Daniel Francis
MP for Bexleyheath and Crayford · Labour · United Kingdom
“As the Minister said, we were friends for many years in London local government prior to being elected to this place. I want to make two points. First, there is the issue of the Changing Places that have been provided in recent years and the amount of information out there about them.”
“As the Minister knows, I will hold her to account on this issue and continue to pursue it. I thank her very much for the commitments that she has given today that we can continue to pursue. I thank the hon. Members for Chester South and Eddisbury (Aphra Brandreth), for Bath (Wera Hobhouse) and for Strangford (Jim Shannon), my hon.”
“An expansion of capital funding for Changing Places toilets would lead to people with profound disabilities accessing more opportunities and more families and individuals contributing to our hospitality businesses, theme parks, leisure facilities and sports grounds—the list goes on. There was, of course, a previous fund.”
“I turn now to the importance of maintaining Changing Places toilets. I mentioned last year that, in Bexleyheath town centre, we had to close a Changing Places toilet because of the vandalism it was receiving, with people living in it and dealing drugs in it.”
“Although I acknowledge that changes to building regulations ensure that facilities continue to be installed in new buildings, I retain concerns that older buildings would greatly benefit from having a Changing Places toilet installed.”
“One said: “Without access to an appropriate facility, I am left with impossible choices: ending outings early, avoiding certain venues altogether, or changing my daughter on the floor of an accessible toilet, which is neither hygienic, safe nor dignified.” I have read through the responses to the survey, and there was a lot of appreciatio…”
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“Friend’s intention, but that is the wording that would lead a doctor to have to help somebody make this decision. My question is: how will we overcome that issue?”
“I absolutely accept what my hon. Friend says about training. I know we have separately discussed places in the Bill where we could replace the word “may” for “must” to make the safeguards stronger. However, I come back to the same points as I made to the Minister. The Mental Capacity Act code of practice, which I presume is what we will be relying on, says: “If it is practical and appropriate to do so, consult other people for their views about the person’s best interests”. However, it does not say “must”, and for adults with learning disabilities particularly, that remains a principal concern. Chapter 2 of the code of practice says: “It is important to do everything practical...to help a person make a decision for themselves before concluding that they lack capacity to do so.” I know this is not my hon.”
“The NHS South East London integrated care board provides services to my constituents, and I have discussed some ways in which we could better deliver services by redeveloping the Erith community hospital site in Northumberland Heath. Is the Minister able to provide an outline of the Government’s plan to provide capital funding for expanding community services like those at Erith hospital?”
“If it is practitioner administration, we are also, obviously, testing capacity right at the moment that we are administering the substance.”
“We assume and hope that they retain capacity, and we strongly advise patients and families that, should they lose capacity, they will have voided their permit and they cannot take the drug, but there is less oversight of that. However, we know that the majority—over 80%—of these patients are connected with palliative care, so we often have community teams going in and seeing them, and we are still touching base with them, maybe more peripherally, and checking capacity as we are having conversations or as we are coming and doing home visits from a palliative care perspective. If it were deemed that the patient is quite delirious, the permit would be voided and we would remove the substance from the house.”
“Q I want to ask about capacity. Chloe, I think you said patients are sometimes given the drug some time before they die, so I want to understand where capacity assessments are taken and at what stage during the process. Dr Furst: Capacity assessments are taken every time a doctor sees the patient. In my state, that would be at first assessment—first request—then a consulting doctor would come and do another hour-long assessment of the patient and assesses capacity at that stage, and then I would come back as the co-ordinating doctor for a second or third assessment of the patient, and assess capacity. They would then be given their drug, if it is self-administered.”
“I have looked at mental capacity a lot in research, and there is no experience of the decision to end one’s own life. It is outside the experience of the Mental Capacity Act, the Court of Protection, the associated research and practitioners on the ground. The reference to the Mental Capacity Act in clause 3 puts you into an area where there is no experience of the central capacity question under consideration. It is very important that Parliament be clear-eyed about that. I can talk about the Mental Capacity Act in detail if you like, but that is the main point that I want to make.”
“Q To elaborate on that point, Professor Owen, the Mental Capacity Act 2005 sets out the principles that a person must be assumed to have capacity, that a person cannot be treated as lacking capacity unless all practicable steps have been taken to support them and that a person cannot be treated as lacking capacity merely because their decision is unwise. Is it those issues that are causing you concern about capacity, or is it something else? Professor Owen: It is a bit more fundamental than that, actually. If you look at how mental capacity features in the Bill, the test or the concept that clause 1 rightly invites us to consider—rightly, I think—is the capacity to decide to end one’s own life. The Mental Capacity Act comes in at clause 3.”
“The clause says that the doctor must stay with them but, first, it is clearly not practical for the doctor to stay with them for a number of days, and, secondly, it goes on to say that the doctor need not be in the same room. Claire Williams: Again, I can only apologise, as my evidence is about a committee-based, panel approach to decision making rather than what happens at that point of end of life. I do not know whether somebody else is able to come in. Professor Preston: I can take that if you want.”
“Q My question is to Claire Williams and follows on from Dr Opher’s question. Clause 18(9) says that once the person has self-administered the approved substance, the doctor must stay with them until they have died, or until it has been determined by the co-ordinating doctor that the procedure has failed. We know from overseas that, in a very small number of cases, the procedure may take three or four days, so clearly the doctor cannot stay with them the whole time. Subsection (10) says that the doctor need not be in the same room as the person to whom the assistance is provided. I want to understand how that could be strengthened in terms of safeguarding.”
“That is why I was saying that it is about having advocacy support around that discussion and, as you were saying, about the role of families. Individuals should be able to choose who supports them with those discussions, whether it is friends or family members or an independent advocate—that would probably be our preference—who is specifically trained to support people with a learning disability who are considering their end-of-life options. There is a lot that could be done in addition to what is in the Bill already to potentially much better support people who are considering end-of-life options and to have other professionals who could input into multidisciplinary discussions, potentially around capacity assessment.”
“The question would be whether, when someone who is terminally ill puts themselves forward for assisted dying, doubts start to emerge about whether they actually have the ability to make that decision in terms of whether they can understand, retain or weigh the information and communicate their intentions. As I mentioned earlier, our concern is how those discussions around assisted dying are initiated. For many people with a learning disability who are terminally ill and in an incredibly vulnerable position, doctors are very important and influential figures. Having a doctor come to you and say, “What do you think about assisted dying—is that something you might want to consider?” could move them towards or into potentially accepting a course of action that they had never considered before.”
“Q My question is to Dan Scorer. In the Mental Capacity Act 2005, the definition of “capacity” means that many people with a learning disability are presumed to have capacity. We have heard comments from others on the panel, and I am trying to understand whether you feel that the existing provisions in that Act would cover those with a learning disability or whether you would need that greater advocacy, as you discussed, or something different from the Act. Do you have any comments on the fact that family members—lifelong carers, in many cases—would have no requirement, under the Bill or the Act, to be involved in the decision or to comment on their family member’s capacity? Dan Scorer: The Mental Capacity Act starts from the principle of presuming capacity.”
“Please will you advise me, Mrs Harris, how I could secure such a motion to adjourn the Committee until we are in receipt of the evidence, as advised by the witnesses yesterday?”
“When we agreed the timetable for line-by-line scrutiny last Tuesday, we were not aware that this assessment would be produced, given it was first reported to the House during the money resolution last Wednesday. There is a risk that there will be a bigger impact on people with protected characteristics, and this will not be understood fully until the Government have produced the equality impact assessment. As things stand, that means that we will move into line-by-line scrutiny of the Bill on 11 February without a full understanding from the assessment of the impact of the Bill. I am therefore minded to request a short Adjournment of the Committee so that, as advised, we can receive the assessments before we progress to line-by-line scrutiny.”
“We heard from Dr Sarah Cox and Dr Jamilla Hussain that evidence from their work shows that this Bill has a higher probability of pushing minority groups further away from seeking healthcare, while inequality pre-exists. As observed through the pandemic and from available data, minority groups do not always trust that their interests will be best represented in institutions that would enable the facilitation of someone’s death, should this Bill become law. I therefore believe that on the basis of that advice, so as not to inadvertently widen health inequalities through Bill, it is essential to have health impact assessments. I appreciate that an equality impact assessment will be produced for Report stage, it will not be available for detailed line-by-line scrutiny.”
“On a point of order, Mrs Harris. Yesterday, we heard evidence about the impact of the Bill on different groups with protected characteristics, including age, disability, race and sexual orientation. We heard from the EHRC, an arm’s length body of the Government, that it strongly recommends that a full impact assessment, a human rights assessment and a delegated powers memorandum be undertaken before the Committee begins line-by-line scrutiny. We have also heard from witnesses about the impact that the Bill will have on disabled people, from Disability Rights UK and others, on black and minority ethnic people, from Dr Jamilla Hussain, from LGBT people, from Baroness Falkner, and on those from a low-income background, from Sam Royston of Marie Curie.”
“Q My question is to both Dr Mullock and Professor House. In your written evidence, you both refer to clause 18(9) and issues regarding the obligations of the doctor if the procedure either fails or if there is a long-delayed death. I accept that it is a small number, but we know from elsewhere that there are cases where the death takes some days—three to four days in some cases—or where the procedure fails. The Bill says that the doctor must stay with the person for the entirety ofthat time. I am trying to understand from your written evidence how you feel that measure should be amended to make it stronger, because at the moment there is no mention what the doctor should do to intervene, and clearly it is not practical for a doctor to stay for three to four days. What are your views on how that could be amended?”
“Q Ms Hadi, we heard evidence this morning that the majority of disabled people support the Bill. I would like to hear your comments on that. What analysis do you have on whether the majority of disabled people support the Bill? Baroness Falkner, based on what we have just heard, if we had had the equality impact assessment before oral evidence was sought and before line-by-line scrutiny, would you have supported the approach more? Baroness Falkner: My answer will be very brief. Every additional piece of analysis is helpful, because there are gaps in the analysis. The problem is that because we have not had a consultation, and because the process of deliberation was not transparent—it never will be with a private Member’s Bill—there is a sense of not knowing quite enough as to the reasoning behind—”
“I always say that people do not know that they have six months to live until they have six weeks to live. We as oncologists do not know that either. In a matter of one CT scan, we can change a person’s prognosis from 18 months to three months. All of a sudden, they start thinking about how they see their life ending, and then they have to engage in a process of application. Out of that three-month period, it might take a month to apply. My recommendation has always been to increase the prognostic eligibility criteria from six months to 12 months and to remove waiting periods, which patients will place on themselves regardless of the legislative requirements.”
“My experience, and that of an almost homogeneous group of practitioners, is that patients serve their own lock-out periods, grace periods and periods of reflection, as I believe you have called them, before applying. Subsequently, there are several logistical pauses throughout the process, which also instigate their own grace periods. The addition of further periods for reflection is, I think, superfluous and unnecessary. Secondary to that, in all our Bills and Acts, we have an ability to bypass those waiting periods. Forgive me if I am wrong, but I did not see the capability to bypass any of those in your current Bill. If the person has a prognosis of less than seven days, they should be able to be expedited and not serve that time. I do not see the purpose of putting extra time on these people to apply for this.”
“Q Yesterday, we heard from some clinicians from the USA, who outlined how they have reviewed the scheme in practice. They said that their waiting period between the two clinician appointments has been reduced from 14 days to 48 hours, and that in some cases the second clinician has been removed and replaced by a nurse practitioner. Have you undertaken a similar review? Have you made any changes as a result? Dr McLaren: We are undergoing our review at the moment. It was meant to commence after the first five years of operation of the Voluntary Assisted Dying Act in Victoria. That review has yet to be tabled or published. Certainly, the recommendations that we have submitted to it involve reducing or removing the so-called grace period, or waiting period.”
“There is also, in some states, the ability for a suitably qualified nurse practitioner to be the administering practitioner in the case of practitioner-administered voluntary assisted dying.”
“Q Could I clarify whether there is also a review of keeping two clinicians in the process? We heard yesterday that that is not the case elsewhere. Dr Mewett: One has to understand that although there are some broad similarities, there are a number of differences state by state, and now the Australian Capital Territory has legislation. In the ACT, they have passed legislation, although it has yet to come into practice, whereby one of the two assessing practitioners could be a suitably qualified nurse practitioner. In all the other states of Australia, each of the assessing practitioners has to be medically trained. Different states have different requirements.”
“It is not clear to me what problem people are trying to solve by doing that, given that the Mental Capacity Act clearly makes the point that the more severe the decision, the greater the degree of capacity that has to be assumed before people can actually take that decision. That is the foundation of some of the disquiet that people have had, but it is central to how the Mental Capacity Act works in practice.”
“The reason why I think it is sensible to base yourself on the Mental Capacity Act is that it is well used and well understood in practice by practitioners every day. Having a system with two completely separate groups of assessment, one of which has never been tested in the courts or used outwith this Bill, would lead to a whole set of potential complications and ambiguities, which are not there at the moment because we have a well-tested mechanism through the Mental Capacity Act. People should move away from the Mental Capacity Act with some caution, because I think that will cause as many problems as it solves.”
“I want to understand your viewpoint on whether it would provide stronger safeguards if those parts of the Bill were tightened to include “must” rather than “may”, and if the reference to capacity were replaced with a separate definition of “ability”, as proposed in our amendments. Professor Whitty: I am probably not the best person to ask about the exact drafting of the Bill in terms of “may” and “must”, but I can answer the second part of your question, which is really important. If there were no Mental Capacity Act, there would be an argument, which has been used for a long time, that the Bill would have to define what was meant with a fair degree of clarity. It would not be able to do that with just one clause; there would have to be quite a lot of clauses, if I am honest. All systems of this sort are going to be imperfect.”
“Q I hear what you have said already regarding capacity. Of course, the Mental Capacity Act relies on the capacity principles. They include the presumption of capacity, the principle that a person cannot be seen as lacking capacity unless all practicable steps have been taken to support them to make a decision, and the principle that a person cannot be seen as lacking capacity merely because the decision is unwise. I also heard what you said about the scaling of decision making, but within the Bill, in some of those scenarios there is no mandating; the word “may” is used rather than “must”.”
“I cannot tell you the number of years’ experience that doctors have in other countries. I felt that it was self-evident that you would want doctors who are experienced—three years, five years or whatever post qualification—and who have seen real life. It is up to the medical associations to stipulate how much experience, but I would not like the idea of a doctor immediately, having got their certificate of training, going off and making these kinds of decisions. That is why I suggested that ballpark figure.”
“Q My question is to Dr Ahmedzai. In the paper you produced you talked about specific recommendations regarding the training and experience of the doctors involved in the process. You suggested five years, for instance, and some other experience. Have you got examples elsewhere in the world where such a scheme has been implemented? Do you believe that we have enough trained doctors in the United Kingdom who have that level of experience and would therefore be taking part in this part of the process? Dr Ahmedzai: You have caught me on the hop, because I cannot quote the level of training that doctors have received elsewhere, except for examples in the Netherlands, where there are additional doctors who are, through their medical association, trained specifically in assisted dying.”
“In the NHS, we do mandatory training for all sorts of things, including washing hands, lifting and basic life support. There should be basic dying support mandatory training as well. Why do we not have that? That kind of provision would become part of training doctors up to become good at those conversations that Dr Clarke is obviously involved in teaching, and in ensuring that they keep up to date with how the law is changing too. I would look to the royal colleges and the GMC to lead on those aspects.”
“Q Just to clarify, is there nowhere else in the UK where we have that? I am just trying to understand, because we would need to go away and do a piece of work on whether there are enough doctors with that level of experience if we were to take on that kind of recommendation. Is there nowhere else in the medical profession in the UK where we insist on that level of experience? Dr Ahmedzai: Probably not, but this is a very, very special situation, and it may be, once it has become embedded in the health service, that that stipulation could move back. I am so glad that Dr Clarke keeps coming back to training. One thing that is absolutely needed if this Bill goes forward is to take the topic of assisted dying out of being an optional training—where people might sign up for a course—to become mandatory.”
“Are they at that point supposed to try and rely on the doctrine of double effect and say, “All I am trying to do is treat the complication, not bring about your death,” but the Bill is saying, “No, you are not allowed to do that”? I understand entirely why the intention is to say that the doctor must always be hands off, as it were, but you need to super clear that you are going to put some people in some very, very difficult positions, and Parliament needs to be clear-eyed about that.”
“At the same time we have a situation where doctors—I am using the word “doctor” slightly loosely, but for present purposes that is what we are talking about—have to be present and have to remain with the person. We know that there will be some people for whom there are complications. My concern is to make sure that there has been sufficient consideration given to what exactly a doctor is meant to do at that point, because it seems to me that it ends up putting the person who is undergoing those complications in a horrible position. It is also—I am perfectly happy to use this phrase—putting the doctor in a position of extraordinary moral distress.”
“Q Alex, in paragraph 8 of your written evidence you touch on clauses 9, 15 and 18 of the Bill and the potential complications that could arise when the substance is taken. Could you expand on the concerns you have about that? Alex Ruck Keene: I should make it absolutely clear that all I am trying to do is make sure that whatever law is passed is a good law and has as few inadvertent consequences as possible. My concern here arises out of the fact that understandably the proponents of the Bill want to make it very, very clear that this is about people carrying out a final act, and no doctor is allowed to do something that involves going beyond that.”
“I thank my hon. Friend for her answer. One of the biggest scandals that we saw under the last Conservative Government was Ministers giving out dodgy covid contracts to their friends and donors. Will the Minister update the House on what steps the Government are taking to ensure that there will never again be a repeat of that shameful behaviour and that where the public have been defrauded, we will get our money back?”
“On a point of order, Sir Roger. Amendment (i) clashes with the sitting times on Thursday suggested by my hon. Friend the Member for Spen Valley.”
“My residents in Crayford, in the London borough of Bexley, have their services provided by one council, but in many cases, residents on the same road have their services provided by two councils—by Kent county council and Dartford borough council—which causes confusion, as the Minister said. Does he agree that the changes introduced in the English devolution Bill will make local government more effective and save money for those taxpayers?”
“I thank my hon. Friend for securing the debate. In the Northumberland Heath ward in my constituency, Councillors Baljeet Gill and Wendy Perfect have been working tirelessly to support local traders who would like to introduce free parking for a very short period for the small range of independent shops in Northumberland Heath. Does she agree that councils should investigate measures to reduce parking charges and also consider free short-term parking arrangements to support, as she put it, the viability of such small independent traders?”
“It will drive high and rising standards in schools through common-sense reform, and it will prevent children from falling through the cracks by introducing landmark reforms to safeguard children’s social care. The Bill is the single biggest piece of child protection legislation in a generation. A vote for the amendment is a vote against the Bill and against the safety of our children, their childhoods and their futures. I urge all Members to vote with me and the Government and to give the Bill its Second Reading.”
“In my local authority, we have schools where over 50% of the children do not live in our borough because of the admission arrangements that our academy schools have decided to put in place. In a borough where 79% of schools have been academised, we rely on their good will as to how many pupils they will admit each year from our local authority and how those applicants will be prioritised. That has resulted in the same Conservative councillors who cheer-led the roll-out of academies openly complaining to me and colleagues that they no longer have control over admissions criteria. Today, we have the opportunity to give this landmark legislation its Second Reading. It will improve education standards and strengthen protections for the most vulnerable children in Bexleyheath and Crayford and across our country.”
“My local authority in Bexley, like many others, has struggled to control those areas with regulation and struggled with the financial aspects. Last year, we saw the largest children’s services overspend of any London borough as a result of those issues. I therefore welcome the measures to limit the profits of specified non-local authority, Ofsted-registered social providers of children’s homes and fostering agencies, which have continually raised their costs far above inflation to profit from the taxpayer and from the care costs of our most vulnerable children. I welcome the changes in clauses 47 to 50 to school admission arrangements, requiring schools and local authorities to co-operate to manage admissions and giving local authorities the power to direct academy schools to admit pupils.”
“For the record, my wife is employed as a special educational needs co-ordinator in a local authority school in the London borough of Bexley. I welcome the opportunity to speak in support of the Bill on aspects relating to looked-after children and academies. On looked-after children, the Bill would make a series of changes on accommodation, as colleagues have commented, which include increasing Ofsted oversight of organisations that operate multiple children’s homes or independent fostering agencies, introducing a financial oversight regime for certain independent agencies and children’s home providers, and allowing the Secretary of State to cap the profits of children’s home providers and independent fostering agencies. From my years as a local councillor, I know how badly those changes are needed.”
“Friend the Member for Dulwich and West Norwood in her asks, but her comments on what can be done to secure more regular MRIs—as was shown in Emma’s case, having more regular MRIs is the only thing that will pick this up—and to ensure that there is greater data collection and transparency on the effects of lobular breast cancer.”
“In Emma’s case, her cancer is likely to return, which leaves her with a very uncertain future for years ahead. On the current data collection framework on lobular breast cancer, there is a lack of documented research about outcomes for and recurrences of lobular breast cancer. Indeed, there is currently just one trial available in the UK for lobular breast cancer patients. This leaves women like Emma unprepared for the potential impacts that the cancer will have on them further down the line. Given this position, I would be grateful if the Minister could address not only the points raised by my hon.”
“Lobular breast cancer is the second most common form of breast cancer and, as has been said, accounts for about 15% of all breast cancers, yet there is still not enough research being undertaken. My hon. Friend mentioned my constituent Emma, who is in the Public Gallery. Emma recently attended my constituency surgery and told me of her experiences with lobular breast cancer. Because of the way it presents, it was not picked up by a mammogram, and it took an MRI—facilitated through a routine private healthcare check—for it to be diagnosed. As has been said, it was initially thought to be a stage 2 cancer, but it was in fact stage 3. Following her diagnosis, she underwent a double mastectomy, followed by chemotherapy for six months, and then 15 sessions of radiotherapy.”
“It is an honour to serve under your chairmanship, Ms Vaz. I thank my hon. Friend the Member for Dulwich and West Norwood (Helen Hayes) for securing this debate, and I concur with my hon. Friend the Member for City of Durham (Mary Kelly Foy) about health outcomes for those diagnosed with cancer. One of my most difficult days was when my wife was diagnosed with cancer. She has now thankfully recovered but, looking back at her cancer and her diagnosis, the fact that it was caught early and was seen as a cancer with greater success outcomes shows the disparity of outcomes—particularly for those with lobular breast cancer, as my hon. Friend the Member for Dulwich and West Norwood described. I pay tribute to the Lobular Moon Shot Project, which aims to give lobular cancer the attention and funding it needs, so that it can be better understood.”
“Under the current rules, it is impossible to predict when fireworks may go off, especially around that time of the year. In my area of south-east London, fireworks are a nightly occurrence for a month or two in the autumn, and they continue into the early hours. I welcome the private Member’s Bill that my hon. Friend the Member for Luton North (Sarah Owen) has introduced, and her asks of the Minister. I hope the Minister will outline plans for stricter enforcement of the sale of fireworks and to give more powers to local authorities such as the London borough of Bexley to stop disturbances. I also hope he will address the asks in my hon. Friend’s private Member’s Bill.”
“Under the current legislation, members of the public are not required to have any form of licence or training to let off consumer fireworks. Public displays are controlled and must take place during set times, but private displays can go on well into the night. A recent study by the RSPCA found that as many as 14 million Britons plan to have a private display each year. Dog owners report that dogs are scared of fireworks and exhibit the five signs of stress. Pet owners say they have no choice but to try to manage their pets, as the fireworks remain out of their control and they cannot remove the triggers. The regulations state that fireworks can be set off past 11 pm on four nights of the year, when the cut-off is extended to 1 am.”
“It is a pleasure to serve under your chairship, Sir Edward. I pay tribute to Alan and his family, whose horrific story we have just heard. I thank the hon. Member for Keighley and Ilkley (Robbie Moore) for introducing the debate on behalf of the Petitions Committee. We are a nation of animal lovers, and it is deeply upsetting to hear stories about pets and wild animals being distressed by fireworks, but equally this issue affects people with PTSD and children with SEND. A growing number of constituents from across Bexleyheath and Crayford have written to me about this issue and the problems with the regulations. I was a councillor when the regulations were introduced 20 years ago; there was improvement at the time, but there clearly continue to be issues today.”