24
Examination of witnesses
Toby Porter, Fraser Rickatson, Dr Suzanne Kite, Professor Sam Ahmedzai and Professor Katherine Sleeman.
Q59 The Chair: Welcome to this, the fifth session of our inquiry into the Terminally Ill Adults (End of Life) Bill. We are joined at this session by Professor Sam Ahmedzai, Dr Suzanne Kite, Toby Porter, Fraser Rickatson and Professor Katherine Sleeman. You are all very welcome and we look forward to your evidence. You have all, very kindly, provided us with written statements, which we have read and are grateful for. I would like to ask you each to introduce yourself briefly. If you have anything to add to your written statements, do so, but briefly, please, before the questioning begins.
Today’s session is being broadcast and a verbatim transcript will be taken for subsequent publication. It will be sent to you to check for accuracy. I hope you will do that and let us know whether there are any mistakes in it. I refer before we start to the list of Members’ interests, as published on the committee’s website.
Professor Sam Ahmedzai: Good morning. I am the emeritus professor of palliative medicine at the University of Sheffield. I am a physician with 40 years’ experience of working in specialist-level palliative care. I have been medical director of a hospice for 21 years. I was professor at the University of Sheffield. I have now given up my licence to practise clinical work, but I carry on with my academic work around the world.
I was appointed by NICE to lead two of the crucial guidelines relating to end-of-life care. That was NG 31, care of the dying adult, and NG 142, service delivery for people at the end of life. I chaired one and was clinical adviser to the other, so I am very well versed in national-level guidelines.
I know from travelling around the world that we in the UK have one of the best infrastructures for palliative care. We also have among the best supplies of medicines and techniques for controlling pain and symptoms. I also realise that, although we are leading in those respects, we have lagged behind many other countries that have opened up another option, and that is assisted dying.
The Chair: I would like to stop you there because we have a lot of questions to put, so very short presentations are what are required.
Dr Suzanne Kite: Good morning. I am a consultant in palliative medicine and have worked in palliative care in the NHS for over 30 years. I am also the President of the Association for Palliative Medicine of Great Britain and Ireland and I represent it today. We are a membership organisation with over 1,400 members. While the majority of our members are not in favour of legislation for assisted dying, we welcome this opportunity and are here today to contribute to the strengthening of this TIA Bill.
Throughout this debate, there has been a strong consensus that current palliative care provision is inadequate, with many services under threat, and that this constrains choice at the end of life. We advocate strongly for the Government to commit to a national policy to ensure universal access to palliative care that is protected from negative financial impact of the introduction of any AD—assisted dying—service, better safeguards for patients, care workers and organisations and a public awareness campaign about normal dying.
Toby Porter: Good morning. I am chief executive with Hospice UK. We represent the community of more than 200 hospices nationwide. Together we raise and spend some £1.5 billion annually to support some 280,000 patients each and every year.
Our view is that uneven access to palliative care, including a hospice sector on the brink, provides a precarious foundation for the introduction of assisted dying into England and Wales. Should the Bill progress, it is therefore essential that government does far more to ensure equitable access to and provision of palliative care ahead of the introduction of assisted dying in practice. This will be a significant but essential undertaking.
I note that, since I gave evidence to the Bill Committee in the House of Commons in late January, almost a dozen hospices have announced significant and involuntary cuts to staff and services due to financial pressures. Hospice beds are being closed and hospice-at-home services curtailed.
Fraser Rickatson: Good morning, everyone. I am the policy manager at Care England. For those of you who may not be aware, Care England is a representative body for the independent adult social care sector. We are a membership organisation and have around 30% of the adult social care sector within our portfolio. That is the largest providers, but also small single homes, as well as supported living, working-age adult services and end-of-life care in there.
In the summer, we conducted a survey with our membership and the wider sector to understand the preparedness for this Bill within the sector if it were to be legislated and come to pass. We found a sector that was deeply concerned, deeply unaware and not consulted or involved in any conversations about how this Bill may impact on them. I am very thankful to be here today in front of the committee to discuss the implications for the adult social care sector and hope that this is the beginning of a longer-term conversation with the sector.
Professor Katherine Sleeman: I am professor of palliative care at King’s College London, where I hold the Laing Galazka Chair in Palliative Care, which is funded by two charities, the Kirby Laing Foundation and Cicely Saunders International. I am also the director of the NIHR policy research unit in palliative and end-of-life care, but I am not here today in that capacity and the views I express are not necessarily those of the NIHR or DHSC.
I have been an NHS doctor for 25 years. I work clinically as a consultant in palliative medicine at King’s College Hospital in south-east London. I am also a member of CLADD. It stands for the Complex Life and Death Decisions Group. It is an interdisciplinary research group based at King’s College London with expertise in palliative care, psychiatry, public policy, law and ethics. CLADD has produced a series of briefings on the terminally ill adults Bill, which are linked to in my written statement.
I am here today in my personal capacity as a clinician and an academic, and, as such, I thought it would be helpful to outline my personal views. I do not have an in-principle objection to assisted dying or assisted suicide, but I have deep concerns about the implementation of assisted dying in a context where palliative care is patchy, fragmented and often woefully inadequate. I believe that there are several aspects of this Bill that can and must be strengthened.
Q60 The Lord Bishop of Newcastle: Good morning to members of the panel. Thank you for appearing before us today. Lord Chair, if there is time, I have a couple of lines of inquiry I would like to pursue. The first of these is on the theme of institutional opt-out. Dr Sarah Cox gave evidence in the Commons, which highlighted the staffing challenges in palliative care settings and said that 43% of palliative care staff said that, if assisted dying was provided in their organisation, they would leave. We heard today from the National Audit Office report into the challenges facing hospices.
My question is initially for Dr Kite and then I would appreciate Fraser Rickatson’s view. Could you tell us more about why it is that so many staff would feel the need to leave if assisted dying is introduced? What are your concerns about assisted dying taking place in hospice and palliative care settings?
Dr Suzanne Kite: Hospices are small organisations. Even if, as we requested, all organisations were allowed to opt out of providing assisted dying services, particularly since some of them have statutes that prevent them from doing so, within a smaller organisation it is much more difficult to ensure the safety of all your staff to have genuine choice in being able to not opt in.
There would also be concern about the impact of providing assisted dying in a setting that already creates some fear among the communities. When you work in palliative care, you are aware of people reacting to you and slightly recoiling, because we are uncomfortable as a society in talking about death and dying. There is already a perception that hospices are where you go to die. I work in a hospital setting. I have to reassure people that hospices are there to improve their symptom management and general support, and that they will go home from there as often as not. That would also be the environment in which people were working.
We see in healthcare that, when there are big changes, and if people do not feel able, through service pressures, workforce pressures or a change in the ask, to deliver the kind of care they wish, without undue moral distress, they move. I do not know whether it will be 43%, but we always see with big changes that people move. We saw this at the end of the Covid-19 pandemic in lots of different, particularly specialist, areas in the NHS. It is what happens when change happens.
Unfortunately, one final comment is that we need to ensure that there are senior doctors working in hospices, because they are vital to provision of specialist-level care. There is that threat.
Fraser Rickatson: In the adult social care sector for residential services, there are over 15,000 registered homes. Each one is diverse in how it is operated on the basis of what care is provided. There are a number of small services and there is also faith-based care. We are also a sector that relies heavily on international recruitment, where they may have different values or beliefs on end-of-life care. It is incredibly difficult for some services to be able to implement this Bill.
In our survey that we conducted earlier on in the year, some expressed very clearly that this goes against their ethos as a care service, but also goes against what they believe in. We believe that an opt-out option is essential to make sure that these services can still deliver the care. That needs to be combined with a referral process with ICBs, local authorities and NHS trusts to ensure that the individual who is looking to receive end-of-life care can still receive the care that they are lawfully able to, but in the services that will be able to accommodate this change in need for them.
The Chair: Can our witnesses try to keep it fairly short? We have a lot of ground to cover. I am not criticising anybody; it is a general warning.
The Lord Bishop of Newcastle: Professor Sleeman and Professor Ahmedzai, we know that access to palliative care, and understanding of what it is, is quite unequal. Through the charitable fundraising of many hospices, inequalities are often exacerbated, since wealthy areas are more able to fund their local hospices than deprived areas. Do you have any concerns that inequalities will be worsened through the passage of this Bill?
Professor Katherine Sleeman: We know that, at the moment, there is a huge gap between the number of people who need palliative care and the number of people who actually receive it. Potentially around 100,000 people die every year across the UK needing palliative care but not receiving it. We also know that palliative care is not distributed equally. You are more likely to receive high-quality palliative care if you are white, are rich, have certain diseases, such as cancer, or live in certain areas. What is more, some of those inequalities are actually getting bigger over time.
We also are aware from studies that we and other people have done that public understanding of what assisted dying is, and what palliative care is, is poor. For example, we did a study last year that showed that one in five people from minoritised ethnic groups think palliative care means giving people drugs in order to end their lives. It sounds shocking, but I witness that, I see that all the time in clinical practice. In clinical practice we work very hard to build trust with patients, particularly patients from some minoritised groups. There is a real worry that this Bill will make that much harder, not impossible but much harder, because some groups already do not trust us. We already explain to patients, not infrequently, that we are not allowed to hasten their death. That is not legal. If this Bill comes in, that may make that conversation much more difficult.
Professor Sam Ahmedzai: If I could respond to the issue of inequalities and how that prevents access to palliative care, there are two types. There are the inequalities within the populations themselves, or subgroups of the population, so marginalised groups and some ethnic minorities et cetera. Excellent work has been done within palliative care to research and break through those barriers in those groups.
There is the other bunch of inequalities and those are the ones that come from the profession in where they are based, which is often separated from mainstream healthcare in independent hospices. There is also the fact that we wait until patients come to us, and usually that is very late. The last figure I have is that the average time from referral to palliative care to death is about six weeks. That is pretty late.
Some 15 years ago, we started working in Sheffield on a screening tool to try to improve access. This was funded by the Sainsbury foundation. We developed a screening tool called SPARC. It is used around the world. It is hardly used in the UK. The point is that it is a way of independently asking patients to state what their needs are. Now we do not need to wait until they are dying. We can identify those needs much earlier. This is the problem. It is not just a problem with the populations. It is our approach. How are we reaching out to them?
Q61 Lord Patel: Thank you all for coming today. Good morning. I appreciate it very much. I will say first—I have said it before in another session—that I am a huge supporter of improving palliative care provision in our country. If nothing else, if this Bill acts as a catalyst to do that, I will fully support it.
My first question is to Professor Sleeman and Mr Porter. There might be some repetition from the answers you have just given, but it might help to reinforce it more. How does the provision of palliative care and end-of-life care compare in the United Kingdom to the best in the world? What will be needed, if it does not compare to the best, to bring about the change?
Professor Katherine Sleeman: There have been global reports that have suggested that palliative care in the UK is the best in the world, but those global reports have looked at infrastructure and processes. They say to me that we have the infrastructure available to provide extremely high-quality palliative care. They do not tell us anything about patient outcomes. We have lots of research from this country that shows that outcomes for people at the end of life are often not good.
To give a couple of examples, we published a very large study last year. It was funded by Marie Curie and called Time to Care, the better end of life report. We surveyed the relatives of over 1,000 people who died across England and Wales, using the ONS generalisable sampling framework so the data reflected the national picture. We found that people’s experiences of palliative and end-of-life care were often extremely poor. Patients frequently went in and out of hospital in their last months of life. They suffered severe debilitating symptoms. Carers were left feeling unsupported, let down and deeply distressed by the system. There was a lot of qualitative data in that report. One carer said to us, and it stuck in my mind, “The overall experience is that no one really cares”.
We know that we could do much better in this country: there is still an enormous gap between what is needed and what is actually provided. We also know that, for example, services such as a 24/7 telephone palliative care advice line that have been recommended nationally for more than a decade - our data shows that only one in three areas consistently provide that, over a decade later.
There is also a NICE recommendation that all hospitals should provide seven-day face-to-face palliative care services. The National Audit of Care at the End of Life last year found that just 60% do.
We know where we need to get to and what we should be achieving, but the services in place are not delivering that and the result is that patients and families are suffering.
Toby Porter: Katherine has spoken about the supply side. I will focus on the demand side. One thing we always try to reassure people in the context of talking about inequitable palliative care is that every single person’s outcome would be improved by asking the right questions and being prepared to ask, “Am I dying? Is my loved one dying? How long might they live?” Then you start to ask about what kinds of services are out there, and I think that every single outcome would be improved.
In that sense, slightly paradoxically, the debate on assisted dying has created more of a national conversation about death and dying than I have certainly seen in my time working in the hospice sector. A question for all of us in the UK is how we can broaden this very passionate, intensive and knowledgeable debate about a cohort of people who may access assisted death in the future to have larger conversations about death and dying in the UK. That would lead to early referrals to hospices and palliative care services, which would, I hope, see a reduction in unnecessary, intrusive and traumatic treatments of people right at the end of their lives.
Lord Patel: That leads me on to a question to you, Professor Ahmedzai. In the evidence session we had with the royal colleges, the president of the Royal College of Physicians, Professor Mumtaz Patel, said that, in her view, it was important to have equity of access to palliative care and assisted dying, and that it could work in tandem. What would be your comment on that?
Professor Sam Ahmedzai: I would totally endorse that. The places I visited around the world and the colleagues I am in touch with have shown me that it is perfectly possible for assisted dying to initially come alongside, because it is a latecomer compared to palliative care, but then become incorporated. There are places where hospices and palliative care services have absorbed assisted dying, obviously in small numbers compared to the general populations they serve, but it can work side by side.
In the UK we have come very late to this, but I cannot see any reason why assisted dying could not start maybe in specialist units in hospitals and then some hospices that are favourable, and in nursing homes also. A lot of assisted dying happens in nursing homes, for instance, in the Netherlands. In many of the countries where assisted dying is legal, it happens at home. That is where people want to die. We do not need to rely on the willingness or readiness of services to incorporate that. People can die at home with assisted dying, with help through the community services and maybe specialists coming in as well.
Absolutely, I agree, these things should happen in tandem. We have been waiting for 60 years for palliative care since the first modern hospice. We have been waiting for 40 years since specialist palliative medicine was founded. We are still going to be waiting in another 50 years. It will take for ever, and for ever is not what our patients have.
Lord Patel: Professor Kite, we have had a discussion about coercion and other safeguards that might be in the Bill that may or may not work. I am particularly interested in your comments about the safeguards that relate to the training of all professionals who may be involved in end-of-life care and assisted dying. Do you think that that safeguard, particularly related to training across the board, is sufficient?
Dr Suzanne Kite: I was very interested in what the royal colleges said about this last week, because they will be responsible for leading on this. We already know that we have a lot of work to do with educating and training the workforce and public about having earlier conversations about the wishes at end-of-life, which, ultimately, we all need to do to ensure our own personal choices. Even now, that is the first level of safeguard.
I heard in the discussion in the evidence session last week about the need to tailor training to the level of involvement in the process, whether involved in preliminary discussions or then in the different assessments. We discussed the skill, experience and competency required to have those conversations, some of which comes with experience. We would wish for more senior staff to have learned and to be trained in those specifics.
The shorter answer, sorry, because I can talk at length, is that there are general training requirements that will be needed for everybody that concern everyday safe, good-quality clinical care and helping people frame choices for the end of their lives. There are specific, very specialist areas related to assisted dying that we will need to tailor to the involvement of the people involved. Currently, without the operational detail on the service model, it is difficult to elaborate further on that.
Lord Patel: I was hoping you were going to say that palliative care training should form part of all aspects of training across the board.
Dr Suzanne Kite: I would like to assure you that palliative care is a core part of training everywhere. The models are there. The funding necessary and the funding following the trainer is not. If this Bill comes through, there will be absolutely massive requirements for palliative care to increase its training across the board.
Q62 Baroness Berridge: Professor Sleeman, under the Bill in Clause 25, a co-ordinating doctor must be with the person, so whether they are doing a home visit or are in an institution. You, in your statement, have raised issues about the lack of clarity of the law in relation to complications from self-administration. Could you outline in more detail what you see the problems are in the circumstances? You talk about complications. Could you also outline what the law is if, sadly—I think the phrase is “lightening”—someone comes back and is communicating something? What would be the obligation on the doctors if relatives are there and saying things like, “Finish them off”, or, conversely, they are saying, “Save me”? What is the legal position for the co-ordinating doctor?
Professor Katherine Sleeman: We, the CLADD group, think that clarity is needed on the doctor’s role in the event that there are complications following self-administration. The Bill as it is drafted, we think, puts not only the doctor but, frankly, the patient and their family in a really difficult position should complications arise. It requires the doctor to be present, but without providing any clarity on what steps they can actually take should those complications happen.
I should note that complications occur in about 10%, maybe 8% to 10%, of assisted deaths that happen in Oregon, so this is not a rare event. They are things such as vomiting, regurgitation and seizures. We need to understand what the doctor is allowed to do and what their powers are in the event of those complications or other distress.
We also need clarity on what the doctor should do should, for example, a person take too long to die. How do we define “too long”? We have heard that this Bill requires that the doctor must stay with the person until they die. That is potentially a very tricky situation. If they are at home, where the person wants to be, what does the doctor do if the person takes an hour, two hours or three hours? In Oregon, the most recent data from 2024 showed that the time from self-administration to death ranged from seven minutes to 26 hours. What does the doctor do in that situation? At what point is the person taking too long to die and what are the doctor’s powers?
I am not a legal expert. I am a clinician, but I would suggest that it is illegal for the doctor to, for example, give the patient an injection in order to cause their death. That would be euthanasia. That is not what this Bill is about. I think that in that situation the doctor would stand back and wait for the person to wake up, but we need clarity in this Bill.
Baroness Berridge: Can you draw out the scenario? Is there clarity around expression of wishes by relatives? Say for instance one relative says, “I have power of attorney. They do not have capacity. I can now decide what happens”. Is this Bill clear at that interface with power of attorney and those expressions of wishes by relatives?
Professor Katherine Sleeman: My understanding of this Bill, and my understanding of homicide laws, is that it would not be possible for the doctor to step in and give an injection to speed things up with the Bill as it is currently written. I do not think that that is the intention of the Bill sponsors that the doctor should be able to do that. That is my understanding.
Baroness Berridge: Would the relative’s wishes have any legal validity or not in that scenario, or do we not know?
Professor Katherine Sleeman: I think that they would be the same as in any other scenario. I would hope that the doctor would have power to relieve symptoms and distress, for example, but it would be helpful to have how far that power goes specified.
Professor Sam Ahmedzai: I totally agree with Professor Sleeman’s view of the range of problems that can happen. Mostly, things happen according to plan, but there are some tail ends. The point I wanted to make is that end-of-life care in normal palliative care also goes wrong and many people do not have a good death in palliative care. We have to have contingency plans for when patients are slipping away and then start vomiting or have convulsions, so it is not that different from normal palliative care. We published on this in the BMJ earlier this year.
Baroness Berridge: The question is not about whether there are bad deaths; it is whether the law is clear on, for example, the double effect of injecting morphine. Thank you for your contribution but the question is about whether the law is clear. Do you have a view on whether the law is clear under this Bill?
Professor Sam Ahmedzai: Looking at the clause, what could be clarified are the steps a doctor could take, but I do not think that that would be in a document such as this. It would have to come from the Secretary of State when things such as the drugs are being decided as well.
Q63 Lord Markham: May I start by thanking all of you? I have personal experience of the brilliant work all of you do. I am a big believer in palliative care. Again, I have seen it first hand in many instances. I am interested to explore a bit more some of the comments Professor Ahmedzai was making. My understanding is that not everyone who wants to have assisted dying requires palliative care. For a lot of people, it is about the comfort of having a time of their choosing and, as you say, being able to pass away at home, surrounded by loved ones. While palliative care is very important in this, I do not think the two are inextricably linked, in that assisted dying should be allowed only if palliative care is totally set up in certain circumstances. I would like to understand your research more, please.
Professor Sam Ahmedzai: That is a really important issue that you raised. It is not as if—let us be honest—palliative care reaches all the parts that it should do. Palliative care has been very good at looking after patients with cancer. Because I come from an oncology background, I know that we are pretty good at it. Once you move away from end-of-life cancer into heart, lung and neurological diseases, the numbers and the proportion of patients cared for with those conditions in hospital-based, or particularly hospice-based, palliative care are very small. Many of those patients are suffering as much as cancer patients, and sometimes for much longer than cancer patients.
Those are the kinds of patients where, if it was determined that they had six months left to live, they would not even normally be on the radar for palliative care services. I do not think that palliative care services could cope with some of those non-cancer patients, or even cancer patients where they are still having treatment but clearly are coming to the end of life. Normally, palliative care services do not get involved with those. I agree that there could be a stream of patients who would be candidates for assisted dying, because of a short prognosis of six months or less, who are not under the purview of palliative care, but would be eminently suitable for choosing when their time was coming up through a Bill such as this.
Dr Suzanne Kite: I have worked in an NHS large teaching hospital for the last 25 years. I have experience with hospices in my training. I am on call. I was on call last weekend for the hospices in my city and the community.
We have put so much work into addressing those inequities. Currently, it is about parity between cancer and non-cancer patients referred to our service. It is usually not that simple. Often, people with cancer also have multiple comorbidities. We work so closely with all of our other specialty colleagues. You will be hearing from the British Geriatrics Society tomorrow. We work with neurologists, vascular surgeons and oncologists, lots of people.
We work in a variety of ways. We directly see patients with the most complex symptoms. We provide telephone advice to specialists. We improve the quality of the end-of-life care for every single person, or we try to anyway, in our hospital, including those we see and those we do not see. We put an immense amount of our resource in reaching out and trying to address the palliative care needs, and having an impact for as many people as we possibly can in our NHS hospital.
Also, we really encourage—and my colleague has done so much work on this—those earlier conversations. When a patient comes into hospital and appears to be in the last months or year of life, we encourage conversations around what they would like to do in the future if this problem recurs and what their wishes are for the future going forward regarding the intensity of care. We record those conversations. Currently, over 1,000 conversations such as that are recorded and follow the patients home every month, so we are doing so much.
Lord Markham: I know. As I say, I have seen firsthand just how brilliant and necessary it is. Fraser Rickatson, I would like to move on to your point about care homes being able to opt out. It is a sensitive issue here. I completely understand why individual clinicians might have reasons for opting out. My concern is that, if a whole home opted out—you made the point yourself—it is people’s home. Them wanting to be able to pass away in their home using assisted dying is a perfectly understandable act that they would like to do.
I would like to unpack that a bit more. I think you mentioned that otherwise maybe there could be some sort of visiting service, so that, even if the clinicians did not want to administer it in the home for individual reasons, which has to be their choice, there would be a facility where other clinicians could visit and allow that to happen.
Fraser Rickatson: We need to look at this answer in two different ways. There is willingness and there is also capacity and capability. There are a number of services that operate on a faith-based operation of care. There are Catholic, Jewish and Muslim homes. In accordance with their religion, they do not believe in this type of care. However, in those circumstances, it is typical that the individual receiving care in that area will not want to consider that option of support or end-of-life care.
The reason why we want to have an opt-out is, in case of any regulatory function, which we believe could be the CQC’s operation, of looking at providers’ policies with this Bill, so that they can say, “As a service, due to these beliefs that we hold, we are withdrawing our support, but we have the procedures in place so that if, for whatever reason, anyone wants to do it, there is the programme that we can follow to make sure that they get that care that they need”.
Lord Markham: I assume that the residents would know before they choose to go into that home whether that home was offering it or not for religious purposes or whatever.
Fraser Rickatson: Absolutely, yes. In the survey as well, there was a massive concern about capacity and capability. There is a distinction between nursing homes and residential homes. A quote here that I would like to highlight from our survey is that a distinction will need to be made between residential nursing homes, given the different clinical capacities.
On top of that, there are concerns about access to support with palliative care, because some services will not have that internally. Only 27% of survey respondents reported 24/7 access to specialist palliative care support on-site. Whatever changes come with this Bill and whatever comes to pass in the end, it needs to come with a fully funded package to support the sector in making sure that this care can be delivered if it is required by law.
Q64 Lord Goodman of Wycombe: This is a question for all or any of you. Many of the people watching these proceedings or following the Bill will be assuming that assisted dying, if it becomes legal, will be provided by the NHS, whether it is delivered at home or elsewhere. Actually, under the terms of the Bill, we simply do not know, because the Bill says “may”. Is that a matter of concern to any of you that we simply do not know?
Professor Katherine Sleeman: It would be very helpful to have clarity on that. I am not sure that I would describe it as a concern. I might describe it as an opportunity to consider a de-medicalised model. We know that several countries have adopted de-medicalised approaches. Switzerland is probably the clearest example. In Switzerland, assisted dying is considered a civil rather than a medical act and doctors are part of the process. They volunteer with right-to-die organisations to perform the necessary measures.
A de-medicalised model may be preferable in the UK, partly because it would remove the involvement of the healthcare service. It would remove, to a large extent, the concerns that we have already discussed around trust in the NHS to provide high-quality care towards the end of life. I would really like to see consideration of a de-medicalised model.
Professor Sam Ahmedzai: While I appreciate what Professor Sleeman has said, I do not think you can argue, “Assisted dying could go wrong and therefore you might need some medical intervention”, but then de-medicalise it. There needs to be a medical input, whether that medical input comes from the NHS, independent sector or possibly even private sector in some other places. That needs to be thrashed out. Remember that currently palliative care is a mash of different kinds of providers, so I do not see why assisted dying should not also be that. I agree that some further clarity would be helpful.
Professor Katherine Sleeman: Could I respond? My intention was not to suggest that we would remove doctors from the process entirely, just that it would not be part of the health and care system. That is the distinction.
Lord Goodman of Wycombe: To anyone else who has not spoken so far, whether one is in favour of a de-medicalised model or not, do you agree or disagree with the Delegated Powers Committee, of which I am a member, that all this should be set out on the face of the Bill so that it can be debated?
Dr Suzanne Kite: Yes. A point that has not been made is that the NHS is the default provider of palliative care in the country. That is where most of us will receive our palliative care. Specialist services are available. If assisted dying is part of core NHS business, delivered by routine clinical care, all the issues people face about not wanting to access care and lack of trust will follow, and there will be potential compromise between the needs of different groups and all of the resource issues.
My understanding is that we would need to change the NHS constitution, which is set up for health. We would need to define what is and is not a medical treatment. It is a big muddle and that would all need articulating. Until you unpack those issues, you do not know what is the safest operational model for delivery.
Lord Goodman of Wycombe: Finally, perhaps to the other two witnesses who have not been able to speak, is it a matter of concern that, if it is not provided on the NHS, there is a risk, therefore, that assisted dying simply becomes a service for the well-off?
The Chair: Toby Porter, I think you wanted to speak.
Toby Porter: It was to answer the earlier point about one of the challenges for hospices. We have not supported either opt-in or opt-out as a blanket right so far, because we do not feel that there is enough detail for hospices to know what they are being asked to opt in to or opt out of. It has made thinking about and preparing it very hard. You know that the sector will be hugely impacted by this but there is no detail, so at this point in time it is very hard.
Lord Goodman of Wycombe: It is a matter of concern to you that the detail is not in the Bill.
Toby Porter: It is the way that the people drafting the Bill have chosen to do it. There will be a long implementation period. There is now an amendment that requires the Secretary of State to consult with palliative care providers. Undoubtedly, a complexity facing the sector at the moment is knowing that this would be such a momentous change for the sector, but not really knowing exactly how that would be felt and manifested.
Q65 Baroness Hayter of Kentish Town: I cannot at the moment think of a question for Mr Porter, but I would like to congratulate you because I think I woke up to hear you on the radio this morning.
Toby Porter: I congratulate you on having slept as late as 8.20 am.
Baroness Hayter of Kentish Town: Oh dear. What a giveaway. I have certainly been fundraising for hospices and I have a close family member who works for the hospice movement. I would like to take up the question that Lord Goodman has just done about inequality. A number of us have a concern that it is particularly those who can afford it who can access end-of-life care at the moment, because they are able to go to Switzerland. Professor Ahmedzai, you talked a bit about inequality and I think you meant within the country. I would be interested to know what you know or whether any research has been done about those who are able to afford at the moment to access assisted dying by going to Switzerland.
Professor Sam Ahmedzai: Yes, that has been an option open for many years. I cannot quote you the actual numbers but it is probably several hundred patients a year who can make that trip. The problem is that, not only do they have to have the financial resources, but they need to be constitutionally well enough to be able to get on to a plane and go over there. Many patients who take that step are possibly ending their lives earlier than they really should, just so that they can be there.
I would like to remind, or maybe inform, Members here that we have a plurality of models for palliative care in this country. There are also private palliative care services working in the country. It is not for us to dictate how palliative care should be given, just to make sure that, wherever it is given and by whichever model, whether NHS, hospice or supported private services, it is done to the same very high standards.
Baroness Hayter of Kentish Town: Coming back to you again, if this Bill goes through—it may get amended—how do you think that will improve what we have at the moment in this country?
Professor Sam Ahmedzai: The numbers of patients who would benefit from assisted dying are obviously very small compared to those who currently, and we hope would increasingly in the future, benefit from palliative care. That has to be what we want to do, to give more people palliative care, but there should be a small proportion of patients who would access assisted dying.
How that will impact on the overall equality of services depends on how well palliative care services are already reaching out to different populations. I hinted earlier on that there are already some diagnostic groups of patients who do not really get offered palliative care. Asking for assisted dying through the Bill may open the door to palliative care, but many of those patients may not have thought of it before. Having assisted dying could help to increase equality. Even though it is not necessarily being pushed for from the palliative care world, the Bill could help to do that.
Professor Katherine Sleeman: My sense of this is that, yes, this Bill helps one small, but important, group of patients, as Professor Ahmedzai has said. But it also has the potential for harm to another much larger group of patients: people who are at risk from this Bill. That is why this is difficult. That is the complexity here. If we simply focus on those who might benefit from this Bill, we are at risk of ignoring a much larger group of people who are at risk.
Baroness Hayter of Kentish Town: That is why we have a committee and we are all working on it. If this was easy, people would have done it before. I do not know the answer to this. Any of you who have done international work I am sure will be able to tell me. My understanding, but I am not an expert, is that a number of people who go through, in other countries, whatever safeguards they have actually never avail themselves finally of it, but it seems that it gives them—I do not know—some comfort or something. Any of you who have looked internationally, is that right? Do you know what the figures are of people who finally, even being allowed it, do not actually use it?
Dr Suzanne Kite: I confess that, working in the NHS, I do not have the time, unfortunately, to go to other countries, which I know other people have done. I have certainly read in the literature that it is a great source of comfort to know that it is possible. Relatives in Australia have told me that.
Toby Porter: It is a scenario of operational complexity. You are definitely right, by the way. People talk about it being the last insurance policy that many people take out if they meet the criteria. They go down the palliative care route, and some people choose to avail of an assisted death and others do not.
Also, you can see one of the operational complexities in that. For example, if a hospice was to say, “We will have nothing to do with you if you wish to have an assisted death”, the risk is that you would deny someone’s right to receive specialist palliative care. A problem we see is that this idea of an institution either completely opting in or opting out does not really do justice to that complexity. There will be some people who will want palliative care and then take a different decision. There are other people who may have taken a different decision, but will feel very well cared for and reassured, and their death will take its natural course.
Professor Sam Ahmedzai: To answer that point, I have lots of statistics here, but not that particular one. I recall that it was either in the US or in Australia where roughly a third of patients who had the prescription did not avail themselves of it. It could be for several reasons. It could be that their disease progressed very rapidly and they could not. It could be that, in going for assisted dying, the door was opened to palliative care and they got everything they needed from there. That is also a good reason not to use assisted dying if the palliative care then opened itself up. The majority of people who want it will go for it. The trouble is that it usually comes too late.
Baroness Hayter of Kentish Town: I think that the estimate is 5,000 to 7,000 people a year who might actually go through this. Does any of you have worries that we are almost setting up too big a structure for quite a small number? I think that you said it was going to be a very small number of people. If we are not careful, the tail will be wagging the dog, if you like. Does any of you have a concern that we are going to go too far in preventing that small number of people being able to come forward?
Toby Porter: My concern would be if we did not do something for the other 99.5%. It is not really a concern about what we might do for the 0.5%. The quixotic thing would be for all our fury and focus as a country to go into this tiny percentage while ignoring all the people having bad deaths, if you like.
Baroness Hayter of Kentish Town: I think that we are all agreed on that bit.
Professor Katherine Sleeman: It comes back to the point about there being two groups. We are not putting in these safeguards in order to make things more difficult for the people who want this. We are putting them in in order to protect the wider population of people approaching the end of life. In my view, it is very important to protect those people.
Q66 Baroness Finlay of Llandaff: I wonder whether Professor Ahmedzai slightly misspoke. If I heard you rightly, you said that several hundred people went to Dignitas each year. Actually, in 2024 there were 37. I wondered whether you meant overall, but you can pick that up later.
I have a research question, because you have done a lot of research work on drugs of different types. I wondered why you felt that there has been no published research and evaluation on the different drugs that are used in different legislatures. Some of the ones used are not licensed in the UK for human use. They are licensed only for animal use and with very variable times to death, as we have already heard. I wondered what you felt the research should be that needs to be done. Then perhaps I have another research question after that.
Professor Sam Ahmedzai: Yes, I misspoke. I almost felt I was doing that as I said it, because I did not have that figure. I was thinking of the overall picture over many years.
To come back to the second point about the drugs that are used, yes, there have been publications analysing patients who received different kinds of assisted dying, whether it has been intravenous or oral. We commented on that in our blog in the BMJ earlier this year. There has not been prospective research. There are no trials. They have been collecting observational data, so that is available. In terms of the licensing, a lot of the drugs we use in palliative care are unlicensed or used off-label, so that is not unusual in palliative care.
Baroness Finlay of Llandaff: I was talking about them being unlicensed for human use. The drugs that we use in palliative care have all been licensed for use in humans and there are recommended doses for different situations, but here you are using massive doses of drugs, sometimes 50 to 100 times a therapeutic dose. In Oregon, they have had very different mixtures. I have not seen any research into why one mixture is preferred over another and what the mode of action is of these different drugs. I see Professor Sleeman nodding. I wonder whether you want to pick up on that.
Professor Katherine Sleeman: The reason why, if you look around the world, different jurisdictions all use different drugs and drug combinations, is that we do not have that evidence. We do not know which drug or drug combination works better than another because they have not been tested. We do not have strong enough evidence to tell us.
Baroness Finlay of Llandaff: Moving on to something completely separate, you have highlighted the number of bad deaths that happen in the UK. I wondered whether you felt that unsafe care that is currently happening within the NHS will result in wrongful deaths through assisted dying. What percentage of deaths would you accept as wrongful deaths, given some of the work that has been done, where you have suggested that people have died inappropriately? In your statement, you highlight the Liverpool care pathway as a source of wrongful deaths.
Professor Sam Ahmedzai: I do not think that any wrongful death or proportion of wrongful deaths is acceptable, but we have to accept that, in all areas of healthcare, there will be mistakes and casualties. My reason for mentioning the Liverpool care pathway in my statement was that there was an example where the hospice movement felt that it had a model for delivery of end-of-life care. It was spread out, with NHS and Department of Health sanctioning, across the country to people who were not familiar with those techniques and not expert in how to use those drugs, which are standard drugs, by the way. A lot of people received poor end-of-life care, which is why it was abolished.
Baroness Finlay of Llandaff: Dr Kite, how often do you find that, when you see a patient, there are areas of unmet need that nobody had recognised before? What do you see as a risk of coercion and pressure on people to go down this road, where they are made to feel a burden, perhaps by the system that they are in—they are worried that they are blocking a bed—or by their family, who are worried about the cost of care when they go to a care home if they cannot go home to their own home?
Dr Suzanne Kite: You touch on things that are part of our daily clinical practice. When we see people, they often have a lot of misunderstandings. I can always say with confidence that we will pick up something. I cannot always tell you what it is. Sometimes we are asked for a referral for someone who has very complex needs, then we go and it is all very straightforward. Sometimes we think, “This looks very straightforward”, then we go and we pick something up. Through a process of visiting, sometimes it is very obvious what that is. Sometimes you build up a pattern. You think that it does not quite fit, so you go back with your multiprofessional team and address the issues.
The hidden costs of caring for people at home are very pertinent and becoming more pressing. We very rarely see in practice the very overt coercion, but we see a lot of internalised coercion when your son or daughter has given up work to care for you, willingly and knowingly. People feel those pressures. We know that there are pressures of, “Can we afford the electricity for the oxygen supply?” There are all these issues. Yes, these are issues we deal with on a daily basis.
Fraser Rickatson: It is really important that we not look at this Bill in isolation, but look at the wider pressures within the health and social care sector. In the adult social care sector specifically we are looking at around a £5 billion funding gap for all services. That is residential, home care and working-age adult services. There will be that systematic pressure in the sense where, when this Bill comes to pass and there is funding only for a certain type of care, there could be an endorsement of a certain type of care over anything else. If this Bill comes to pass and comes through, we need to make sure that there is a whole complete funding package for all sectors, so that the individual’s choice is not in any way influenced.
Professor Sam Ahmedzai: Sir, through you, may I ask Baroness Finlay to clarify the point she made about drugs that were not for human use? Could you be more specific please, because I think you need to explain?
Baroness Finlay of Llandaff: I am slightly cautious about mentioning its name because if you put it into a Google search an alert comes up: “Do you need to see the Samaritans?” It is the drug that is used for euthanasia of dogs. It is licensed for that in this country and has been used by vets for suicide, but I think we should move on.
Professor Sam Ahmedzai: I have never seen that used in assisted dying.
Baroness Finlay of Llandaff: It is used in assisted dying in some countries.
Q67 Baroness Scotland of Asthal: Can I say, to each and every one of you, thank you so much for this information? It really has focused our minds on the needs not only for the minority but for the majority. I was very struck by what has been said about the 99.5%. I want to ask, if I may, a specific question in relation to the impact. Do you feel that, at the moment, there is real choice for individuals if there is not a sufficiently funded palliative care service? Is that a real choice as to what they can do?
Dr Suzanne Kite: You have hit the nail on the head. That is very much where we are coming from, as the Association for Palliative Medicine, in trying to ensure that choice is at the heart of what we are trying to do.
Baroness Scotland of Asthal: I get the impression from what you are saying that, at the moment, so many people do not have a choice because their choice, if it was available, would be palliative care.
Dr Suzanne Kite: Yes, that is what we are saying.
Baroness Scotland of Asthal: If we are thinking about where we should focus our resources in order to ensure people have the real choice, from what the panel are saying, that focus should be on providing the 99.5% of people who need it with the service that they should have.
Dr Suzanne Kite: Yes. I think what we have struggled with over the years is that, when I go and talk to managers and commissioners, there is a very clear need, and it works on every level, to prioritise co-ordinated palliative care. It is very rarely the top priority, and that is our problem. How do we become the priority among the sea of priorities? That is why we need a national policy. It is why we need robust commissioning, service specifications, outcomes. It is a hodgepodge. It needs to be pulled together, and our patients access care in all settings. I work in the middle of a hub-and-spoke regional area. All of that has to join up. It has to be done at that level.
The Chair: Professor Sleeman, you wanted to add something.
Professor Katherine Sleeman: Yes, please. We have just published some detailed modelling work that estimates that specialist palliative care not only reduces distressing deaths, et cetera, et cetera, but has the potential to save the NHS significant amounts of money. Our estimates show that about £8,000 for each person who dies at home would be saved if they received specialist palliative care, and about £6,500 for each person who dies in hospital would be saved. Palliative care is a high-value intervention. It is a rare thing in health and care. It improves outcomes for patients and carers, and it improves value for the system. It saves the system money overall, so absolutely that is where we should be focusing.
Baroness Scotland of Asthal: The other evidence that you seem to be giving too is that, if people have that sort of care, their likelihood of choosing to have other assistance diminishes exponentially.
Professor Katherine Sleeman: We know from evidence, and I see it in clinical practice, that palliative care can alleviate the wish for a hastened death. Palliative care can help people who want to die want to live. That is why the CLADD group believes that a palliative care assessment—just a single assessment—is absolutely essential as part of that preliminary discussion. It will not identify and solve all suffering. You cannot do that in a single assessment. You need three to six months of palliative care to be maximally effective - I appreciate that is out of the scope of this Bill - but a single assessment would pick up suffering that has not been identified so far, and suffering that could be alleviated.
Baroness Scotland of Asthal: If I could just stay with that for the moment, I was very struck that a number of you have said that a multidisciplinary assessment taken early—and I think it was said by almost all of you—gives equity of access. Would it be helpful if clinicians were to be advised that, where they have a patient who has a multiplicity of difficulties and they think may have a limited lifespan—six months—at that stage, there should be a multiagency risk assessment as to how to manage holistically the end-of-life care? Instead of waiting to the six weeks that I think one of our colleagues spoke about, they could do it early. Would that be helpful?
Dr Suzanne Kite: I think it would. It takes different formats. I think, within all of the cancer guidance, it is called a holistic needs assessment. I think the geriatricians tomorrow will talk about comprehensive geriatric assessment, frailty assessments, so it takes on different guises, but certainly, yes. The point for us is that you cannot go on prognostic time, but when people’s function is deteriorating, the medical treatments are no longer so effective, and there are no more disease modifying treatment options, you can see that people are heading towards the last months or years of life. From that point on, there needs to be high vigilance for assessing need.
Fraser Rickatson: I think that that should be expanded as well to those with non-clinical roles. There are a lot of services in the adult social care sector that may not have that clinical capacity, but there should be guidance and funded training for carers and workers to be able to understand the initial warning signs and to go to multiagency for confirmation and support on how to address that.
Baroness Scotland of Asthal: There is one last issue, because I was very interested in and concerned about what all of you said about families and the issue in relation to seeing the patient. Do you think it is essential that whoever does this assessment must know the circumstances of the family and see them in order to make that assessment a real one?
Dr Suzanne Kite: Ideally, we would always wish to see patients with those people who are really relevant and close to them and who matter. If they decline that, that would be the only circumstances in which you would not. People are free to choose.
Professor Sam Ahmedzai: If I may, can I come back to the earlier point about access to palliative care? It is not just a question, as we have talked about, of the volume and making it available to more people. That is really important, but it is the timing as well. Palliative care tends to come very late, and I gave that statistic of an average of six weeks. It could be eight weeks. The point is that most of the suffering has already been happening, in cancer and in other conditions as well.
The NICE guidance NG142 says that, from about the time when you think somebody is in the last year of life, you should switch gear, so these patients are already on the radar. When we then say, “Now they have maybe six months to live”, they are already very far down. Palliative care will be even further down, so to have something such as assisted dying available earlier for those patients as an option is an excellent idea. They may not need it, but why not just have the facility for patients to think about assisted dying, and then, if and when palliative care knocks on the door, they could try that as well?
Professor Katherine Sleeman: On capacity, complex capacity assessments do conventionally require triangulation, with input and information from the family. This is, by definition, a complex capacity assessment, so yes, that would be fairly standard that the family would be involved in this kind of an assessment.
Baroness Scotland of Asthal: Is it not right that the trigger should be an assessment of the patient or individual’s need as opposed to either assisted dying or palliative care? If you have got them clinically in need of care, that is the moment that you have to make the assessment, and it goes whichever way it goes thereafter. Am I right in that?
Professor Sam Ahmedzai: You are absolutely spot on. It is a holistic needs assessment that is required. NG142 said you should do that when you recognise that somebody may be in the last year of life from whatever condition.
Baroness Scotland of Asthal: So you do not need the catalyst of someone saying, “I want it to be assisted dying”. You need to make that at a time when they need it, so they have all options open to them.
Q68 Baroness Smith of Newnham: We seem to be almost unanimous in the importance of adequate palliative care, even noting that, for some people, it might not be an option they wish to take, but it also seems to be an issue that, at the moment, there is not adequate palliative care available across the country. Professor Sleeman, in her opening remarks, said there are currently 100,000 people a year dying who do not have access to the palliative care they need.
Clause 5 of the Bill is currently framed to say that a medical practitioner would need to make clear to somebody in a preliminary discussion all appropriate palliative care, hospice or other care that is available. Given that we already know there is not adequate palliative care for those who are seeking to access it, as Professor Ahmedzai said, now very late in the day, are there going to be sufficient safeguards in this Bill for everyone, or are those people in areas that do not have adequate palliative care going to face less choice? If they do not have adequate palliative care, will they be told, “Well, we could offer you this, but it does not exist in our area”, and might that make them more prone to think an assisted death might be the only option for them?
The Chair: I think everybody is putting their hands up. Shall we start off with you, Fraser Rickatson, first and go along the line? I am not sure whether Toby wanted to make a point as well.
Fraser Rickatson: I am just going to take a step back from that question specifically and talk about the entire sector. I think that this Bill, and through its implementation phase and when it gets further amended, et cetera, should trigger a wider conversation on a long-term funding settlement for the adult social care sector in its entirety, including palliative care but going beyond that to residential care services.
At the moment—you are absolutely right—there is a postcode lottery and there are people either stuck in hospital or people at home who need that support and are unable to access that because the funding situation or workforce situation is so dire in some localities that they cannot get the access to care that they deserve. That is a problem that needs to be addressed more widely, but I will pass over.
Dr Suzanne Kite: I share your concern. Our members share your concern. That is fundamental to our position on this Bill.
Professor Sam Ahmedzai: I feel that the Bill is, basically, a passport for patients who want to talk about assisted dying, such that they would then get a door open to access palliative care if they also wish it and need it.
Professor Katherine Sleeman: I think your point is exactly why the CLADD group has suggested that offering a referral to specialist palliative care is not enough. Everyone who says that they want an assisted death should receive a palliative care assessment, and that would go some way—not all of the way, but it would go some way—to addressing what we know about the inequalities in terms of access.
Q69 Baroness Berger: If I can just pick up on one of the points that was made, Professor Sleeman, I was struck by your response to the question from the Lord Bishop of Newcastle when you said that inequalities in this country will be worsened by the passage of this Bill. Can I ask you, perhaps together with Dr Kite, how specifically you think this Bill, as currently drafted, will widen inequalities with reference to the protected characteristics in the Equality Act of 2010, but also to socioeconomic disadvantage?
Dr Suzanne Kite: I have already alluded to the fact that there is, from some minoritised and ethnic groups, a fear and mistrust of healthcare services, particularly since the Covid-19 pandemic, and I think that the fears around that will influence access. I think about the current situation where we are seeing palliative care services being reduced. We have seen the report from this morning that Toby Porter has referred to. NHS services are always constrained.
Whenever there is a resource shrinkage or a lack of services, it impacts most the most vulnerable, who will be people from minoritised ethnic groups, older people, and people with certain diagnoses. So, yes, they will always bear the brunt of it when things are stressed and strained.
The Chair: We are right up against our time, and we have another panel to fit in, so I am going to ask Baroness Hayter first and then Lord Winston, and then we will have to stop.
Q70 Baroness Hayter of Kentish Town: Dr Kite has slightly alluded to it, but I think CLADD is saying there must be a palliative care assessment, which seems to take away any agency from the patient, in that you are really insisting they must have this assessment separate from everything else that is going on. I wonder whether you really mean that. I think Dr Kite said that the patient could opt out, but, as a palliative care doctor, would you be willing to participate in that and to give an assessment, even if you, yourself, were not in favour of assisted dying? I am worried about this agency issue.
Professor Katherine Sleeman: The agency issue is really important, but we are requiring people who ask for an assisted death to do all sorts of other things, so, in my mind, it is just part of the process. Yes, I would absolutely be happy to be involved in that process, because it is about identifying unmet need. That is what palliative care doctors and teams do all the time. You are right to ask the question, because we know that a very high proportion of people in palliative medicine are not in favour of assisted dying. It is about 80%—very high. I do not have the data, but my instinct would be that a lot of palliative medicine physicians who are against assisted dying—and I am not one of them—would be happy to be part of the preliminary discussion, because it is about addressing unmet need. That is what palliative care is.
Q71 Lord Winston: This is a very quick question to perhaps either Professor Sleeman or Professor Ahmedzai. There was unclear reference to the way that the drug would be administered. Can I just make a little bit more clarity there? I agree completely a doctor needs to be there, probably continuously. That would be an important part of this. That drug may need changing during the course of the treatment. Surely, that must be in the hands of the doctor, not the Secretary of State. This is part of that medical process that, in fact, is really under the control of the professional taking the decision with the patient.
Professor Sam Ahmedzai: That is a really very good and a very subtle insight into what goes on in that interaction. For a start, the doctor does not have to be at the bedside. The doctor could be in the same area—in a house, it could be in another room—and this is what happens very much in other countries. A lot of assisted deaths occur in people’s own homes, and the health practitioner is sitting somewhere else and called in only when the patient stops breathing.
Do not forget that the normal rules of good healthcare apply to whether somebody is having palliative end-of-life care or assisted dying end-of-life care. If something untoward and unexpected happens, then the healthcare practitioner there—the medic—should kick into action and take measures to relieve whatever else is happening, whether it is vomiting or convulsions. The two ways the drugs can be given are orally or, which we have not discussed in detail, intravenously through a device that is triggered by the patient. It has to be triggered by the patient. If there was intravenous access, then something else could be given to relieve the possible small chance of distress, not to speed up the dying—absolutely not.
Lord Winston: We are running out of time. It is a very important point, but I can see that Professor Sleeman wants to come in.
Professor Katherine Sleeman: I think your question was also asking about whether the specific drugs should be on the face of the Bill. Was that also what you were asking about?
Lord Winston: That is, I think, up to our advisers to tell us.
Professor Katherine Sleeman: I am not a legislative expert, so I do not have a view on that, but it is extremely important that Parliament debates, and is aware of, the safety and efficacy of these various drugs and drug combinations, because it is not obvious which choice one might go for.
The Chair: We will have to leave it there. I am very sorry. We would love to spend more time with you, but we have another session coming on this morning. Can I thank you all very much indeed for your evidence, which is much appreciated, and remind you that the transcript will be sent to you? If there are any errors, please point them out to us. Thank you all very much indeed.
