Dr Neil Shastri-Hurst
MP for Solihull West and Shirley · Conservative · United Kingdom
“I am normally a temperate man, but this is a farcical situation. I have huge respect for the Leader of the House, but I suspect that he has come here with gritted teeth, because the reality is that our constituents want to hear from the new Prime Minister.”
“We have seen it in genomics and targeted therapies and we see it in the increasing recognition that treatment must be shaped by the biology of the disease and the needs of the patient. There is no reason that lobular breast cancer should be left behind in that progress. There has been movement—it is right to acknowledge that.”
“One duty of a good health system is to reduce the burden on the patient and prove that they are worth listening to. Susan Michaelis understood that deeply.”
“Compassion reminds us why we keep working. Responsibility requires us to bring those two factors together. The last Government invested in cancer research, including support for the Institute of Cancer Research and the Royal Marsden biomedical research centre, along with wider work relevant to lobular breast cancer.”
“We have heard about how she challenged assumptions, gathered evidence and pursued truth in an area where the consequences mattered for passengers, crews and the wider public. In 2013, she received her devastating diagnosis of invasive lobular breast cancer.”
“We cannot dispute that that is a significant sum, but we have to look at it in the context of national health spending and what cancer costs: the cost to families and patients and the cost to the NHS when it is detected late or treated inadequately. We have to bear those factors in mind.”
The complete record
Every one of 599 lines we hold for Dr Neil Shastri-Hurst, in date order, each linked to its source. Free to read, in full, without an account. Page 10 of 12.
“I will try to make some progress. I want to move on to the other point I want to address, which is around bogging down the whole process with layer upon layer of bureaucracy. We are talking about a relatively small group of patients who are in the last six months of life and are then battling against the system that is meant to be helping them. If we put in layer upon layer and hurdle upon hurdle, it will become a much more difficult system for people to navigate. That does not mean that it would be a less robust system, but it would be a more difficult system. We are trying to make life easier, not harder, for those patients.”
“We cannot be removing the autonomy of patients when their decision-making process is that they choose not to engage with that. They may want to speak to their GP because they have had a relationship with them over 30 or 40 years and have the patient-doctor relationship that is so important when dealing with these important discussions. Perhaps they would feel less comfortable having that discussion with a clinician they had just met for the very first time.”
“The hon. Member makes a valid point. The reality is that, regardless of specialty title, there will be individuals who are better placed to have certain conversations and discuss certain issues than others. I look back at my own clinical practice: some colleagues would have had a better bedside manner than others, for example. I do not think this comes down to the name of the specialty; it comes down to the underpinning skills and knowledge. That is the point I am trying to make. We can get bogged down by saying, “Everybody has to see a palliative care specialist”. Of course, that is open to people: if they wish to have a referral to a palliative care specialist, they can see one. However, as the hon. Member for Stroud said, some people may not want that.”
“The Bill as it stands allows that flexibility for patients without confining them. But it gives them the very welcome option of a palliative care referral; that is entirely open to them—it is not closed off from them. Of course, they will be fed into the palliative care route anyway, following the trigger of their terminal diagnosis. They will be going on the journey, and having further conversations around their end of life care. Those are the points that I wish to make.”
“That, of course, will be set down in regulation. The other point that the hon. Member for Bradford West made is that clause 4(4)(c) says that any clinician having that discussion must be able to explain “any available palliative, hospice or other care.” It therefore follows that if the clinician is unable to do that because of a lack of skill or knowledge, they should refer on to somebody who can do it. That is the fundamental principle of having informed consent and discussion with patients. If a clinician cannot provide that information, they ask for somebody who can. That was not uncommon in my practice: if I had something that was outside of my area of knowledge or specialist interest, I would refer it to a colleague. That is how those conversations take place.”
“I am grateful to the hon. Lady for her intervention. She makes a number of points. First, may I say that I am sorry about her own health issues? I think she hit the nail on the head when she said that the GP may not be able to offer that service. For instance, take shoulder injections. Some GPs can do a shoulder injection with steroids; some will refer to the hospital for it. My father was a GP who could do them, but others would have referred to me when I was an orthopaedic surgeon and I would have done them in clinic. This will not be right for every single general practitioner; the issue is about having a cohort of general practitioners who have the skill and ability, and about having a flexible system that works for patients. It all circles back to the training point. The individuals who do this have to have the requisite skills.”
“I do not think that offends the principle at all. Whether I was working within the NHS or the private sector, if a patient requested an onward referral to a different specialist, I would action that. If I did not have the requisite skills or knowledge, or felt that they would be better served by a different speciality, I would refer on to another clinician. I do not see how it would be treated any differently in the NHS than it would be privately. I am afraid that I do not follow that argument.”
“My hon. Friend is making a valid argument, but I want to pick up the point made by the hon. Member for Stroud. He talked about illnesses that are inevitably progressive and cannot be reversed by treatment. For type 1 diabetes—I think that is what my hon. Friend the Member for South Northamptonshire (Sarah Bool) is addressing, as opposed to other forms of diabetes—a person either has insulin or does not.”
“Forgive me, Chair. I will come to the point. If the person does not have insulin, the diabetes could be treated by administering it. Does my hon. Friend accept that, in those circumstances, it would fall within this clause?”
“If we aim to create a better future for our children, if we truly believe in progress and not merely maintaining the status quo, and if we are to be believed when we talk of improving life chances for generations to come, the Minister should commit to reforming this outdated and harmful system, and ensure that all child arrangement cases are appropriately considered by a qualified judge.”
“The system in England and Wales is virtually unique in permitting lay magistrates to determine such matters, with most jurisdictions across the world entrusting the decision to a suitably qualified judge. In more complex cases, we should consider the use of specialised panels, as deployed in other tribunals. Such panels could have a judge as chair and suitably qualified wing members, who may include experts in child psychology. By adopting this model, the panel can take a more holistic approach to decision making. My ask of the Minister is very simple.”
“Far too often, one hears of cases simply being decided as a timetabling exercise, and of a child’s weekly diary being carved up without proper thought or consideration of the impact on that child. Removing the role of magistrates in private law family cases, and ensuring that all such cases are heard by a specialist family judge, would ensure greater consistency of decision making, applying a more judicious and impartial approach. On this most consequential of issues, we should ensure that those who preside over family cases are not only appropriately legally trained but well versed in the emotional, psychological and social factors at play. There should be much greater focus on ensuring that decision makers are trained in childhood development, domestic abuse dynamics and trauma-informed practices.”
“Furthermore, in the absence of formal legal training, subconscious bias is likely to run higher among magistrates than among members of the judiciary. We can also take note of the approach taken by other courts in England and Wales. Specialist judges preside over employment, immigration, business and property, and social entitlement cases. Even in cases where a panel of three hears the case, it is a legally qualified, specialist judge who sits in the chair. Given the importance of such decisions to a child’s long-term prospects, the outdated practice of magistrates hearing private law children’s cases should, in my humble opinion, be abolished. It is an inefficient and unreliable system of dispensing justice in the modern world, and it runs the risk of reaching inconsistent decisions of varying and questionable quality.”
“In comparison, a district judge hearing such cases undergoes much more rigorous training and must have a law qualification as a prerequisite. The stakes in cases such as these could not be higher. This singular, most important decision, if misjudged, can set in motion a truly devastating series of events, thereby irreversibly damaging a child and their life chances. Let us contrast that with the role of magistrates in the criminal courts. The maximum sentence that magistrates can hand down is 12 months. Sentences beyond that are remitted to the Crown court to be heard by a circuit judge. In comparison, a decision about a child’s domestic arrangements until adulthood are frequently made by individuals with no specialist knowledge or training in family law.”
“The reason for mounting this argument is simple: there is an inequality in our legal system when it comes to private law family cases. These are cases that decide the nature and degree of contact a child has with each parent, determine the long-term future of a child and, by their very nature, have a significant, lasting impact upon any child. Presently in this country, private law children’s cases can be heard before a bench of three magistrates or a district judge with a family ticket. Magistrates are a lay bench who, well-meaning as they may be, are not required to hold any formal legal qualification. While magistrates undergo some specific training following their appointment, it is not more than a handful of days a year.”
“Magistrates have formed an integral element of the England and Wales legal system since the 12th century and the reign of Richard I, who appointed the first keepers of the peace. Almost 200 years later, pursuant to the Justices of the Peace Act 1361, the term “justice of the peace” was formally introduced. I do not propose reform of the role of magistrates lightly. However, I have reached the view that there is an overwhelming policy argument for doing so. I am not for one moment suggesting that magistrates do not have an important role to play in the justice system; self-evidently, that would be a fallacy. However, I am increasingly convinced that the nature and focus of their work should be reconsidered, and in the case of child arrangement orders, it is my overwhelming view that the magistrates court should no longer play a role.”
“This is a child who feels different from their classmates because they are forced to go to school with their overnight bag; a child who constantly lives with the anxiety of turning up to school without their sports kit because it is at the other parent’s house; a child who feels nomadic, often confused and invariably distressed. The scale of the problem can be seen starkly in the figures from the Children and Family Court Advisory and Support Service. As of 31 August last year, there were 16,671 open private law children’s cases involving 25,670 children. In the first quarter of 2024, the average time for such cases to reach a final order was some 44 weeks. During that period, children are left with uncertainty.”
“This is the story of a young child who, by virtue of their age, cannot fully articulate their wants or desires, whose loyalty is split in two, who does not want to be seen to betray either parent, who is already dealing with their world being turned upside down and whose future is decided in a sterile magistrates court, often as a mere timetabling exercise. That child now faces birthdays, Christmas and Easter all split in half, with weeks cut in two and weekends alternating between one household and another, leaving them with no sense of oikophilia—the love of home.”
“The reason is simple: the anchor point in all family law cases involving a child should always be that child’s best interests, and the creation of an outcome that supports and promotes the child’s safety and emotional and psychological wellbeing and protects his or her future prospects. It is almost inevitable that each and every Member of this House will have had experience of child arrangement orders in some way, shape or form, whether through constituency casework, personal experience or family and friends, because such cases are sadly far from rare. If you will indulge me, Madam Deputy Speaker, I will tell the story of one such case, which I suspect will resonate with many up and down the country, because it is sadly an all-too-familiar experience.”
“While it may be the intention of the system to protect the privacy of individuals and families during these hearings, the reality is an increasingly inefficient and, at times, unresponsive system that fails to place the emotional and psychological needs of the parties at its centre. The flaws in the present system are regrettably clear for all to see, and in failing to address them, parties are left with a system that undermines the very values that it seeks to uphold—values such as fairness and natural justice, with the wellbeing of children at their core. This is such a vast topic that it would be inconceivable to address all the issues in the course of an Adjournment debate, and I will therefore focus on the constitution of those on the bench who hear child arrangement order cases.”
“It is a sad reality of life that marriages fail. It can happen for a variety of reasons, and I do not seek to provide a critique on the underlying causes in today’s debate. However, one of the tragic consequences of divorce is the disruption and pain that it causes to children. It is evident that an amicable relationship between parents would enable arrangements in respect of where a child resides following a divorce to be made without the intervention of the courts, avoiding much additional heartache and the adversarial nature of contested hearings; but such contested hearings cannot be avoided in each and every case.”
“There are also relationships where one has acquired over another a measure of influence or ascendency, of which the ascendent person takes unfair advantage without any specific acts of coercion. Could my hon. Friend set out why she thinks “unduly influence” would add something beyond what “pressured” already does in the Bill?”
“I have no doubt that my hon. Friend speaks to the amendment with very good intentions due to genuine concerns about the safeguards. We have talked a lot about coercion. Clause 1(2)(b) sets out a requirement that the person, “has made the decision that they wish to end their own life voluntarily and has not been coerced or pressured by any other person into making it.” “Pressured” is an important word. If we look at the case law, there are the comments of Lord Nicholls in the case of Royal Bank of Scotland plc v . Etridge (No. 2) in 2002. He looked at two components of the concept of undue influence. There are acts of improper pressure or coercion, such as unlawful threats, which fit with the coercion element of the Bill as drafted.”
“I just want to understand this, so that I can appreciate the amendment in full. I believe that my hon. Friend—he will correct me if I misheard—spoke of encouragement effectively being pressure: that there is the act of encouragement and then an individual being pressured into making a decision that is not in their best interests. We have talked much about coercion but if that is my hon. Friend’s position, can he elucidate why the words “or pressured” are not sufficient to deal with the issue that concerns him?”
“It may be that I am a dense former surgeon, so please help me, but could my hon. Friend the Member for East Wiltshire give an example of what, in the definition of “encouragement”, would be broader than “pressure”? If we are not saying that supporting somebody through this process is acceptable, what would be a specific example where “encouragement” comes into this that would fall outside the scope of “pressure”?”
“The hon. Lady spoke movingly about her own experiences, which clearly fell into the category of benefiting others, with no benefit for herself. Can she elucidate how she envisages this amendment working in the following scenario? Let us say that in some years to come, this law is enacted and I have a terminal illness—I have six months or less to live—and I do not want to face intolerable pain and suffering in those last moments of life, but I also do not want my son or my wife to watch me suffer. They benefit from that decision, because they do not see me suffering, but I am also doing it for my own sake. How does the amendment fit into that scenario?”
“My hon. Friend makes a powerful argument, but if that is his intention, the amendment does not achieve it. It does not refer to agonising pain; it just refers to “physical pain”. On a scale of nought to 10, it could be one or two—it does not necessarily mean that it is nine or 10. While his intention is clear, can he explain how the amendment achieves that wish?”
“That would make the operability of the Bill so much harder and would move us away from the Mental Capacity Act, which has a heritage of some 20 years and is already well established in the use of advance directives around organ transplantation, the withdrawal of treatment and the decision to undergo major operations that can have life-changing or life-limiting consequences.”
“I thank the hon. Member for Richmond Park for tabling the amendments. Fundamentally, I do not agree with them, but I am grateful for her good intentions. I understand the concerns that she has raised, and she makes an eloquent argument, but I fundamentally disagree. In my view, the amendments would only lead to abandoning the well-established principles codified within the Mental Capacity Act. They would introduce a degree of woolliness and legal uncertainty by introducing of a new term that is, as yet, undefined.”
“It would be an oversimplification to suggest that the provision as drafted would deal with those issues in a satisfactory way that would provide confidence not only—although most importantly—to those who are making a decision around an assisted death, but to the medical practitioners who are part of the process and the courts, which will have to grapple with the issues that will inevitably arise from a new definition.”
“My hon. Friend makes incisive points clearly and concisely, as always, but I cannot agree. This is a short clause that is dealing with a hugely complicated issue that is presently codified within the Mental Capacity Act, which runs to some 183 pages. I do not think that it is as simple as saying that the new clause deals with the issue. There is also the two-stage test, which determines both the functional ability to make the decision and whether that decision is impaired in any way.”
“The hon. Member is absolutely right that capacity can change. It is an evolving piece: someone’s capacity at one point in time will not necessarily be the same as their capacity on a future or a previous date. However, the whole purpose of the Bill is to put a series of mechanisms in place that assess capacity to ensure a robust decision-making process. I should also mention that the Mental Capacity Act allows the capability of individuals to make an advance directive. Where they have capacity at a point in time to make a decision for a future date, capacity can be inferred at that future date for that decision. That is acknowledged within the 2005 Act.”
“As always, my right hon. Friend makes a very good point. The Mental Capacity Act allows for advance directives on a whole variety of choices, including withdrawal of treatment, decisions on care or financial elements, and decisions on having treatment as opposed to not having treatment. It creates that ability and it is deemed robust enough for those purposes. It must therefore follow that it is robust enough for the purposes of the Bill.”
“The hon. Member makes an interesting point, which I had already considered; in fact, I have tabled a new clause that would address it. It is not grouped with the amendments now before the Committee, but I will touch on it, if I may. There is an argument that, if an individual with an advance directive has gone through the two-stage test in the Bill and then loses capacity, the advance directive should hold weight. My new clause 6 would deal with that point. Sections 27 to 29 of the Mental Capacity Act deal with exclusions from advance directives, including issues around voting rights, marriage rights and Mental Health Act implications. There may be a mechanism, for example, to exclude an advance directive that deals with assisted death, either through the Bill or through an amendment to the Mental Capacity Act.”
“Capacity lies on a spectrum: if I am doing major abdominal surgery, the level of capacity required to make a decision will be much greater than if I am removing a small bump or lump on an arm. As well as having been tried and tested by medical practitioners, the MCA has been tested in the courts, as the hon. Member for Penistone and Stocksbridge said. It has been right up to the highest court in this land, it has been robustly tested and it has been found to be good legislation. The risk we now face is that it will be replaced not only with a new legal concept, but with an entirely different process for assessing capacity in this setting. Although there may be good intentions to improve the system, that will only add to the folly of it and overcomplicate the issue.”
“My hon. Friend makes a valid point. I have concerns about public confidence in the Bill without that additional safeguard, as this is such a consequential decision, but of course any advance directive would be predicated on having gone through those two stages first before capacity is lost. I feel that on this occasion additional tightening is necessary so that the public can be confident that a robust process has been gone through. The MCA is a tried and tested piece of legislation used by practitioners up and down the country. The hon. Member for Stroud uses it every day in his practice; I have to say that I did not, but I was not consenting patients for surgery every day. Every time I did so, however, I had those conversations.”
“The hon. Member makes a reasonable point. I agree with her on many issues, but on this issue I have some reservations. Clause 18(4) says: “The coordinating doctor must be satisfied, at the time the approved substance is provided, that the person to whom it is provided…has capacity…has a clear, settled and informed wish to end their own life”. Of course, under the wording of section 26(1) of the Mental Capacity Act, that decision can be made at an earlier time and deemed to have currency, once capacity has been lost, for its enactment at a later date. I think that there could be a minor tightening of the wording or reassurances from Government to address that, but it is an important point to raise and air.”
“The Bill is very clear in determining that it is for those who have a progressive illness, disease or medical condition that cannot be reversed by treatment. On my reading of the Bill, it excludes that category of individuals who choose not to engage with treatment that in ordinary circumstances would prevent the progression or deterioration of their condition. I therefore do not see it as analogous with the hon. Member’s scenario of someone who could have a long life expectancy if they had taken their treatment, but who chooses not to. That is not captured within the Bill, in my interpretation.”
“With the greatest respect to the hon. Member, I think that she is conflating two issues. Someone can stop treatment under the MCA; over time, that will lead progressively to death, with some conditions—she gave the example of being a diabetic without insulin—but that would not be a terminal illness in reference to this Bill. The Bill is very clear that it is about an inevitable and progressive illness, disease, or medical condition that cannot be reversed by treatment. Diabetes, treated with insulin, is not a progressive condition that becomes a terminal diagnosis; it is terminal only by virtue of somebody refusing treatment, which therefore would not be captured within the Bill.”
“My hon. Friend makes a valid point—the Committee can see that I was an orthopaedic surgeon, not an endocrinologist. It is not necessarily a progressive condition; it is a condition that can be managed and maintained. It does not fall within the wording of the Bill. We are not talking about a condition that is inevitably progressive, and for which there is no treatment option available to pause, reverse or prevent its progression. We are talking about a relatively limited group of conditions that will inevitably lead to death when someone, for want of a less blunt phrase, has reached the end of the road in terms of their therapeutic treatment options.”
“I will keep my answer very brief by saying that I will return to hon. Lady’s point when we come to the clause on terminal illness, when perhaps I can elucidate, improve and work on my responses in a way that is conducive to understanding.”
“Doctors over the road in St Tommy’s will be using it at this very moment, and they are adept at knowing and sensing when they need to escalate, whether by getting the opinion of a psychologist or a psychiatrist, because they have concerns about underlying issues. The Act is a robust piece of legislation, and we should be using it to enhance this Bill, not introducing further complexity, which will only put us into a quagmire of uncertainty.”
“The hon. Member is right: there is a huge spectrum of patients when dealing with these complex issues, and it would be absolute nonsense to arbitrarily say that anybody with depression is unable to make an informed decision on any issue. There are individuals who have mild depression—indeed, I suspect that most people with a terminal diagnosis would have some form of depression or reactive disorder, whether formally diagnosed or not, because of their circumstances. That does not mean that they are unable to make a rational, informed decision; we have to look at each patient individually. The Act is a tried and tested piece of legislation that doctors up and down the country use every day.”
“My hon. Friend puts it with his usual candour. He asked a straight question, so I will give him a straight answer: I think there is a difference between somebody who is depressed and somebody who is depressed and suicidal. I have no personal moral objections if someone who has a terminal illness, who suffers from depression and who has capacity as set out through the two-stage test in the Mental Capacity Act, ultimately wishes to end their life because of their terminal diagnosis. If they are doing it because they are suicidal as a consequence of their depression, that is a different and distinct issue. We are talking about individuals who want to end their life because of their terminal diagnosis, not because of their mental disorder.”
“That is one of the additional safeguards in the Bill. This Bill has more in-built safeguards than any similar piece of legislation across the world. I think the hon. Gentleman makes a valid point: when a doctor has concerns about somebody’s mental state, they can escalate the case and seek further, specialist opinion.”
“37, Q14.] It is that foundation that we are building on, and it is central to how these things operate in practice. Although I understand the position of the hon. Member for Richmond Park, and I have a degree of sympathy with those who support the amendments, I invite them to reflect, in the time we have left for this debate, on whether the amendments achieve their stated aim. Do they make the Bill better or do they make it more complicated and convoluted? I say that they make it more convoluted and that, despite the best of intentions, they should not be supported.”
“Of course, there will always be voices on different sides of the debate, and we can frame the evidence we have heard to favour one set of arguments over another. However, I am significantly persuaded by the chief medical officer, given his wide experience as not just a clinician but a public policymaker. In his evidence to the Committee on 28 January, he said: “It is not clear to me what problem people are trying to solve by doing that,” —he means moving away from the Mental Capacity Act— “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.” –– [ Official Report, Terminally Ill Adults (End of Life) Public Bill Committee, 28 January 2025; c.”
“I will make some progress, if I may, because I think I have indulged your patience for far too long, Ms McVey. I am cautious about introducing this new test. I may not have persuaded everyone, but I have set out my reasons. We risk making the system overcomplicated. We would move away from the well-established mechanism under the Mental Capacity Act and into tiger country, with untried and untested systems that the courts have not considered, which will inevitably lead to challenge. There is no need to do that, because we already have robust mechanisms in place and doing so will merely lead to ambiguity and potential complications. This is not me reaching this conclusion in isolation.”
“I wonder whether the hon. Lady can help me with an area of her argument that I am conflicted by. I have heard the points made by my hon. Friend the Member for East Wiltshire, drawing the distinction between those who refuse treatment for a condition that is then terminal and those actively seeking assistance in ending their life. There is a third group who choose to refuse food and nutrition. That is not a treatment in the conventional sense, to combat a disease process, that is normal sustenance that would keep someone alive. Given that the MCA applies to that decision and someone’s ability to refuse on that basis, how does that interplay with the amendment as proposed?”
“It may well have been the way that I phrased it, but the point I was seeking to make was that the Mental Capacity Act, as it currently operates, can be used for those patients who choose to refuse food and water. My view would be that that is a distinct group of people who are refusing active treatment. Given the hon. Lady’s distinction between those who refuse treatment in the conventional sense and those who are seeking assisted dying and her view that for the latter group the MCA is not the appropriate mechanism, is she saying that for that group of individuals who refuse food and water—effectively choosing to end their life through starvation—the MCA is not an appropriate mechanism to assess their capacity?”