Lord Birt:

Moved by Lord Birt

35: Clause 1, page 1, line 14, after “life”, insert “, delivered and supported by the Assisted Dying Help Service (see section (Assisted Dying Help Service)) and”

My Lords, I shall speak also to all the other amendments listed in my name and that of the noble Lord, Lord Pannick, who, having assiduously attended our sessions on the Bill thus far, as all will have noticed, deeply regrets that he cannot be present with us today.

Our discussions to date have focused overwhelmingly on risk, and I do not for one moment dispute the necessity and the value of that. I will return to how best we can manage those risks later in my remarks. However, let us not forget that we are not pioneers. Thirty countries, states or jurisdictions across the world have already introduced assisted dying. The first did so over 80 years ago; there has been a steady stream this century and, hot off the press, just two days ago, an assisted dying Bill for the Channel Island of Jersey passed its First Reading by a two to one Majority and is expected to pass into law next month. It is therefore at the very least equally important that we do not just focus on risk but lean on the well-established experience of others when considering the critically sensitive matter before us, which we know from serious studies carries overwhelming public support.

For my part, I have been exposing myself to the Australian experience, with considerable help from senior practitioners, for which I am most grateful. Without exception, those to whom I have been exposed come over as deeply caring and enormously considered. What I have learned from them, and from the copious data that is available, is reflected in the amendments before your Lordships today. Much that I have discovered has been surprising as well as enlightening. First, applications for assistance in Australia are not automatically accepted; something like one-third are turned down. Secondly, around 75% of those seeking assisted dying have cancer, and somewhere between 75% and 90% of all those who come forward are already in receipt of palliative care and are more motivated by their distress and misery than by their pain. Although I completely agree with all noble Lords who have stressed how vital it is to have effective, universally available palliative care, it is clear that it is not sufficient for many experiencing truly horrific medical conditions.

For those who have not read it, I commend Jonathan Dimbleby’s moving account in a recent New Statesman of his brother Nicholas’s harrowing final days. Nicholas had fallen victim to motor neurone disease. It became impossible for him to take solid food without choking. He then had a tube inserted into his stomach, through which he had to feed himself. Nicholas became increasingly hard to understand. He was barely able to move. He lost control of his bodily functions. He was often frightened and sometimes terrified. He gasped in vain for breath. Nicholas Dimbleby, finally and mercifully, died in February of 2024. Other UK practitioners I have met recently, simply by chance, have shared with me equally horrific accounts of deaths that they have witnessed in the ordinary course of their work.

Such experiences must explain why, in Australia, although around 10% to 15% of those seeking an assisted death apply some months in advance of their anticipated need, a significant proportion wait until their suffering is unbearable. As a result, around 25% of applicants die within nine days of their first request—I repeat, 25% of applicants die within nine days of their first request. A further 25% die within 10 to 19 days. Thus, in Australia, around 50% of applicants die within 19 days of their first request. The leading Australian practitioners who have advised me insist that sheer misery is the primary determining motivation of individuals seeking assisted dying. Further to illuminate the complexities of the process, around one-third of those who ask for and are given the death potion do not take it and choose to die a natural death.

My Lords—

No, I am sorry—I have an argument to put; I am not going to take any interruptions.

Furthermore, one of Australia’s most senior and experienced practitioners tells me that, although in theory it must be a risk, she herself has never experienced a single example of coercion. On the contrary, she says, she has on occasions experienced the very opposite: loved ones understandably pressing someone who wants assisted dying not to embark on that course of action. Overwhelmingly, her experience is of applicants who know their own minds and are perfectly able to make a considered decision.

From all my discussions, I have concluded firmly that if this Bill passes into law, it is vital that the processes are based on day-to-day realities, as well as risk, and work efficiently and sensitively for any individual of firm and settled mind coming forward in a state of deep distress. We need more flexibility in the timelines of the process than the present Bill allows and a fit-for-purpose organisational focus that delivers promptly and humanely for individuals in severe need.

In our amendments, the noble Lord, Lord Pannick, and I propose three key measures. The first is to create a new organisation, the assisted dying help service, to enable the individual easily to navigate the complex process set out in this Bill, which in essence we retain. The second is to ensure that the assisted dying process is expeditious and, when conditions demand it, flexible. The third is that the commissioner acts solely as a regulator, with oversight but without any delivery responsibility.

The process currently set out in the Bill involves a 10-stage process, with three separate medical consultations with three different doctors, a confirmatory panel and two periods of reflection, the first of seven days and the second of 14 days, the latter of which can be shortened. Absent a bespoke organisational focus, this process in a stressed NHS could take a wholly inappropriate and disproportionate period of time. Hence our proposal is that we adopt a notion present in many jurisdictions of a purpose-built organisation—an assisted dying help service—that would provide a personal navigator to take the dying person and their loved ones through the whole complex process, providing introductions, keeping to timelines and piloting the individual through their final challenging and traumatic journey. Our amendments also propose appropriate flexibility, at every stage, with safeguards for doctors to act with urgency if the individual’s condition demands it.

The final arguments for a bespoke delivery organisation are based on global comparators. We estimate that, in due course, once the system is well established, something like 7,000 people each year in England and Wales will avail themselves of the assisted dying opportunity. A focused organisation can acquire dedicated medical and other staff, and create a network of consultants, specialists and volunteers to call on, including for instance to provide palliative care. A focused organisation can offer and validate training, issue and update advice for practitioners, and develop appropriate tech-supported systems for managing the complex process set out in the Bill. Absent such an organisation, the provision of an assisted dying service could be chaotic and prolonged.

I will mention two other matters covered by my amendments and those of the noble Lord, Lord Pannick. We propose that, in the first medical consultation, the doctors should take the patient through all the options available, including palliative care and the hospice opportunity. Having sat through the whole Committee stage so far, I have further concluded that, on Report, we should formally build into either the first or second consultation a requirement for the medical practitioner to explore whether the individual’s request is influenced by any of the following factors: an inaccurate prognosis; their vulnerability, particularly resulting from disability; their mental incapacity; their financial concerns; or, finally, their possible exposure to coercion. Moreover, help is at hand from the assisted dying help service, which would offer an alternative to assisted death for anyone found to be at risk in any of those ways.

We also propose that the commission’s role should simply be as a regulator and that its prime responsibility should be oversight of the assisted dying help service. It would ensure that practitioners are compliant with the provisions of the law and that data is collected and trends reported. It would issue guidance and guidelines where necessary.

I hope that the sponsors of the Bill will be persuaded of the benefits of the additional measures that we propose, which no doubt can be improved even further through dialogue before Report, not least with those who have concerns about the Bill. I conclude by asserting that we should put no obstacle in the way of someone of sound mind, of a settled view, in deep distress, with death imminent, being allowed a dignified ending to their life on earth, at a moment of their choosing. I beg to move.

My Lords, I thought we were taking the remote contributors first. If we are not, since there are amendments from my noble friend Lord Mackinlay of Richborough to which I have attached my name—he is unable to be here today; he sends his apologies and has asked me to speak to his amendments—I will speak to Amendments 223A, 223B, 223C, 495A, 771ZZA and 771ZA. For the avoidance of doubt, I am perfectly happy to take any interventions, if anybody wants to ask me any questions, if anything I am saying is not clear or if anyone wants to challenge my arguments.

The primary reason for these amendments, as was ably explained by the noble Lord, Lord Birt, is that the Bill does not really give the patient choice. It is designed to preference one option—that of seeking assisted suicide—rather than to help the patient navigate all the options that may be available to them.

There were limits on the way my noble friend could table his amendments. The advice that we received was that any amendments requiring a personal navigator to help secure or facilitate access to palliative, hospice or other end-of-life care, as an end in itself, were out of scope because the Bill’s collective purpose is provision for assisted suicide, not the wider delivery or co-ordination of end-of-life care. So amendments were admissible only where consideration of alternatives were explicitly tied to eligibility for or progression within the assisted suicide process. If anyone has any criticisms at this stage of the way that my noble friend’s amendments are drafted, I say that they are drafted in such a way as to fit with the advice that we received, so I will be perfectly happy to take criticisms of the drafting on the chin.

I start with a point that the noble Lord, Lord Birt, acknowledged in his opening remarks. He said that it was of great importance that there is universally available palliative care. He went on to say that, in his experience of talking to people, even where that palliative care was available, it did not always do the job that the person required it to. However, he skated over the fact that high-quality palliative care is not universally available. In the debates that we have had so far, to which the noble Lord, Lord Birt, referred, many of us have thought that, if high-quality palliative care is not available as part of the choice that you face, seeking assisted suicide is not the result of a proper, freely reached choice, because you do not have all the range of things in front of you. I think I am right in saying that, when the noble and learned Lord, Lord Falconer, was tested on that, he accepted that you have to make your decision based on the choices that are actually available to you. Many of us think we should actually be trying to make sure that everyone has access to that high-quality palliative care and understanding that should be part of this process.

The point of the amendments that we have tabled is to try to ensure that this navigator does not just have a conversation at the beginning; if you seek palliative care and it is not available to you in the normal course of events, this person could help you seek that, rather than being able only to help you seek assisted suicide. They can help you get the full range of choices that you might wish were available to you because, if they were, you might make a different choice. So that is the purpose of the amendments.

This is a point of clarification about access to high-quality palliative care. It should also be about timely access, because we know that, even in the parts of the country where high-quality palliative care exists, around 100,000 people do not get it at a time that would amplify it and ensure that they get the maximum benefits.

I am grateful for that Intervention; it is a very good point. The importance of it is emphasised by one of the points that the noble Lord, Lord Birt, made in his opening remarks: that many people do not seek to make decisions on these matters until quite late in the process. If you were facing considerable pain as a result of your medical situation, not only might you not think about assisted suicide early on but, if it not available in your area, you may not have sought high-quality palliative care early enough. Again, that needs to be available at pace, as well as the choice of assisted suicide.

The second reason why I think these amendments are important is this. I do not know whether I am the only noble Lord to have thought this, but it does seem odd that what we are, or the noble Lord is, proposing here is a personalised service, I presume funded by the taxpayer—the noble Lord nods his assent—which would support somebody in a very personal, individual way to seek one particular outcome. But as far as I am aware, unless something happens in the National Health Service that I am not aware of, we do not offer a personal navigator to help somebody with their journey through seeking medical treatment that will actually help them live and live well, and it just seems to me a slightly odd sense of priorities that we are proposing to put in place a service that is only available to help somebody die.

I wonder whether my noble friend could think a little bit about the money involved in this. I am sorry—it sounds a bit odd, but I do feel very strongly that we ought to talk about how much all this is going to cost and where that money is coming from. In the very unsatisfactory answers from the Minister, who gave the opinions earlier on in previous arrangements, I asked directly whether she would assure the House that this money was additional money, rather than money that would otherwise come from the National Health Service. I wonder whether my noble friend would think to himself about the extra cost that this would mean. Where would it come from, and why are we not spending it on a lively attitude, which is to help people when they are ill with better palliative care, instead of going in for this death concept?

I am grateful for my noble friend’s comments, and he is right: we had an extensive exchange on this subject on a previous Friday, and I am sure the Minister will correct me if my interpretation of what one of her ministerial colleagues said was incorrect, but it was very clear when I asked whether the Government were going to fund anything in the Bill. The Minister confirmed that, if Parliament were to choose to pass the Bill, the Government would indeed fund it and make sure it could be delivered. But when I asked the Minister whether that funding would be extra funding from the Treasury or would be taken from other parts of the public services—I think this was in the context of the extensive debate we had on the proposals on the court system by the noble Lord, Lord Carlile—it was made very clear that that assurance was not given. I am afraid that the only conclusion I could come to, which was not challenged by the Minister—if she thinks I have got it wrong, she is welcome to intervene—was that the money would come from other parts of the public services.

I have to say for myself that, if this assisted dying navigator proposal were to be funded by taking money away from NHS services to pay for it, I think people would find that quite extraordinary. I personally would find it indefensible that we were, again, taking money away from services to help people live to pay for a service to help them die. That would show a very odd sense of priorities. When the Minister responds, because she is the only one who can answer this question, not the sponsor of the Bill, because he is not, as far as I am aware, responsible for His Majesty’s Treasury, I hope she can tell us—

My Lords, I think I heard my noble friend say that NHS resources should be used just to help people live. Of course, we would all agree that is a very important thing, but surely palliative care is all about helping people to die comfortably, which I think we all believe in as well. Given that, maybe my noble friend would agree that helping people to die comfortably, such as through palliative care, is a very good way to spend NHS resources as well.

I agree that palliative care is a very good way to spend NHS resources, to help people live the rest of their lives in as comfortable a way as possible; it is not about accelerating their demise. That is a fundamentally different thing. In the exchange towards the end of our debate last week between my noble friend Lord Markham and my noble friend Lady Finlay about what palliative care is and is not, we had that, and I think it came out very clearly.

I do not wish to overstep the time available to me. The purpose of the amendments is to challenge some of the premises of the proposal set out by the noble Lord, Lord Birt. I hope I have set out some of the concerns that we have, and I hope that the House will support the amendments I have supported on the Order Paper.

My Lords, my noble friend Lord Birt was, of course, perfectly entitled to refuse my attempt to intervene in his speech. I am, however, disappointed that he chose to defy the determination of this House that we should not have repeated Second Reading speeches. Every one of us here can stand up and make a Second Reading speech on any of these amendments if we defy that determination, and I hope that he will not do it again. I am sure it was a misunderstanding on his part about the way in which he was able to move his Amendment.

As to his amendment, I am afraid that I am suspicious about his group of amendments, and I think he gave the game away in the way in which he later turned to and referred to them. It is clear that he is very keen on there being a more extensive provision for assisted suicide—that people far beyond the scope of the noble and learned Lord’s Bill should be able to claim and achieve assisted suicide. Some of his amendments I agree with—I would love to see better care for people who are facing the end of their lives—but behind his amendments is a death service. As the noble Lords, Lord Deben and Lord Harper, said, what he is providing is a way to death, not a way to enjoy and make the most of the rest of your life. I would urge noble Lords not to support these amendments, because I regret that their motivation is not even consistent with that of the sponsor of the Bill.

My Lords, I speak specifically against Amendment 771, which would require the Secretary of State to establish an assisted dying help service as part of the National Health Service. I believe that that is a conceptually misplaced proposition in that, if we cast our minds back to last Friday, it was completely evident that the sponsor of the Bill does not intend that only in cases of unbearable pain or suffering would a person be eligible for the assisted dying service. Instead, concerns about your finances or being a burden on your family would be defined as legitimate bases for making the choice to opt for an assisted death.

It is not the proper function of a national health service to deal with financial burdens or pressures on people’s families in that way: that is a category mistake. Indeed, the founding charter for the NHS, the National Health Service Act 1946, is quite clear, and all successive health Acts have laid out the purpose of the NHS, which is

“to promote the establishment … of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness”.

Assisted dying does not fall within the scope of that purpose. In fact, I think that must be evident indeed to the drafters of the Bill, because somewhat camouflaged at Clause 41(4) is the suggestion that, by regulations, that founding charter for the National Health Service could be amended to include assisted dying. They reference the fact that change is probably required to the most recent iteration, the 2006 Act, to bring that about. I do not think it can be said legitimately that this is a part of the purpose of the National Health Service, and it is unnecessary in practice, organisationally.

Just because doctors, like lawyers and social workers, are proposed to be involved in this, it does not mean it is inherently part of the National Health Service. Doctors do DWP assessments, but that does not mean the National Health Service runs the benefits system. Doctors are involved in driving licence assessments, but that does not mean the National Health Service runs the DVLA. Doctors are involved in the criminal justice system as forensic medical examiners, but that does not mean the NHS needs to run the court system.

Does the noble Lord agree that removing life support is not part of the health service?

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.

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.

My Lords, in his opening remarks, the noble Lord, Lord Birt, cited Australia. I am sure that he is aware that no Australian jurisdiction is recognised as one of the 10 comparable jurisdictions in the Bill’s eligibility criteria and the Government’s impact assessment. The most comparable are New Zealand and the United States. This discussion was resolved in our Select Committee by receiving evidence from New Zealand. We need to be consistent and mindful of the Government’s impact assessment and ensure that our comments align with it.

My Lords, I agree entirely with the noble Lord, Lord Stevens, with his vast experience, and the noble Baroness, Lady Hollins, with hers.

My point is a simple one, which, as a lawyer, has been troubling me for a long time: conflict of interest. There is an internal conflict of interest here within the health service. Are you going to spend the money on this or on palliative care? Will it affect decision-making by medical practitioners? I have talked to a number of them—one of them is a member of my family; I will not embarrass them by saying more—and know that it is a matter of real concern, because this is not treatment, but something quite different.

We do not have to have non-medical things such as, as we have heard, Department for Work and Pensions assessments done under the NHS label. That is contrary to everything the NHS stands for. There would be a conflict of interest within any trust that funds and administers this as to where the money goes. Will it be given more money, specifically? Will it be limited?

The obvious overseeing Secretary of State for this is the Secretary of State for Justice, because you are going to be dealing with the administration of life and death, not simply trying to cure people and save them from death. It is quite different. You are saying, “You can die, and we are satisfied that there are no bad people around you who are encouraging you to opt for this course”. Then there will be the selection and management of the panels, which will be performing a quasi-judicial function, like other assessment panels.

The obvious place for this, which would remove, or at least limit and reduce, the risks within the health service, would be a separate, specific budget given to the Ministry of Justice. We would then know what is being spent. Otherwise, the XYZ trust will say, “Gosh, what do we take this from?” I will not give emotive examples, but that is what will happen in practice, so we need to know that this is a specific service and that the country has said it will have hundreds of millions of pounds a year to run it, but that it will be on top of and ancillary to anything the ordinary health service provides to people who actually want to live, or at least live in comfort.

We really must be told, by the promoter and by the Minister, which Secretary of State will be responsible for choosing the panel, because there are a lot of references to the Secretary of State in the Bill. Will it be the Secretary of State for Health, or whatever the relevant one is at the time, or will it be the Ministry of Justice?

Is it not also the case, if we are looking at assisted dying much more from a justice prism, that one of the broader, important elements to establish, where death has occurred, is whether there has been any criminal action or intent, in terms of the administration but also in a situation where people coerce somebody to die? That is another reason why, if this is to happen, it should sit much more with the justice side of things than with the health side.

I agree entirely with the noble Lord. That is why at the start, perhaps briefly and elliptically, I talked about bad agencies and people. That is not the health service’s primary role. It will happen from time to time. I know a medical professional —I mentioned this at Second Reading—who has a relative in charge of safeguarding in a major London trust. One of the concerns they have, and what they have to deal with from day to day, is families who are not all united in their support for an elderly and tiresome relative and would often, in fact, like them helped on their way. I will not say more, but I think the point is clear that this structural point is a major failing in the Bill.

My Lords, the noble Lord, Lord Stevens, who speaks from great experience and professional knowledge, made a very clear case about how the assisted dying navigator is quite outside the normal purposes of the National Health Service. I guess it could be described, in effect, as a form of advocacy. In the ancient world, the dead were carried across the River Styx by Charon. It seems that role would be performed by the navigator, because where is he navigating you to? It is to the River Styx; he is not trying to navigate you to anywhere else.

If that is included in the National Health Service, it would create a quite different purpose from the normal purposes, as the noble Lord, Lord Stevens, described. I wonder, therefore, whether we should consider whether this actually amounts to the National Health Service trying to persuade people to accept assisted dying. If it does, and if you think of the vulnerability of the individual cases that so often will occur, could it be argued that it might become an institutionalised form of coercion?

My Lords, I merely point out that this is not a choice between investing in palliative care or changing the law so that we have an assisted dying service. We need to do both. I am mindful of the point made by the noble Lord, Lord Stevens, about the lack of response from the Department of Health and Social Care. It would be very good if some others of us could press for that, because it would be interesting to know how, when and how much the Government are going to invest in palliative care. Whatever we believe about assisted dying, we all fundamentally believe that palliative care needs more investment and should not be a postcode lottery.

My Lords, I ask the noble Lord, Lord Birt, to reflect on the equality implications of this suggestion of a special treatment service for those seeking assisted death. Following on from the previous contribution from the noble Baroness, Lady Royall, it seems to me that everybody would want, if they are a patient or for their loved ones, a personal, state-funded navigator. But maybe for care, those people on trolleys, waiting for operations, or trying to find their way into the care system would all say, “Can we all have one?” If we do not afford every patient in the country a personal navigator, is that not an unequal access to services? It seems a two-tier system, and one that I think the public would not approve of.

On another issue, I ask the noble Lord, Lord Birt, to detail the workforce demands that this service would require from the NHS, following on from the excellent contribution from the noble Lord, Lord Stevens. I note that the assisted dying help service—which, by the way, would be awarded significant regulatory powers by these amendments that would not be subject to approval by Parliament—would have the power to set training and qualifications for practitioners. That seems like a blank cheque. I would like to know what the skill set of a navigator would be and who decides that. In all seriousness, this whole new Shadow service being set up, with its own qualification system and recruitment, is a bit worrying. We are not sure who they are going to be.

My final query is that I know that a lot of the Bill’s supporters are frustrated and have raised problems with some of the amendments that have been tabled on the basis that they would somehow create bureaucratic, preventive barriers to people who genuinely want to afford themselves an assisted dying service. In other words, there is an attempt to overengineer the process. Therefore, I commend the noble Lord, Lord Birt, on this creative attempt at cutting red tape. However, on these amendments, we all know that mandated timelines can mean shortcuts that could make the process unsafe. Could he comment on that?

Speed and process-driven decision-making are risky in any instance but, where careful assistance and safeguarding are contested, it seems rather dangerous that panels would have to decide within two days of referral, even sitting over the weekend or bank holidays to make decisions. By the way, I think we should apply that to everyone in the NHS: they should do operations and doctors’ surgeries should be open over weekends and bank holidays. I wish the courts would sit over bank holidays and weekends, because then we would not have to get rid of jury trials, allegedly. That would mean that a referral on a Friday evening would have to be decided by a Monday. How would a panel have time to investigate and read everything thoroughly? Surely it would just end up skimming things.

I also really worry about the reflection period being cut to 24 hours, when experts warn that initial depression after diagnosis, which is completely understandable, might well be temporary, treatable and certainly remedial. It could last a few weeks but then be replaced with a more positive attitude. In fact, the CEO of Mind told the Lords Select Committee that they have

“gone to the brink, have come back and have then been able to say three or six months later, ‘I’m so glad that that did not happen’”.

All I am saying is that saying, “Oh we’re being really efficient; we’re going to make sure that your reflection is cut to 24 hours so that you can get what you want”, might well mean that you do not get what you would have wanted if you had had a bit longer to reflect.

My Lords, there is an unreality about this debate that gives rise to a question for the sponsor of the Bill and the Minister. The unreality is this: the noble Lord, Lord Birt, has made the case for his amendments, and my noble friend Lord Harper and others have made the case against them, but there is hung on this whole debate an assumption that the NHS will deliver assisted dying. I remind the Committee that there is no guarantee of that in the Bill.

If noble Lords would kindly turn to Clause 41(4), they will see that the only reference to the National Health Service is:

“Regulations under this section may for example provide that specified references in the National Health Service Act 2006 to the health service continued”, et cetera. That is the only reference to the NHS in the Bill. We do not know whether the NHS will or will not deliver assisted dying services. It is an extraordinary weakness in the Bill.

The noble Lord and I sat on the Select Committee on the Bill. He may recall that I pressed the Minister specifically on this point: to clarify who would be delivering an assisted dying service in this country should the Bill be accepted. Only after a number of questions did the Minister acknowledge that it was the Government’s intention that the NHS would commission an assisted dying service. He could not clarify or confirm whether it would be delivered by the NHS, the private sector, the voluntary sector or charitable organisations and, if it was the private sector, whether it would be allowed to generate any profit. We are still unclear. It is very challenging to us, and I hope the Minister in her response might be able to give us further clarity on that important point.

The noble Baroness, Lady Berger, is quite correct. That is exactly what happened in the Select Committee. For my sins, I sit on a surfeit of committees, including the Delegated Powers Committee, which drew attention to this very deficit in the Bill. So the question for the noble and learned Lord, Lord Falconer, is: since the Minister was questioned in the Select Committee by the noble Baroness, Lady Berger, in the weeks that have followed, has he had any guarantee from the Government that they will ensure that the Secretary of State by regulation ensures that the NHS delivers voluntary assisted dying services? When the Minister replies to the debate, can she cast some light on this matter so that we know whether or not the proposal that the noble Lord, Lord Birt, has put forward and my noble friend has opposed really has any basis in reality?

My Lords, I was delighted to hear the noble Baroness, Lady Fox of Buckley, hit every nail on the head of everything that is wrong with the Amendment moved by the noble Lord, Lord Birt. I shall speak to the amendments in the names of my noble friends Lord Mackinlay of Richborough and Lord Harper, and I have signed some of them. I have done so because the Bill as drafted, and as now proposed to be amended by the noble Lords, Lord Birt and Lord Pannick, promises choice while quietly engineering speed, centralisation and a single-minded pathway to assisted death. That is not a neutral design choice. It reshapes incentives, shifts resources and narrows real options for people at the end of life.

I will give three short examples of why the amendments proposed by the noble Lord, Lord Birt, are wrong, and end with a direct challenge to the noble and learned Lord, Lord Falconer of Thoroton.

First, the amendments would turn life and death decisions into a fast-track process. From first declaration to possible assistance, the clock can run down to 30 days, or as few as 18 days if death is deemed imminent. Panels must decide within 48 hours of referral. Reports are forced within 24 hours. Reflection periods can be cut to 24 hours. That is extraordinary. Courts take months to resolve urgent life issues. Prognoses measured in months are notoriously unreliable. Rushing assessments in this way risks premature deaths, misdiagnoses and inadequate exploration of reversible causes of despair. My noble friends’ amendments, including the ones that I have signed, push back against that compression.

Secondly, as others have pointed out, the assisted dying help service and the personal navigator create an asymmetric system. The navigator is designed to shepherd people quickly through the assisted dying pathway. There is no equivalent statutory guarantee that a person will get timely access to palliative care, hospice support, social services or mental health interventions. In practice, a patient could reach assisted death faster than they could gain access to pain control, a care package, meaningful social Intervention or, as the noble Baroness said, a GP appointment these days. That is a perverse allocation of scarce resources and a distortion of choice. When one option is actively facilitated and the others are not, choice becomes a funnel.

Thirdly, the Bill permits remote and pre-recorded assessments. Video cannot reliably reveal who is in the room, what pressures exist off-camera or the subtle cues clinicians use to test capacity and voluntariness. Evidence from telemedicine and remote court hearings shows the limits of video for assessing vulnerability. The criminal offence of coercion is reactive. The assessment process must be preventive. Face-to-face contact is not nostalgia. It is a practical safeguard against coercion, miscommunication and error. The amendments insisting on face-to-face steps are therefore not bureaucratic nitpicking but essential protections, and even more so if you are going to have a fast-track procedure such as this.

The noble and learned Lord, Lord Falconer of Thornton, has argued for a patient-centred, safe system. I put to him now: will he accept that a system which institutionalises speed, creates a dedicated navigator only for assisted death and allows remote assessments cannot credibly claim to be the highest standard of patient protection? If he truly believes in patient choice, will he support amendments that restore time for reflection, parity of support for palliative options and a presumption of face-to-face assessment so that choice is informed, free and real, not the product of a fast-track service designed to deliver one outcome? This is not about denying choice. It is about ensuring that the choice is genuine. I support the amendments tabled by my noble friends Lord Mackinlay of Richborough and Lord Harper.

I apologise to the Committee for not being fully engaged today. I have appointments elsewhere, and my father’s funeral was yesterday. I remember during the Covid period Ministers stood behind a sign reading “Stay home, protect the NHS, save lives”. My real concern now with the thought of a navigator that has only one direction is that will it be—I know it sounds rather flippant—“Save the NHS, choose a navigator, choose death”? That seems to be the chilling direction that the concept of a navigator and one choice only seems to be directing us towards.

I feel tempted to try to answer that very quickly. I too will be leaving the Committee before we get to a vote on this or at least some decision from the Minister about what the Minister is going to say. I have to say that this discussion about the cost of treatment is not a reasonable one. The noble Lord, Lord Stevens, did not discuss this in his speech, but I think the speech of the noble Lord, Lord Birt, is overwhelmingly important because it is about the notion of our sensitivity in this situation.

There are many people who go to the health service who do not get treatment. It is not always a treatment. For years, I was pioneering in vitro fertilisation, which was not successful for a very long time. We got 16 babies worldwide in the first four years. There are now millions of happy families as a result, many of them in this House some of the time. The people in this House who opposed in vitro fertilisation—believe me, there were many of them—would probably have refused to accept assisted dying too. The fact of the matter is that the health service develops. It is not static. It changes depending on what the need is. In vitro fertilisation, instead of being an orphan subject, is now a major treatment funded by the health service. Unfortunately, it should be more funded, but we are getting a lot of success doing it in the way we are, and we will increase that.

It is also fair to point out that there are medical treatments developing all the time in the health service, which are not funded at the time when they are developed. Take cancer treatments, which are extremely expensive, very often with the most expensive drugs. Of course, we have to deal with the internal market in the health service, but we persuade the people who understand the need for healthcare, are faced with patients and have to treat them in the best way—

My Lords—

I will not give way. I will answer at the end. I have almost finished what I have to say.

The fact of the matter is that this is not a true argument. There are many examples. In my practice, probably about 60% of the time when people came to my clinic, and it was always true even when IVF was successful, I refused them treatment. I refused to treat them, not because there was no money or we could not afford to treat them, but because I thought the treatment would increase their distress because it was so unlikely to be helpful.

When that happens to people, it is a kind of death within them, but they have the great advantage that they can mourn that death and overcome it by doing other things. Unfortunately, in this situation, when people are dying in the way they are, often horribly, there is something that we need to try to do purely out of compassion.

To build on that, I will put the financial numbers into context. The impact assessment has it down as £28 million; I believe that is 0.000175% of the NHS budget. It is right and proper that we decide how NHS resources are spent and in which direction, as the noble Lord, Lord Winston, said. We make those decisions all the time—for example, whether we put more funding into cancer or other services. It is entirely appropriate.

One of the key phrases was, “It is our NHS”, and what do we know about assisted dying? That 70% of the public support it. Given that, surely it is entirely right that resources are spent in that way.

The point that is being missed was made by the noble Lord, Lord Stevens, and it is the problem with what the noble Lord, Lord Winston, was saying. Can the noble Lord respond to it? We are talking about what the aim of this is, but it is not a health aim. The noble Lord, Lord Winston, spoke of better treatment for cancer and in vitro fertilisation. Are the noble Lords arguing that death is a health aim?

My Lords—

I apologise to my noble friend. The guidance of the House is that you cannot intervene on an Intervention.

Let me answer that, then I will be perfectly happy to be intervened on—

I am sorry to interrupt. If I am correct, the noble Lord can speak again, but he cannot intervene on an Intervention.

I believe I am answering the question. Once I have finished answering, the noble Lord can intervene on me and say what he would like to say. If he is willing to wait a few moments, that would be the appropriate point.

We spoke earlier about how palliative care is a way for people to choose to ease the way they die. I would say that assisted dying is also giving people the choice to die in a way they want to. In birth services, people have a birth plan. I remember going through this recently and there was a midwife who played a role very similar to that of a personal navigator, helping us talk about what sort of birth plan we wanted: whether we wanted a home birth and what we wanted to do about pain relief. It was very similar to many of the things that the noble Lord, Lord Birt, was talking about. The fundamental point here—the noble Lord, Lord Winston, is free to intervene at any point now I have answered that—is that it is giving people choice and autonomy. I believe that choice in the way you wish to die and when you want to die, if it is certain that your diagnosis is that you will die within six months, is a fundamental choice and a health choice.

Part of the noble Lord’s argument is based on assisted suicide being so popular with the general public that 70% of people want it. If that is so, perhaps he can help me to understand why none of the parties in this House put in their manifesto that they want assisted dying?

Given that I did not write any of the manifestos, I am not sure I can say. If I was writing them, it is something that I would probably put in. It is something that everyone agrees is one of personal choice, like many other issues, and of course that is why everyone has a free vote in this matter. It is undeniable that there is overwhelming public support for this and, as it is “our NHS”, it is entirely fitting that if it is the decision that money is spent in this way, it should be directed towards this service.

The question becomes one of what I believe the noble Lords, Lord Birt and Lord Pannick, are trying to do in their amendments, which is to take what we know is a complex system and make it as easy to navigate as possible. We know that it is a time of great distress. In many cases you have just been diagnosed with a terminal illness, and sometimes you will be told straightaway that you have only a few months to live, so automatically you are within the six months and it is something you want to move on quickly. It is entirely right and proper that you want to ensure that it then happens as efficiently as possible. That does not mean you do not want other services to happen as efficiently as possible in the NHS. It is not a binary choice between one and the other.

The noble Lord has repeated on several occasions the fact of overwhelming public support for this. Does he agree that there are a lot of other areas in which opinion polling may show public support, but the job of this House is to ensure that the support is buttressed by legislation that is deliverable, is compassionate, respects the rights of all and is applicable across a range of different situations?

Yes, absolutely. That is what these debates are all about: trying to find an approach that makes assisted dying tight and safe, safeguarding all sorts of vulnerable groups, but also navigable. I know that is what the sponsors of the Bill are trying to do and what the noble Lords are trying to do in this Amendment. I commend the amendment for that reason. I do not think they are trying to be prescriptive. They are trying to start a conversation with the Bill’s sponsors that will go on between now and Report, which is an entirely constructive way to do it.

On how the service is best provided, I was on the Select Committee and it is one for the NHS to commission in the best way. Commissioning can use the NHS or voluntary services, and I think we would all agree that, in the hospice sector, voluntary services provide very well. It is wrong at this stage for us to try to be prescriptive in terms of a one-size-fits-all NHS provision. The main thing on these amendments is trying to get a constructive approach, which I am sure the Bill’s sponsors will pick up, to how we make this as simple as possible to use for those who are in the most distressing period of their lives, when they have less than six months to live and they want to die in a method of their choice and in the most comfortable way possible.

My Lords, of the 43 amendments in this group, 35 are in the names of the noble Lords, Lord Pannick and Lord Birt. They propose a framework for a completely new process outside that already created by this defective Bill, requiring a service of both advice and assistance. This includes the provision of assisted suicide every day of the year, including public holidays, Christmas, Easter et cetera, from 8 am to 6 pm, unless the doctor is in the house where the drug is being administered, in which case he has to stay. As has been said, there is no impact assessment on the cost of this new service and it is a relevant matter. Concerns must arise, given the advice of the Health Secretary that there is already a lack of access to high-quality end-of-life care and that there are tightened finances within the NHS, which could add to the pressure faced by dying patients.

These amendments require a new service that must be part of the NHS. We have heard arguments against that, and I support them. They impose deadlines and create processes for enforcing those deadlines, which will provide assisted death at a time when the person who is terminally ill will, in many cases, struggle to access palliative care; they may even never be able to do so.

The assisted suicide service would take priority. There is no process, as has been said, for a personal guide to get palliative care or the necessary social care. Would the noble and learned Lord, Lord Falconer, be willing to accept amendments that would require palliative care treatment options to be available and accessible within similar structures and timeframes?

We are being told that a system is to be established that will have to take priority over all the other processes because, as we were told two weeks ago by the Minister, what Parliament wants, the Government will deliver. But the Government are not delivering a health service, despite the best efforts of many of those employed in it. We would be naive to think that the Government could deliver this without diverting resources from other health service processes, or from the justice system. There is not a bottomless pit.

The Minister said last week, in the context of the Amendment requiring that an applicant for assisted death must have been recently visited by a GP, that that again poses operational challenges for GP resources. I ask the Minister: if the NHS cannot deliver an occasional visit by a GP, how could it deliver an assisted dying process? I ask the movers of these amendments: what will be the cost—we need to know—and what will have to be sacrificed to pay for them? If the noble and learned Lord, Lord Falconer, is minded to accept these amendments, can he provide your Lordships with a costing of the proposed service in all its elements?

There has been no consideration of the consequences for people such as GPs, 76% of whom already say that patient safety is being compromised by excessive workloads. The process that the amendments advocate is undeliverable, given the scarcity of the relevant personnel, such as clinicians, nurses, lawyers, social workers and psychiatrists. It has not been impact-assessed and it would require greater concentration of resources. There are major issues in relation to access for all people—I am among those who have written to the Minister for an updated equality impact assessment. If, for example, a person were to seek such a death and to choose to die at home, then assistance in reaching this goal would have to be present and available every day between 8 am and 6 pm. When the patient decides that the time has come, the doctor is required under Clause 25 to remain with the person until they have died or changed their mind.

The process of assisted death is not instantaneous; it can take up to 30 hours. In some cases, such as one in Australia that I heard about in a meeting organised by the noble and learned Lord, Lord Falconer, it took seven days. Under the Bill, the doctor has to stay with the person. Given the comments I have just quoted about the availability of doctors, can the noble and learned Lord, Lord Falconer, and the Minister tell us how they propose to ensure that doctors are available to provide the service? We have had very public statements by the royal colleges and professional associations about their negative views of the Bill and the established shortage of practitioners.

The amendments will take control of the processes of assisted dying away from the Secretary of State and give it to this assisted dying help service. It is not a help service when one examines the amendments; it is an entire process and it should be called the assisted dying service. Amendment 771 requires that it has a regional structure and that it will validate training qualifications, provide licences and so forth. Can the proposers of these amendments or the Minister tell us how this structure will be established, managed, supervised and held to account?

The primary point of contact, as we have heard, will be the personal navigator. One of the difficulties that I have with this is that there is no definition in the 35 amendments tabled of who might be a personal navigator and what qualifications they should have. There seems to be no requirement that they even have some form of medical or nursing qualification, yet their task will be to ensure that the services required by the person concerned are delivered as required and to the timeline set in the Bill. This presumes that the personal navigator is able to understand precisely what the person is seeking, to ensure that the person understands the consequences of what he or she is seeking—not only in terms of death, but in terms of the difficulties that may arise after lethal drugs have been taken—to record and report on these timelines and to be able to assist people requiring assistance to obtain exemptions from the timelines. That is not a mere administrative job. There has to be consideration with the person seeking death of what they want to follow in each of the timescales provided for in Amendments 223, 301, 321 et cetera. It is complex.

If an assisted death can be made available in 30 days but accessing palliative care takes months, will there be a choice? I will not rehearse the truncated timescales, but their effect would be that a person could choose an assisted death and be dead in 30 or 32 days, depending on the interpretation of the amendments, or in 18 days, if death is considered to be imminent. As we have heard, suicidal ideation is common following the delivery of a terminal diagnosis and it is often the case that people fear death and the process of dying, but that is a remediable, short-term bout of mental ill health. As we have heard, only 32% of prognoses in the weeks and months range are accurate.

These amendments will not provide time for adjustment. People will be ushered down a rapid path and lost to their loved ones, whereas time and the provision of care and assistance will almost inevitably result in a decision to live to the end with dignity. The amendments impose time limits, which it seems must be met, yet a doctor may not be able to carry out that necessary first assessment within 24 hours and a second doctor may not be able to carry out a further assessment within another 24 hours, following the seven days for reflection. Can the proposers of these amendments explain whether personal navigators will be given some sort of coercive powers? The personal navigator will not be able to enforce compliance with these standards, unless there is a disregard for all the other professional commitments of those involved and for the consequential harm to other patients.

The timescales of this Bill are unachievable as things stand. Equally unachievable will be the 48-hour turnaround right through the year, even at Christmas, which would require that panels be established at a time when there is a significant shortage of lawyers, social workers and psychiatrists. The Royal College of Psychiatrists has said that it will not engage and it is profoundly unlikely that there will be any ability to provide such a service as is required by these amendments. In any event, may I ask the Minister and the noble and learned Lord, Lord Falconer, what safeguards exist against coercion when timelines are this compressed? What opportunity will there be for the considered professional assessment that will be necessary?

The noble Lord, Lord Mackinlay, and the noble Lord, Lord Harper, through a series of amendments, seek to ameliorate the situation created by these amendments. I support them in those attempts, but the amendments in the names of the noble Lord, Lord Birt, and the noble Lord, Lord Pannick, are simply unworkable at the present time.

My Lords, I have great respect for the noble Lord, Lord Birt, and his practical ideas are very sensible, but I think that there is a much more fundamental problem that probably frustrates him. The Government are hiding from us what in fact they want to do on this Bill. I do not blame the noble and learned Lord, Lord Falconer, for this. We are being encouraged to pass a Bill that, as we have heard, will put enormous obligations on the health service’s budget and people, but we are being given no direction by the Government. Will they pay? Do they have the money? Do they have the trained staff to deal with it? While HMG hide behind this flawed Private Member’s Bill, noble Lords are being urged to legislate blind. It is not remotely acceptable or responsible for noble Lords to make life and death decisions when there is no clarity about the future intentions of the Government. I say to the noble Lord, Lord Birt, that this is a great idea, but who pays for it?

I apologise but I must remind noble Lords of the guidance of the House, which is that noble Lords should not summarise or repeat others at length. I know I try to find a different way to say this every week, and broadly speaking I fail. I also realise that noble Lords have spent a lot of time preparing their remarks, but it is my duty to remind them of the guidance of the House.

I love your Lordships’ House because it is the place where all this detail comes on to the Floor of the House. Debates like this, even though they are complicated and difficult, are always encouraging to people like me. The people involved in this, even though they take very different positions, I like a lot. I sat in the debate in June down the Corridor, and I heard lots of emotional stories on both sides of the debate, and good points and all that, but it did not have the level of detail that we are dealing with in this House. This is encouraging to me.

My life has been spent in the East End of London on housing estates, dealing with practical issues in a very grey area of the world and often, if I am honest, the dysfunctionality in practice and in detail of the NHS on housing estates. I have had to deal with the GP who is doing female circumcisions in his surgery that none of the systems had even noticed, and the GP who had bought a cheap fridge from B&Q and given out 10,000 illegal injections, and no one had noticed because there was lots of ideology about race that was preventing anyone from coming to terms with the detail of that.

My colleagues and I really got into the health system, as the noble Lord, Lord Deben, knows, following the death of a young woman called Jean Vialls from cancer in appalling circumstances with a disabled mother, a mentally ill dad and two children sleeping in the same bed. The NHS systems, processes and machinery absolutely failed to deal with that stuff. We would not have built the Bromley by Bow Centre, which now has 55,000 patients—it is starting to operate across the country with a whole programme that I now lead—if it had not been for the noble Lord, who, as the then Secretary of State, intervened in a very serious practical matter following a senior-level inquiry at the London hospital and enabled us to build the first working model of an integrated health centre that tried to deal with this complexity.

The NHS, in my experience—I am dealing with it with colleagues across the country—is broken. It is in a great deal of difficulty, in my experience. Our GPs are overwhelmed by bureaucracy and a whole range of things, and they are excellent people. My point in saying this, because I come from the world of practicality—

I am sorry to intervene again but I invite the noble Lord to address the Amendment directly.

I was just going to do that. I address the Amendment because I worry that, while the amendment and the idea of a navigator seem very straightforward intellectually, I am trying to suggest that in the real practical world out there, when you engage with it, as my colleagues and I have done over the last 40 years, you see something quite different.

My Lords, I shall speak to Amendments 287A, 287B and 771ZB. I call the noble Lord, Lord Birt, my noble friend. We went to the same school, although admittedly not at the same time. I am conscious that he has come at this with an approach of a lot of research, as he set out. The noble Lord knows that I disagree with him, but I understand why he is trying to speed up. However, I wonder whether he has taken account of evidence presented already. The noble Baroness, Lady Fox of Buckley, talked about the CEO of Mind, but also Marie Curie spoke about this and indeed the Royal College of Psychiatrists.

I am particularly thinking of the speeding up and that moment of reflection, which is really important. I think the noble Lord is already suggesting in his Amendment 771 that patients should be aware of their right to withdraw from the assistance process at any stage. There is quite a lot in here that sets out a framework that could be done through the NHS. I completely agree with what the noble Lords, Lord Stevens of Birmingham and Lord Mawson, have said: it worries me that, if this ends up in the NHS, it will accelerate in becoming a routine end of life. In my meetings with the Royal College of GPs, it has been clear that it does not want this to be part of the NHS and it would absolutely resist it being part of the NHS contract.

On that point, and the point raised earlier about a conflict of interest, one of the problems if this is in the NHS is the money. The cost of the drugs to end someone’s life, according to the impact assessment, is £14.78, but the saving you would make from four months of healthcare not used would be £13,075, and anyone with any experience of NHS budgets knows that that contrast would inevitably drive people to being pointed towards assisted suicide.

I understand where my noble friend is going with that. I intend to come back to some aspects of this when we get into informed consent because I was somewhat struck by what the noble Lord, Lord Winston, said, about declining to give treatment because he wanted people to, in effect, accept that they were dying—I think that is what he said, although I had better go back and check that because I do not want to misquote him. I have seen that myself; I saw it with my mother when doctors just had not treated her, and then when it came to it, when it was near the end, we had to fight to avoid even having a DNR on the ambulance so that she could die at home in a place of her choice. That is true patient autonomy—I am not trying to override that.

In terms of thinking through some of what the noble Lord has put forward in his propositions, others have already reflected on the concerns about working days and whether that is practical. I would be grateful to hear from both the sponsor and the Ministers about what assessment they have made of these amendments. I am also concerned about proposed new subsection (2)(g) in Amendment 771, about providing

“publicly available information on assisted dying”.

How does that vary from what is considered advertising, which is explicitly ruled out in other parts of the Bill?

The key point of my amendments links to this almost becoming its own service within the NHS. Various clauses start to remove powers from the voluntary assisted dying commissioner. This service would start to appoint the panels, and at the moment it is taking up all the training, licensing and all those different things. It is my understanding that this does not happen in the NHS today. What we actually get, and what I propose with my amendments, is that, for a start, we have a separate regulator through the Care Quality Commission, and that the General Medical Council undertakes the roles that it does for other parts of what happens in the NHS today. If the noble Lord, Lord Birt, brings this back on Report then I hope he will think more carefully about how to make this practicable, because I hope the Minister will say it is simply not operable, even if well-intentioned in what the noble Lord is seeking to achieve.

The noble Lord, Lord Mawson, has just started talking about the East End of London. It is important that noble Lords consider carefully not just the evidence that has been given to this House but evidence outside about the real concerns of people from BAME communities. It is evident that people in those communities seem particularly worried about this, and that has been communicated directly to this House through witnesses. Instead of not trusting the NHS as it is today to give treatment, imagine, as you go in and are unsure, your already overworked GP saying, “Here you go; here’s some information. Someone can hold your hand”. I worry that too many people would stay away from the NHS when they desperately needed treatment in other aspects of their lives, whether in addressing prostate cancer or the other rare cancers that we debated in the Chamber last week.

I remind noble Lords—I appreciate that this is probably the third time I have said this—that for me this comes back to the practical experience of when the NHS was left to deal with end-of-life care in certain ways. The Liverpool care pathway was so horrific that I cannot in any way see how it could be controlled if we were to adopt the proposals put forward by the noble Lord, Lord Birt. We saw it go badly wrong, and I am pleased that Ministers eventually intervened. It took time, but it did happen.

On these regulations and other aspects of running this service, if we are going to have it, I agree with my noble friend Lord Sandhurst that it should be more of an MoJ focus. Inevitably, it has become a big health focus. It is not clear, from what noble Lords have set out in their proposals, how this interacts with the whole Wales situation. The Bill’s sponsors have, I think, about 12 officials from the Department of Health and Social Care working on the Bill, which is three or four times the number at the MoJ, so there should be some understanding of how this will work. I genuinely hope that the Minister will start to share that, so that this House can make informed choices as we consider such a significant change in what could be the future of our NHS.

My Lords, I am grateful to the noble Lord, Lord Moore, for answering much of what would have been in my Intervention to the noble Lord, Lord Winston. In my 15 years in your Lordships’ House, it has been the usual practice to give way, but I recognise that noble Lords have the prerogative not to accept an intervention. But I find it surprising—and I have never known it before—that the noble Lord is now no longer in his place. That is not in accordance with the advice that the Chief Whip gave this morning that we should treat each other in this House with respect.

The only additional point I make in response to the noble Lord, Lord Winston, who clearly did amazing work on the creation of life—it was on the television as I grew up—and the noble Lord, Lord Markham, who talked about the pathway that midwives give for the safe delivery of that created life, is that it is entirely different to talk about a situation where the state pays for and facilitates lethal drugs to enable a citizen to end their own life.

Looking at the Amendment—

If I may respond to the noble Baroness’s first point, I believe that the noble Lord, Lord Winston, as well as the noble Lord, Lord Mackinlay, who is not in his place either, mentioned that they had appointments that they needed to go to. I believe that that is why the noble Lord, Lord Winston, is not here now.

Well, I hope that he will write to me personally about this.

In relation to the evidence on which the noble Lord, Lord Birt, is basing his argument, I was surprised that the right reverend Prelate mentioned the Australian non-comparable. Paragraph 8.4 of the impact assessment, on the delivery model, states that

“in most jurisdictions where assisted dying is legal it is provided through the healthcare system”, so looking for international comparators is an unusual approach. The 30 jurisdictions that we keep hearing about include the Isle of Man, Tuscany in Italy, and only 13 of the 50 United States. This is not a wave that we must get with, as many progressive politicians like to say it is. Denmark considered this in 2024, and 16 out of 17 members of the Danish Council of Ethics voted against introducing assisted dying into their jurisdiction. Only yesterday, the French Senate decided not to go forward with legislation. This is in no way a progressive train that we need to get on.

My second point relates to the speed of these decisions for families. We know that the Bill is philosophically based on individual autonomy, which is anathema to many communities. For families to know that this was done within 18 days will only compound what we believe will be complicated grief. I am particularly concerned about how the speed of service will fit in with the increasing uncertainty of diagnoses for 18 to 25 year-olds because of the various positive effects of treatments for them. The noble and learned Lord, Lord Falconer, has admitted that there are, sadly, deficiencies in Clause 43 in relation to advertising. I do not think I am a cynic, but I am sorry to say that I can see a competition: “Can I get to 18 years and 18 days and be the first young person to meet that milestone?” We do not want a culture of speed in this process, limiting reflection.

Finally, maybe I am the only noble Lord sitting here without the benefits of the pre-legislative scrutiny of a consultation white paper but, with many amendments, I am wondering how this service will fit together with a panel—or will it be a judge, or a judge with a couple of other members? That is the deficiency: in Committee, we are still trying to put right the lack of pre-legislative scrutiny, and I do not know whether that is possible.

The noble Baroness raised the issue of speed. It comes back to a point raised by the noble Baroness, Lady Fox. Often in public policy issues, there is a trade-off between the speed of a decision and its quality. Sometimes when we short-circuit or fast-track decisions it can inevitably lead to a greater level of mistakes being made. But in a wide range of other public administration or public policy decisions, there is at least the advantage that if a mistake is made, there is the opportunity at a later stage to come back and correct it—to perhaps appeal, review or reverse it. Of course, the major problem with this is that if we fast-track things and it leads to a death that should not have occurred, we cannot bring the person back to life.

I agree with the noble Lord, Lord Markham, who said in response to an Intervention from the noble Baroness, Lady Berger, that he perfectly acknowledged that we should have the safest possible system—I see that he is nodding now. I therefore find it very difficult to see how we get the safest possible system if these amendments go through and decisions are fast-tracked, inevitably leading to greater numbers of mistakes and shortcuts.

My Lords, in introducing this group of amendments, the noble Lord, Lord Birt, said that one of the reasons he tabled them was that the proposals in the Bill are potentially chaotic and prolonged. This group is in some ways something and nothing. The proposals make the case for a profound imbalance, with assisted death actively facilitated, accelerated and led through the dedicated service with speed. As my noble friend Lord Stevens said, this is not in scope for the NHS and NHS services, and we have to look at the NHS constitution. I ask the Minister whether, in the light of some of the proposals, there is a plan to rewrite the NHS constitution as well as the fundamental principles of the NHS, as read out by my noble friend.

The Amendment’s structural conflict is between efficiency and caution. In responding, can the noble Lord, Lord Birt, explain how the clock will be stopped and by whom, and whether a request to shorten the process will trigger enhanced scrutiny? If so, how that will be done? Will all the assessments be face to face to improve the chances of detecting coercion to death? Will all the contacts with the navigator be recorded and audited so that one can be sure that the auditor is not acting in a profoundly subtle and coercive way?

The navigator seems to bypass a search for many things and, without the amendments in the names of the noble Lord, Lord Mackinlay, and others, I cannot see how that imbalance would be corrected. At least the imbalance is there, but Amendment 771 gets to the heart of the problem: it tries to make all of this a profound NHS responsibility. As we have heard, the NHS cannot cope. We have patients on extra beds in the middle of wards, seriously ill patients being looked after in corridors and patients sitting on plastic chairs waiting for a bed, sometimes dying on those plastic chairs.

The NHS is not the place to have a dignified death in a hospital setting in the lovely planned way that seems to be described and desired by some people. People are working themselves into the ground trying to manage their current workloads. As has been said, the workforce itself is completely on its knees. GPs are already overstretched. Evidence suggests that assisted dying would require around 30 hours for an individual case, yet many palliative care doctors and psychiatrists would opt out, therefore decreasing the pool. That is relevant to the way these amendments are put together.

I will respond to some of the points raised about whether the public want this. When the public are asked in polls what they understand about assisted dying, 52% say that it is a right to stop treatment. They already have that right. Nobody should be treated against their will, and they should be supported in that decision. Some 17% of people think that assisted dying is hospice care.

We have heard remarks today about people dying horribly and we have heard about research moving progress forward. So I ask the noble and learned Lord, Lord Falconer: why is there no requirement in this Bill for everything undertaken to be subject to rigorous evaluation and research, with the data available to be looked at in detail?

In the spirit of helpfulness on public opinion and whether people understand the question, there are numerous surveys on this. A very clear one has the wording “Do you think doctors should be allowed to end the life of a terminally ill patient at their request?”, which was supported by 75% of 18 to 34 year-olds, 80% of 35 to 64 year-olds and 78% of those aged 65-plus. I do not think you could get a question clearer than that, or a level of public support greater than that.

I am grateful to the noble Lord for his Intervention, but I think we need to stay focused on the amendments in this group and not get diverted. That is what I am trying to do.

In terms of palliative care provision, I am extremely worried that the amendments put down to the amendments tabled by the noble Lord, Lord Birt, had to be limited because palliative care is repeatedly being deemed out of scope of the Bill. That is a major problem. We hear about bad deaths, but we know that actually, if clinicians act with urgency and have a 24 or 48-hour limit before they call for specialist palliative care intervention—so there is rapid intervention, with highly specialised knowledge—all of the outcome measures show an improvement, using things such as the IPOS scale and so on. Family reported outcomes can also improve. To view bad deaths as something that we should just leave and tolerate, and to say the only solution is the proposal in these amendments, does not recognise the reality of the services that are available already.

In introducing his amendments, the noble Lord quoted extensively from Australia and painted it as everything being perfect. I would like to briefly counter that by quoting the honourable Robert Clark, who was Victoria’s Attorney-General from 2010 to 2014. He has written about the Australian experience of assisted suicide. He describes a change in “attitudes”, with the “ethos” of the medical profession moving away from the practitioner’s primary duty to solve the problems the patient has, and a grave risk that this will lead over time to doctors forming views that a patient ought to be opting for assisted suicide and becoming inclined to regard that patients should go down that road.

He also highlights that there are things going wrong. I will not detain the Committee because of time, but I think there are alternatives. He points out that there are some doctors who, when they have resisted going along with a request for an assisted death, have found their whole careers eventually becoming somewhat blighted. Although there is a Clause in the Bill which tries to avoid that, there is concern that that clause is incomplete. So, when we quote international evidence, we also have to be quite balanced in it.

The proposal in the amendments from the noble Lord, Lord Mackinlay, do us a favour, because they demonstrate that this cannot be part of the NHS as it is at the moment. It begins to move us towards viewing some kind of proposal like this being completely outside NHS services but not planted in the NHS. Then, of course, the funding question arises. If funding erodes palliative care funding, which has happened in other places, we really have a problem, because recent evidence to the Public Accounts Committee showed that, if you have specialist palliative care in place and available, as it ought to be, the savings to the country would be about £800 million a year.

My Lords, I was not intending to stand up today, so I apologise, but this group has not gone at all how I thought it would.

When I looked at Amendment 771 and the proposed assisted dying help service, I was confused. I had thought that navigators might take a similar role to that of independent advocates. We have a group about the importance of independent advocacy, which I am a huge supporter of, and about advising people on other care, health or treatments. That is coming up in 19 groups’ time. But it seems that Amendment 771 is illustrating the flaws of the entire Bill, whether that is geographical provision, training and qualifications, the right of practitioners to withdraw and the need to support vulnerable people.

We have also had a debate today about the funding of the proposed assisted dying help service. We have another group—group 30, which I hope we get to—on the provision of an assisted dying service by groups other than the NHS. I suggest that noble Lords opposite take the suggestion of the noble Baroness, Lady Royall, to press the Government to provide clarity, before we get to that group, on the funding of an assisted dying service and—following the point from the noble Baroness, Lady Finlay—the future funding and support for hospice care.

I have an amendment in that 30th group, which I tabled because I think that the proposers of this Bill have missed a bit of a trick. If you want to set up an assisted dying service, you should do so in parity with the current arrangements for the hospice service. If we understand what the funding for the hospice service will be, we can have our debate in group 30 on alternative provisions.

I mentioned the future of palliative care. I did not mention the costs of an assisted dying service, which I am very willing to ask for as well, but at that stage I was focusing on palliative care.

I thank the noble Baroness for her Intervention. I think both would help us, because there is confusion about the future of support for palliative care, and confusion as to whether the funding of an assisted dying service will take away from other services within the current NHS provision.

Finally, I just want to say that it is very different from the Scottish Bill, which very specifically does say that it will be within the NHS.

It may aid the Committee to know that, before Christmas, the Minister in the other place indicated via a Statement that the Government were currently developing a palliative and end-of-life care modern service framework for England, and that it is planned publication date was the spring of this year. In that context, I hope that the Government and the Minister here will hear the calls from people—both those who support the Bill and those who do not—that it would be very helpful to us all in the deliberations on this Bill if the framework, its details and funding were provided to this House as soon as possible.

On the point the noble Baroness made about funding, unfortunately the Minister has now communicated that it will not happen until autumn 2026, which any former Minister knows means 24 December.

My Lords, I wonder whether the proposer of these amendments, the noble Lord, Lord Birt, can tell us whether he has any indication from the relevant royal colleges that their members would be available for this service. The idea is that you will have senior clinicians on a 24-hour basis, 365 days per year. I wish our facilities had sufficient capacity, but it is nonsense; there is not the remotest possibility of the National Health Service and the relevant clinicians being available.

If I am wrong, and the noble Lord, Lord Birt, has an indication from them that their members will be available, the sooner we get that information here the better—but I just cannot see it. We cannot even deal with what we have at the moment, never mind adding to the burden.

On another issue, I must say to the noble and learned Lord, Lord Falconer, that it is 12.10 pm. By the time we finish this group, we will be at the lunch break. I have to say to him, as I said last week, that if we go on at the rate we are going, he is partly responsible. He needs to bring forward meaningful amendments, so that we can see the colour of his money now and not in weeks to come.

We are debating other people’s amendments at the moment. This debate has ranged pretty far and wide. These are not my amendments; they raise three particular issues. First, should there be a new organisation, an assisted dying help service? Secondly, should we ensure a different and more expeditious series of arrangements than that put in my Bill? Thirdly, should the commissioner act only as a regulator? Those are the three essential parts. I think there is merit in much of what the noble Lord, Lord Birt, has said, but I am not in favour of an assisted dying help service. Further, my Bill sets out very detailed provisions for safeguards that are longer and less flexible than those proposed by the noble Lord, Lord Birt. As for the commissioner being solely a regulator, I am not in favour of that. I think we need a regulator and the CQC has been suggested in relation to that. That seems quite sensible. I simply say that we have ranged so far and wide that I am slightly miffed at the idea expressed by the noble Lord, Lord Empey, that I am detaining people from their lunch because we have had this long debate.

I have to say that that was not my intention—the noble and learned Lord knows that perfectly well. I raised the point merely to indicate the length of time that this is taking and that a lot of the proposals and amendments on the Marshalled List could be addressed if we had amendments put forward by the noble and learned Lord, which he indicated in an email last week would be forthcoming. They are not here.

I think that the reason why the noble Lord, Lord Birt, has put down these amendments is that it is not clear, from what the Government have said or what the Bill says, where this service is supposed to be—I see that the noble Lord, Lord Birt, is nodding at that. If the sponsor of the Bill had set out in the Bill more detail about how it would work and where it would sit, if there had been a proper process, many of the amendments from people with concerns would need to have been tabled and we would be moving faster. It is because of that gap and that failure, which is the sponsor’s responsibility, that this is taking a long time. It is necessary scrutiny to get the Bill right. That is what the public would expect of us.

My Lords, I think that we can clear quite a number of these things away by taking one central issue. The big problem about being in government is that it is not a single issue that faces you; it is a whole range of issues, and you have to get a balance between them. When we talk about cost, it is perfectly possible to say that there is a Majority of people who want this thing, and there is a majority of people who want that thing. The Minister and the Government have to decide how to share out the money that is available between those things. That is crucial to any decision made by this House. My concern is that we are not facing up to that. This is a single issue being presented to the House as if it can make decisions about single issues, irrespective of the effect of the decision on all the rest of the single issues that people also have strong views about.

If you asked the public whether they wanted more money for palliative care, they would almost universally say yes. If you asked the public whether they wanted a National Health Service where they could get an appointment with their GP within a week, they would say yes. If you asked the public whether they wanted a National Health Service where there was someone who could help them through complicated arrangements, they would say yes. The problem for this House is that we have to decide, first of all, what burden these proposals place on the National Health Service, the judicial service and the Government as a whole.

In terms of, hopefully, being helpful, it is in the impact assessment. It is £28 million or, as I said, 0.000175% of the NHS budget.

I am perfectly happy to accept the Intervention, but I understand why the noble Lord, Lord Birt, did not accept any intervention, as he might have found it difficult to answer the questions that we are asking.

The point that I am making is very simple and it remains: we have to make a decision always among priorities. The problem with this decision—and it is why this should have been a government Bill and not a Private Member’s Bill—is that, as a Private Member’s Bill, it is a single-issue Bill. It is promoted by people who want this to be decided irrespective of its effect on everything else that happens. That it is not acceptable, it seems to me, for the Government. The purpose of my comment is that it is not about how much the proponents think it will cost; it is about the effect of this over the rest of the National Health Service. If the Bill is passed, where is it going to fit? The Government really cannot get up and say that we are entirely independent. They have to tell us, if this Bill is passed, where they see it sitting, because the proponents of the Bill have not expressed this. What is the real cost; that is, not the sum of money, but the effect of it on the rest of the service provided? They also have to tell us how it will impact the essential demands that the public have for so many other things.

We can argue about what the public think about this Bill—I am pretty sure that they think about this Bill rather differently from what it actually is—but we have to recognise that the public also have very strong views about what money should be spent in other areas. The Government have to tell us, from their point of view, how much it will cost, what the effect will be on the other services provided, where it will sit if it is passed, and how they will overcome the problem that many of those who may be asked to support it have said that they will not. Those are things for the Government to tell us and, so far, they have been unable to put answers to any of those questions, which is the second reason—the other is the point that the noble Lord has just made about amendments—why we have constantly to go on arguing, in detail, about this Bill.

My Lords, I will give a specific example. On 8 January, at col. 1416, the noble Lord, Lord Stevens, made a short speech, which consisted of about six specific questions. One of them was about the interaction of the health service and the Bill. Later that evening, I said to my noble and learned friend in Intervention that he should come back within the next 10 days and answer those questions. The fact that he has refused to do so, and the suspicion being he has no intention of doing so, is why the amendments will keep being raised. That is basically the point that the noble Lord, Lord Empey, was making: there is a suspicion that they will not be answered. If we could do that, we could make more progress anyway because of the nature of the amendments that have been put down.

My Lords, I am wholly in agreement with the noble Lord, Lord Rooker, and my noble friend Lord Deben, that greater clarity, both from the promoter of the Bill and from the front bench, would assist the Committee in making sure its mind could be made up on these delicate issues.

The noble Lord, Lord Birt, used to be my boss when I was a junior journalist at the BBC; I owe him a great deal. In framing this Amendment, he has shown that a fine line, by insisting on speed and precision, can show us just what expedited delivery of a public service can achieve. If only the skill with which the noble Lord, Lord Birt, has ensured that the ratchet moves forward at speed in this legislation had been applied, for example, to our planning system, or to any of the other areas where government is laggard and failing. As the noble Baroness, Lady Fox of Buckley, pointed out, if the same degree of precision had been applied to the operation of our courts and tribunals, we would not need to be contemplating the end of trial by jury.

However, in putting forward this proposition, I fear that the noble Lord, Lord Birt, is guilty of falling prey to two fallacies. The first is the Gadarene swine fallacy: the idea that, because so many are moving in one direction, we must follow expeditiously. He cited the fact that Jersey has voted for a form of assisted dying, and we are aware the debates are carrying on in Scotland and Wales. I shall not go into the devolutionary and union ramifications of those debates here—we will return to those later; they are critically important. But, as was pointed out by the noble Baroness, Lady Berridge, the arc of history does not bend in any one particular direction, and certainly not in the direction that the noble Lord, Lord Birt, wishes to see it bend. We have been reminded this week that Denmark can say no to being told what to do by others, not just in geopolitics but in other areas as well. What we can learn from Denmark, and indeed from the French Senate, is that the consideration of the detail of legislation matters.

The other fallacy which was inherent in his speech is the Robespierre fallacy: the belief that one can discern and interpret the general will and then push in a particular direction. As we have heard on the Floor of this House, opinion polling on the question of assisted dying gives us almost the conclusions that we might want to have. I was struck by the opinion polling cited in the British Medical Journal, cited by the noble Baroness, Lady Finlay, which pointed out that the Majority of those asked, when they were compelled to share what they thought assisted dying meant, thought that it either meant the withdrawal of existing treatment at a particular point, at the request of the patient, or improved palliative care. Of course, the noble Lord, Lord Markham, cited other opinion polling as well, but the critical thing is that opinion polling points in different directions. It causes me concern. But it is the purpose of this House and the purpose of legislators here not to attempt to discern the general will and to enact it, but to look at specific legislation and to decide whether it is fit for purpose.

That takes me to another point about the assisted dying help service: a question for the promoter of this amendment, the noble Lord, Lord Birt, for the promoter of the Bill, the noble and learned Lord, Lord Falconer, and for the Front Bench. It is undoubtedly the case that, if the amendment standing in his name and the name of the noble Lord, Lord Pannick, were agreed, the process would accelerate, relative to that which is contained within the Bill. Yet, at the same time, it is the case that a new service is being set up, which, as a number of colleagues here have pointed out, might draw resources away from other aspects of the NHS. How is it possible that a service that is set up explicitly to accelerate, to be a concierge service in that way, will also attract, be staffed and operate in a way which ensures that at every point, objective, neutral, balanced advice is offered? Is it not in the very nature of this service that those staffing it—and one has to ask who would volunteer or would be paid for that role—would become engineers of a particular purpose? Is it not the case that those who would move towards recruitment in this area would be people who would be motivated I am sure from the best and most idealistic of motives, but those who would want to advance the path to death and accelerate suicide rather than incur reflection?

That takes me to a question for the noble and learned Lord, Lord Falconer, who might say that this is an amendment from the Back Benches, not something that he has been party to and that we as the Committee might consider it overall. He might well say that he has his own timetable in this legislation to which he is attached, which he would like us to pay particular attention to as we reflect on the Bill. But the question for the noble and learned Lord, Lord Falconer, is: if he could, would he back the amendment of the noble Lords, Lord Birt and Lord Pannick? Is he in sympathy with the desire to accelerate this process? It is not enough for him to say, “Look, I haven’t put this forward”. The key question is: if he is in sympathy, will he say so, and if not, why not? If he believes he is not in sympathy, is that because he thinks it is right that there should be appropriate, greater reflection, and that there is something momentous about this decision? Is it also right that he believes that this would mean a diversion of resources?

I support the safeguards in my Bill, because I think they are the right safeguards. So, I do not support the proposals made. The Bill has got to be properly safeguarded, and my Bill gets the balance right.

I am grateful to the promoter of the Bill for that, but that is a broad defence of the legislation as written and it takes us to the critical question for the Minister, which relates both to resource and timing.

The Government have committed additional money for palliative care, for hospices, which is welcome: £100 million for adult care in hospices; £80 million for children’s care in hospices. But those who lead the hospice service say that this additional money has already been swallowed up in additional costs. It does not augment palliative care. Yet, money is inevitably going to be diverted, if we pass the Amendment of the noble Lord, Lord Pannick, and set this service up, as the promoter of the Bill acknowledges. Yet, as the noble Lord, Lord Stevens, has pointed out, we have not had from the Government any adequate response on what additional resource might be devoted to palliative care, despite the fact that we had a national report into end-of-life care, produced by Marie Curie Cancer Care and others, more than 15 months ago. There has been no adequate response to that report. As the former Prime Minister, Gordon Brown, has said, it is unconscionable that we should pass the Bill until we have had that response from the Government. It would be illuminating to know what the Government’s plans are on resources, not just if the amendment is passed but for care overall.

There is another responsibility on the front bench as well. Is it the case that, in the particular framing of the Bill we have in front of us, a future Government or Administration could create the service that the noble Lord, Lord Birt, wants by the simple assertion of a statutory instrument, 90 minutes’ debate, no proper vote and then, suddenly, the creation of exactly what the noble Lord, Lord Birt, wants with his assisted dying help service? It will not be good enough for Ministers once again to talk about studied neutrality and to canter through the speech that may have been written for them by diligent public servants in their own department. We need to know: if the Bill is passed, could it be the case that the service that the noble Lord, Lord Birt, wants could be created by statutory instrument without appropriate scrutiny? Because if the Bill does mean that, then what we know is that we are creating a Bill with holes, opportunities, lacunae, slippery slopes, whatever language you may wish to use—a Bill which is, in itself, unsafe.

My Lords, I am not a Whip, but I have been here all morning and I think that many of the issues have been debated at length. The questions asked by the noble Lord, Lord Gove, are very pertinent, but I suggest that it would be good to hear from the Front Benches at this stage.

My Lords, I will be brief; I want to make only one point. I am slightly surprised to be making it, because I expected others to make it during this now quite lengthy debate, although it was hinted at by my noble friend Lord Harper and the noble Baroness, Lady Fox of Buckley. It is to do with public reaction.

The noble Lord, Lord Birt, said that in Australia a very large percentage—I am afraid I have forgotten the figure—of applications for assisted dying came from people with cancer diagnoses. Last week we debated and gave a Second Reading to the Rare Cancers Bill. One of the features of rare cancers—which, collectively, are not that rare; they account for over 40% of cancer diagnoses—is that the prognosis at the time of diagnosis is so short in many cases that they would immediately be in scope for this Bill. The effect of those cancer diagnoses is absolutely catastrophic—many of us have had that experience in our families—and it creates a huge sense of anxiety. There is, first, the anxiety about how you get through the process—what does it involve?—and, secondly, the obvious anxiety of whether you will be able to start your treatment within the NHS target deadline.

If these amendments are adopted, what families will see is that, while they are left in their anxiety, those who opt for assisted dying will be given a Rolls-Royce service. They will be given a personal navigator. They will be expedited through the process and have their hand held at every stage—something that the NHS simply cannot afford to do in the case of people who are suffering from cancer and want to live. I think there will be a profound sense of injustice, and indeed revulsion, if these amendments are carried and such a service is established. What is being proposed is simply unreal. It cannot advance.

My Lords, I listened carefully to what the noble Baroness, Lady Royall, said, but I believe it is important that Members who feel they have a contribution to make are able to make that contribution without being cut short.

Forgive me. I did not realise that there were other people who wished to speak. There was a pause.

I thank the noble Baroness for that.

This has been a telling debate thus far, because we are told that some of the points are based on opinion polls. We are not an elected Chamber and therefore we do not have to be swayed by how we are to get elected next time. Therefore, it is so important that we do not make Laws on opinion polls. In fact, we have to debate the issues carefully—and trust that we are therefore making mature decisions—and seek to get the Bill right, because the issue that we are debating concerns life and death.

I have found something somewhat surprising whenever the cost has been talked about. Many people are rightly demanding an answer concerning the cost. The noble Lord, Lord Markham, mentioned it a number of times. I was in this House when he was a Minister, but he is not now answering for the Government; I believe it is important that the answer comes from the Government Minister, who should give us the up-to-date cost. For any of these issues, costs do not minimise over the years. In fact, they increase—we will find at the end of the day that the costs will escalate. We heard in the debate yesterday that the cost of the Chagos Islands will be £3.4 billion, yet it was suggested on the Opposition Benches that it will be £34 billion. I am sure Members realise that there is quite a difference between those two figures—there is a dot between £3.4 billion and £34 billion. Nevertheless, we are talking about massive sums of money. We are also talking about money that could be taken from another part of the health service, which in many parts of the country, and certainly in Northern Ireland, is crying out for money; it needs every pound it can possibly get.

I believe the Bill was defective as it came from the other House, but I also believe that what has been proposed by the noble Lord, Lord Birt, would make the Bill worse. The proposal here undermines choice even more. There is no equity of access under these amendments. What genuine choice is there if you can get an assisted death within 30 days but you have to wait months for the palliative care that you need? Palliative care is not available in many parts of the country; it is certainly not equally available right across the country.

Do the supporters of these amendments accept similar amendments that require palliative care treatment options to be made available and accessible within the same timeframe as this? They might say, “Yes, we would accept that”, but it is not a reality. There is no reality in which you will get palliative care within 30 days, because it is not available in many parts of the United Kingdom. How is it fair that terminally ill people get a personal navigator to support them through the process of getting an assisted death, but they do not get a personal navigator for gaining access to the palliative care they desperately need?

There are issues that need careful reflection. In the light of what the noble Lord, Lord Empey, said, I note the following. In our debates over the past few weeks, the noble and learned Lord, Lord Falconer, has said that he would reflect on some of the issues raised, but up to now I have not heard what that reflection has brought about in changes that need to be made to the Bill. Perhaps it would speed up the debate if we could get some knowledge about the reflections that he has had and some of the changes, in the light of the debates that have already taken place, that he will actually make in order to make the Bill more acceptable to many noble Lords.

The issue that we need to continue to reflect on is the extraordinary speed suggested by the noble Lords, Lord Birt and Lord Pannick. It undermines safeguards. Mandatory timelines force decisions without proper investigation. Panels must decide within two days of referral, even over weekends. I know of no other decisions made in the health service for which you can be promised that. There is also no judicial precedent for such haste, because courts take months for life and death decisions—yet this process is so fast.

Then we come to prognosis inaccuracy, which seems to be ignored. As I said to the noble Lord, Lord Pannick, in a previous debate, I have known people who were given a six-month prognosis but continued to live three years later. Therefore, there is no consideration of prognosis inaccuracy. Rushing assisted death risks premature deaths.

Then we come to mental health risks. Reflection periods would be cut to 24 hours. Experts warn that depression after diagnosis is often temporary and treatable. Why can patients get an assisted death in 30 days but have to wait months for palliative care? Also, the amendments erode protections rooted in law and ethics; suicide prevention remains government policy.

In conclusion, I ask the Minister these questions. How can panels make life and death decisions within 48 hours without sacrificing due process? What safeguards exist against coercion when timelines are compressed, as suggested by the noble Lords in their amendments? How will the National Health Service meet these demands when GPs and social workers are already overstretched? We had and have, in past debates and up to this moment, numerous questions, but, from the noble and learned Lord, Lord Falconer, the front bench and the Government, we have very few, if any, real answers that we can hold on to.

My Lords, I read this group of amendments with a lot of interest, in terms of whether a different way would be possible. I thank my noble friend for tabling them.

I agree with the right reverend Prelate the Bishop of Newcastle that Australia is not an accurate comparative country to look at. Actually, it makes me feel even more strongly, and the Minister will have received a letter this week from many of us asking for the impact assessment to be looked at again. One of the reasons for that is that the impact assessment looks at about the first 10 years in Oregon. If we compare data between Oregon and the state of Victoria, it took Oregon 17 years to reach the same number of deaths that was hit in the state of Victoria—not Australia, but the state of Victoria—in the first 12 months of its Bill passing.

I accept that the first voluntary aided death in Victoria was described as beautiful, but in the time that that legislation has been enacted, it has thrown up many issues. In 2023-24, there were a number of complications with intravenous injections. There were technical problems in 5% of cases. In 10% of cases, the death took longer than expected—one person took seven days. In 29 responses, the death more than two hours. In seven reported cases, it took more than six hours, and the longest was 11 hours. So, we have to be really careful about painting other jurisdictions as the sunny uplands.

There was a case reported in the Times on 22 March last year, where a man had requested the drugs to end his life. He had decided that he wanted to have longer left to live, and his wife gave him the drugs anyway, because, I presume, she decided that it was his time to go. It is a very different jurisdiction, but it again raises issues of coercion.

We also have to note with Victoria that, since its legislation has passed, elder suicide has risen by 50%. These are the things that we must take into to account when we are looking at what happens in this country.

I thank the noble and learned Lord, Lord Falconer, for arranging a meeting last year, when we were able to meet some Australian medics, but that gave me even more cause for concern, because there was a story of man who had taken a while to come to a decision to have an assisted death. The day he finally decided to have it and started taking the noxious mixture, he did not want to carry on and his family said, “But, Dad, you’ve decided to die today, you need to keep taking the mixture”. All these things worry me when we look at the speed with which these navigators might be able to push someone towards assisted suicide. In principle, a navigator sounds great, but they are only pushing people one way. We do not know enough about the training or whether, potentially, an AI bot might be used at some points. As has been raised, this could potentially just be debated in a 90-minute debate on a statutory instrument. So we have to look much more carefully at these areas. I do not think these amendments are adequate for what we want to do.

My noble friend Lord Birt raised the extremely sad case of Nick Dimbleby. But, as far as I understand, with his condition, MND, he would be not eligible for assisted suicide under the Bill. I would welcome the noble and learned Lord, Lord Falconer, confirming that.

It has been raised in different ways and on different days that our experiences of pain are very different. In other debates, we have talked about incontinence: what one person thinks is awful, another might think “I can live with it, it’s okay”. My noble friend Lord Birt talked about someone being PEG fed. Unfortunately, there is an inequality of the system in this very Chamber. My noble friend Lady Campbell is not able to respond to this group of amendments because she can only speak at the start. She cannot intervene later, so she is not able to listen to the debate and pick up points. I am sure she will be able to raise it, and I beg your Lordships’ tolerance because she might have to raise this in another group. There has been talk about being PEG fed being awful, but being PEG fed has enabled her to survive and to contribute. I worry about the inequality of this Chamber in terms of people being able to contribute properly.

Amendment 223 looks at this happening in four days. I do not believe that there is any system that will be able to, in that period of time, assess whether somebody has been coerced. Amendment 336, which says that the second assessment could happen after a period of reflection of seven days, does not even vaguely take into account the five stages of grief. There are not that many papers on people with spinal cord injuries, but one that I have read says that it can take up to seven years for a wheelchair user to get over the experience of traumatic injury. If you take that into account, people will be forced very quickly to end their life, when the ability to deal with the issue that is in front of them has not been taken into account.

Amendment 571 talks about 18 days. I do not know of any system or policy that we have in this country that gets the right support to a disabled person in 18 days. It just does not exist. We must not forget that anybody with a terminal condition, by nature of that, has a disability. If I was trying to get a new wheelchair, the absolute minimum time for accessing a wheelchair through the NHS would be 18 weeks, and that is if I or another wheelchair user had the simplest wheelchair available. A complex wheelchair could take 18 months to be provided, and I have cases in my inbox where it has taken up to three or four years for a chair to be provided.

Jumping very quickly back to Australia, a gentleman there requested to end his life because he was told that the wait for support services at home was 10 months, and he just decided that he could not live with that. These are the things that we must take into account.

I agree with the noble Lord, Lord Gove, about polling. I am sure noble Lords will be very grateful that I have crossed out pages on polling that I was going to quote. It shows that there is a lack of understanding of what assisted suicide actually means. A lot of people do not understand that you can refuse disease-modifying treatment but still receive palliative care. In terms of education, there is so much more we need to do to educate people about the services they can currently access.

Finally, a report came out from the Commons Library on 8 January 2025. This was about addressing the speed at which the navigator might push somebody through. It looked at the data of 300 patients who were referred to hospice care in London for palliative care. Some 33 of those, 11%, had a very strong desire to hasten their death, but, after four weeks of hospice care, a quarter no longer desired a hastened death. The amendments in front of us would not give any time to allow a person to absorb any information to be able to clearly make that decision. I do not think that, in its current format, this would be an addition to the Bill.

We hear a lot about the Bill being enforceable and workable. We have been told it is the safest Bill in the world. I would like the noble and learned Lord to commit to making the Bill safe, not just safer.

My Lords, this has been a long and comprehensive debate, and a number of points have been raised. I will try not to hasten it—

Noble Lords:

Oh!

Sorry, I will try to hasten it, actually, in many ways. Maybe we should slow down.

I start by thanking the noble Lord, Lord Birt, for the amendments in the group and the whole idea of establishing the assisted dying help service. As the noble Lord said, it is based on well-established experience. It seeks to address a number of important questions that the current draft of the Bill does not address. How will important services, such as care for the families of those who are seeking assistance under the Bill, be provided? Who will publish the appropriate information about the provisions of the Bill in the public domain? How will those seeking assistance be supported throughout the process? These are thoughtful amendments, but a number of noble Lords have quite rightly raised concerns about the potential downside to speed and efficiency in this case.

The amendments in the name of my noble friend Lord Mackinlay seek to ensure that when a personal navigator is allocated to the person seeking assistance—that sounds like a good suggestion—there must not be a presumption that, when they appoint that navigator, the person will necessarily continue with the process to its end. That gives the person who seeks it the option of changing their mind.

A number of the issues that we have discussed today have been discussed throughout the passage of the Bill. I have a number of questions; they are more for the Minister than the Bill’s sponsor, but I think that many noble Lords have questions for the Minister.

On the specific matter of the assisted dying help service, as well as the duty to publish information on the Act’s provisions, what consideration have the Government given to the interaction between the legitimate dissemination of information about assistance with ending one’s life and the encouragement of suicide, as prohibited by law under the Suicide Act 1961? I know that this issue came up very early on but, in this specific context, it is worth repeating.

A number of noble Lords have rightly asked about the workability of the help service, including what the cost of managing the service and the other running costs might be. Do Ministers feel that resourcing the service adequately might undermine the effective delivery of other parts of government? As a number of noble Lords have said, the Government have not really answered those questions about the available resources and where the money will come from. Once again, I am taken back to Second Reading, when the noble Lords, Lord Stevens and Lord Hunt of Kings Heath—the latter being a former Health Minister—both said, “We know how the system works. This money will come from somewhere, and it will be at the expense of palliative care”. We are assured by those who support the Bill that that will not be the case; indeed, Ministers have themselves said that sufficient money will be made available. However, a couple of weeks ago, I asked almost the same question as my noble friend Lord Deben asked—albeit in a less eloquent way—of the Minister from the Ministry of Justice, and, last week, of the Minister from the Department of Health. To be fair to the Government, I received an answer from the Minister; if noble Lords allow me, I will touch on a few extracts from that letter and paraphrase where possible. The Minister’s letter to me said

“you sought confirmation that the Government is confident that palliative care will be sufficiently funded, so that those who may seek assisted dying services are offered a real, as opposed to theoretical, choice on palliative care to support them making a more informed decision”.

So far, so good. As my noble friend Lord Gove said, the letter talks about support for the hospice sector, including £100 million for adults and £80 million for children—I almost sound like a Minister responding here, I know, but we have to be fair when we challenge the Government on this. The Minister also mentioned the all-age palliative care and end-of-life care modern service framework for England to improve the services. The noble Baroness, Lady Berger, said that it would be published in spring 2026, but the letter says that it will be published in autumn 2026—I think the Minister answered that; let us be fair: that is better than the answers that many Ministers from all parties have given over the years, where they often say “at pace” or—what is the other phrase?—“in due course”, but at least this gives us a real timeframe. The Minister also talked about the framework being aligned with the ambitions of the 10-year plan.

On that point, I also got a copy of that letter. It is worth saying that, in the 10-year plan, there is no ambition for high-quality, universal palliative care. It is not there. So, if the plan the Government are going to publish in the autumn is aligned with it, I think we can see that they do not plan on making universal, high-quality palliative care available in the next 10 years. That is a real problem for decisions taken under this Bill.

I thank my noble friend for that Intervention. Before commenting on the content of the Bill, I was seeking, just to be fair to the Government, to lay out what they have told me.

May I pursue the important point that the noble Lord is making? The Minister for Care, Stephen Kinnock, was before a Commons Select Committee on this very point that the noble Lord, Lord Harper, has discussed. He declined to give any commitments about the content of the modern service framework for palliative care and declined to say that resources would be made available to fill the gap; the only specific commitment he gave was that a new 24/7 phone number would perhaps be put in place in 2027, I believe.

I thank the noble Lord for that Intervention, as well. It reinforces the points I am going to come to—if that makes sense.

The Minister, the noble Baroness, Lady Merron, ends the letter by saying:

“Through these actions … we hope to ensure sustainable funding for palliative care and end-of-life care sector in the long term”.

This is the Government’s stated intention. The next bit says:

“I hope this letter has provided clarification on the queries you raised”.

I will let noble Lords be the judge of whether it provides clarification. To be fair, the Minister copied the letter to all Peers who tabled amendments, as my noble friend Lord Harper said, and put a copy in the Library. I urge all noble Lords to read that letter to see whether they believe that it provides the clarification that many are seeking. If we feel that it does not, we should come back to this point in future weeks and raise these issues with the Government again.

I hope the Minister, the noble Baroness, Lady Blake, will take that on board when she answers. If she does not have the answer to many of these questions, we should wait for other noble Lords to read that letter, then maybe raise the questions again and ask whichever noble Baroness is on duty as the Minister in future weeks to answer questions on areas where we still believe there are gaps.

I am grateful to the noble Lord for referring to that letter and quoting the amounts of money in it. Does he recognise that that is one-off and not recurring funding, and there is no intention for funding to increase as cost of living and so on increase, and to meet the gaps in services that we have been talking about?

I have to be very careful because I am not answering for the Government; I am just trying to reflect that letter. However, the Minister did make it clear that the children’s hospice funding is over the next three years and that it will account for £80 million in total. We all know how Governments work, and I not sure that any Government could give a commitment beyond three or four years or beyond another election. To be fair to the Government, I believe that they have answered the question about how much resource they will be allocating. It is up to noble Lords to decide whether they believe that that is sufficient, but if, whichever side of the debate they are on, they feel that the Government have not answered those questions, it is up to them to come back in future weeks and press the Minister on duty.

I thank noble Lords for their thoughtful comments, particularly those on the amendments proposing an assisted dying help service and a minimum timeline for the assisted dying process. I thank the noble Lords, Lord Birt and Lord Mackinlay, and the noble Baroness, Lady Coffey, for their amendments in this group.

I also thank the noble Lord, Lord Kamall, for his helpful comments on the detailed letter that has been sent to noble Lords. I hope that noble Lords can therefore accept that that is in train and that they will refer to the letter. Of course, there will be other opportunities to come back on particular details if required.

The amendments tabled by the noble Lord, Lord Birt, aim to set up a new statutory body entitled the assisted dying help service, which would be part of the National Health Service. From a workability perspective, these amendments would create many new concepts and relationships that would conflict with the current provisions of the Bill. I note that considerable further policy development and legal drafting would be required to create a workable system should noble Lords support these amendments.

Amendments 287A and 287B tabled by the noble Baroness, Lady Coffey, would create a new role for the General Medical Council—GMC—to set the requirements for training, qualifications and experience, and introduce new licensing, for assisted dying. Although the GMC has a function to set standards for doctors and recognise specialisms, it does not set requirements for training and qualifications for specific services, or license doctors to provide them. This would be a significant departure from the way that the GMC operates and would require it to identify a new process to identify the doctors on this register who are licensed to provide this service.

I refer to the noble Baroness’s request for a view on an assessment of how publicly available information works with the prohibition of advertising. The Bill, as currently drafted, requires the Secretary of State to make regulations to prohibit advertising and that those regulations may contain exceptions. The provisions on providing information publicly, as mentioned by the noble Baroness, would need to be considered as part of the work on developing the prohibitions of advertising.

Amendment 771ZB, also in the name of the noble Baroness, Lady Coffey, seeks to make the Care Quality Commission—CQC—the regulator of the assisted dying help service. Requiring the CQC to regulate such a service would result in an extension of its remit.

On the group of amendments on a minimum timeline for the assisted dying process, the Government are unable to confirm that this specific timetable is either clinically appropriate or operationally deliverable. The Government have not undertaken detailed design work on an existing dying service model, as we do not wish to pre-empt Parliament’s decision on this legislation.

My Lords, we have asked the Minister on several occasions to give us the information that I think the Government still need to give us: what is the cost of doing these things? The letter does not meet that. She has just said that there would be difficulties, but we want to know the cost in detail, because it is for the Government to help the Committee to make decisions. Could she please say now, and, if not now, give the undertaking that she will investigate the cost, so we know how to make a decision?

My Lords, I was just about to go on to the whole issue of funding, which many noble Lords have raised throughout this morning’s debate. The Government’s position is absolutely clear on this. Should Parliament pass the Bill, the Government would work to undertake development of the delivery model. Until the parliamentary process is complete, we are making no assumptions as to what the delivery model for an assisted dying service would be or what the role of specific departments in delivering the service would be.

My Lords, may I ask the Minister something that I do not think is an operational decision but a decision in principle, as mentioned by the noble Lord, Lord Stevens, and does not require the Government to take a view on whether they support assisted suicide or not? Is it the Government’s view—do they agree with the noble Lord, Lord Stevens—that we would have to change the founding principle underpinning the National Health Service to put this service in the NHS? If they agree with him, is that something the Government support? The Government can remain neutral on the principle of assisted suicide, but I want to know whether they think it should be inside the NHS or not.

My Lords, I am very aware of the repeated requests and comments. I come back again to the point that we have been making throughout the debates on these amendments, and throughout the process: until the parliamentary process is complete, we are making no assumptions as to what the delivery model will be. That is absolutely clear and straightforward, and has been emphasised by other Ministers before me.

My Lords, I do not want to unfairly ascribe views to the Minister on behalf of the Government, but, just so I understand this, is she saying that the Labour Government do not have a view at all on whether we should change the founding principles of the National Health Service away from it being one that delivers medical treatment to save lives to one that also helps people to die? Is she really saying that they do not have a view?

I am saying that, at this point, the Government are neutral on the whole area.

That is extraordinary.

I do not think it is extraordinary, but I am sure the noble Lord will keep expressing his point of view.

The Government can perfectly well say that they do not have a view on this, but, for Parliament to make a decision, surely they have to tell us whether, if we made this decision, they would have to change the basic principles of the National Health Service. That is the only question that we must ask. The Government must be able to tell us whether, if we make this decision, that is inevitable.

I am sure that the noble Lord and others will find other ways of asking the same question. I refer to my earlier answer.

I honestly believe that noble Lords are asking this question in good faith. I reiterate to the Minister—maybe she can think about this and come back—that we are being asked to make a decision about a huge change in healthcare provision, staffing and money, and the nature of what the NHS is. We are not trying to catch the Government out. We simply want to understand. Nobody could vote for this—even if you supported it, you could not vote for it. Can the Government please tell us, even if not now, what the implications will be if we vote for the Bill?

The Labour Government would say that the NHS is the most important, precious jewel in the crown, that nothing should damage it, and that we had to sacrifice an awful lot to save it only recently. I do not then want to vote for a Bill that is going to upturn the nature of the NHS inadvertently because the Government say they are neutral and cannot tell us otherwise. That is a big risk—risking the NHS, so that they do not have to answer. Even if the Minister cannot answer, we have to have that question answered; otherwise, we cannot seriously be asked to vote for the Bill.

I repeat that I am happy to write to noble Lords further on this point. I do not think that Members are going to move away from this point, so I am very happy to do that.

The noble Lord, Lord Gove, asked whether the assisted dying help service could be set up through statutory instrument, and I am happy to write to him to clarify that point. I will write to the noble Baroness, Lady Finlay, on the point of the constitution. That is the most straightforward way to deal with this.

With the undertaking that the Government will write on the points that have not been addressed, I hope noble Lords will understand that, on the areas that I have not raised, we cannot confirm that the amendments are workable. That is the point I must make. With those comments, I hope that the noble Lord will withdraw his Amendment.

I thank everybody who has contributed to this debate, in particular my noble friend Lady Blake, who ended up caught up in the eye of a storm that was not of her own making. I very much sympathise with her. I thank the noble Lord, Lord Kamall, for his mature and helpful interventions.

The amendments from the noble Lord, Lord Birt, would, as he said, effectively do three things. First, they would introduce a new organisation called the assisted dying help service that would be responsible for providing both the judgment and the navigation through the process of assisted dying. Secondly, they would give the assisted dying help service specific power and a timeline that is much shorter and more flexible than the one in the existing Bill. Thirdly, the noble Lord insisted that the commissioner not give guidance, provide leadership, collect information and make assessments as to what is going on. Instead, the commissioner would be solely a regulator, without monitoring and other functions.

As I have indicated, I do not support those amendments. In relation to the key point, the safeguards in the Bill at the moment, as the noble Lord indicated, consist of three doctors, including the preliminary doctor, the panel, the periods of reflection and the doctor who gives the assistance at the end having to be satisfied that all the requirements are still in place and operative. That structure is the one we support, and we stick by it, because we think it provides a safeguard. We are not in favour of changing that.

Separately, in relation to the assisted dying help service, I am strongly in favour of the basic principle outlined by Stephen Kinnock, when he gave evidence to the Lords Committee, and of the points made by the noble Lord, Lord Markham, and my noble friend Lady Blake. The Bill gives the Secretary of State the power to determine how it should be delivered. I accept that Clause 41, which was criticised by the deregulation committee in this House for being too vague, needs more detail. I said that I would come forward with more detail, so let me indicate what sort of detail, because people have indicated that they want that. I particularly isolate the noble Lord, Lord Goodman, whose speech was effective in that respect.

It will name as the possible commissioners ICBs, the National Health Service England—which I appreciate is itself in a terminal condition and will shortly be abolished, but it has to be kept there—or the Secretary of State. Picking up the regulation point, it will specify that the services will have to be regulated by either NHSE or the CQC. It will specifically impose duties that currently reside with the NHS commissioners on the people who can make the commission. It will indicate the principles that the Secretary of State has to provide in doing the commissioning and it will limit the Henry VIII power in Clause 41(6), which is currently very wide and, as the deregulation committee said, needs to be limited. We will make considerable progress on that. I apologise for that not being available at the moment, but there are a number of amendments to be dealt with. I hope that is helpful. That deals with the essence of the points that have been made.

The points made by the noble Lord, Lord Harper, and the noble Baroness, Lady Coffey, were in effect about the problems with the Amendment from the noble Lord, Lord Birt. Because I do not support that amendment, it would be otiose and time wasting for me to go through them.

I will deal with two other points: how much it is going to cost and where it is going to come from. There is an impact assessment that, as the noble Lord, Lord Markham, said, suggests that in year 10 the annual cost will be something under £30 million. It is ridiculous to suggest where that money is going to come from in 10 years. The noble Lord, Lord Deben, says that we need to know where the money is going to come from and how much it is going to cost.

The noble Baroness, Lady Grey-Thompson, says that maybe the money will come from somewhere else. The noble Baroness criticises the impact assessment because she says it is based on Oregon, not on greater experience. If the Government take the view that they cannot rely on the impact assessment for the points that she makes—it is not a promoter view; it is a government view—then no doubt the Government will have to make a decision about whether they need a new impact assessment. For my part, the impact assessment looks careful and rigorous. When we make the decision about assisted dying, we know how much it will cost on the basis of the impact assessment. We have to make a decision as a Parliament as to whether, in the light of that cost, we think it should go ahead. It is true to say that it is a very small part—a tiny part—of the total budget for the NHS.

Secondly, the question was asked repeatedly of my noble friend Lady Blake as to whether this is contrary to the founding principles of the NHS. I assume that question is not, as it were, a broad question of principle but a reference to the National Health Service Act 2006 and whether it is in breach of Section 1, which broadly—I preface here—says that the purpose of the NHS is to provide medical care.

For my part, providing somebody with an assisted death, if properly safeguarded, is providing them with a good death if that is what they want. I certainly regard that as a part of what the National Health Service should be doing, which is providing people with the best death that they can have. For example, where somebody suffering from MND wants their artificial respiration to be removed, that is not a question of double effect; everybody knows that will have the effect of almost certainly bringing that person’s life to an end. That can, if that is what the person wants, provide the best death for that person.

On the broad principle, I take the view that an assisted death is well within the founding principles of the NHS. There is a separate legal question, which I do not think is really the question that the noble Lord, Lord Stevens, is raising, but it needs to be addressed: does that require some amendment to Section 1 of the NHS Act? That is a strict legal question; government lawyers have to answer that one.

On that very point, the noble and learned Lord’s Bill, at Clause 41(4), does indeed propose that an interpretation will be imposed on Section 1(1) of the 2006 Act, suggesting that he thinks there is some ambiguity on that point. As to the question about withdrawing care from an MND patient, surely the distinction between an act and an omission—the ability for somebody to choose to decline treatment—is a well-understood principle that has no bearing on the question of an assisted death.

They are fundamentally different, but the idea that removing the respiratory equipment does not involve some acts is not realistic. But I completely accept the proposition that they are different. On the legal point, there is some ambiguity about what the section means and whether it needs to be changed, but I am making it absolutely clear that, from my point of view and that of the promoters of the Bill, it is most certainly not outside the broader founding principles of the NHS.

I accept that very much from the noble and learned Lord. The question I asked, because I think it important, is for the Government to say what the legal situation is, which they have a duty to tell us before we can make the decision. I entirely accept what the noble and learned Lord said about his own position, but this is a question for the Government, if they are independent of this. They have a duty to provide information to the House before we can make these decisions.

The broader question of whether this contributes to healthcare is for each of us to make our own judgment about. If noble Lords take the view—I am talking not about the legal issue but the broader issue—that this is wrong and contrary to the basic founding principles of the NHS, they can vote against the Bill. But if Parliament passes the Bill and says, “We are happy that that is the position”, it is saying that it is an acceptable part of healthcare.

The noble and learned Lord really must accept that there is a problem with this being a Private Member’s Bill. He can say what he likes about the Bill, and I acknowledge and accept his absolute honesty about it, but the Government have the role of informing the House. Indeed, they do it: every time we have a debate, the Minister gets up and says that this or that would be difficult or awkward, or would be contrary to the European Court of Human Rights. I am only asking that they do that job on this. Is what is being proposed contrary to the founding position? Would the law have to be changed? It is up to the Government to tell us. We can then decide whether that matters.

It is for Parliament to decide whether it is willing to pass the Bill. If Parliament is willing to pass the Bill, there may be the need for the legal change that the noble Lord, Lord Stevens, referred to. Whether or not you are willing to make the change is, for the reason I have said, a matter of what you think is the principle. Those are the only remarks that I need to make in relation to that, and I invite the noble Lord to withdraw his Amendment.

There will later be a group of amendments that relate to freedom of conscience. The noble and learned Lord has outlined another group of people in response to solving the issue from the Delegated Powers Committee around commissioners and NHS England. At this stage, in an effort to use our time efficiently, will he think about how wide the conscience Clause will need to be to include people who have objections to this—it is not just clinicians; it may be those who do not want to be involved in commissioning these services—so that we do not end up with a huge group later in Committee?

I will certainly think about it. I am not quite sure what the noble Baroness is asking, but whatever it is, I will try to co-operate as much as possible.

The noble and learned Lord made it clear that he felt that there needed to be further clarity in the Bill following the point made by my noble friend Lord Goodman about who would eventually provide the service. Is it the case that he believes that the Bill, as written currently, would allow the Government to create an assisted dying help service by means of statutory instrument?

I expect that it would not, but I cannot give a definitive view in relation to that. The reason I responded to the noble Lord, Lord Goodman, in the way that I did is because I have already committed myself, in the light of the Delegated Powers Committee’s report, to limit the scope of Clause 41.

I am very grateful. I note that the noble and learned Lord says he suspects that it would not. It might be of assistance, certainly to me if to no one else, if he, and indeed the Minister, could let me know, with greater clarity, whether or not my concerns can be addressed with a greater degree of certainty.

I will certainly try to provide that co-operation.

My Lords, I will try not to keep us too long from our lunch. This has been a lively and helpful debate, and I think it has exposed a fair number of critical issues that are yet to be resolved.

My past has caught up with me in this debate. How many people here knew that I used to be the boss of the noble Lord, Lord Gove? It was not my fault. He was a genuinely distinguished young BBC journalist, in all seriousness, and hugely admired by his colleagues. The debate has also revealed that the noble Baroness, Lady Coffey, and I went to the same north Liverpool grammar school, so anybody who objects to anything that she or I put forward can blame the Irish Christian Brothers.

I cannot possibly deal in any detail—and noble Lords would not want me to—with the many points raised over the past three hours. I approached the construction of these amendments, with the noble Lord, Lord Pannick, with a truly open mind, and I retain an open mind. The Chief Whip often tells us that his door is always open. My door is always open—not that there is one, because I do not have a proper office—and I am completely open to discussing any issue that has been raised. I am sure that the noble Lord, Lord Pannick, and I will wish to return to these matters when we come to Report.

I will just say a few things now. I approached the Australian practitioners with a completely open mind. I was in favour of assisted dying but I wanted to understand what real-life experience was like. I am very data-driven, as the noble Lord, Lord Markham, has often pointed out, and wanted to immerse myself in the Australian data. It was my learning, and then discussions with the noble Lord, Lord Pannick, that caused us to frame our amendments in the way we did.

The central thing that emerged from those discussions, which has been lost in our debate so far, is that, actually, people are not coming forward. They already have palliative care. Their pain is more or less controlled. The central point that the Australian practitioners wanted to get across to me, over and again, was that this is about misery, and people running out of time and wanting to end their life. Hence the key Australian data I shared was that, roughly speaking, 25% of people who come forward for assisted death die within nine days.

That is why I told the Committee about the Nicholas Dimbleby experience, because I thought that was indicative of the kind of people who want it. It is at the end of a very painful, prolonged process of suffering that people want an expeditious end. That is why the noble Lord, Lord Pannick, and I have sought to retain the process that is in the Bill but tried to make it more flexible, to deal with what can be genuine emergencies. And it is an emergency. There is a part of the National Health Service that deals with emergencies on Christmas Day—it is called A&E. We are talking about a service that will deal with genuine emergencies.

My apologies for intervening, but my noble friend mentioned the number of people who access palliative care. The state of New South Wales promised £743 million in extra funding for palliative care over a five-year period, but, when the law was passed, it cut that funding by £150 million and diverted money to assisted suicide. Does my noble friend accept that, although he says people are getting palliative care, big promises are being made and then ripped away from people? It limits the choice they have, because there is not as much palliative care support as they originally thought. There is a feeling that that was promised just to get the Bill across the line.

The one issue that unites the whole Committee is that we have to have an effective service of palliative care in this country. The data in Australia, which varies from state to state, tells us that somewhere between 70% and 90% of people who come forward already have palliative care.

The noble Baroness, Lady Fox, talked about navigation. It is a complex process, even in the Bill as it stands. If you analyse the likelihood, you will find that it will probably take, without the right process involved, 30 to 60 days, which is completely inappropriate in the context of the Australia experience. By the way, the navigator is an administrative role to help the person manage a complex system with multiple practitioners, who themselves have real authority.

To clarify, I am sure the noble Lord knows people who have tried to get a hip replacement or a wide range of other medical treatments. It is the most complex process that you could ever go through. Many people are vulnerable and could do with a navigator. Does he understand the two-tier nature of appointing a navigator in one instance and not in another? This follows on from the earlier question from the noble Lord, Lord Moylan. Can the noble Lord see that anything that seems to give preferential treatment to those seeking assisted dying over those who are suffering pain from a bad hip or who have a rare cancer and are terminally ill would cause political problems? Immorality might be part of the issue there.

Believe it or not, I have had cause, at various times in my life, to navigate the NHS, as probably everybody in this Committee has, and of course it is very difficult. However, when you go into A&E, you effectively do have a navigator. I do not think this is about the hip operation example; it is about people in a genuine emergency situation.

I have been to A&E many times, particularly with my son, and I have never had a navigator. How does one have a navigator in A&E?

I am sorry; perhaps the noble Baroness can talk to me later, as I could not take in what she said.

I am, frankly, open-minded about the NHS question and accept the strength of what the noble Lord, Lord Stevens, says. It may well be that this is an organisation that should be apart from the NHS but uses some of its services. However, I am happy to talk to others about how best to do that.

I reassure the noble Lord, Lord Harper, that the process can, and should, be designed not only to support assisted dying but to painstakingly explore the alternatives to assisted dying, and I did say this. We suggest that palliative care should be one of those services and, whatever the reasons that people have for assisted dying—there may be others beside their chronic near-death state of mind—we also propose that the organisational body should be able to help the person in other sorts of ways. We want it to be a balanced process.

I am grateful to the noble Lord for taking my question at this stage of the debate. I listened very carefully to him when he was setting out his proposals and I welcome the fact that he said that the navigator can discuss palliative care and such issues with the person concerned. Unless I misunderstand his amendments, they do not propose to help secure those services for the person. They might set out what they are, but they do not get them, so there is an imbalance there. They will help them get the assisted suicide but not proper palliative care.

I do not think it for us, in framing in principle amendments, to deal with that level of issue, but the noble Lord is right—that is exactly what the body should do. We are talking about highly distressed people, and it should facilitate different kinds of response and reaction to their difficulty.

If I heard the noble Lord correctly, he said that anyone going to A&E gets a navigator. He was challenged by the noble Baroness, Lady O’Loan, but he did not hear her question. She said that she never experienced that in her life and neither have I. If any noble Lord has, I would be grateful to hear it. If you go to St Thomas’, the first people you meet are two security guards who are there to keep people out.

Plainly, the NHS is a very large organisation and it offers a variety of different kinds of experience. I hope none of us uses A&E very often but, like everybody else, I have used it and, in my experience, I have found it very efficient indeed at handling everything.

As I have said already, there are many issues and if anybody wants to talk to me and the noble Lord, Lord Pannick, about them, please do. I end with a very simple point, and I address this particularly to the noble and learned Lord, Lord Falconer. I am utterly convinced that this needs a proper organisational framework. You cannot throw this complexity of issues at the National Health Service. It also needs a more flexible process than currently exists to deal with the complexity that I have outlined, which comes out of the Australian experience. Both those things need to be in the Bill, and the noble Lord, Lord Pannick, and I will be returning to these issues on Report with, I hope, as much help from across the Chamber as possible. In the meantime, I beg leave to withdraw the Amendment.

Amendment 35 withdrawn.

Amendments 36 to 39 not moved.

Sitting suspended. Committee to begin again not before 2.15 pm.