Terminally Ill Adults (End of Life) Bill

Debate between Lord Stevens of Birmingham and Baroness Hollins

Committee stage
Friday 23rd January 2026 Lords Chamber

[Lord Stevens of Birmingham (CB)]

As the noble Lord will well know, the ethical principle of the doctrine of double effect is in place there. There is no doctrine of double effect associated with assisted dying; it is a completely different ethical principle. In fact, part of the reason why it would be dangerous to include assisted dying in the National Health Service is because it risks undermining the very trust that people have in their clinicians.

It increases the risk of what you might call self-coercion in the name of altruism. People thinking that they are reducing not only the burden on their families but on the NHS from an earlier death is a genuine risk. We saw that, frankly, during Covid, when the slogan, “Protect the NHS”, was used. A number of us were opposed to that, fearing it would put people off coming forward for needed care, which is precisely what happened. The idea that an NHS-branded assisted dying service might, at least in people’s minds, come to be associated with helping to protect the NHS by virtue of choosing an earlier death blurs the lines, which we should be careful to avoid.

Fundamentally, it is unwise to include assisted dying in the National Health Service because it blurs the distinction between palliative care and what is proposed in the Bill. As we have just heard from the noble Lords, Lord Harper and Lord Deben, many of us have concerns that the choice on offer will not be a genuine choice if palliative care is not available, and I am afraid the Government have been less than forthcoming as to what they envisage palliative care services looking like over the coming years.

Two months ago, I asked the Government a very straightforward Written Question: can they tell us whether the palliative care and end-of-life care modern service framework, which they are going to publish, will quantify the incremental funding needed to make sure that everybody who would benefit from specialist palliative care would get it? I did not get an Answer to that straightforward Question before this House debated the palliative care elements of the Bill. This week, I received a two-sentence response—it was not an Answer —which said:

“The Government is developing a Palliative Care and End of Life Care Modern Service Framework for England. I refer the Noble Lord to the Written Ministerial Statement … on 24 November”.


That was the Answer to the Question: will the Government’s framework specify the funding gap, identify funding to meet it, and ensure that people have access to care? On that basis, we are entitled to conclude that they probably do not intend to move in that direction. Therefore, the concerns about having an assisted dying service as part of the National Health Service, when palliative care needs go unaddressed, are all the more acute.

For those three reasons—the fact that the proposal is conceptually misjudged, organisationally unnecessary and inherently risky—I oppose the proposition that assisted dying should be part of the NHS.

[Baroness Hollins (CB)]

My Lords, I support and have added my name to Amendment 771ZA, in the name of the noble Lord, Lord Mackinlay, which would prevent the assisted dying service being part of the NHS. I agree with the points made by my noble friend Lord Stevens.

Integration into mainstream healthcare appears to normalise the practice and lower barriers to the use of assisted dying. International evidence is instructive—where it is embedded within publicly funded healthcare systems, such as in Canada and the Netherlands, uptake rises steadily over time and eligibility criteria broaden. As we know, in some jurisdictions it is available to minors, people with non-terminal conditions, psychiatric diagnoses, and even people with learning disabilities and autism, as my own published research on the Netherlands has shown.

I agree with my noble friend Lord Stevens that assisted dying is not a treatment. That is a further reason why it should never become part of the National Health Service. The substances proposed to be used neither treat nor prevent disease; they fall outside the legal definition of a medicinal product. The drug regimens proposed are unlicensed, have not undergone appropriate clinical trials and lack international consensus. The drugs that have been used more widely and successfully to provide the much-lauded pain-free and quick death, such as in Switzerland, are not even available or licensed for human use in the United Kingdom.

My noble friend Lord Birt seems to seek to introduce similar criteria as are used in Switzerland, and not just for terminal illness—he spoke about suffering, pain, and conditions that are not eligible under the Bill. In Switzerland, non-profit organisations such as Dignitas operate within that narrow but deliberate legal space created by Article 115 of the Swiss Penal Code, which states that assisted suicide is punishable only when carried out for selfish motives. That means that if it is provided purely out of compassion, with no personal gain, it is not a criminal offence, enabling Dignitas and other similar non-profit organisations to function lawfully so long as they can demonstrate altruistic intent and ensure that the individual is acting autonomously.

Interestingly, Article 115 of the Swiss Penal Code, contained only one clause—I think just one sentence—when it became law in 1942. One wonders whether the smoke and mirrors of the 59 clauses in the Bill and the various proposed new clauses from my noble friend Lord Birt disguise a similar intent. The potential changes and development of the proposals before us today are concerning. Indeed, if something as straightforward as is provided in Switzerland is intended, I do not understand why it was not proposed in the first place. We do not want this in the National Health Service.

Mental Health Bill [HL]

Debate between Lord Stevens of Birmingham and Baroness Hollins

Committee stage
Monday 24th February 2025 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, building on many of the important points we have just heard, I will speak to Amendments 163 and 164 in my name. I thank the noble Baronesses, Lady Tyler of Enfield and Lady Neuberger, and the noble Lord, Lord Kamall, for their support for these two modest proposals, which are parsimoniously drafted but nevertheless potentially impactful if adopted.

The first amendment quite simply says that we will do away with “mañana, mañana” when it comes to implementing this Bill, which we have all spent so much time on and which the patients and advocates are so keen to see adopted, by putting a five-year backstop from the date on which the Bill becomes an Act through to commencement. Commencement of all its provisions must happen no later than five years after the Bill receives Royal Assent. The logic for that is that we all believe that, on balance, by the time the Bill has worked its way through Parliament, it ought to be an injection of improvement for mental health services, so why would we want to delay?

Of course, part of the answer is that there are some rate limiters, which are described elsewhere, including in the impact assessment. If we go through the impact assessment and say, “All right, what are the specific things that it suggests won’t be possible or won’t have got going until year 6 after Royal Assent?”, we will find it is a relatively modest number. For those who want to take a look, it is in table 1 of the impact assessment, at page 17. There are some changes to the second opinion doctor, to the CTOs, to the CTPs and so on, but both the pound note impact and the extra staffing at year 6 and beyond are incredibly modest compared with the overall size of mental health spending that we will incur. The incremental costs beyond year 5 are somewhere between £15 million and £25 million, on a budget that runs to billions. I believe that, in the real world, if we strain every sinew, it will be possible to get this thing done within five years.

There is another reason for thinking that it is useful to have a statutory backstop to implementation in the Act itself: the unfortunate tendency that we have seen in various other pieces of legislation that, when push comes to shove, the decision is made just to kick the can down the road a little further. I think it is fair to say that both principal parties have criticised the other for doing so with legislation that has passed. I think we had some measures in the health Act that the noble Lord, Lord Kamall, steered through on obesity and junk food. They never quite saw the light of day, despite Parliament deciding that they would be a good thing. The then Government were criticised for that. Likewise, we put the time in to create the Higher Education (Freedom of Speech) Act. I think the Opposition criticised the Government for delays in implementing it, despite the fact that Parliament had passed it. Of course, the cause célèbre is social care reform, where we have been happily kicking down the track legislation that has seen dither and delay for over two decades. That should not be the fate of this legislation. Therefore, this simple amendment would put in a backstop to save us from ourselves. Parliament is sovereign. If we want to get the job done, there is no reason to think that we cannot make these changes in less than the time it took this country to fight and win World War II. That is the rationale for Amendment 163.

Amendment 164 simply says that, during the intervening period while this Act is being implemented, it would be unreasonable to shrink the size of the slice of the pie going on mental health services, for all the reasons that we have heard throughout Committee. To make sure that there can be no argy-bargy on how the drafting is laid out, we have lifted the wording exactly from the health Act as it currently is on the statute book around the proportion incurred by NHS England and ICBs that, taken together, relates to mental health. It says that it

“must not fall as a share of their expenditure (taken together) on all health services”,

with a little kicker: to stop the Department of Health and Social Care marking its own homework, the National Audit Office will do a review after each year and provide a report that we can all scrutinise.

Here are some reasons why the Government should not object to this. First, it does not tie their hands on the overall sum of funding allocated to the National Health Service. That is a decision for the Executive and negotiated each year; nothing here would constrain the ability of the Government to increase or cut expenditure on the National Health Service. Nor would it constrain the ability of each integrated care board to make a judgment on its own priorities. It simply says that, in the round—taking the 42 ICBs and NHS England together—it would be unreasonable to think that the share of health service spending on mental health will go down at a time when there is an incredible gap between need and treatment, and when we are trying to implement this legislation.

Fortunately, just before Christmas the Secretary of State, Wes Streeting, signalled his support for the mental health investment standard. This is the opportunity to provide legislative cover for that very welcome announcement. It is possible that the current Secretary of State will not be the Secretary of State for the totality of this Parliament—nobody has a crystal ball. Looking out five years beyond Royal Assent, it is also possible that year 5 will be the first year of a new Parliament. So it is entirely reasonable for Parliament to support the Secretary of State’s intent by legislating in the way set out in Amendment 164, not least because there are some concerning signals from around the NHS that, for the first time since the mental health investment standard was introduced, it is possible that the share of funding on mental health will go down, not up, when taken in the round. We have not yet seen the figures, but perhaps the Minister can confirm whether that is correct. In any event, that simply serves to underline the acute importance of this safety net provision to ensure that the financial firepower is there to get this Act done.

[Baroness Hollins (CB)]

My Lords, I apologise for my absence from earlier debates in Committee. I will speak very briefly in support of these amendments. My noble friend said that we need to save ourselves from ourselves. Actually, we need to raise aspirations to change the culture of believing that it cannot be done and thinking that it will cost too much to take a more preventive approach, to care properly for people in the community and to achieve parity for mental health outcomes. These amendments are really important to try to achieve that, so I support them.

--- Later in debate ---

[Baroness Hollins (CB)]

In adding my support to these amendments, I welcome particularly the contribution from the noble Baroness, Lady Ramsey.

This debate has emphasised why the pathway of care, from the community through to any kind of hospital admission and discharge, must be considered as a whole. It is not okay to separate bits off. That is why the amendments are so important: unless we put provision in place to make sure that, when admission is necessary, it is timely and to a place which has the skills to provide the therapeutic care that people require, detention and admission will in fact be longer and costlier. We cannot contemplate making legislation that does not take account of the whole patient pathway.

[Lord Stevens of Birmingham (CB)]

I have been inspired by the previous two contributions. I will briefly pick up a point that the noble Baroness, Lady Tyler, made about Amendment 134 on the availability of community services, particularly psychiatrists. I think the Minister referred to the longer training times for psychiatrists and other mental health professionals as one of the rate-limiting factors that would affect the speed with which the measures in the Bill could be implemented.

I have a request for the Minister. It is quite hard to tease out from the impact assessment what the Government think the incremental requirements for psychiatrists will be, year by year, over the implementation period. In fact, slightly perversely, they use mixed currency: the Minister responded, rightly, to Amendment 163 by saying, I think, that there was a requirement for 400 additional psychiatrists for the second opinion service; but when you look at the table in the impact assessment, it turns out that that is a headcount number driven by a number that is not a whole-time equivalent. However, for all the rest of the workforce, a whole-time equivalent number appears to be shown.

It would be good to nail down what the incremental requirement will be for psychiatrists, year by year and on a whole-time equivalent basis, so that between now and Report, colleagues can consider what the ramifications of that might be for a backstop on implementation. If that incremental requirement could be juxtaposed with what the Government think the organic increase will be in the number of psychiatrists over that period anyway, driven by the already published NHS workforce plan, that would be supremely helpful.