Rebecca Paul MP: speeches

Speeches

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I wholeheartedly agree. There is much to discuss today and there is little time, so I will start at the beginning of the Bill, at the point at which the criteria for eligibility for an assisted death are set. It is there that important safeguards are needed to ensure that those who should never be eligible are excluded. We should not make the mistake of assuming that a doctor will always make the right decision or that they are infallible. It is incumbent on us to put in place law that makes it harder for them to get it wrong—that makes it harder for someone vulnerable to fall between the cracks.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I am sorry, but I do not have much time and I wish to get through my points. How can we be happy with a process that does not exclude such reasons? Instead of providing the support that is actually needed, the state is content to put them on a pathway that leads to their death. I hope that the House will recognise that, whether one supports assisted dying in principle or not, it is morally bankrupt not to have some kind of best interests test to protect those who are not seeking death to alleviate pain from a terminal illness. Another group that is particularly vulnerable is those with eating disorders. In Chelsea Roff’s oral evidence, she set out that “at least 60 people around the world have been euthanised or assisted in suicide” with “anorexia nervosa listed by name as a terminal condition.” ––[ Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 29 January 2025; c. 139, Q175.] To paraphrase her, these were young women who were not terminally ill and had decades of life ahead of them. It is important to make the point that someone suffering—

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I will therefore speak to my new clauses 17 and 18, which would provide important protections for hospices, which are currently lacking in the Bill. New clause 18 makes it crystal clear that any regulated care home or hospice can decide whether to provide assisted dying on its premises, and new clause 17 makes it clear that they cannot be subject to any detriment for not providing or permitting assisted deaths, and that their public funding cannot be conditional on their providing this service. Whether one is in favour of assisted dying or not, we must preserve the rights of organisations, companies and charities to choose whether to offer it. They must never be forced into it by public funding being conditional on the provision of assisted dying. I note that new clause 10, tabled by the hon. Member for Spen Valley (Kim Leadbeater), would expand the protection for individuals not to participate in the assisted dying process if they so wish. It seeks to protect employees from being subjected to any detriment for participating or not participating in the provision of assisted dying. This sensible protection would ensure that if an NHS hospital provides an assisted death service, any member of staff who does not want to participate would not have to do so and would suffer no detriment as a result. However, there needs to be a sensible mechanism balancing that against the employer’s right to set their own policy on assisted dying, and that is what my amendment (a) to new clause 10 seeks to do—we have already talked about that, so I will not go over it again. I did want to talk about process and family, but it looks like I will not have time to do that. I will end there. I thank you for your patience and generosity, Mr Speaker. I am grateful that I have had the chance to speak in support of the amendments, and I look forward to hearing from other Members.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I agree, and I will come to that point in more detail in the second half of my speech.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I would love to give way, but—

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  It is a privilege to speak in this place on such an important Bill. Having been part of the Committee that scrutinised it line by line, and, on some occasions, word by word, for several months earlier this year, it is a pleasure to see so many of my colleagues from Committee Room 10 present today—a reunion of sorts. I am here, as always, with the intention of improving the Bill, so that if it does indeed pass, vulnerable people are as protected as they can possibly be from unintended consequences. It is important to remember that on Report and Third Reading we are not voting on whether we agree with the principle of assisting someone to end their own life. Our role is to vote on the law in front of us—on whether the words on the page are clear and do what is intended, on whether the statutory process is safe, and ultimately on whether the provision of assisted dying benefits our community. I am not against assisted dying in principle, but I am against this Bill. I am happy to put it on the record now that I have no personal religious beliefs; I am against the Bill for the simple reason that it will harm far more people than it will help. The people who will be harmed are the most vulnerable in our communities, and I am not willing to accept that collateral damage. Today is important, because we have the opportunity to improve the safeguards in the Bill so that some of those groups are better protected. I urge Members to take that opportunity to the full. It requires very little skill to draft law that works for 90% of cases, but there is much skill in ensuring that the other 10% is catered for as well. I urge everyone to set the highest standards today and think about how we can ensure that those unordinary and unexpected cases are adequately protected, too. It really is life and death, so please do not accept anything that is not good enough.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  The evidence is clear that palliative care does not get better when assisted dying is introduced; we heard that in the Bill Committee. We should absolutely look to address palliative care, because that will benefit more people. I will come to that point later in my speech, so I will not discuss it any further now. I do not want to get ahead of myself. There are many helpful amendments in this vein—namely, new clause 16, new clause 9 and amendments 80, 14, 38, 81, 24, 30 and 31. In simple terms, they seek to tighten and refine the eligibility criteria for an assisted death by setting out when and for what reasons an assisted death should be allowed, and by ensuring that those who are vulnerable are protected from something that may not be in their best interests. Interestingly, on Second Reading the argument put forward for assisted death was that those who are dying should be spared unbearable pain. This is an argument that everyone understands and has full sympathy with. No one in this place wants people to endure pain as they come to the end of their life; I certainly would not want that for my loved ones or indeed for myself when my time comes. But then the arguments being put forward changed. There was less emphasis on pain, and more on choice and autonomy. The word “autonomy” came up again and again in Committee—and autonomy is important, of course, but up to a point. From a proposal to provide a humane end to someone’s pain when it cannot be relieved in the last months of their life, we have moved to a proposal to provide an assisted death service to those who choose it for any reason, even if the pain can be alleviated by palliative care. This approach, however, comes with a cost to others: family, clinicians and broader society. This really is momentous. There is no going back from such a massive shift. A move to autonomy trumping everything else changes everything.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  The key point is that we need to improve palliative care. We are spending so much time and effort focusing on this Bill rather than doing the thing that would actually help more people. My amendment 80, in combination with amendments 30 and 31 tabled by my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer), would drive significant improvements to palliative and end-of-life care, getting us closer to consistent and universally available care for all.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I completely concur.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I apologise, but I do want to get through my speech. It is important to make the point that someone suffering with anorexia, or indeed any mental condition, is not intended to be eligible for an assisted death. However, in the case of anorexia there are physical manifestations of the illness, such as malnutrition and diabetes, that might mean the patient meets the definition of being terminally ill, and that is the nub of the problem: the Bill does not adequately rule out physical manifestations caused by mental illness. That is why amendment 14, tabled by the hon. Member for Bradford West (Naz Shah), is so important, because it would ensure that anyone who voluntarily stops eating or drinking is ineligible for assisted dying. I support the amendment strongly as it addresses a big risk. Lastly, on eligibility specifically, I want to talk about capacity. There are such problems with the current approach to determining capacity that I barely know where to start. When it comes to ending one’s own life, a higher standard should be applied. The current definition of capacity was not created with such a monumental decision in mind, and if it were being drafted from scratch today, it would look very different. That is one of the reasons why the Royal College of Psychiatrists does not support the Bill. Under the Bill, a person is assumed to have capacity in the first instance. A clinician only needs to be over 50% sure that a person has capacity. If the person is making unwise decisions, that is not taken into account, and a person can be “helped” to make a decision—for example, when a patient has learning disabilities. I ask all Members today whether they are happy with that. Does that sound like a robust approach to assessing whether someone has capacity to make the decision to end their own life? Let us begin with the starting presumption of capacity. That, too, lacks the standard for assisted death decisions. I therefore support amendment 24, tabled by the hon. Member for Bexleyheath and Crayford (Daniel Francis), which would disapply section 1(2) of the Mental Capacity Act 2005 for the purposes of assisted dying. One of the biggest issues for me is the fact that the current approach requires an impairment or disturbance of the brain in order for someone to be considered not to have capacity, irrespective of whether they can make a decision. In the real world, that would mean a doctor could assess a patient who gives the impression of being confused, illogical, erratic, inconsistent—everything about them could scream that they are not in a good place to make this decision at that point in time—but they would still be considered to have capacity if there is no identifiable impairment or disturbance of their mind or brain. That could potentially put those with depression, anxiety, learning disabilities or eating disorders, or even those just experiencing physical pain that is driving them to distraction, in danger of being considered to have capacity when they do not. So far I have focused on eligibility. I will now talk about hospices.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  My hon. Friend makes a good point, and I agree. In the interests of time, I will make some progress. The current situation, whereby fully funded palliative and end-of-life care is not available in certain postcodes, means that those unfortunate patients do not have a real choice. We know that 25% of people who die in this country do not get the palliative care they need—that is more than 100,000 people a year—and if the Bill goes through, they will be offered a fully funded assisted death as the only reliable way to end their pain. That is no choice. I urge Members who want to see improvements in palliative and end-of-life care to vote for my amendment 80, and for amendments 30 and 31, tabled by my hon. Friend the Member for Runnymede and Weybridge, if they are pushed to a vote.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I thank my right hon. Friend for making that point; he is absolutely right. I have tabled amendment 80, which would bring the Bill back to its original intentions. It would require that in order to be eligible for an assisted death, the pain and discomfort experienced or expected from a person’s terminal illness could not be reasonably relieved to their satisfaction through palliative care. It seeks to limit assisted death to the very small group of people who may benefit from it, not the larger group who just need adequate palliative care to give them the comfortable, dignified death they deserve.

• 16 May 2025 · Terminally Ill Adults (End of Life) Bill · Hansard source

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  I will not because I do not have much time. I will move on to the lack of a best interests test in the Bill, which my new clause 16 seeks to remedy. Patient autonomy is of course important, but it must be balanced against what is in someone’s best interests. In certain situations, when it is in their best interests, treatment can be given against a patient’s will—for example, force-feeding a young girl with anorexia. It is not an easy balance to get right, but in the absence of any best interests test in the Bill, following the process rigidly would lead to devastating results in some cases. The Bill currently prioritises autonomy of the patient in a specific moment of time, rather than what might be in their best interests in the long run. It makes no allowance for the fact that someone may feel a certain way temporarily due to other considerations. For example, when someone has just received a terminal diagnosis, it can understandably cause a depressive state and suicidal feelings, but those feelings do not necessarily last, so it may be in the best interests of the patient to allow a little time to pass, to give them a little breathing space before considering the assisted death route. New clause 16 essentially tries to provide a best interests test by excluding certain reasons, other than the alleviation of pain, that might be driving a patient’s decision. For example, we have heard a great deal about the internal pressure from patients themselves that is driven by their concern not to be a burden, and we heard clearly in Committee that a patient could tell a doctor that they are want an assisted death only for financial reasons, and that would still be approved. We know from the experience of overseas territories that patients will often opt for an assisted death because of social and welfare issues, such as being homeless.

• 30 Apr 2025 · Gender Incongruence: Puberty Suppressing Hormones · Hansard source

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  I beg to move, That this House has considered the potential impact of puberty suppressing hormones on children and young people with gender incongruence. It is a pleasure to serve under your chairmanship, Ms Lewell. I am pleased to have the opportunity to shine a light on this important topic, one that impacts the health and wellbeing of some of the most vulnerable children in our country. This debate must be led by science, data and evidence, not by ideology, bias or belief. I will do my best to do that today. The number of children and young people presenting to the UK NHS with gender distress has increased year on year since 2009, with an exponential rise in 2014. What is behind the increase among Generation Z is unclear and the reasons are likely to be multifaceted. It is speculated that the factors may include 24/7 internet access, increased acceptance of trans identities, or even peer, social and cultural influences. Over the last 20 years we have seen groups such as Stonewall and Mermaids call for better access to treatment and increased rights for trans people. Large corporates have gone big on diversity and inclusion to boost their brands, impactful TV dramas centring trans stories, such as “Butterfly”, have been widely viewed, and the public sector, from the NHS to the police, has been flying the progress flag at every opportunity. So it can be no surprise that gender identity is at the front of young people’s minds in a way that it simply was not when I was growing up. In 2009, only 51 patients were referred to GIDS—the NHS gender identity development service for children—of whom two thirds were male. In 2016, there were 1,766 referrals and two thirds of them were female. That is quite the change. There has been an overall surge in the number of children suffering gender distress, but the increase is especially notable among girls; we also see over-representation of neurodiversity, mental health issues and trauma in this group. To put it another way, these children are much more likely to have been in care, to suffer with anxiety and depression, to be autistic and to have been abused. It is a group of incredibly vulnerable children. GIDS was established in 1989. Its main approach to treatment at that time was therapeutic—referred to as watchful waiting. Early studies from the 1980s showed that in around 85% of cases, the gender incongruence or distress ceased in the child after going through puberty. Later studies reached a similar conclusion, with between 67% and 90% desisting after puberty. Only a small cohort of children continued to experience gender dysphoria or incongruence after puberty, and it was that small group who would likely adopt a permanent trans identity in adulthood. Everything changed with the emergence of the Dutch protocol, which involved the use of puberty blockers from early puberty. Puberty blockers are gonadotropin-releasing hormone analogues, which supress oestrogen production in girls and testosterone in boys. They are licensed for use in children with precocious puberty—when puberty starts much too early and it is beneficial to suppress it until a more normal developmental time and age—but in the case of gender dysphoria they are used to delay or even indefinitely stop natural pubertal development and maturation, and it is important to note that puberty blockers are not licensed for that purpose. The original rationale for using puberty blockers to treat gender dysphoria was to press pause on puberty and give children time to think, but for some the aim was also to increase the chances of a child passing as a member of the opposite sex in adulthood. GIDS started trialling puberty blockers in the UK after 2011. The preliminary results in 2015-16 did not demonstrate psychological benefits, with some of the females suffering a worsening of symptoms, including higher incidence of wanting to hurt or kill themselves. The results of the study, which were not formally published until 2020, demonstrated no statistically significant improvement in gender dysphoria or mental health outcomes. It is also important to remember the early studies that told us that in the majority of cases, going through puberty could relieve gender distress. It follows, therefore, that stopping or delaying puberty using medication could derail that natural desistence, essentially locking in or prolonging the gender distress, rather than allowing it to naturally resolve. One would think that, in the absence of any evidence of benefit from puberty blockers, the NHS would have stepped back from using them after the trial. Furthermore, the high numbers of autistic, traumatised, mentally unwell and same-sex attracted youth in the group of children referred should have rung alarm bells loudly, but no; instead, puberty blockers and cross-sex hormones were routinely made available to an even broader group of children, including those with neurodiversity and complex mental health presentations. An independent systematic review of published studies on puberty blockers, of which there were 50, was undertaken by the University of York as part of the Cass review. It was found that puberty blockers do indeed suppress puberty effectively. It was also found that, given that most children progress on to cross-sex hormones after starting puberty blockers, the main objective of pausing development is not achieved. No reduction in gender dysphoria or improvement in body satisfaction was demonstrated, and there was limited evidence of positive mental health outcomes. Worryingly, bone density in those taking puberty blockers was compromised, and height gain may lag behind normal. In the case of biological males, it can make vaginoplasty more difficult in future, due to insufficient penile growth, forcing the use of gut tissue instead. The Cass review reports: “There seems to be a very narrow indication for the use of puberty blockers in birth-registered males…in order to stop irreversible pubertal changes. Other indications remain unproven at this time.” I take that to mean that those drugs have been given to young girls, not because they benefit them specifically, but because they might benefit a very small group of males. Professor David Bell, a retired consultant psychiatrist at the Tavistock, and Dr Sinead Helyar, a clinical trial nurse, also warned of the potential harms in a recent article. “Current known and potential harms of puberty blockers are multi-fold and include a reduced bone density and early-onset osteoporosis, brain swelling and concerns around impairment of future sexual functioning and ability to form emotional relationships. A recent review of the impact of suppressing puberty on neurological function highlighted that adolescence is a critical window of neurodevelopment and puberty plays a critical role in this process. The author concluded that suppression of puberty impacts brain structure and the development of social and cognitive functions, in which the effects are complex and often sex specific.” The over-representation of same-sex attracted girls and boys in the group of children being treated with puberty blockers is particularly worrying. In a study in the Netherlands of 70 patients given puberty blockers between 2000 and 2008, 89% were same-sex attracted, and most of the rest were bisexual. The same pattern was seen in most of the other trials, with the majority of the children growing up to be same-sex attracted adults. A paper from GIDS in 2016 reported 89% of the biological girls being either same-sex attracted or bisexual. Why would same-sex attraction be over-represented in that way? Could gender distress be symptomatic in some cases of struggling with sexuality? Is sufficient emphasis put on reassuring those young adolescents about their sexuality, to establish if the gender distress is linked or separate; or is our society’s hyperfocus on gender identity and gender conformity putting them on an unnecessary medical pathway to change their body? Keira Bell, who has now detransitioned, says, “I became attracted to girls. I had never had a positive association with the term ‘lesbian’ or the idea that two girls could be in a relationship. This made me wonder if there was something inherently wrong with me. Around this time, out of the blue, my mother asked if I wanted to be a boy, something that had not even crossed my mind.” The Cass review received several reports from parents of biological females that their child had been through a period of trans identification before recognising that they were, in fact, a lesbian. That begs the question: why are so many young lesbians being medically transitioned? Before I move on to my questions to the Minister, it is important to note that almost all the children and young people who take puberty blockers go on to take cross-sex hormones. I raise that because it links the two treatments. The impact of puberty blockers cannot be looked at in isolation, because cross-sex hormones may lead to further surgeries, lifelong medication, and loss of fertility and sexual function. These are catastrophic impacts. How can a prepubescent child really understand what never experiencing an orgasm means and the impact that could have on their future relationships, or indeed what losing the opportunity to have children could mean? It is very apparent that the lack of solid long-term data on outcomes for patients who are treated with puberty blockers is problematic. No doctor should prescribe something in the absence of strong evidence of its effectiveness and a clear understanding of the side effects. In May 2024, the previous Government temporarily banned the use of puberty blockers for the treatment of gender incongruence and gender dysphoria in under-18s, following the Cass review’s findings of insufficient evidence to show they were safe and effective, and this ban was made permanent by the current Secretary of State for Health and Social Care in December 2024. In the light of everything that I have set out today, I fully support that decision: it is sensible, has full regard to the data, and puts the safety and wellbeing of children first. It is also important to note campaigners’ claim that suicides among young patients with gender dysphoria increased due to puberty blocking drugs previously being restricted, following the High Court decision in the Bell v. Tavistock case, has been disproved by Professor Louis Appleby’s investigation and report, published on 19 July 2024, in which he confirmed that the data did not support such assertions. He concludes that: “The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide. One risk is that young people and their families will be terrified by predictions of suicide as inevitable without puberty blockers.” At the same time that the Secretary of State announced the permanent ban on puberty blockers, he announced that a clinical trial would be set up in 2025 to examine the use of puberty blockers, in order to establish a clear evidence base for the use of this medicine in gender incongruence. The £10.7 million trial, called Pathways, will be carried out by a team at King’s College and is due to run until 2031. Over two years, it will track: “the physical, social and emotional wellbeing” of young people who want to delay puberty, and whose parents and the gender service agree with this treatment option. I will be grateful to the Minister for an update on the trial and how she intends to ensure that children are not physically or psychologically harmed. A trial of this nature of a drug that is unlicensed for gender incongruence raises many ethical concerns. In the words of Professor David Bell and Dr Sinead Helyar: “The first duty of any clinician inside or outside of a clinical trial is to ‘do no harm.’” Can there ever be a situation where it is ethical to run such a trial when the harms could be significant? It is important to remember that the children who would participate in this trial are physically healthy children who stand to have worse health by the end of it. This trial is in no way similar to a clinical trial for a cancer drug, where the patient is seriously unwell at the beginning of the trial. Secondly, approximately 9,000 children and young people were treated by GIDS over the years, which provides a plentiful supply of data about the long-term outcomes for those who took puberty blockers and those who did not. Would the Minister please clarify matters and explain why a new trial is needed, given this abundance of data? Will she please provide an update on the exercise that is currently under way to obtain more data? Thirdly, the current trial only proposes to look at outcomes over a two-year period. To put that into context, a child who starts puberty blockers at the age of 13 will only have their outcomes followed and assessed until the age of 15. That is not long enough to understand medium and long-term outcomes. A positive result for a 15-year-old might look very different for a 25-year-old, when physical health, sexual function and fertility are likely to be more important and relevant to them than when they were 15. Does the Minister agree that two years is not a sufficient timeframe to properly evaluate the impact of puberty blockers on physical and mental health? If this trial goes ahead, will she commit to funding and ensuring that there is long-term follow-up of these children into adulthood? Fourthly, how many children will the trial be limited to, and what criteria will be used to determine which children are eligible and which are not? Is it possible that all eligible children will be included and prescribed puberty blockers as part of the trial? How many children in total does the Minister expect to take part in the trial over its duration? How will the trial establish an appropriate control group? Fifthly, given that gender nonconformity sometimes correlates with same-sex attraction in adulthood, how will the trial safeguard those children who may simply be uncomfortable with their sexuality rather than experiencing true gender distress? Sixthly, given the high rates of progression to cross-sex hormones following puberty blockers, will only children who agree not to progress to cross-sex hormones be accepted on to the trial, so that the impact of the puberty blockers on outcomes can be seen in isolation? If the answer is no, given the corresponding likelihood of impaired sexual function and loss of fertility, which are monumental ramifications, how will the children taking part in the trial be able to give consent? Finally, will the Minister please provide details of other trials that have been approved for paediatric medical interventions with equivalent or similar diagnostic uncertainty, to reassure the public that moving forward with a trial in this situation has precedent? I look forward to hearing the Minister’s answers and thank everyone for attending this debate.

• 23 Apr 2025 · Hospitals · Hansard source

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  I can confirm to the hon. Member that if the Conservatives were in power, we would be delivering that hospital. I want to be clear: the trust is ready to move forward, and clinical consensus has been secured; what is now urgently needed is commitment from the Government to drive the programme forward. After all, patients and staff alike deserve better than to spend another decade or more in facilities that are not fit for modern healthcare delivery. They deserve to know that promises made through the new hospital programme will be honoured, not quietly shelved or endlessly deferred by this Government. I urge Ministers in the strongest possible terms to look again at the decision to delay Sutton emergency care hospital and to provide the long-term certainty the trust needs to proceed—not in 2035, but now.

• 23 Apr 2025 · Hospitals · Hansard source

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  I am grateful for the chance to speak in today’s debate and to be able to give voice to so many of my constituents’ frustrations about how their right to access quality healthcare has been deprioritised by this Labour Government. Many of my constituents, especially those in the north of my constituency, are served by the Epsom and St Helier university hospitals NHS trust. To be blunt, the situation at the trust today is simply not sustainable—clinically, financially or structurally. The trust currently operates two acute hospitals, in Epsom and St Helier, with duplicate services spread across both sites. The arrangement, while a product of historical necessity, today places considerable pressure on clinical teams. Allocation of staff members between sites is challenging and service delivery is stretched. No matter how committed the staff—their dedication is beyond question—they are constantly being asked to do more with less, in buildings that are often quite literally falling apart around them. To give just one brief example, earlier this year St Helier was forced to cancel scheduled blood tests because of widespread flooding in the phlebotomy section. We simply cannot go on like this. Indeed, time is not a luxury we have, with the estate now deteriorating faster than it can be fixed. The trust is spending millions every year simply to keep the most urgent problems at bay: patching leaks, coping with flooding, and addressing the worst outbreaks of damp and mould. I think we all agree that these are not the conditions in which 21st-century healthcare should be delivered. That is why it was so disappointing to learn earlier this year that the planned specialist emergency care hospital in Sutton—a long-standing scheme under the new hospital programme that was carefully conceived to address the very issues I have mentioned—has been delayed to the point that work will now not even begin until 2030 to 2035, with opening coming in 2037 at the earliest. The new hospital will consolidate emergency care into one state-of-the-art facility, delivering world-class treatment, faster access to care, and safer outcomes. At the same time, it will allow for major investment at Epsom and St Helier hospitals, helping to modernise crumbling buildings, improve planned care pathways and ensure that most services remain close to home. Under the trust’s plans, 85% of services would remain on the Epsom and St Helier sites, including out-patient care and diagnostic appointments. Local people would continue to receive the vast majority of their care where they always have done, but would benefit from shorter waiting times and access to better facilities, particularly for surgery. I passionately believe that the new hospital at Sutton is a once- in-a-generation chance to overhaul healthcare provision and ensure that my constituents receive the high-quality care they deserve in a timely fashion.

• 28 Mar 2025 · Looked After Children (Distance Placements) Bill · Hansard source

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  I am pleased to contribute to this important debate, and I congratulate the hon. Member for Rother Valley (Jake Richards) on bringing the Bill before the House. I commend him for shining a spotlight on an issue that affects some of the most vulnerable children in the country. These children are not simply statistics or case numbers; they are young people who have experienced trauma, instability and, in many cases, loss. It is essential that they get the loving home and the support that they deserve, so that they can flourish. He has brought this issue to the House with compassion and care, and I commend him for doing so. As a serving Surrey county councillor and a former member of the corporate parenting board, this is an issue close to my heart, too. I have seen at first hand many of the challenges and systemic failings that have been talked about. As was set out, local authorities have a duty, so far as reasonably practicable, to ensure that looked-after children are placed in accommodation that meets their needs in the local area, but many local authorities fail to achieve that, and often shockingly high numbers of children are placed out of area. I am sure that the inclusion of the words, “so far as reasonably practicable” was intended to give some leeway to local authorities where needed, and to recognise that sometimes distance placements are in the best interests of the child. However, I am afraid that in far too many cases those words have become a licence for abject failure. Yes, I accept that there are many challenges for local authorities in meeting their duties, including the higher cost of living, which makes it difficult to recruit and retain foster carers; the increased national demand for placements; and even the recent ban on using unregulated accommodation for 16 and 17-year-olds. Those pressures are real, but it is unacceptable that high numbers of looked-after children are being placed in accommodation far away from the communities that they know—far from their schools, their extended family and their support networks. Such placements are often made not because they are seen as the best option for the child, but because there is simply nowhere else to put them. The problem is that it becomes almost normal to send high numbers of children out of area, so it becomes more acceptable. I am here to say that, except in specific cases, it is not acceptable. Local authorities and national Government need to do more to ensure that the sufficiency duty is met. The wellbeing and safety of these vulnerable children depend upon it. The damaging consequences of these long-distance placements are obvious. Children placed miles away are more likely to experience educational disruption, go missing and lose contact with friends, siblings and trusted adults. In some cases, the sense of being cut adrift from everything familiar only deepens an already present feeling of abandonment. It should be noted that these placements are often beyond the local authority boundary, giving rise to myriad further risks. It is self-evident that the system needs further intervention, and I am pleased that any policy decisions taken in the future will build on the major reforms introduced by the previous Conservative Government. Perhaps the most impactful reform in this space was the introduction of the staying put policy in 2014, which allowed young people in foster care to remain with their foster family until the age of 21. That was a transformational step. For the first time, young people in care were offered the stability and ongoing familial support that many of their peers take for granted. It was also the previous Conservative Government who rolled out regional adoption agencies, which are designed to reduce delays in the adoption process and increase the number of children finding permanent, loving homes. Since their introduction, adoption timeliness has improved, and agencies have been better able to match children with prospective parents across wider geographical areas. We also published our strategy and consultation, “Children’s Social Care: Stable Homes, Built on Love”. Our strategy was backed initially by £200 million of additional investment over two years to transform children’s social care, including by delivering a decisive multi-agency child protection system and ensuring that every child has a valued, supported and highly-skilled social worker when needed. Finally, the publication of the independent review of children’s social care in 2022, commissioned by the last Government, was a landmark moment. It provided a comprehensive and honest assessment of the system’s challenges, and offered a road map for reform focused on early intervention, family help and a more relational, less transactional model of care. Those milestones, taken together, demonstrate that we have always taken the needs of looked-after children seriously, and we will continue to work constructively alongside Government Members to improve the support available to these children; I know Government Members have the same overarching objective of transforming life outcomes for these children. I return to the Bill. The ambition of improving the transparency of data about placements of looked-after children is much welcomed. The Bill would place a duty on local authorities to publish such information, making it easier to identify where there are issues, and where local authorities are not performing. We will start to see tangible improvement only when the extent of the issue nationally is clearly laid out. As is often the way, measurement prompts improvement. Undoubtedly, one of the most consequential aspects of the Bill is the requirement for the Secretary of State to produce a national sufficiency strategy for looked-after children. Local authorities can and should do more to collaborate at regional level to ensure that children are put in placements close to their homes, but the structural challenges faced likely cannot be solved by local government alone. National leadership is essential, and I urge Ministers to look seriously at how best to increase placement capacity where there are shortages, and at how to ensure that the right children end up in the right locations, not just the cheapest locations. That is not to say that local authorities are not at the heart of this challenge—they are—but I know that they find it increasingly difficult. The residential care market is now heavily dominated by private providers, and the cost of placements continues to rise, placing a huge strain on local authority budgets. A shift to a more strategic approach is needed, and I recognise that the hon. Member for Rother Valley has sought to kick-start that shift with the requirement in his Bill for local sufficiency strategies to be published by local authorities in England. At this point, I should acknowledge that for all the justifiable talk today against distance placements, there is a very limited set of circumstances in which they are appropriate and necessary. Some children need specialist provision that simply does not exist locally. Others may need to be placed at a distance to ensure their safety if they have become involved with gangs or are threatened by an abuser. The question is not whether distance placements should be banned—they should not—but how we can get to a point where they are used only when it is truly and demonstrably in the best interests of the child. A key focus is how we recruit, retain and support foster carers, and how we encourage local authorities to invest in local residential provision at a time of such pressure on their budgets. Many of the answers lie in not only legislation but funding, training and leadership, both local and national. I look forward to the Minister’s comments on these important issues. When a child is taken into care, the state becomes their parent. That is not a responsibility to ever be exercised lightly. We must hold ourselves and the systems we put in place to the highest standard—the standard we would expect and demand for our own children. The hon. Member for Rother Valley has brought this Bill forward in precisely that spirit, and I congratulate him once again on doing so. It was truly a pleasure to speak on it.

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-eighth sitting) · Hansard source

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  It transformed the quality of life of British citizens at a time of mass unemployment and widespread slums, ensuring free healthcare, in the words of Beveridge, from cradle to grave. The provision of healthcare free at the point of delivery was life-changing and life-prolonging. Although it is far from perfect, we have seen time and time again that as a country we can be very proud of the NHS. The National Health Service Act 1946 came into effect on 5 July 1948, as a direct consequence of the Beveridge report. Section 1 of the Act states: “It shall be the duty of the Minister of Health…to promote the establishment in England and Wales 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”. It was set up to help people to get better and live healthy lives, and to give hope in situations where otherwise there would be despair. It was lifesaving and life-changing. New clause 36 turns all that on its head. Subsection (4) states that: “Regulations under this section may for example provide that specified references in the National Health Service Act 2006 to the health service continued under section 1(1) of that Act include references to commissioned VAD services.” If this new clause passes, the founding principles of the NHS will be monumentally changed to include helping eligible people to commit suicide. That is what it does. I want to be really clear that it is entirely possible to support assisted dying—to want to ensure that a small group of people, whom palliative care cannot help, have that assisted dying option—but not to support this new clause, which forces provision of the service through the same channels as normal healthcare. Assisted dying is not a medical treatment or a healthcare service and accordingly there should be a degree of separation. We should be incredibly cautious about incorporating the service into the NHS. It will forever change the relationship between doctor and patient, breed mistrust and fear, discourage vulnerable groups from seeking the healthcare they need and fundamentally violate the Hippocratic oath. Dr Catherine Day, a senior partner of a large GP practice in Coventry, states: “Trust lies at the heart of the doctor patient relationship. I believe this trust will be shattered if patients consider that their GP…may think that they should end their life and stop being a drain on our NHS.” Siwan Seaman, a palliative care consultant said: “How could a terminally ill patient trust a doctor if they know that the doctor was prescribing medication to the patient in the next bed in a bay or cubicle with the intention of ending their life. Letting these assessments take place alongside other NHS services will irreversibly impact on patients’ trust in healthcare professionals and negatively impact our therapeutic relationship with patients as doctors.”

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-eighth sitting) · Hansard source

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  I will come on to some of that, and it goes back to my belief that there should be a degree of separation. I think it should be separate from normal healthcare services and there are multiple ways that we could do that. I regret that we are not specifically debating the various different options, with a proposal in front of us detailing exactly how it would work. I am assuming, from the new clause put forward, that the proposal is for this to go through the NHS as healthcare; that is the only assumption I can make based on what is in front of me in this Bill, because there is no other detail to give me any other impression. Sarah Davies, a consultant respiratory physician in north Wales, argues for a separate service so that ordinary NHS care is not associated with assisted dying. She said: “It is already my experience that patients and their families are anxious about limiting treatment when they are dying. Many people believe that symptom control medication, such as those delivered in a syringe-driver to aid symptom control amount to hastening or bringing on death. This perception can hinder the patient’s acceptance of medications which can afford significant alleviation of distressing symptoms.” I have raised my concerns about providing an assisted dying service alongside and in conjunction with day-to-day healthcare many times over the last few weeks. I think it is a massive mistake both for patients and healthcare staff. It blurs the lines of what a treatment is, increases the risk of bad decisions and, as we heard so powerfully from Dr Jamilla Hussain, it will discourage some of the most vulnerable groups from seeking essential healthcare. We have received so much evidence and it is really important that we take it on board, so I will be quoting some in my speech. Dr Green of the BMA said: “It should be set up through a separate service with a degree of separation. We believe that is important for patients, because it would reassure patients who may be anxious about the service that it would not just be part of their normal care… It would reassure doctors, because doctors who did not want to have any part would not feel that it was part of their normal job, whereas the doctors who wanted to go ahead would be assured of having support, emotional support and proper training.” –– [ Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c. 45, Q32.] In oral evidence, Professor Preston argued for a separate system and pointed to the Swiss example. She said: “In covid, we did research in care homes, and there was real concern about ‘do not resuscitate’ orders and emergency care plans that were blanketed across the care homes. Care home staff were traumatised by that, so there are real issues. We know that there are real issues day to day in how people are treated within the NHS. I think it is unconscious—I do not think people are intending it—but we know that people are treated differently and that different things are done. That is partly why we think a system outside that would protect them, because then you are not within the healthcare team that is treating you and giving you advice about such things”. She went on to talk about the Swiss system, also being adopted in Germany and Austria, which seeks to “protect these people by keeping it one step removed” from normal healthcare. She said: “Most hospitals in Switzerland will not allow assisted dying to occur, because they do not want a lack of trust in their patient group.” –– [ Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 30 January 2025; c. 246, Q317.] I therefore support amendment 525, tabled by my hon. Friend the Member for East Wiltshire, which would amend clause 32 in order not to allow the provision of the assisted dying service to be done through the health service. That would ensure that much-needed degree of separation. In light of what the Bill’s promoter has said, I recognise that there are different ways to do that; I am very open to those different ways, but I need to see that degree of separation from normal healthcare. I also support new amendment (a) to new clause 36, also tabled by my hon. Friend, which does the same thing. Let me come to the other amendments in this group. Amendments 537 and 528, tabled by the hon. Members for Shipley and for Richmond Park respectively, are important to debate—we have had some good debate on them this morning—as they raise the different ways of delivering an assisted dying service. I have been listening closely to the points made. Amendment 537 would limit the provision of an assisted death to charities rather than to the NHS, and conversely, amendment 528 would limit provision to public authorities only. I do not have the answer on the best way to do this, and that is why I regret that a royal commission has not been set up to properly investigate and evaluate all the options and recommend the best way forward. Instead, we are here without all the relevant information and expertise available to us, trying to land on the best way to do it. That is not the way to make such an important decision. I can tell the Committee, however, that—like many others, including my hon. Friend the Member for East Wiltshire—I have huge reservations about delivering such a service through the NHS alongside normal healthcare. I agree with much of the evidence that has already been cited: there should be a degree of separation. The BMA said that assisted dying could be part of the NHS, but should be outside existing care pathways and separate in some way: “Our view is that assisted dying should not be part of the standard role of doctors or integrated into existing care pathways—it is not something that a doctor can just add to their usual role… The separate service could take the form of a professional network of specially trained doctors from across the country who have chosen to participate, who come together to receive specialised training, guidance, and both practical and emotional support. They would then provide the service within their own locality—for example, in the patient’s usual hospital, or their home. Or it could be a combination of some specialist centres and an outreach facility.” In its written evidence, the Royal College of General Practitioners also proposed a separate service: “The establishment of a separate service which covered every stage of the process would ensure healthcare professionals of multiple disciplines (including GPs) who wanted to do so could still opt in to provide assisted dying, but this would be arranged through a different pathway.” I agree with both bodies that the service should be separated out in some way. It is now apparent that my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer), whose amendments would have created an assisted dying agency, was on the right track. I regret that the Committee did not explore his ideas in any real detail during our proceedings. We received important written evidence from Robert Twycross, a pioneer of palliative care who sadly died in October, but had given his friend Ariel Dempsey permission to submit it. Dr Dempsey writes: “Twycross recommends a de-medicalized model in which AD is a separate service, delivered outside of healthcare practice. He argues for a standalone Department for Assisted Dying, separate from the NHS. He writes, ‘Data indicate that the primary reason for a persistent desire for AD is to relieve distress over a perceived loss of autonomy and to experience a sense of personal control over the circumstances of their dying. These are not medical reasons. Thus, for patients fulfilling the legal criteria, a separate AD service should be established. Indeed, this would be the best way to prevent a corrosive effect on medical practice generally.’ ‘Given the widespread disquiet felt by doctors, a law with minimal medical involvement would be the most equitable.’ He suggests, ‘One way to achieve this would be for [AD] to be delegated to a stand-alone Department for Assisted Dying, completely separate from the NHS and with its own budget. Victoria almost achieves this with its combination of Care Navigators, mandatory training for participating doctors, and a separate Voluntary Assisted Dying Statewide Pharmacy Service.’ Twycross emphasizes that hospice and palliative care must be a ‘sanctuary’ for patients – ‘an assisted dying free zone. Even in the absence of AD, some people decline referral to palliative care despite unrelieved pain and/or other distressing symptoms because they fear they will be “drugged to death”…This unfounded fear will most likely be enhanced if AD is legalized, particularly if palliative care is involved’ and result in an overall increase in suffering.”

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-eighth sitting) · Hansard source

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  It is a pleasure to serve under your chairmanship, Ms McVey. I rise to speak on clause stand part and new clause 36, and in support of amendment 525 and amendment (a) to new clause 36, tabled by my hon. Friend the Member for East Wiltshire. This is a really important debate. The NHS is the greatest achievement of any Labour Government, and maybe even of any Government.

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-eighth sitting) · Hansard source

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  I thank the hon. Member for his intervention. I was quoting written evidence, so I just quoted it, of course, as written. We should be ashamed if what I have set out is where we end up as a result of this Bill. How would it in any way recognise patient autonomy and give them a real choice? Clearly, it would not. We will end up with patients taking an assisted death because there is no alternative to dying well. If as much effort was put into improving palliative care as has been put into legalising assisted dying, a much greater number of people would be given the dignified, comfortable deaths they rightly deserve. It is a travesty that we find ourselves considering the introduction of assisted dying while hospices are on their knees and patients face a postcode lottery when it comes to receiving adequate end-of-life care. Accordingly, I will vote against new clause 36.

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-eighth sitting) · Hansard source

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  It is important that there is a degree of separation, but I would say to the hon. Lady that it would have made more sense for her to put forward a proposal that we could evaluate, assess, and identify the upsides and downsides of. It would be much easier for me to then come up with suggestions. It does not make sense to ask me, “What is the solution and how would you do this?”, and for me to lay out the many different ways that this could be done, without having first laid a proposal in front of me.

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-ninth sitting) · Hansard source

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

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-ninth sitting) · Hansard source

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

• 25 Mar 2025 · Terminally Ill Adults (End of Life) Bill (Twenty-ninth sitting) · Hansard source

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  It is a pleasure to serve under your chairmanship, Sir Roger. I rise to speak about amendments 518 and 520. As we have said, it is important that we understand what coercion means in a legal sense, and I am really grateful to the hon. Member for Penistone and Stocksbridge for trying to set that out, because it is not an easy task. Like her, I am concerned that defining it in this way may make it harder to prove coercion and may undermine the safeguards in the Bill. Under the amendments, the assessing doctors and the panel are meant to look not just for evidence of coercion but for evidence of intent to induce assisted suicide, and they will have to show that the applicant is requesting assisted suicide against their will. That could make the law powerless against many kinds of behaviour that we want to prohibit. To start with the point about intent, coercion and pressure take many forms, and they do not always involve a clear intent. Amendment (b) to amendment 518 and amendment (b) to amendment 520, in the name of the hon. Member for Lowestoft, very reasonably draw attention to family relationships. On Second Reading, the right hon. Member for Hackney North and Stoke Newington (Ms Abbott) said: “people do not generally write letters to sick relatives urging them to consider assisted suicide and then put those letters on file. Coercion in the family context can be about not what you say but what you do not say—the long, meaningful pause.” —[ Official Report , 29 November 2024; Vol. 757, c. 1030.] But even in more blatant cases, we cannot necessarily prove intent directed towards assisted suicide. Sue Smith, a clinical psychologist, said in written evidence that coercive control often ramps up when the abused partner receives a cancer diagnosis: “The seriousness of the cancer diagnosis may be systematically and actively denied or minimised, claims can be made by the male partner that she is attention seeking, or she is accused of making up the effects of treatment, and can be left isolated and alone when in physical need…a woman learns to doubt her reality and experience, and is extremely isolated. This can lead to heightened anxiety, hopelessness and helplessness, and abject despair, which can lead to a person wishing they were dead.” That could be seen as coercion towards assisted suicide, but in that scenario does the abusive partner demonstrate clear intent? I am not sure the doctor or panel could demonstrate that in that instance, especially as they need to be satisfied only on the balance of probabilities that there is no coercion. If the panel think that there is a 45% chance that there is intent, but no more than that, they have to grant the application. The harrowing story of Ryan Wellings and Kiena Dawes shows that even when coercion can be proved, proving that an abuser intends someone else’s suicide is a completely different matter. After Kiena Dawes took her own life, Wellings was convicted of coercive control and assault. The judge told him: “from May 2020 until her death you abused, assaulted, exploited, controlled and demeaned her. When she died it is clear that she had begun to believe your lies to the effect that she was deranged, physically disgusting, friendless, worthless and an unfit mother. You had persuaded her that she had no one to turn to.” Before her death, Dawes wrote a note saying, “Ryan Wellings killed me.” Although he was convicted on other counts, Wellings was acquitted of manslaughter. That demonstrates that coercive control, even if it is followed by suicide, does not always mean that intent can be demonstrated. It is really tricky. Similarly, people may pressurise a relative without intending to override their will. The barrister Ruth Hughes KC, who has been quoted before, said: “It is surprisingly easy for a relative, whilst completing a variation on ‘the classic asset strip’, to persuade themselves that they are actually acting in their aunt Dorothy’s best interests or in accordance with her wishes”. In other words, someone can pressurise a relative into assisted suicide without intending to. Again, including intent here could actually muddy the waters. I have a similar concern about the phrase “against that other person’s will”. That sounds very straightforward, but in practice it can be much less clear. Part of the effect of coercion is that people lose confidence in their own will and adopt that of others. In written evidence, many frontline workers pointed out that coercion does not always clearly appear as someone acting against their will. Janet Reiss, a specialist doctor in palliative care in Wolverhampton, says patients will not “even necessarily be aware of being coerced”. Dr Jennifer Hardes Dvorak, a senior lecturer at Canterbury Christ Church University specialising in medical law, states that the Bill “does not consider how people internalise feelings of coercion and…act on this.” If someone has internalised a feeling that they would be better off dead, that may be their will, even if we hope we could change it. Anni Donaldson, a domestic abuse expert at the University of Strathclyde, said: “Decades of work examining the impact of coercive and controlling behaviour has shown that ‘coercive control’ is not merely persuasion, but a complete change in the perspective of the victim so that she truly believes that she is worthless, a burden to her partner or wider family, and would not be missed should she die…Women are regularly humiliated, demeaned, and told they would be ‘better off dead’, or, that they are a ‘useless mother’, or that the children would be better off without them. This abuse erodes women’s confidence, autonomy, and self-esteem. Cut off from support, women often come to believe these lies, fearing reprisals from their partner if they report the abuse, many choose to tell no one. This long term, relentless, dehumanising process can result in a woman believing that she is ‘disposable’.” Similarly, the writer and campaigner Sarah Ditum warns that the Bill may not protect “the patient who, through lengthy cruelty and coercion from a partner or carer, becomes genuinely convinced that she (or sometimes he) is a burden who would be better off dead. Such a person may even refuse treatment, causing a curable disease to become terminal and placing them within the purview of the bill.” So we might not believe that assisted suicide is in someone’s best interests, but there is no best interest test in the Bill or the amendments—just a reference to the person’s will. If a victim of coercive control truly believes they ought to die, it is not clear how the doctor or the panel can refuse their application, unless coercion can actually be proved, and proving it is not always easy, as we have just discussed. My hon. Friend the Member for East Wiltshire has tabled amendments to remove the phrase “against that other person’s will”. Obviously, that is all academic now, as we are not pressing the amendment to a vote, but I would support doing that, because that phrase does more to narrow the definition than anything else. On another point, amendments 518 and 520 refer to pressure and coercion from organisations. I do not know exactly what the hon. Member for Penistone and Stocksbridge has in mind with that. I guess an example might be the cases we have heard about in other jurisdictions where a health insurer or provider tells someone that they cannot fund a treatment but can fund assisted dying options. It could be that the hon. Lady had other things in mind there. That would possibly count as pressure under some circumstances, but it would be very hard to show that there was intent on the part of the organisation. It is not clear that the amendments help us to identify and avoid coercion and pressure in that sense. Before I finish, I would like to point out something else that might be missing from the amendments: it is my favourite topic, the question of undue influence—my apologies to the Justice Minister, because I know we have gone over it a few times.