted were people who had cancer. So what consideration has been given to the relationship of the private oncologist with the local GP, given that terminally ill people in in significant enough numbers that we all need to be conscious about their numbers in this bill may well have been, shall I say, passed on from the GP.

I have the experience. Just a final point. I have the experience of requesting, once I have the diagnosis of requesting treatment at my local, walkable, distance leading cancer teaching hospital in the United Kingdom. And I was told by my GP when I rang about that after the diagnosis, I was told, they won't take you because now you've gone private. I leave that to the noble Lords to reflect upon.

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My Lord. Could we please give way to. Those noble Baroness and peers

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Those noble Baroness and peers who have tabled amendments? I'd say.

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say. To speak to amendment 21. Which is. Tabled in my name. And I did this from a personal I did this from a personal experience, and I think the richness of the debate today shows that even in your Lordships Chamber,

12:22

Baroness Grey-Thompson (Crossbench)

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we all have completely different experiences of how we access a GP practice. So I partly table this debate from personal experience and it was looking, trying to look at how we provide continuous care to a patient. Now my own experience I'm disabled, I'm not sick. But I've had some very interesting experiences of interacting with doctors. Fairly recently, I was asked by a doctor how I caught, how I caught spina bifida and had to explain to him that it was congenital, but also my husband's experience of the healthcare system.

He had a spinal cord injury in 1984, and in a recent visit was continually asked, was it 1884 that you had your accident? Now, I know he looks good for his age, but so this is not to be flippant, my Lords, which I have been accused of before, it's actually to try and ensure that we have proper continuity of care for a person who wishes to end their life. And my amendment was also grounded in coercion, detection and the limitations of any capacity assessment.

And when I tabled amendment, I was thinking that perhaps a GP could provide extra knowledge to contribute to the decision that was made. But then I hear of the experience of my noble friend Baroness Falkner, which is absolutely appalling. It shows that there's far more work that we need to do on not just the National Health Service, but making sure we provide the right care. And the noble Lord Baroness talked about, you know, the NHS we wish to have. Well, actually, this might be a chance to think about the NHS that we wish to have.

I would like to take the opportunity to welcome my new noble friend, Baroness Gerada, and the experience that she brings to the chamber. I have to say it's left me slightly more confused. I do have amendments on data recording which we're going to be debating later. I think her comments show that the data recording and sharing is really important, and I got a bit confused about if there's a named clinician as part of that process. Doesn't that sort of ultimately feed around to some of the points that have been made today? But I'd welcome the chance to discuss that with her outside the chamber.

My Lords, I think the continuity of care is really important and how it relates to improved patient outcomes. So while in 2012, 56.7% of patients had a preferred GP, that is declining, and there is a link between your preferred GP and being able to access that GP, and the decline has happened regardless of baseline continuity, rural or urban location or level of deprivation. But for me, if we can provide a better experience to patients, it's actually making those final weeks months better for them.

Now, the Royal College of General Practitioners published work in 2021, which was excellent on why the relationship with the general practitioner is so important to the patient. But research on coercion and undue influence demonstrates that standard capacity assessments, while necessary, I don't think they're currently sufficient to identify subtle forms of coercion, and that's why I tabled amendment in response to my noble friend Lord Pannick comments about what happens if a GP died, I felt that I'd be happy to be corrected.

I thought the provision in the bill, which was about if your GP that would cover a general practitioner as well as as any other doctor involved in the process. My Lords, what we're talking about here is really complex decisions and consulting and established GP or GP practice might mean that they possess the nuanced knowledge which would help somebody make a choice. And the requirement GPS confirmed they could have a good understanding of the individual's personal circumstances. To me, represents a better form of safeguard, ensuring this knowledge is actually exist.

We can't assume anything during this process and the assessment provides, you know, should provide abuse detection capacity and available in other types of consultations. So for individuals who care is family dependent, you know, potentially the home visit element. And I have had one, you know, not so long ago. That element can play an important part in identifying coercion. My Lords, if the debate has raised nothing else today, it's that this is a really complicated issue which

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needs much further work. If I may. Just ask a question on that, on

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Just ask a question on that, on all of that, I haven't heard an answer to what happens. Everyone believes that a GP should be able believes that a GP should be able to conscientious object. And so what happens in that circumstance? Surely we do need a circumstance as happens today, as Baroness Gerada was saying in terms of team based approach, because otherwise you approach, because otherwise you could have formed a great relationship with a GP who, you know, then conscientiously objects and we think that's absolutely suitable, then withdraws himself from the situation or herself and

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then can no longer take part in it. Surely a team based approach is better? Yes.

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Yes. The comments made by noble friend Baroness Gerada and she explained the team based approach explained the team based approach that seems very sensible in terms of providing that continuity of care. I'm very lucky. I see the care. I'm very lucky. I see the same GP every time I go, and it's interesting to understand that not everybody experiences that, so I'm not absolutely welded to it. Being a single GP. For me it's about ensuring that we have continuity of care, the right support for an individual and doing it in the right way.

That enables them to make the best choice and they are not experiencing any coercion in terms of making that decision. So the the more frequent contact means that a GP or a practice will or should may be able to understand some of the really difficult family complications that we absolutely know goes on. And anybody who many of noble colleagues worked on domestic abuse Bill will see that coercion is very subtle and it's understated. It happens in numerous different ways.

And I do think we have a duty in making this bill the safest bill in the world. My noble, the noble and Lord will say this. I think we slightly disagree on it being the safest bill in the world, but I think we have a duty to make it safer.

12:29

Baroness Finlay of Llandaff (Crossbench)

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12:42

Baroness Hollins (Crossbench)

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my name to the very reasonable amendment 21, tabled by my noble friend Baroness Grey-Thompson. I think the debate hasn't been about whether assisted dying should be whether assisted dying should be part of a GP role. The debate has been about, and I think it's been been about, and I think it's been very helpful in focusing on the importance of continuity of care and accurate records. And I congratulate my noble friend Baroness Gerada on her first contributions to committee. Noble Lady is correct that GP is now work as part of a multidisciplinary team.

I think the patients accept this, but they do expect that a doctor is ultimately responsible for their care when they are seriously ill. And perhaps amendment 21 could meet the noble and learned Lords requirements if it was amended to, say, to refer to the medical practice rather than the general practitioner.

12:43

Lord Empey (Ulster Unionist Party)

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The debate on these amendments is really focussed on safety, in my is really focussed on safety, in my opinion, but we've turned it into a sort of a generalised whinge fest about the shortcomings of the about the shortcomings of the National Health Service, of which we are all aware. There are many, however, having from recent personal experience, I accept that, Baroness Gerada says. Of course, I'm fortunate. We have a local health centre. It's got four floors and it's got four practices in each group, separate practice in each floor, and those practices have multiple members within them, and they come and go and so on.

But generally speaking, if somebody is seriously ill and very fortunate that we were able to have established contacts with more than one of the team. However, the noble Lord Jordan Faulkner said he wanted the GPS mentioned to be a central point for records. And here we come to an entirely different issue. I have seen records which comprise what the GP practice puts in, but they also get discharge letters from the various hospitals that people have been in. Those discharge letters are written by an F1, which is the most junior doctor just coming out of university, and it is regarded as one of the worst things that a doctor has to do and sit late at night writing these discharge letters.

I have seen serious mistakes in those letters of even one of the problems that the patient had, and to try and get those records changed is very, very difficult. But if you're making decisions on the future of an individual on the basis of a record, that might be totally wrong or misleading, that is why we need additional protections. It's only common sense because humans were all frail. We all make mistakes. We write mistakes. We say mistakes, we overlook things.

And these are very significant because the the complaints that a person condition might be suffering from requires a certain type of medication. It may be that the person is suffering from multiple issues requiring multiple medications, and at least the doctor who knows the patient has some sense of how that individual reacts to those various medications. So I would just make the point that it is coming to the safety. I think Lord Deben had some good ideas there because the issue was general practice.

We all know some people have accessed, some don't. Some are good, some are bad, some are sold, some are closed, and entire practices can be moved into another practice where they have no knowledge of the individuals whatsoever. So we've got a sort of a mixed bag here, but I think I have to say, my Lords, it does illustrate a couple of things. It's down yes, to the safety, but I have to respectfully suggest that it shows the immaturity of this bill that we're having this discussion this morning.

We should have had a royal commission and a government bill instead of trying to do it and

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negotiate on the hoof. This is the only group in which I intend to speak today. I could I intend to speak today. I could have spoken in the last group since my former constituency abutted the Scottish Borders, Dumfries and Galloway, and a mere 85 yards Galloway, and a mere 85 yards across the River Sark was Gretna. I was aware, aware of our glorious 600 year history of border raiding for cattle and women in that order, and now it seems we can add free and now it seems we can add free prescriptions to the list as well.

My Lords, these amendments strengthen the safeguards by demonstrable ongoing clinical relationship with a GP. The risk reducing error, coercion and administrative confusion whilst supporting clinical judgement and continuity of care. Requiring 12 months registration plus a minimum number of person contacts, I think gives a straightforward, verifiable test of reasonable clinical involvement and I think we need robust practical safeguards and clear eligibility checks. And I think these are essential to prevent vulnerable people, to protect vulnerable people by evidencing local care and oversight.

A sustained relationship with a local GP who has seen the patient helps ensure the patient is informed, voluntary and free from subtle pressure. My Lords, the GPS direct knowledge of the patient's circumstances is therefore, in my view, a critical safeguard rather than a bureaucratic hurdle. Of course, the big problem is, my Lords, and this has already been said today, who sees the same GP twice running these days. I am very, very lucky and possibly some other noble Lords as well. With that superb GP practices in multidisciplinary GP practices in Cumbria.

But I almost always see the same GP and we can email as well. In fact, in 40 years living in that constituency, I've only had two GP's ever. But that is not the national picture where patients see a different GP every time they visit. There are many of them see a different GP every time. Therefore, for this part of the bill to work, it cannot be any old GP from the practice. It has to be a GP who has treated the patient personally on a few occasions or over a period of time.

Now, my Lords, yesterday I had the wonderful privilege of hearing in this House from a GP who satisfied all the criteria on these amendments because of her deep knowledge of her patients. I was present and indeed was able to congratulate her later for the excellent maiden speech of the noble Lady, the Baroness Gerada, a former president of the Royal College of General Practitioners. I am delighted to see see her joining this this morning. I understand this morning she was doing the day job and actually treating patients in her constituency.

Now I know the noble Lady is in favour of assisted dying, but what she said in one part of her speech yesterday was directly relevant to these amendments. She said and I'm rather vexed at the right reverend Prelate. The Bishop of Norwich sort of stole these lines earlier this morning because the noble Lady said, I became a GP in Kennington and I've lived and worked in the community of serf ever since. My very first patient was a young woman who suffered a stillbirth.

Decades later, I look after her children and now their children to that continuity. Seen lives unfold across time gives general practice its unique moral and social power. It allows us to see people as whole human beings, not as isolated organs or diagnoses. We are interpreters of experience, translators of suffering and witnesses to change. My Lords, that's exactly the sort of GP who I trust to make decisions on whether or not a person has has a confirmed wish to opt for assisted dying, not just any general practitioner who may have never met the patient before and has just ten minutes to form an opinion.

I would love, my Lords to find a way to include that magnificent sentence, that continuity seen lives unfold over time if general practice its unique moral and social power. I'd love to see if we could incorporate that into this bill, because it sets the right moral climate. As I said, I've got a GP and like the noble Lady Baroness Carr Baroness Gerada, but for those millions who are not so lucky, then these amendments, I believe, balance safeguards with practicality. Setting a modest minimum of context is proportionate.

I think it is enough to demonstrate an established relationship with imposing unrealistic burdens on patients or practices. Now, many have spoken of multidisciplinary teams. Now can can perhaps a noble, noble Baroness tell me or anyone tell me how many of all the GPS in this country, how many are still single practice doctors? My Google search suggests there's about 63%. That seems terribly high. There must be more multidisciplinary teams than that, but there are still an awful lot of single handed GPS, single practice GPS, and even on teams.

On the rare occasion I have not seen my GP, the other GP has had to look at the computer, read all my clinical notes but doesn't really know who I am. Maybe that's just his good fortune. Now these amendments by Lords support patient safety and public confidence. Public trust in any assisted dying regime needs to be visible. It needs to be enforceable safeguards and online and and clinicians be able to attest to a patient's circumstances. So I support them. Finally, can I say to the noble and learned Lord Lord Falconer of Thoroton, that I was dismayed to read some very hostile comments about noble Lords and Baronesses in the weekend press.

The complaint was that some peers had tabled a large number of amendments, and that was somehow wrong. Now, if they were the only peers who spoke to them, then that criticism would be valid. But those noble Lords and ladies as profession were professionals and experts and were table amendments many of us wanted to speak to, and we left them to do it, because those periods have experienced and scores of peers have spoken to their amendments, so they were not abusing the House.

I'm absolutely certain that the noble Lord, noble and Lord and Lord was not behind that bad mouthing because he's a gentleman as well as a noble Lord. But some supporters of this bill are trying to drown out, close down any proper scrutiny. And finally, could I remind him in the House that the Dignity in Dying website boasts that the bill had 29 committees sitting committee sittings in the Commons and over 90 hours of consideration. Now, since the bill came to us from the Commons, we have the devastating criticisms from the Constitutional Committee, the Delegated Powers Committee and experts giving evidence to the noble Ladies End of life Bill Committee.

And today we are only in our fourth city, I think, 18 hours of debate. So I say to the noble and learned Lord, please tell some of the others. Call off the attack dogs. This house is doing a proper job.

12:53

Lord McCrea of Magherafelt and Cookstown (Democratic Unionist Party)

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Yeah, yeah, yeah. >> Yeah, yeah, yeah. >> Like many noble Lords in this house, I grew up at a time whenever the doctor, the family doctor, was the doctor, the family doctor, was looked upon as a family friend who could always be depended upon whenever you were ill or a time of crisis. But unfortunately, that situation is not as it is today. And there is a major problem across the United Kingdom where people are desiring patients or desiring to see a GP and find themselves sitting on a telephone, perhaps ringing to surgery for 120 times and still not getting someone and giving up at the end of it.

That's reality of the situation in many places. But I am. I have to say that I, I'm sorry that Lord Pannick isn't here because he posed a question to the noble Lady Lawler concerning what happens if your GP retires. Well, let me give just a small experience. My GP was in his late 50s and he was an excellent GP and actually, in fact, during the time of Covid, unlike many other practices, he still allowed patients to come to his surgery.

And actually, whenever the patients couldn't come, elderly patients, he actually went out to the house and visited them in their own homes. Unlike many other practices and GP. But unfortunately, he took a cancer and in his late 50s, just recently, he passed away. Now we were left with a practice in our town with several thousands of patients, but nobody, nobody to take the practice over. So what happened to us? Our GP, actually not a retired GP, died. So what happened was without any consultation whatsoever, we were all farmed out to seven practice, 7 or 8 practices around the countryside, some of them not even close, but just who would ever take us.

So to imagine that somehow that a new doctor would have any knowledge of the pressures or the problems or the complex challenges that a person was facing, their new the new patient was facing, he would not have any continuity of care whatsoever. And I would say that it even was worse than that, because it was several months before the notes went to the next practice that you were actually farmed out to. So therefore you were put to a practice.

Your notes concerning any illnesses of the patient did not immediately follow. There were several months before they actually arrived. And so what I'm what I do believe is what has been suggested in these amendments today, strengthen safeguards. And therefore I do believe they're worthy of the support of the noble Lords in this House.

12:56

Lord Sentamu (Crossbench)

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My Lords.

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On the GP practice, because they've actually they're the hub of they've actually they're the hub of information. I'm one of those people. Since I arrived in this country, I've had a lot of treatment for all kinds of conditions, and all the National Insurance have been paying. He's Insurance have been paying. He's been paid back to me about a hundred times. So I'm a walking hundred times. So I'm a walking miracle. The amazing thing recently, when my anaemia was so high, didn't think I'd survive it, I went to see a consultant in Newcastle Hospital.

a consultant in Newcastle Hospital. He called up my records from 1975 and what was amazing, apart from one GP who didn't keep the records properly, he had it all and therefore I was able to get proper treatment. Friends, the record keeping some don't do it well. The record keeping on health in this country is amazing, really is amazing. The records are very clear and the GP's that are good always will keep up their information digitised so that they can send it quickly.

So for me, the whole picture is not just the GP doing it, but actually GP practice as the hub from which a lot of information about anybody can be gathered. You, you sever that and you put it somewhere else, you may not actually get it. I have got every confidence that in my GP practice at the moment has got nine doctors. They will have access to that information. So, noble Lord, I think you should still stick with what is in the measure, rather what is in the bill about the GP because it is the information actually we want to get.

And I think you get it and I'm amazed. So I'm very thankful for actual care that I've received and the records that actually speak about my journey. And I want to thank all of those

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being involved in my health. Conferences. We have had a long discussion about these issues, and discussion about these issues, and we've moved into the danger of repetition. We've already had a, a, repetition. We've already had a, a, a response from the sponsor of the bill to, I think it is now the turn Well.

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I'm actually going to I'm actually going to raise some new points at my Lords that haven't yet

12:59

Lord Harper (Conservative)

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been raised in the debate. And I have every right looking at the companion, as the government Chief Whip instructed, I have every right to do so. And I think my noble friend Lord Blencathra made some very good points. I've listened. I've been here for every minute of the debate on this bill, and I've listened with care and courtesy to every noble Lord, whether they were making points I agreed with or which I disagreed with, and I expect the same courtesy to be afforded to every member of this House.

Now, my Lords, I'm I'm agree with the sentiment of these amendments, and I think it's been a very valuable debate, because I think there's been a general sense in the House about the importance of.

13:00

Baroness Winterton of Doncaster (Labour)

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The noble Lord. And I go back a long way, and I certainly long way, and I certainly appreciate what he just said. But I would also ask him, does he agree with Baroness Butler-Sloss, that it with Baroness Butler-Sloss, that it is important that this bill gets to Report stage and that this House Report stage and that this House has the time to not only consider it at Committee stage, but also at Report stage?

13:00

Lord Harper (Conservative)

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I'm trying to make some comments on the amendments. Let me do that. on the amendments. Let me do that. And then if I have time in my remarks, because I'm very careful to keep within the guidance of the companion to stick to a speech less than ten minutes, I will, of course, address the the noble Lady's points. And she's right. There's when I was government chief whip, she was my position. We had a very good working relationship and I want to continue having that in this house.

What's come out of the debate is, I think, a general view from from everybody, whatever their view on this bill about the importance of the relationship people have with their general practitioner, whether it's an individual one or as the the noble Lady, lady Gerada said, a multidisciplinary practice. I think that's a very important point. And the amendments that have been tabled are to clause one about the eligibility criteria for whether someone is able to make a request for an assisted death.

But I think the flaw in the amendments, which is why I support the the idea behind them, but I don't support them, is because they don't, I think, actually make an appreciable difference to the safeguards in the bill because and I think the noble Lord, Lord Falconer of Thoroton, when he made some remarks in this debate, I think put his finger on it. There's no requirement in the bill for the GP or or the the team in the GP practice to be the doctor that actually makes the assessment about whether the person has the capability to to make this decision or not.

That is as I think the noble Lord Lord Scriven made the role of the coordinating doctor who doesn't have to have had any relationship with the patient at all. And if I may just quote some some views of the noble Lord, Lord Falconer, when he looked at this issue before, there was a report from the Demos Assisted Dying Commission, which the noble Lord, Lord Falconer chaired, which recognised in its recommendations the need for a doctor who both knows the person and supports them and their family.

And it also said that doctor Who knows the person and can better assess whether the request to die is a cry for help, a sign of poor care or a result of coercion. They also said that if an assisted death was to go ahead, the First doctor should be responsible for arranging support for the patient and their family during and after the assisted death, and they envisaged that the first doctor would have a higher level of involvement, and they envisaged that that doctor would have an established relationship with the person requesting the assistance and be familiar with their personal history and family context.

And that, I think, seemed to be the general view of all of the noble Lords who have spoken. The problem is that in the Bill that is before us, there is no requirement for the GP to be the coordinating doctor. There's no requirement for the GP or the multidisciplinary practice or GP practice to even be consulted before the coordinating doctor makes the first assessment. And it is absolutely true. As the noble Lord Lord Scriven said, that when the coordinating doctor has made the assessment, he does absolutely have to send, he or she has to send that to the GP practice.

But at the moment, as the bill is drafted, the role of the GP practice is to act as a postbox is to log the report and I see the noble Lord Falconer of Thoroton nodding at that, logs the report, pops it on somebody's medical records. There is no requirement, no duty at all on that GP practice to read the report, to make an assessment of the fact that the person with whom they do have a relationship is decided they wish to die, or to do anything about it at all.

That is the flaw in this. So the problem with the amendments that we're considering is if all of those amendments were adopted in the eligibility criteria, which is an administrative point, what they don't do is ensure that that knowledgeable person, the person with whom the patient has a relationship, whether it's with an individual or with the practice, has any role whatsoever in making this important decision and to involve the family or to consult anybody at all. And it seems to me that is the flaw.

So I think this has been a valuable debate, because I think it's demonstrated and I think the noble Lord, Lord Falconer, in his earlier comments, recognised that there was value in that relationship. And I'm not surprised by that, given what the commission that he chaired, the conclusions it came to. But the problem is that's not that's not reflected in the bill at all. And if I may just conclude on this point before I address the remarks of of the noble Lady, Lady Winterton, that the the point of why we have these debates and the point of doing them, and the reason for hearing from noble Lords with opinions is because it it highlights the flaws that do exist in the Bill.

And the point of this process is that that then enables the sponsor of the Bill and all noble Lords to listen carefully to the debate and then to bring forward improvements at Report stage. And I hope in his response, Lord Falconer will draw on the the concerns that have been highlighted and he can indicate his approach. And it may be that if he is minded to bring forward amendments that deal with some of these things, that that clearly then means other people don't need to do so if he indicates he isn't minded to do that, then other noble Lords can bring forward amendments to deal with it, which can then be debated and voted on at report.

That's the point of our process. It's the point of why we debate these things in the chamber, so that everybody can hear the debate. And the point it's a better way of improving the legislation than having lots of private discussions, to which most of us are not party. And what I'd say to the noble Lady, Lady course.

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To give way one second. I think there's a misconception by the noble Lord on how general modern general practice works through the electronic patient record. If the report goes like any report goes to report goes like any report goes to a GP, it is clinically coded and there would be a flag on the patient's electronic patient record, patient's electronic patient record, which would indicate to the GP and anyone in that practice that an anyone in that practice that an assisted death had been requested through the coordinating doctor.

So it just to use the noble Lords words wouldn't just be postbox, it would be automatically registered on the electronic patient record. And a flag came up for anyone in

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happening. No, I that's a very helpful intervention and I absolutely accept that. And I understand accept that. And I understand that's the way it works. And certainly with the way the NHS works now and, and many noble Lords works now and, and many noble Lords may use the NHS app, you're able to go on to your own, onto the app and you're able to access your own you're able to access your own patient record, and you can see all of those various notifications and you can see them all registered.

you can see them all registered. The problem? He's absolutely right that there would be a flag raised. The problem is there's no requirement in the way the bill is drafted at the moment for that GP practice to do anything. As a result of that flag being raised, there's no requirement at all. And I think there should be and we can come on to that as we progress through the bill. When we get to to clause ten, that is the point I was trying to raise.

Let me just deal briefly. So I want to go over my time with Lady Winston. Look, I agree with her. It's right that the House scrutinises its bill properly. And if you look at the number of days of debate in the House of Commons, I think there were 11 days at committee. And if you look at the just the normal way this House conducts itself, because we tend to do a more detailed level of scrutiny than the House of Commons, you'd expect, as a rule of thumb, about 16 days of debate in committee.

And then we normally have 50% of that in report and Third Reading. So I don't disagree with her. It may be that this bill requires more time, and that is clearly a discussion for the sponsor to have with the the government chief whip about making that time available. So but I think the wrong response is for us to not do our jobs properly, to not scrutinise the Bill, not make sure that it is a properly fit piece of legislation to get on to the statute book.

That would be the wrong response. And if we were to do that, we would be failing in our duty to legislate properly for the people of this country.

13:09

The Lord Bishop of Gloucester (Bishops)

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Yeah, yeah. >> So I am going to rise to speak to these amendments because I want to make a new point, a very vulnerable population that we must vulnerable population that we must continue to remember is the prison population. They will deal with the prison population more fully in the group. Coming up, we must remember that this bill currently does not exclude prisoners from being eligible. That means we must consider how each issue is likely to play out in a prison setting.

And this set of amendments, as we've heard extensively, deals with two main issues. Firstly, access to primary care and secondly, how well that primary care physician knows the details of your medical history. Now, the first is very closely related to inequalities and making sure that those who do not have worse access to care are not more likely to choose assisted dying. The prison population is therefore a key group that must be considered, since their health and access to healthcare are worse than the general population.

And that's evidenced by the recently published report by the Chief Medical Officer. This report also highlights the access to healthcare for those in prison. There is no automatic or compulsory enrolment for prisoners into primary care on the prison estates. Over 20% of the prison population do not complete registration on arrival. For those that do, the service is often slow or inaccessible. According to the Nacro Report on Physical Health, in prison, 2 in 5 prisoners waited for a month or longer for a GP appointment, and 1 in 13 never got one, according to the chief medical officer's report.

1 in 3 prisoners do not have their full electronic health record available to prison healthcare staff. And these are not just statistics. When I visit prisoners and talk with prisoners about their wellbeing and purpose, access to healthcare is always spoken about. So turning briefly to the issue of how well a primary care physician knows your medical history, I do not believe this has been sufficiently considered from a prison context. If a GP may be the person to conduct a preliminary discussion, consider a person's application for an assisted death.

How will they do this safely with incomplete information about their patient's health record? We must be questioning eligibility along these lines. So I hope that as we talk about the next group of amendments, I hope that in this group of amendments, there will be important safeguards against prisoners on these issues.

13:12

Earl Howe (Conservative)

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My Lords, the noble and learned Lord has already been very helpful in the undertakings and Clarificatory comments that he made earlier in the debate. So I shall be very brief in following up those comments, could I return to the question that I raised in the previous group of amendments? It seems to me that the bill very consciously steers clear of insisting that a person's GP must always be involved in the process of process being pursued by that person in seeking an assisted death, other than the GP having a duty to note in the patient record that the preliminary conversation, a discussion has taken place.

The entire process, in other words, could be conducted by the patient in conjunction with hospital based medical consultants. Do I understand correctly that the noble and learned Lord is willing to look closely at ways of making sure, by whatever means, that the crucial judgements made by clinicians about a patient's capacity, about coercion, about that person's settled wish to end their life are firmly and soundly based. Now, the route to achieving that may well be the GP practice and the multidisciplinary team within it.

But as we've heard, that source of information may not be practical or useful in every single case, so will the noble and learned Lord. Therefore ensure that he will consider more generally in the round possible safeguards that will forestall the possibility of superficial or cursory assessments being made, especially, perhaps by assessments by hospital consultants who may only have enjoyed a brief acquaintance with the patient.

13:14

Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)

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Lord Howell. >> My Lords, I thank all noble Lords for their contributions on Lords for their contributions on proposed safeguards relating to general practice, and I will keep my comments limited to the amendments on which the government has major legal, technical or operational workability concerns. On that basis, I would like to draw the attention of noble Lords to operational workability concerns in relation to amendments 1920, 21, 2930. Be 265A and 443A amendment 21 tabled by the noble Lady Baroness Grey-Thompson, stipulates that an individual must have an established relationship with the GP, who has good knowledge of their personal circumstances.

However, My Lords, the amendment does not specify how this requirement is to be satisfied or when in respect of amendments. 20 tabled by the noble Lady Baroness O'Loan and amendment 29 tabled by the noble Lady Baroness Finlay. These would require the GP to have made a home visit to the person, and for the person to have attended a certain number of appointments. In addition, amendment 19, tabled by my noble friend Lord Rook, requires an individual to have been registered with a GP in England or Wales for 12 months and to have seen a GP at that practice at least twice to meet the eligibility criteria in relation to these amendments, I would say that not everyone will require face to face appointments or a home visit with the GP, and we would be concerned about the operational impacts of mandating a specific number of consultations or visits where this is not based on clinical need.

Additionally, in relation to amendments 20 and 29, specifically, home visits are generally only offered where clinically appropriate for the patient, and the stipulation on this may restrict eligibility. My Lords, I now turn to amendments 30 B, 265A and 443A, tabled by the noble Lady Baroness Hollins. The effect of these amendments is to require a person seeking an assisted death to have a letter from a GP who has known them in a professional medical capacity for at least two years, and who has

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seen them at least six times. It's just.

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A pardon, but I, I think she's referring to my amendments, not referring to my amendments, not those of Lady Hollings. 30 B265 and

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443. I think it's nice. I'm most apologetic and grateful

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I'm most apologetic and grateful for the clarification. I hope the noble Lady Baroness Hollins will noble Lady Baroness Hollins will forgive me to. To continue. And who has seen them at least six times in face to face appointments during those two years. Noble Lords may wish to note that these amendments introduce requirements that may result in people seeking GP appointments that are not clinically necessary. This may have an impact on wider access to GP services, and noble Lords may also wish to note that even if a person has seen their GP the required number of times over the two year period, their GP could still refuse to provide the explanatory letter as they are not under any duty to participate in the provision of assistance.

As per clause 31 of the Bill. This would result in the person being unable to access an assisted death. Lastly, turning to amendment 220 tabled by the noble Lady Baroness Foster, this amendment seeks to add an additional step in the assisted dying process. It would not be a compulsory step, therefore it would not have a major impact or be unworkable. This amendment, however, has not had technical drafting support from officials and while the issues raised are rightly a matter for noble Lords to consider and decide, this amendment would likely require further consideration in order to be fully workable, effective or enforceable.

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noble Lady the Minister if if there are 3.5 on average there are 3.5 on average consultations a year face to face, excluding calls and so on, which excluding calls and so on, which bring it up to 8.7, surely it isn't going to put it isn't necessarily going to put it isn't necessarily going to make for additional unnecessary appointments. If that's an average when one would expect a an average when one would expect a person with such a condition, that would be my first clarification.

And the second would be if if a letter is required and the person the the doctor concerned doesn't want to assist in the process, the letter isn't about the process. The letter would specify would go into the person's history. Over the two years that person has consulted the doctor. It has nothing to do with the process of seeking an assisted

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death. Well, in acknowledging that the amendments are is referring to, as amendments are is referring to, as I said, were indeed the noble Lady. Baroness Lawlor, I haven't got Baroness Lawlor, I haven't got anything to add to the points that I have already made, other than to I have already made, other than to say that as the noble Lady herself used the word average, and therefore there is a question about therefore there is a question about workability, and I will have to say that therefore our interpretation.

On second point, the noble Lady raised does differ.

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My Lords, I indicated what my >> My Lords, I indicated what my position is in my intervention. Can I very briefly summarise my understanding of the amendment, summarise what my response is to summarise next steps. First of all, effectively all of the amendments effectively all of the amendments in this group require some sort of requirement. In addition to having a GP before you can have an assisted death. So my noble friend Lord Rook suggests having a GP for

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Lord Falconer of Thoroton (Labour)

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at least 12 months and having seen him twice before the first him twice before the first declaration. Baroness O'Loan and Baroness Grey-Thompson refer to having an established relationship having an established relationship with a GP. Baroness Finlay refers to one consultation and a home visit before the application. Baroness Lawlor refers to a two year relationship. An average year relationship. An average number of visits face to face, and then a letter which relates to the medical condition, the treatment and the state of mind of the patient.

As I indicated, the GP in the structure of the bill is not somebody who has to be involved. The purpose of the GP and the noble Earl Howe encapsulate this perfectly is somebody who is effectively receiving information. All of these provisions for making it necessary to have a better relationship with your GP than just having a GP. Don't touch. In reality, the safeguards quite separately from that. They have an air and I support what the noble

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