Baroness Finlay of Llandaff:

Moved by Baroness Finlay of Llandaff

26: Clause 1, page 1, line 12, at end insert—“(e) has had their needs fully assessed by a multiprofessional specialist palliative care team, and appropriate care provided to the extent necessary to enable them to decide whether such care would affect their wish to end their life,”Member’s explanatory statementThe Amendment ensures that all terminally ill persons seeking to take up assisted dying support have had their needs assessed by a multiprofessional specialist palliative care team and met to the extent necessary to enable them to decide whether such care would affect their wish to end their life.

My Lords, we move on to a group of amendments that are extremely important and, in some ways, complementary to those in the previous debate. Autonomy is the lodestar of the Bill. The amendments in this group are designed to reinforce and respect that patient autonomy; they do not block access to an assisted death but aim to ensure that people have accurate information to make informed decisions. For a decision taken, people must have three things, whatever that decision is: accurate information, the capacity to make the decision and to be making it voluntarily. Those are the fundamentals of respecting a person’s autonomy.

These amendments are to ensure that the patient has the opportunity to know what is available. They do not force a patient to be looked after by a palliative care team, and they do not stop a patient from proceeding with an assisted death. There is clear evidence from studies that underserved groups have poor access to palliative care, and there is poor understanding generally of what palliative care is and can do. General doctors often do not understand palliative care, so how can an assessing doctor give good, accurate information to a patient if they themselves have a deficit in their knowledge? It is worth noting that in a five-year medical training course it has been estimated that the average time spent on learning about palliative care is only 20 hours, and only recently has palliative care come into the finals questions. So there are thousands of doctors out there with almost no education in palliative care.

Many patients and the public do not understand palliative care either. A significant number think that assisted dying is palliative care or hospice care, while others think that palliative care simply hastens death. Sadly, misunderstandings are widespread. When patients access appropriate specialist palliative care, the desire for a hastened death is often alleviated, and they experience an improvement in quality of life that they never believed possible. But that does not apply to everybody. The role of this Amendment is simply to give everyone the best opportunity to access the care that they need, whether or not they continue to pursue an assisted death and whether or not they decide to take up the opportunities that may be revealed by such an assessment. The processes relating to an assisted death can occur in parallel with, but not as an integral part of, palliative care provision.

There has been concern that palliative care teams could not cope with a sudden influx of referrals, but currently any palliative care team prioritises a patient who is in such despair that they want to die. That is basic care, a core part of the job. Palliative care will not turn its back on patients who are in despair; teams want to deliver gold standard care.

In Oregon, 92% of assisted death patients are recorded as being enrolled in hospice services. Palliative care needs assessment gives patients options to make an informed decision. The patient may conclude that there are other options that they have not been aware of and want to try, or that they simply want to pursue an assessment for an assisted death. Evidence from Canada has shown that some patients seeking referral for medical aid in dying are actually asking for palliative care; they seek assisted dying as a way in which to get their problems sorted out.

A palliative care needs assessment must always be non-judgmental. I stress that this is not a bad faith amendment; it is to ensure that patients know what they could have and are making an informed choice, respecting their autonomy.

For every decision in life, we want the best information, whether it is knowing that the house we are buying is not full of dry rot or that a car or sales loan has not been mis-sold to us. The Bill’s processes must ensure that applicants are fully informed. This is not a costly option. There is high-quality evidence that specialist palliative care reduces the chance of dying in hospital and increases the cost effectiveness of home and hospital-based care for those with a poor prognosis.

Therefore, the adequate provision of services to ensure that every patient seeking an assisted death can have their needs assessed will decrease, not increase, costs to the NHS. Home specialist palliative care is associated with reduced costs of nearly £8,000 per person and increased quality life-adjusted years. In the hospital sector, costs also reduce but only by about £6,500 per patient, again with increased quality-adjusted life years overall. Provision of specialist palliative care to ensure, wherever the patient is, that they have the option of accurate information with which to make their decision has been estimated to reduce system expenditure by over £800 million per annum.

Unfortunately, I fear that the Bill’s proposers have rather misunderstood multidisciplinary care working, and I am afraid that my friend and colleague Dr Sarah Cox, who I respect enormously, has indeed been slightly misquoted. As the noble Baroness, Lady Gerada, said in our last debate, modern care is delivered by multiprofessional teams, which come together around an individual patient, comprising doctors, nurses, physio, occupational therapy, social work, et cetera, depending on the needs of that individual patient. Patients often communicate more readily with the lowest paid in the team, such as the carers, to whom they feel they can talk freely, as there is not the power differential that exists between patient and doctor. That multidisciplinary and multiprofessional team reviews and monitors things together. That is quite different to bringing a panel of three different disciplines together specifically to make one decision and then move away from it without that continuity of knowing people. It is important that we are clear what we mean in clinical care.

In the hospice, I used to always have the care assistants as part of our weekly multidisciplinary review of patients. They had valuable insights and much to contribute. A mandatory assessment would ensure that people knew what was available. It is up to the person to decide whether to try one route or another.

Why make this mandatory? Unfortunately, the amendment to the Health and Care Act 2022, which I pushed for very hard and was glad to see come in, and which stated that palliative care is a core service, has not resulted in commissioners adequately commissioning services, in part because they themselves are ignorant of what to commission. If assessment is mandatory, commissioners must make sure that patients seeking an assisted death have a service that can provide a proper needs assessment and give them information. The patient can choose whether to try or not try.

I know that my noble friend Lady Hollins has an amendment about this, and there is indeed a definition in an amendment that has also been tabled in relation to what specialist palliative care is. To try to summarise that very quickly, it is about having the appropriate specialist skills in every setting, with advice available at all times of the day, every day, equipment and medication available, and a point of contact so that people can go back and explore and discuss things as they think more about the complexities of their situation, and they can access the support that they need.

As my colleague, Dr Rachel Clarke, pointed out when she gave evidence previously, the moment of people having a diagnosis of severe life-limiting illness is their time of peak vulnerability. Is the patient’s request for an assisted death a knee-jerk reaction to a new diagnosis that terrifies them? Have they been plunged into a suicidal depression that might pass? Might a desire to die be replaced by a desire to live when they receive the patient-centred care that they need? Is a malign partner lurking in the background, putting insidious unvoiced pressure on the person to believe that he or she would be better off dead? In New Zealand, we hear about patients seeking an assisted death when they are clearly caught up in a cycle of despair and hopelessness, while actually they want and need to know what is available but often the services are not there for them.

I hope that my colleagues who have tabled amendments in this group will speak to them, and I have tried to lay out a background template for why the mandatory ability to have an assessment of need is important. I beg to move.

My Lords, I speak to the six amendments in my name in this group. I do not need to explain what they say because they are all replicated by other amendments in the group, so I can be very brief. All these amendments are intended to ensure that a person seeking assistance to end their life first be referred to a registered medical practitioner who specialises in palliative, hospice and other care for the purpose of a full assessment—the operative word being “assessment”, not necessarily treatment. The Bill currently requires merely that a medical practitioner “offer” a referral to a specialist palliative care practitioner. This is inadequate in relation to such critical decisions as choosing whether to live or seek a state-assisted death.

It is important to note that all these amendments are based on evidence. In countries with assisted dying—Oregon has been referred to—experts say that patients who request help to die often change their minds if provided with proper palliative care. Yet the Government’s impact assessment confirms that fewer than half of dying people have input from a specialist palliative care team in the last three months of their life. It seems hard to dispute the case, therefore, for the Bill requiring that persons seeking a state-assisted death be given a full palliative care assessment, with the opportunity to choose to experience modern specialist palliative care at its very best. It is about doing everything humanly possible to keep people alive with as little pain and suffering as possible, and giving priority to life over death wherever possible.

Recalling our debate yesterday about which amendments the noble and learned Lord, Lord Falconer, might be prepared to accept, the amendments in this group are, like the previous group, pivotal to the decision a dying person will have to make if this Bill is enacted. It would save much time on Report if the noble and learned Lord could indicate now whether he can accept one or more of them. The Government would then have a responsibility to ensure that adequate palliative care specialists are available.

I recall, as I did at Second Reading, the wise words of the Minister, the noble Baroness, Lady Merron, who, in answer to an Oral Question in this House on 4 September 2024, said that the Government’s

“commitment is to ensure that any debate on assisted dying … takes place in a broader context of access to high-quality palliative and end-of-life care

The amendments in this group would help to ensure that a person at least has a real choice of whether to access that palliative and end-of-life care or whether to seek a state-assisted death.

My Lords, my Amendment 51 and others would require the providers of assisted dying services to ensure that all persons seeking such services have discussed the range of end-of-life options available to them with a palliative care specialist.

The Government and proponents of the Bill have promised that end-of-life care will not suffer in order to accommodate assisted dying. I have significant reservations about whether this would be possible, and I fear a push factor, particularly for those who are vulnerable, those who are without family and, to be absolutely frank, those who are poor and cannot fund their own care. When done right, as we know, palliative care can provide a dignified end of life and alleviate the desire to hasten one’s death. Equitable access to options for end-of-life care must be a cornerstone for this Bill, which is why I have laid these amendments. I want to ensure, as far as humanly possible, that all people have and know that they have equal access to palliative care, to treatments that may extend life and to specialist teams to manage the symptoms and pain and to provide dignity.

This Committee must accept that equal access to these services, as for many public services, is not guaranteed and is rarely delivered. I give just one example, due to time. A Liverpool resident with the terrible asbestos-related mesothelioma cancer can undergo a specialist injection that has a high chance of abolishing the pain, whereas a resident of the Midlands, who may be unfit to travel to Liverpool, simply cannot because there are so few specialists trained to take this work on. Therefore, access is obviously limited.

Clauses 5 and 12 require doctors to have discussions about disease prognosis, treatments and symptomatic alleviation with patients. Clause 5 includes an offer to refer them to a specialist. Although these are important discussions, which must be had, they have to be conducted by somebody properly trained and experienced in such matters. For conditions that are specialist care cases, such as motor neurone disease, most doctors will have minimal involvement in the management of that condition and will likely not have the skills and training to adequately fulfil the duties that the Bill places on them. A specialist referral is absolutely necessary to that ensure patients are able to reach an informed decision about their care with somebody who properly understands the disease, how that disease will progress and what can be put in place to alleviate their distress and pain.

A person seeking assisted dying will be worried about their future, losing their independence and dignity and placing a huge burden on their families. A dedicated palliative care specialist would have the expertise, skill and training to provide the highest level of information and support, tailored to the individual needs of each patient, and have specialist knowledge of the condition that the patient is experiencing. Clause 1 requires that a person

“has a clear, settled and informed wish to end their own life”.

I believe that you can ensure a settled and informed wish and reach an informed decision only after properly exploring all available care and treatment options with dedicated palliative care specialists and having those options available to you. My amendment would therefore create a duty on all people involved in the provision of assisted dying services to ensure that those discussions have occurred, covering care options including symptom management and home care provision.

I welcome the amendments tabled by other colleagues that would ensure a dedicated palliative care assessment is part of the assisted dying process and I believe that my amendment can work alongside theirs. My amendment would also cover consultations with palliative care specialists that occur prior to a person seeking assisted dying, providing they cover the criteria outlined in the amendment. You can reach a clear, informed decision to end your own life only after having the advice and support to truly be able to weigh your options. That guarantee should absolutely be in the Bill.

My Lords, when I first read this Bill, I realised that there was something important missing—a first stage, if you like. This group of amendments is probably one of the most important to address before the Bill can really make progress. Ther Bill, in its drafting, has perhaps failed to recognise the provisions of the Health and Care Act 2022, which my noble friend Lady Finlay referred to, with regard to the new obligations on integrated care boards to commission for the palliative care needs of their local populations.

There are several amendments in my name in this group. I have also added mine to my noble friend Lady Finlay’s Amendment. The most important amendment is Amendment 221, and I will try to explain some of the rationale. The amendments are intended to ensure that specialist multidisciplinary palliative care is a mandatory, properly resourced and integral part of any assisted dying pathway. The central purpose is quite simple: it is that no person should progress towards assisted dying until their palliative, psychological and wider social care needs have been fully assessed and understood and, where appropriate, addressed. The medical royal colleges have endorsed this request.

Not all doctors are trained or equipped to provide comprehensive information about prognosis, symptom control or the full range of palliative care options at the end of life. This is not the remit of general practitioners or general physicians, nor should such complex and sensitive discussions be taking place in routine medical settings. For that reason, I disagree with the preliminary discussion clauses and the clauses about first and second declarations in the Bill as currently drafted. Instead, I propose that once a terminally ill person requests an assisted death under this Act, they must be referred for

“a multidisciplinary specialist palliative care assessment” alongside a psychological assessment within established palliative care services. Given the urgency that often accompanies such requests, this assessment should be completed within seven days of referral. To ensure that any subsequent decision is genuinely informed, the individual must then be offered access to appropriate palliative care and psychological support

“within 48 hours of the assessment being completed”.

A person should not be eligible to proceed until their needs have been assessed, and the treatment and support options have been made available. That is why I propose that, before an application can proceed, there must be written confirmation from a consultant in palliative care medicine that all relevant specialist palliative and end-of-life care options have been discussed, offered and, where appropriate, tried.

Medicine routinely works in this careful, stepwise manner. It is entirely consistent with good clinical care that evidence-based palliative care should be fully explored before considering the irreversible act of ending a life. I have heard discussion in the media suggesting that these amendments would mean that people would be forced to have palliative care against their will. No, that is not their intention; the intention is twofold. First, it is to make sure that patients can make an informed decision. Secondly, it is to ensure that specialist palliative care services are available for people who want them, and that people are not choosing an assisted death because the NHS is not commissioning for the palliative care needs of the population.

Obviously, specialist palliative care itself needs to be properly defined, funded and made universally available and accessible. It is far more than the prescription of high-dose medications at the end of life. It is an active, multidisciplinary approach that supports patients and families at home, in hospital, in care homes and in hospices. That is why defining specialist palliative care, as set out in one of the amendments before us, is so important.

At present, access to such care is inconsistent and heavily dependent on charitable funding. Before introducing assisted dying on a national scale, we must ensure equitable access to high-quality specialist palliative care across the country. As part of the multidisciplinary palliative care assessment, I propose that every individual applying for assisted dying should be considered for NHS Continuing Healthcare through the fast-track funding process. This is an existing, well-established process, although perhaps not well understood within primary care or perhaps even within your Lordships’ House.

Continuing healthcare provides fully funded health and social care support, including assistance with medication, mobility and activities of daily living, but it can be slow to arrange. However, the fast-track pathway exists precisely to ensure that people with rapidly deteriorating or terminal conditions can access this support within 48 hours of their request. It works in practice. It is already there; the architecture already exists.

This can make an enormous difference, enabling people to choose their place of care, arrange nursing support, secure equipment or home oxygen, and relieving families of both emotional and financial burdens at a critical time. Encouraging fast-track access to continuing healthcare within the Bill would ensure that individuals receive timely, holistic support and are not driven towards assisted dying by unmet care needs. Furthermore, patients approved for fast-tracked continuing healthcare funding are more likely to have an accurate prognosis of six months or less. Taken together, these amendments would place specialist palliative care where it belongs: at the centre of end-of-life decision-making, ensuring dignity, compassion and genuine informed choice.

I will end by remarking that there is a world of difference between a multidisciplinary panel and a multidisciplinary specialist assessment. The royal colleges support the latter—it is part of normal clinical care—but they do not like the multidisciplinary panel. The Royal College of Psychiatrists in its briefing commented on the psychiatrist’s expertise and where and when it is appropriate. It says:

“Psychiatrists can only work within their professional competencies and expertise, and should not be required to do any aspect of assessment for which they are not appropriately trained or skilled”.

It also comments—I think this is quite important—that in a well safeguarded process, a person should not access assisted dying

“if they would have made a different decision had they received effective treatment for a mental disorder affecting their decision-making. To this end, we expect that psychiatrists would be involved in an AD … service in two ways: … the identification and treatment of unmet psychiatric need; and … supporting assessments of capacity to decide to end one’s own life”.

My Amendment 178A would require that those who are seeking assisted suicide are referred to a consultant physician in palliative medicine, who will assess them fully and draw up a plan for care. The Bill recognises the importance of patients knowing about palliative care and being informed on the choices, but in so weak a manner that these amendments have been tabled. Other noble Lords who have spoken in the group have very good amendments, which I support, to the effect that a patient would be referred to a specialist team in palliative care or a team which is dedicated to the treatment of this problem.

I propose that, in the first instance, the patient should see a consultant in palliative medicine, who will, one to one, discuss matters with the patient, assess them and prepare the care plan—not instead of the other people involved in the care team, but as the person responsible for doing that. My experience of medicine in other areas is that that is always the first call; care and treatment are then taken from the consultant physician who is responsible.

I say this because other people on a team may lack the detailed knowledge, experience and intellectual rigour of those who have reached the most senior level in their area, and who are responsible for training and leading a team of hospital doctors specialising in their subject. They see many hundreds of end-of-life patients each year. There is also a very good reason to believe that consultants are more likely to be independently minded and beholden to the virtues of their profession rather than the guidance of officials.

The amendment would require a full assessment, because only after an assessment can a patient know the options, as other noble Lords have said, and be in the best position to decide. Yes, it might put a strain on palliative care consultants, but in that case we need more such consultants. We should not put the Bill into effect without them. More broadly, my amendment stresses that, as we see in France and as other noble Lords have said, any move to assisted dying needs to be accompanied by more attention and commitment to palliative care.

My Lords, I speak as a member of the Select Committee that your Lordships’ House decided to convene at the end of Second Reading, partly because, although I am sure that noble Lords participating in this debate and this legislation will be fully aware of the evidence we took, this debate is broadcast and followed much more generally, so I think it is useful to put on record some of that evidence. We took evidence on palliative care from experts, some of whom oppose the principle of assisted dying and some of whom do not, but almost all raised concerns about the adequacy of palliative care in the United Kingdom.

In particular, following the contribution of the noble Baroness, Lady Brown of Silvertown, I quote— I apologise for reading, but I am reading from our report—Dr Suzanne Kite, president of the Association for Palliative Medicine of Great Britain and Ireland:

“Throughout this debate, there has been a strong consensus that current palliative care provision is inadequate, with many services under threat, and that this constrains choice at the end of life. We advocate strongly for the Government to commit to a national policy to ensure universal access to palliative care that is protected from negative financial impact of the introduction of any AD—assisted dying—service, better safeguards for patients, care workers and organisations and a public awareness campaign about normal dying”.

My first question is to the Minister. I realise that she is representing the Ministry of Justice rather than the Department of Health, but I hope she may nevertheless be able to respond. When we discussed the business Motion in the Chamber yesterday, the noble Lord, Lord Stevens of Birmingham, said that the Minister in the House of Commons had suggested that the Government’s next information about the provision of palliative care would not come until after the assisted dying legislation had gone through Parliament. I think many people, whether or not they support the principle of assisted dying or support this legislation in principle, would feel much relieved if they could believe that palliative care was going to be more equitable across the country and that those in more deprived parts of the country would have the same access to palliative care as those in more affluent parts, because there is a disparity.

For many, there is a concern that the choice of an assisted death, which is what advocates of the Bill say they support, will not necessarily be an unconstrained one. If the choice were, “I have been offered everything, including state-of-the-art palliative care, and I still want an assisted death”, that would be quite different from the current proposals. Clause 5 says that the medical practitioner would need to make clear to somebody in a preliminary discussion all appropriate palliative, hospice or other care that is available. But if there is not adequate palliative care available—we know that 100,000 people are already dying without adequate palliative care—then the choice the medical practitioner is giving will not be a real one.

When I raised concerns with the experts who were giving us evidence on palliative care and whether this was a constrained choice or not, there was very much a sense from Dr Kite that she shared the concerns I had raised about the disparities of palliative care and that, for some people, there would not be a real choice. Her response was:

“I share your concern. Our members share your concern. This is fundamental to our position on the Bill”.

Professor Katherine Sleeman, who is also a professor of palliative care at King’s College London and a member of the Complex Life and Death Decisions group, who is not opposed to the principle of assisted dying, said that my point was

“exactly why the CLADD group has suggested that offering a referral to specialist palliative care is not enough. Everyone who says that they want an assisted death should receive a palliative care assessment, and that would go some way—not all of the way, but it would go some way—to addressing what we know about the inequalities in terms of access”.

In light of the evidence we received, I would be grateful to hear from the noble and learned Lord, Lord Falconer of Thoroton, how he would respond to the amendments in this group about palliative care. They seem to be fundamental to the concerns not just of people who might be opposed in principle to this Bill but of experts who really understand the detail. It is surely the duty of this House to ensure that any legislation passed really meets appropriate standards, and we should be very cautious about supporting legislation that does not ensure adequate access to palliative care.

My Lords, I will be brief, because many of the points have been made, but I would really like to make two points. My first point follows the comments of the noble Baroness, Lady Smith, about—I hesitate to use this term—“levelling up”. We know that there is a spectrum of provision available, not just in palliative care but in all the other aspects of care that a dying patient needs, as referred to in Amendment 221 in the name of the noble Baroness, Lady Hollins. I would love there to be the kind of wraparound care within the community that my noble friend Lady Gerada described, but for some patients that is not the case. So, specifying those components that should be available and making them available should be the basic right of every dying patient, particularly one who is carrying as onerous a decision as seeking an assisted death.

But I think the second, and equally important, point about this is front-loading the multidisciplinary assessment, and, ideally, having it clearly written down and held by the patient, which empowers the patient to hold that information and take it with them. Therefore, it facilitates the co-ordinating doctor, the independent doctor and the panel or judiciary process to have available that information from the team who know the patient best, so that they are not having to delay the process by scurrying around in hospital notes or seeking additional information late on in the process, when the patient will inevitably have made a decision, potentially with their family, and a delay due to missing information would be unbearable. So, front-loading is absolutely key to streamlining this process throughout.

My Lords, I have put my name to nine amendments in this group and I declare my interest as an unpaid trustee of a hospital which has a hospice attached to it.

We are very fortunate in your Lordships’ House to have among us distinguished doctors who have spoken with great experience and understanding of the need for access to expert palliative care when a person faces death from terminal illness. For many people, particularly those in care homes, such palliative care is simply not available. I think of my own mother, who died just three years ago and was in a care home, and for whom such care was provided either by the GP or by paramedics who came and administered morphine—that was not expert palliative care. Many people, if this Bill is passed, will be in exactly the same position as my mother, unless there is change to the current systems. Expert palliative care, as has been said, is unavailable in many parts of the country, and so it is not enough to know that expert palliative care could be available, it must be available. That is the most significant thing.

Very small matters can tip people into making a decision for death. Sometimes, people just give up living because their circumstances feel so difficult to them, and they may feel, in this situation, that they have no option but to opt for assisted death, when they do not want to burden their family and friends with excessive costs, including the cost of care homes. Some of these costs may seem trivial to those of us who do not have to count our money so carefully but, for those who are very poor, as I once was, getting to hospital or a hospice to visit someone who needs to be visited and whom you wish and need to visit can be very difficult. It can cost money that you do not have, and it can take time. People may have young children, and those children need to be looked after. There are all sorts of complications which ensue from the situation in which terminal illness occurs. People may not have a car, and things such as fares and buying coffee, lunch and a gift all cost money. For poor people, given the current cost of living, every penny counts. Money spent on hospital visits and other expenses is not available for food and heat. The terminally ill person may know this and may wish to spare their family.

I think the Bill is predicated upon the existence of an informed, independent decision—that has already been spoken about at length, so I will curtail my remarks. But people feel very vulnerable, and I think one of the things we learned to do as children was to trust the doctors—the doctors would come and help us—but when these conversations are going to be had with people at their weakest and most vulnerable, they may well feel that they should save everyone the cost of letting them die in dignity and peace naturally by opting for assisted dying. Many people have said that they feel that they might be unable to trust doctors. The people who say that particularly include those who have existing disabilities and who have had experiences in A&E departments and things like that where assumptions have been made as to the value and dignity of the lives they live. I was going to quote Dr Rachel Clarke on these moments of peak vulnerability, but the noble Baroness, Lady Finlay, did that very articulately.

I once asked palliative care experts what the longest time was that it had taken them to bring what seemed to be untreatable pain under control when a patient was admitted to a hospice. They told me the longest it had taken them was 12 hours. Now, the Bill does not require that a patient is suffering pain for the system to operate, but those who are scrutinising how it would work in practice have been repeatedly accused of making people suffer unbearable pain. Treatment for pain is almost invariably available from experts, provided those experts are provided by the state. Our failing as a country is that we do not provide the expert palliative care to those who need it—my emphasis is on the words “expert palliative care”. I ask the noble and learned Lord, Lord Falconer, this: does he still accept that all options for end-of-life care should be fully explored? He once described this as a prerequisite for assisted dying. Again, can he share with the Committee any assessment of the cost or logistics of making further provision for access to palliative care experts? Will the Minister share any information as to the real costs of extending provision for palliative care and the savings from assisted death which may inevitably result if this is not done?

My Lords, I have added my name to two amendments in this case.

My Lords, could we please first hear from those noble Lords who have tabled and signed amendments before the rest of us speak? I apologise if the noble Baroness is a signatory, but I did not think she was.

I have my name on a number of amendments. I did not know that those rules applied—anyway, they do not.

I have added my name to a number of amendments from the noble Lord, Lord Carter of Haslemere, in this group.

In general, I am glad to support many of the amendments on palliative care in this group. The Bill asks us to accept that assisted dying is a medical Intervention, albeit an irreversible life-ending one, which is something I am not entirely happy with. It seems obvious to me that there must be guaranteed input from the best-placed medical experts in end-of-life care: that is, palliative care specialists. That is essential for the informed consent of the patient.

I imagine and hope that the noble and learned Lord, Lord Falconer, is very sensitive to the importance of palliative care. I know that he is in the much-cited Demos Commission, which I will not bother quoting again, and I am hoping that he has not changed his mind. I think the noble Lord, Lord Carter, made a very important point earlier to the sponsor of the Bill about the number of amendments, for which we have all been chastised and finger-pointed at and tut-tutted at. I kept my patience last night, although my blood pressure did go up.

None the less, I genuinely think that the number of amendments could be really slimmed down if the sponsor of the Bill were to go through, for example, all the amendments on palliative care and say to us, “I accept the principle of this and I will come back with my own Amendment” or what have you. We would then not have this issue. We are not an organised political grouping; people table amendments and add their names to them in good faith, which is what I have done, and they then speak in good faith. We are not trying to repeat things for the purpose of delaying the Bill but because we think that it matters and is important. That is what we are doing here.

On this group, and the concept of 10 important themes, we need an assurance that real choices will be offered to a patient with a terminal illness and they will be given the option of a palliative care assessment and, hopefully, then, possibly palliative care. That safeguard would really reassure us, and it is a key theme, and so on. One of the reasons why I say that is, under the Bill, GPs can mention palliative care to a patient. I am a great fan of GPs; they are fantastic generalists who do a good job. But very often they do not have all the expertise of a palliative care specialist in knowing how precisely medical intervention can improve a patient’s condition, or indeed change their will to live.

It is important for the Committee to note that research has shown that those who wish to hasten their own death often change their mind when they receive more information. Palliative care can mean that people who want to die then want to live, and that is important if we are going to talk about choice. It is possible that you might want to die, that you are determined you want to die in assisted death terms, having had your terminal diagnosis. But why is it that you want to die? That is the motivation behind the discussion in this group.

One of the things that happens is that many people are frightened and fearful, and one of the things they are fearful of is pain and terrible symptoms, which by the way are often graphically described by supporters of the Bill, and I think that they can scare people. It is the idea that your pain and symptoms cannot be controlled. When I talk to supporters of the Bill—some of my friends, colleagues and members of the public—they are completely compassionate in talking about how the Bill will help people who are suffering intolerably and in excruciating pain. None of us wishes that on anyone—or, indeed, on ourselves. It is a frightening prospect.

That is actually often a fear and a dread that the right kind of care can mean will not be realised. Patients are understandably frightened of being in that kind of pain, so they need to know that. Toby Porter, the CEO of Hospice UK, summed up the way I feel about this. He said:

“An outcome in which someone chose an assisted death because of a real or imagined fear that they could not get pain relief or other symptom alleviation, or because their family would not get support through their illness, would clearly be a moral and practical disgrace to any country”.

That is absolutely right.

We all know family and friends and so on who have died and who have had terminal illnesses. People will say that morphine is simply not enough to control the pain. That is the kind of thing that I would say, because I know nothing about medicine. So, it is a great relief to discover that palliative medicine resident doctors say that morphine is the tip of the iceberg for pain management. There are countless other options available, but to know this requires training and experience, which I have not got. When you are having a chat in the pub with mates—or indeed, when I was in hospital pumping in the morphine—it is good to know that somebody, somewhere, has got the experience. That is the palliative care specialist and every terminally ill patient should at least be offered the option to go to see one. This is a modest but meaningful addition to the Bill and I hope that the noble and learned Lord, in the spirit of listening, accommodating and compromise that we heard about last night, will make changes to the Bill accordingly.

There is also a question for the Government and the Minister here. The noble Baroness, Lady Smith of Newnham, explained this very well. In relation to the point made by the noble Lord, Lord Stevens, yesterday, it was a shocking revelation that the Minister responsible for palliative care said that the Government would not publish their modern framework until after the Bill had passed through Parliament. The noble Lord, Lord Stevens—

With respect, he did not say that. The noble Lord, Lord Stevens, said it would not be done “in effect”, the implication being—I do not disagree with what the noble Baroness is saying—that the Government have given a date which is beyond when this is expected to be law. The Minister did not say, “We’re waiting until after the Bill”. The crucial words of the noble Lord, Lord Stevens, were “in effect”. He was very careful in what he said.

I had thought I was implying that. I was not trying to imply some conspiratorial holding back; it is just that the noble Lord, Lord Stevens, said this was

“a dangerous reversal of the timetable we require

That is the point I was really getting to. That is shocking: not because anyone is malignly behaving in this way but because the Government therefore need to commit to bringing forward that report, so it is available before we reach Report. I urge the Minister to reassure us that that is the case.

I will finish off by saying that the noble Baroness, Lady Brown of Silvertown, explained excellently that, for all of the importance of palliative care, hospices and so on, not everyone has equal access to them, which is well documented. I want to see that framework, because this is one of the chilling aspects of the Bill. For those of us who campaign to raise money for hospices, and who are desperately keen that palliative care is well resourced, to hear, as we heard earlier today, from the noble Lord, Lord Carlile, who stated baldly and perfectly reasonably that whichever choice we had in the previous group would cost a lot of money, makes me think, “Oh, spend the money somewhere else”.

My Lords, I had not intended to speak on this group but, as the only nurse present, I want to say that nobody could deny the principles of the amendments that are being discussed today. They are right and proper in respect of good health care for the nation.

I have two concerns, however. One is that we have talked considerably about my medical colleagues, who are absolutely essential, but the vast Majority of palliative care is delivered by specialist nurse practitioners. I feel that it is essential I draw the Committee’s attention to that. I want to read from the ICN Code of Ethics for Nurses, which says that nurses—and, I believe, other healthcare professionals—have four fundamental responsibilities, including

“to promote health, to prevent illness, to restore health and to alleviate suffering”.

What we are talking about today is alleviating suffering.

There is no doubt that suffering and pain are perceived differently by different patients. What some people can cope with is not the same as for others; it is essential that we recognise that. I have not yet put down an Amendment on this matter, but I will do so on Report if we do not have one by then. At some point, if you advance directives, you should be able to say that you never want anybody to discuss assisted dying with you. You could make that clear from a faith or culture perspective—perhaps at the age of 50, if that were appropriate.

My other concern is that a lot of people who work in palliative care have deep religious beliefs and do not wish to discuss assisted dying with their patients. We have to find a way round that in order to ensure that patients are given options but we do not lose important people from our healthcare teams because they are expected to do something that makes them very uncomfortable. We have dealt with that in relation to abortion; we need to think about it in the longer term. I am not proposing an amendment now, but I really felt that I had to speak.

My Lords, I will speak very briefly in relation to Amendments 186, 251 and 380, all of which were tabled by the noble Lord, Lord Hunt of Kings Heath, and two of which are supported by me. The noble Lord has asked me to give his apologies to the Committee; his wife has suffered an accident and he is, quite rightly, looking after her at home.

I know that the noble Lord, Lord Hunt, would have agreed, as I do, with many of the speeches that have been made to the effect that palliative care knowledge must be a prerequisite in any person’s decision-making. There have been many excellent speeches. I simply refer to two as examples: one from the noble Baroness, Lady Brown of Silvertown, and the other from my noble friend Lord Carter.

I represented a Constituency in rural Wales that consists of 839 square miles with no general hospital. I absolutely take the point made by my noble friend Lady Watkins that a great deal of the skill and knowledge in relation to palliative care does not depend on there being a general hospital and can be supplied by nurses; for example, those who work in the area concerned. However, it is extremely important that nobody—whether they live somewhere remote, or they live somewhere populous but feel remote—should be deprived of a contribution from, and knowledge of, palliative care before ever making such a decision.

My Lords, it is now 2.33 pm. I suggest that the Committee might like to hear from Front-Benchers now to ensure that we can conclude proceedings in an orderly manner, as planned, around 3 pm.

I have an Amendment to which I have not yet been able to speak. Surely it is right and proper that those of us who have tabled amendments should be able to speak—especially where, as is true in my case, a noble Lord was a member of the Select Committee that examined this Bill. If the Committee will allow it, I would like briefly to quote some of the evidence that we heard.

My Lords, the House generally rises around 3 pm on Fridays. To go beyond 3 pm, we would need the consent of the Committee.

I will be extremely brief but, as I said, I have tabled an Amendment and have been waiting patiently to speak to it, if I may. My Amendment 394 would require the assessing doctor to arrange, and require the person to attend, a consultation with a palliative care specialist. Like the noble Baroness, Lady Finlay, who moved the lead amendment in this group, and the noble Baroness, Lady Smith, who spoke earlier, I was on the Select Committee. I will not repeat the evidence that the noble Baroness, Lady Smith, quoted, but I shall very briefly quote a little more, because the merit of having these Select Committee reports is that the House hears them.

The Royal College of General Practitioners said:

“It is essential to ensure that every patient approaching the end of life has access to high-quality palliative care”.

Secondly, Professor Mumtaz Patel of the Royal College of Physicians said:

“What I really fear is that people are making sometimes these choices because of the lack of provision around good palliative care”.

Thirdly, Hospice UK, in its written evidence to us, said:

“Should the Bill progress, it is therefore essential that Government does far more to ensure equitable access to and provision of palliative care ahead of the introduction of assisted dying in practice”.

I could quote more, but because of the time constraint, I will come to a conclusion, as requested.

My conclusion is this. When the noble and learned Lord, Lord Falconer, gave evidence to our committee, he stressed at the start that the guiding principle of the Bill is autonomy, but autonomy is compromised if there is not real choice. To those who say that you cannot have real choice between assisted dying and palliative care because the palliative care is not available, my response is that that is precisely why this should have been considered by a royal commission, rather than being brought into this Bill, which has been so heavily criticised by two Select Committees of this House. However, we are where we are, this is the Bill as we have it, so I wait to hear from the sponsor of the Bill which of these amendments he is prepared to accept and, if he is not, which amendments he himself will bring forward in due course.

Noble Lords:

front bench!

My Lords, I will be very brief. I have tabled two amendments, Amendments 183 and 184, which I shall comment on very briefly. They are designed to address the consistent concern within this group about the availability of palliative care. I shall put some data to this which has not been mentioned.

Every day, it has been estimated that between 250 and 300 people die without adequate palliative care, and more than one-quarter facing the end of life do not receive the care they require and deserve. This is a serious figure: the service is under immense strain. It is a lottery. It varies significant depending on where you live, with ethnic minority groups facing even greater difficulty in accessing the service. One benefit of debating this Bill is that it has brought renewed focus on the palliative care crisis we face. We cannot introduce an assisted dying option without first having addressed this serious concern and without having qualified palliative care advice available to those who may want to choose end-of-life options.

Amendment 183 is a further strengthening of the extremely important amendment from the noble Baroness, Lady Grey-Thompson, which would require quality palliative care to be offered to anyone who may be considering an assisted death, so that no one dies without having had this option. They would have to opt out—that is important. Secondly, Amendment 184 would require a definition of what constitutes a palliative care professional. This has been mentioned before and is extremely important. As a caring society, I believe we have a responsibility to ensure that patients can spend their final days being supported by a quality palliative care service, to relieve their suffering as far as possible. In short, no one should feel that they have no choice but to end their life due to gaps in the care system that we have failed to bridge.

Noble Lords:

front bench!

My Lords, I have five amendments in this group and I beg noble Lords’ indulgence—I will get through them as quickly as I possibly can. I have tabled Amendments 179, 182 and 185 and I am a signatory to Amendments 262 and 263. We have talked a lot about choice, and I believe that patients should have real choice, not partial choice, which is why I have tabled amendments that focus on specialist palliative care.

In Another place, the Public Bill Committee accepted Amendment 108 in the name of Polly Billington requiring doctors to offer palliative care support, but this could almost be a case of, “This is what you could have won”. Without a guarantee of that support being made accessible, it does not offer patients the choice that they may be expecting. We have seen cases such as Canada, where they are told, “Yes, you can have this, but we’re not going to fund it”. If the Bill is to be the best in the world, we genuinely have to offer patients every choice that is available. On the previous group, we talked about cost. We were not able to cost this up, but if patients feel that they have no choice but to end their life, we are stripping choice away from them.

Amendments 179, 182 and 185 are in my name. The Bill does not require a medical practitioner to ensure the patient has access to specialist care for their consideration. During the conversations, I believe it is important that the patient is automatically referred to specialist care, ensuring that they have a real choice about the treatment that they may choose to have. It is very important that my Amendment 179 goes beyond what the Bill says, which is just offering to refer, and says they must be referred. Until you are in that situation where you have been given a terminal diagnosis, even if you have a family member who is going through it, it can be slightly different when it is you. How does a patient know about all the different treatment options unless they are given them in a way where they have the time to understand them?

Amendment 182 is about needs being assessed by an appropriate health or social care professional, and proposed new subsection (5A)(b) states that patients must

“be provided with palliative and end of life care in line with their assessed needs”.

We should not be doing this as a case of, “This is what you could have won”—I apologise, but I cannot think a better way of saying it—but we see that in other jurisdictions, such as Canada, you are told, “You can have it, but we’re not funding it”. That puts patients in a really difficult and impossible situation. Amendment 185 also refers to the specialist support that I think is important.

My Amendments 262 and 263 are amendments to Amendment 261 in the name of the noble Baroness, Lady Ritchie. They would add the specialist part of it. I am struck by the number of people I have spoken to who say they have had access to palliative care, but when I have interrogated it, it turns out that they have had access to some medical support. It might be a district nurse, but it does not necessarily mean somebody who has had specialist training. That is incredibly important.

I have lost both my parents. I thought my mother had access to good palliative care, and this is a sense of guilt that I and others feel. It was only when my father was dying that I realised what that could and should look like. They died eight years apart in the same hospital. You would have expected a similar level of treatment and support, but it was very far from that. My father was involved. He had a multidisciplinary team. There was lots of information that we were given time to understand. He was given time to understand what the situation might be.

One of my concerns with the Bill, and why it is so important that the specialist element is there, is that when we were having discussions about my father, we were told he was approaching end of life. We were told that it was very serious, we could let him slip away and that was what we should encourage to happen. That is what he was encouraged to think about. This is why I have real concerns with many parts of the Bill. At that point in my father’s life, he had had his foot amputated. He was told that he would not have a normal life and that he would not be able to live in the same house. It was the house I grew up in, and it was vaguely adapted. He was told it would not be possible to get a wheelchair. If there was one thing I could do for my father, it would have been to get him a really good wheelchair.

This comes back to one real issue I have with the substance of the Bill: how it could be misused by families who are not caring, loving or kind, or by doctors under huge pressure who encourage people to consider ending their life. It is important that the full gamut of options is available, so that individuals can make genuinely open choices about how they choose to end their lives.

I am very conscious of time—I thank the Committee for indulging me by allowing me to speak in favour of my amendments—so I will very briefly pick up on the words of the noble Baroness, Lady Fox. I am one of the Peers who has been heavily criticised for the number of amendments I have tabled to the Bill: being a Cross-Bencher is quite a lonely place. I would very much welcome the noble and learned Lord’s answers to many of the questions that we are raising about moving the Bill forward. Last night, there was, I think, a commitment to answering questions. Would he agree that there is a great deal of difference between generic palliative care and specialist palliative care, and that specialist palliative care is what we should be offering people? Will he commit to exploring the best support under this kind of specialist terminology, so that people are able to make a genuine choice from what is available to them?

In his evidence to the Select Committee, Alasdair Henderson referred to the lack of services and how that might influence choice. I would not in any way want people to think that, because of a lack of social support, poor housing or myriad other reasons, this is the only option they have. If we are going to do this Bill it properly, it must be based on a genuine settled wish, with people being given the best possible choice available to them.

My Lords—

My Lords, I just want to make one point—

Noble Lords:

No!

No, I am sorry, there is no requirement in the Companion that you can speak in a debate only if you have tabled an Amendment. If we want to finish at 3 o’clock, we can either go slightly past 3 o’clock or we can stop at 3 o’clock and resume this group next week. I wish to make one point that has not yet been made and which I think is pertinent to the debate, and I believe I am perfectly in order doing so.

The point is this. Two Members have raised the valuable contribution made in yesterday’s procedural debate by the noble Lord, Lord Stevens of Birmingham—a man who knows what he is talking about on the NHS, as he ran it for a number of years—about the timetable for the Government to publish their modern framework for palliative medicine. He said that, at the moment, that framework is likely to be published after Parliament has considered the Bill, and he felt that that was the wrong way around. The reason that matters is that the Government have published a 10-year plan for the NHS, and nothing in that plan will significantly change the provision of palliative care in England.

We know that only about half the people who require specialist palliative care are able to get it, and that the Bill’s sponsor, the noble and learned Lord, Lord Falconer of Thoroton, believes—or believed and still believes—that good palliative care is a prerequisite for there to be assisted suicide, so I think it very important that the Minister answers the question and confirms that the Government will at least think about publishing the modern framework for palliative care before we get to Report on the Bill, so that this House can make a properly informed decision about the amendments before it on palliative care.

My Lords, this is a self-regulating House, and that does not mean that a Government Whip can regulate who can speak and who cannot. I echo the point made by my noble friend. If the only way one can speak in these debates is to sign amendments, I know what to do in future.

I spoke for five minutes on the Friday before Christmas and said not a peep in the debate earlier today because it was not my speciality. I have been waiting here for two hours to make a speech on palliative care, and we seem to have been refused the right to do so because the Government Whip wants us not to say anything so that we can finish at 3 o’clock. I agree that we can finish at 3 o’clock—it is a simple matter for the House to adjourn and come back to polish off this matter next Friday morning—but it would be absolutely outrageous for noble Lords who have not had a chance to speak at all on palliative care to be refused the right to do so because the Government have imposed an arbitrary timetable on us.

My Lords, it is not an arbitrary timetable. Many people have spoken on palliative care both at Second Reading and today, and I respect that totally. I am just saying that we need to respect the rules of the House to be able to adjourn. It is better if we finish this Amendment so that we can start the next session with a new debate.

Why must we finish this group and start the next session with a new Amendment? In Committee, we often adjourn at 10 pm when we are half way through a large group, and we come back and polish it off the next day. Nothing in the Companion suggests that we are honour-bound or duty-bound to finish a group on a certain timescale. There is no problem with coming back and completing it then.

The noble Lord is of course completely correct that there is nothing in the Companion. It is however difficult for many Members, when they have spoken in a debate, not to be able to hear from the Front Benches because they have arrangements for another occasion. I say gently to the last two speakers that we are not talking simply about the Companion; we are talking about last night’s decision and the mood and concern of the House that we make progress. It is very unfair to attack the Government Whips on this when they are trying to work their way through the input of last night’s decision.

I respect what the noble Baroness has said, but it is also the case that it is disrespectful to Members who have prepared speeches, wishing to say something on palliative care, and who deliberately stayed quiet in previous debates so that they could make a point on a subject in which they are interested. They are now being deprived of the opportunity to do so.

My Lords, one reason I was reluctant to get up is that I believe very strongly that all who want to speak in these debates should be allowed to do so, but I ask noble Lords to please bear in mind that there are many others who may want to speak to the group, and we should not make Second Reading speeches. We should repeat what the Chief Whip reminded us of a number of times: please can we speak to the amendments and keep to the point? I will try to do so in summing up very quickly.

It is quite clear that these amendments relate to palliative care and whether people who seek assisted dying services are offered a meaningful choice—not just a choice in theory or on paper because it says it somewhere in the current version of the Bill but a very real choice. I pay tribute to the noble Baroness, Lady Finlay. When I was the Minister taking the Health and Care Act 2022 through the House, she came to speak to our officials in the Department of Health and Social Care who did not know as much as her. She held a teach-in. She did not have to do that, but many officials in the department said that they welcomed the opportunity to learn from such expertise. That is why I think it is important that we learn from all noble Lords, whatever their expertise. We should also thank everyone, especially specialists, currently working in the palliative care sector, which is under pressure.

This refers to a point made early on at Second Reading, when the noble Lords, Lord Hunt and Lord Stevens, said that we know how government works and how money is shifted around government. I do not want to argue about the merits of the Bill—personally, I am torn on it at the moment and am listening to the debates to make up my mind—but the noble Lords said that, if it goes through, the money has to come from somewhere. They feel, having been in government—one having run NHS and one having been a Health Minister—that that money will come at the expense of palliative care. I think that that concern is behind many of the amendments in this group.

It seems that the principle is that anyone who is making that decision, or who seeks that help, should make a meaningful choice, so I welcome the intent of all those who laid amendments in this group—I will not waste time by naming them all; they know who they are, and I thank them. But I point out to them that, as some noble Lords have said, palliative care is mentioned in the current version of the Bill. We see it in Clause 5, on preliminary discussions with registered medical practitioners; in Clause 12, on doctors’ assessments; in Clause 39, on codes of practice; in Clause 40, on guidance about the operation of the Act; in Clause 47, on reporting on the implementation of the Act; and in Clause 50, on review of the Act.

Surely, the crucial question at this stage to both the sponsor of the Bill—the noble and learned Lord, Lord Falconer—and the Minister, are whether they believe that these clauses in the current version of the Bill, as entered this House, address the concerns raised by the many probing amendments discussed in this group. That is the crucial question to the sponsor of the Bill and the Minister.

I have a further question for the Minister, and I know that it is a little unfair because it is probably more a question for the Department of Health and Social Care and perhaps the Treasury, so if the Minister does not have the answer to hand, we understand that she will write to us and place a copy in the Library. Are the Government confident that palliative care will be sufficiently funded so that those who seek assisted dying services are offered a real as opposed to theoretical choice on palliative care, so they can make a more informed decision, understanding what is available to them? I recognise that that may be a difficult question and may put the Minister on the spot, but I hope that she can go back to the Government and ask for an answer that can be shared with your Lordships.

I look forward to the answers from the Bill’s sponsor and the Minister.

I shall be as quick as I can on this group. My comments are restricted to those amendments on which the Government have major legal, technical or operational workability concerns.

I make one preliminary point very quickly at the beginning. Pursuant to Section 3 of the National Health Service Act 2006, the provision of palliative care is a statutory requirement. Integrated care boards must arrange for palliative care to meet the reasonable needs of their populations. This can be delivered through universal services, such as GPs and community nursing, or through specialist services where appropriate. Importantly, not all patients will require specialist palliative care.

With that in mind, I turn first to Amendments 53, 54, 64 and 221, in the name of the noble Baroness, Lady Hollins. While many people at the end of life may benefit from specialist input, this would normally be based on clinical judgment and patient need, rather than being a blanket requirement. The Committee should note a workability concern in relation to these amendments, in that they diverge from this person-centred and needs-based approach. It should also be noted that these amendments conflict with current NHS statutory requirements on the provision of palliative care.

Whatever the intention, the Government’s view is that the effect of these amendments as drafted is to exclude someone from eligibility for assisted dying if they refuse the additional assessments. Consenting to, or refusing, medical treatment engages Article 8 of the convention. The Committee may wish to note that these amendments could give rise to legal challenge on the basis that excluding that group of people from eligibility might not be justified under Article 2, or might amount to unjustified discrimination under Article 14. Any differential treatment would need to be objectively and reasonably justified.

Amendment 178A in the name of the noble Baroness, Lady Lawlor, would introduce an additional requirement on the preliminary discussion stage. Every person who wants to have a preliminary discussion with their doctor about an assisted death, irrespective of whether they are eligible for an assisted death, would have to be referred to a consultant physician in palliative medicine for a full assessment and care plan. However, preliminary discussion could take place before a person met all the eligibility criteria, and it could happen more than once. Therefore, including an obligation to refer anyone who has a preliminary discussion to a consultant physician in palliative care would create a significant resourcing burden. This appears contrary to usual clinical practice, whereby the involvement of such specialist services depends on an assessment of need and on the wishes and preferences of the person, rather than via a mandatory requirement. This amendment removes the patient choice in this decision. Finally on this amendment, the phrase

“for the purpose of a full assessment and care plan” is broad and undefined.

I turn now to Amendments 178, 252, 316, 345, 385 and 454 in the name of the noble Lord, Lord Carter of Haslemere, and Amendment 186 in the name of my noble friend Lord Hunt of Kings Heath. The Government have workability concerns in relation to these amendments. First, it is unclear what the full assessment is intended to cover and what is required for it, potentially making it difficult to demonstrate compliance. Secondly, the amendments would require repeated referrals at different stages in the process. It would be resource intensive to repeat the same full assessment three times in addition to the existing assessments in the Bill. This might cause delays in the assisted dying process. The Government do not have a detailed delivery model, so we are unable to comment on the point at which the process cannot be delivered within a reasonable timescale. Finally, I note that it is unclear what happens if the individual declines any of the referrals, including if the individual has, in fact, undergone such assessments. That might result in ambiguity for those seeking an assisted death or for the assessing doctor and panels in fulfilling their duties under the Bill.

Amendment 182 and Amendments 261 to 264 in the names of the noble Baroness, Lady Grey-Thompson, and my noble friends Lady Ritchie and Lord Hunt would require someone seeking an assisted death to have their palliative and end-of-life care needs assessed and care provided by an appropriate health or social care professional if the person requests it. These amendments would also place a duty on the Secretary of State and Welsh Ministers to make regulations about the provision of palliative and end-of-life care. There would need to be justification for the different levels of palliative care being offered, on the one hand, to terminally ill patients seeking an assisted death and, on the other, those in comparable situations where patients are not seeking an assisted death. The Government have some concerns, as I said earlier, about creating unequal access to palliative care, with the potential effect of prioritising resource for those who wish to pursue an assisted death rather than for those with the greatest clinical need.

My Lords—

I am not going to take any interventions, I am sorry. I am simply giving the Government’s view. We are very short of time. I apologise to the noble Baroness.

Would my noble friend—

I am not taking any interventions.

These amendments create a further risk of incentivising the use of palliative care when it is not in line with the wishes of the individual. If a patient has relevant and available palliative care options, as with all treatment options, it remains their decision whether to pursue them.

Lastly, I turn to Amendment 832 in the name of the noble Baroness, Lady Hollins. The Government have workability concerns in relation to the amendment, which states that no person may access an assisted death unless a consultant from palliative medicine has

“confirmed in writing that all appropriate specialist palliative and end-of-life care options … have been discussed and, so far as reasonably practicable, tried or considered”.

This appears contrary to usual clinical practice, whereby the involvement of specialist services depends upon an assessment of need and on the wishes and preferences of the patient. As Amendment 832 excludes people from eligibility unless they have tried or considered particular options for care, this could give rise to legal challenge on the basis that it is not justified under Article 2 or 8 or may amount to unjustified discrimination under Article 14.

My Lords—

I am not taking any interventions. I would invite the noble Baroness, with the greatest of respect, to write to me, and we will deal with the matter then.

In answer to the noble Baroness, Lady Smith, who raised the issue, along with others, including the noble Lord, Lord Harper, I can confirm that the Minister for Care said this week that we will publish an interim report in the spring and a final modern service framework by the autumn. We want to get this right, so we are not going to rush it. I remind all noble Lords that this is not a government Bill; it is a Private Member’s Bill.

For completeness, as the Committee will be aware, none of the amendments in this group has had technical drafting support, so the way they are currently drafted means that they may not be fully workable, effective or enforceable, but the issues raised are a matter for Parliament to consider and decide.

Finally, I had almost forgotten—how could I forget?—the noble Lord, Lord Kamall. I am going to commit the noble Baroness, Lady Merron, to writing to him.

My Lords, the relationship of palliative care to the Bill is very important and concerns both everybody in this House and people generally, so this is an important group of amendments. The amendments approach the issue in a number of ways. First, they approach it on the basis that, as the noble Baroness, Lady Finlay of Llandaff, said, in order to make a decision, you have to be properly informed. So there is an information aspect, which I will address in a moment. Secondly, there is an issue about whether, if you want to make an application for assisted death, you have to subject yourself to a compulsory assessment of some sort. Thirdly, there is the issue of whether you should be entitled to an assisted death only if you can access better and therefore more appropriate palliative care than might actually be available to you in the place in which you live. I will deal with each of those three issues, which are right at the heart of this group of amendments.

First of all, should you be properly informed? Yes, you most certainly should be properly informed of what palliative care is available to you, and the Bill should make that clear. I submit that the Bill makes that clear and does so in a reasonable way. I draw your Lordships’ attention to Clause 5, which says, on the preliminary discussion:

“If a registered medical practitioner conducts such a preliminary discussion with a person, the practitioner must explain to and discuss with that person … all appropriate palliative, hospice or other care, including symptom management and psychological support, and offer to refer them to a registered medical practitioner who specialises in such care for the purpose of further discussion”.

All the palliative care options that are available to you have to be discussed with you by the doctor in the preliminary discussion and, if you want, you can be referred to a specialist in palliative care as well. In addition to that, I refer your Lordships to Clause 12(2)(c)—I am grateful to the noble Lord, Lord Kamall, who took us through the provisions very helpfully—which says that each of the two doctors has to explain to the patient

“any available palliative, hospice or other care, including symptom management and psychological support”.

Therefore, there are three occasions on which the detail of the palliative care available to you is explained to you.

The noble Baroness, Lady Finlay of Llandaff, says that maybe they would not know the full detail. I recognise that that might be possible, but is it dealt with adequately in the Bill in terms of the information being provided? My own view is that it is. I do not think you need to make further provision as far as information is concerned. I am very happy to talk to any noble Lord in relation to that, but I think that this question has been addressed head-on and that a proportionate and sensible solution has been reached—proportionate even having regard to the fact that this is the most serious decision that somebody could take.

The second issue is whether, nevertheless, should you make a referral mandatory, it has to be done, you have to be examined and you have to have a meeting with a multidisciplinary palliative care team. I say no. I say that that is a choice, because the obligations of giving information are sufficient in relation to that.

The third issue raised by this group is that palliative care is patchy throughout the country; it is better in some places than others. I completely accept that. Everything that we do in relation to assisted dying should not lead to any reduction in finance for palliative care. I am sure that it will not. As those who have read the impact assessment provided by the Health Department will know, it makes it clear that the amounts of money we are talking about to fund assisted dying are in the tens of millions, which is not going to make a difference to the provision of palliative care in this country. I am not in favour of additional provision being made to provide palliative care for those who want an assisted death, nor am I in favour of saying that, unless the standard is the highest or a reasonable standard, you are not entitled to it.

As to the first of those two points—namely, that you are entitled to a higher standard if you apply for assisted death—the Minister said that that might well be contrary to the law, but put that to one side: we should do our best for everybody in relation to palliative care, and you should not get a special advantage if you apply for an assisted death. Secondly and separately, of course, nobody wants the absence of palliative care to be the reason you apply for an assisted death, but we have to give everybody this choice on the basis of the way the world is for them. It should not, for example, be available only in the areas where the best medical attention is available. As long as you know what you are entitled to, it should be available to everybody, not just those who live in Oxford or Cambridge or those who live close to St Thomas’ Hospital and other palliative care places.

The various amendments are all twists on those themes. My view is that we should make sure that they have the right information, and they should have access to a specialist who will tell them it if they want it, but I think the Bill does that. Although I am open to any discussion people want, I think we have done enough and addressed head-on these issues, so I invite the noble Baroness to withdraw her Amendment.

In the time that is left, I would have loved to respond to all the points, but I am not going to go through them in detail. I am deeply disappointed in the response from the noble and learned Lord, Lord Falconer, because it seems that he has not taken on board some of the really important points that were made. I believe that the Amendment spoken to by the noble Baroness, Lady Brown of Silvertown, is the beginning of a very important statement. I believe that we must—not just will but must—come back to this on Report, with all those people who have shown an important investment in time to consider the needs of the individual who is in such distress that they want an assisted death. We cannot accept that some people are potentially going down that road simply because care is not available. With that, and with the commitment to come back later, I beg leave to withdraw the amendment.

Amendment 26 withdrawn.

House resumed.

House adjourned at 3.13 pm.