Chamber and committees

I ask colleagues from across the chamber to support my amendment 250 and the consequential amendment 309, which would ensure that any assisted dying provision in Scotland was delivered through a dedicated specialised service rather than through general practice.

I hear Jackie Baillie’s point on that. The proposal is similar to other amendments. Amendment 250 is necessary to ensure that any system that we create is safe, informed and as compassionate as possible. It seeks to answer the question: if such a service is introduced, how should it be delivered? We must recognise the reality that faces general practice. As we know, GPs across the country are already operating under pressure. Asking general practice to absorb an entirely new, complex and emotionally demanding clinical responsibility risks placing further strain on the system.

More importantly, a briefing from the Royal College of General Practitioners suggests that many GPs would not feel able to participate in assisted dying. Engagement with the profession indicates that a significant proportion of GPs would choose not to take part whether for ethical, professional or personal reasons. That is entirely understandable but it also means that expecting assisted dying to operate through patients’ own GPs would be neither practical nor equitable.

It is entirely possible that, in some communities—perhaps particularly in rural or less populated areas—many local GPs could opt out, which could result in a postcode lottery whereby access to a lawful service depended on where a person happened to live. Amendment 250 introduces a dedicated service that would avoid that risk.

That is not what I am saying, and perhaps I will be able to clarify that a bit more as I go on.

By creating a specialised opt-in service, we allow clinicians who feel able and willing to participate to develop the expertise, training and professional resilience required for that sensitive work. That answers Ross Greer’s question—they can opt in. Concentrating the experience in that way ensures that patients are supported by professionals who are confident, well prepared and equipped to manage the clinical and ethical complexity involved.

It is important to emphasise that a specialised service does not mean creating something outside the NHS, nor does it necessarily require new buildings or separate facilities. Such services could—and, in my opinion, should—be community-based and delivered either in or close to the patient’s own home. What distinguishes a service is not the building that it sits in but the dedicated teams that provide it. Those teams could bring together a multidisciplinary group of professionals who are capable of supporting the whole person—their physical needs or emotional and psychological wellbeing, their social circumstances and the needs of their family.

The reality is that any assisted dying provision would be a deeply human process that would affect patients, loved ones and professionals alike. Families may require support before the process, during it and afterwards, through bereavement. Patients need time to explore their choices, fears and circumstances. That level of care requires co-ordination, continuity and expertise, and a specialised service allows for exactly that. It would enable dedicated teams to support patients through the entirety of their journey, ensuring consistency, trust and a continuity of care. At the same time, a patient’s own GP could continue to provide all other aspects of care, ensuring that their existing relationship with primary care remains intact.

Such a model would also protect the workforce. The emotional weight and time commitment associated with assisted dying must not be underestimated. A dedicated service would allow for protected time and the provision of mandatory training and appropriate psychological support for the professionals involved. That is far more difficult to guarantee if the responsibility is dispersed across thousands of GP practices. I think that such a set-up would go a long way towards addressing many of the concerns that members have shared over the past couple of days. I will not go over all of them again, but some of them could be addressed by a single service.

There is also the question of expertise. Based on current estimates—I think that this has been highlighted already—most GPs would only rarely encounter an assisted dying request. That makes it extremely difficult to build the experience and confidence that are needed to navigate such a complex process. In this chamber, we regularly hear about the importance of enabling healthcare professionals to gain experience in relation to specialist work rather than distributing that work thinly across the system. The same principle should apply here.

To answer Jeremy Balfour’s point, it is true that a specialist service might require greater investment. I do not know what those figures might be, but I believe that, when we are legislating for something that would have such profound implications for individuals and families, cost alone cannot be the deciding factor. Safety, expertise and dignity must come first. However, on the issue of cost, I would say to Jeremy Balfour that I do not see such a system being set up separately from what health boards have just now.

My amendment would also allow assisted dying services to sit as a delegated responsibility within Scotland’s integration authorities and our health and social care partnerships, strengthening links with palliative care, social services and community support. That approach would not only improve co-ordination but also ensure that multidisciplinary expertise is built into the system from the outset.

Members may wish to note that my amendment 250 is supported by the Association of Palliative Care Social Workers, the Royal College of General Practitioners, the Royal College of Nursing, the Scottish Association of Social Work and Social Work Scotland. It has good and credible support from many organisations representing the people who would be working in such a system.

I was quite open and honest in my answer to Jeremy Balfour about that: I have not done any costings personally. I worked with the organisations that I have outlined to draft the amendment, but that work did not include costings.

I urge members from across the chamber to support amendment 250.

I thank Ivan McKee for that helpful intervention. That was raised by some of the organisations that I have just outlined. The answer is unknown just now, but that approach might indeed be less expensive.

20:00

I will come back to the costing issues. I will not be able to answer all of the questions that Jeremy Balfour asked me but I will come back to the matter and perhaps be able to answer some of what he asks.

I thank the member for painting a picture of the Western Australia model, and I welcome her putting that on the record.

The point that I have been making in my contribution today is that coercion is a very complex area, and we have heard that across the board. I think that my amendments today would add another safeguard to the bill, and would strengthen the integrity of the process and the confidence that the public can have in it.

I am happy to do so. We think that, in the majority of cases, the consultant would check with social work. That would be a simple check of the records to find out whether the person is known and whether there are any safeguarding concerns. Ross Greer is right to raise that point, but we do not see that as a concern. All the social work agencies have told us that they feel that they can easily manage that in their current systems.

For the reasons that I have given, I urge colleagues across the chamber, whether they are for or against the bill, to consider my arguments and to please vote for my amendment 171, and for amendment 306, which is consequential.

I refer members to my entry in the register of members’ interests—I am registered with the Scottish Social Services Council.

I will focus my remarks on my amendments 171 and 306, not least to stay on the good side of the business manager. I place on record my thanks to the Scottish Association of Social Work, which has been pivotal in bringing the amendments to fruition.

Supporting amendment 171 would ensure that social work services are encoded as a statutory safeguard within the assessment process for assisted dying. Whatever view members across the chamber hold on assisted dying, we all share a duty to ensure that the safeguards in the bill meet the essential minimum required to protect those who might be vulnerable. Where a decision is irreversible, our safeguards must be beyond question.

Scotland already has a strong, carefully constructed legal framework that is designed to protect adults who might be vulnerable due to incapacity, mental ill health, abuse or coercion. The Adults with Incapacity (Scotland) Act 2000, the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adult Support and Protection (Scotland) Act 2007 are all key pieces of legislation that form the backbone of Scotland’s safeguarding system.

16:45

I will come on to that point.

The acts that I mentioned were designed to ensure that, when decisions carry profound consequences, they are made with proper scrutiny, appropriate expertise and a full understanding of a person’s circumstances. However, the bill as it is currently drafted risks bypassing the safeguarding structures that the Parliament has already put in place.

Medical practitioners would be central to the assisted dying process—no one is doubting that—but they cannot be expected to assess alone the complex issues of social risk, coercion or safeguarding that may shape a person’s decision. Those factors are social, relational and often deeply contextual.

Social workers and safeguarding professionals hold expertise in identifying coercion, undue influence, domestic abuse, financial exploitation and situations whereby individuals may feel pressure. Those pressures might be from others, from circumstances or even from the self-belief that they are a burden.

Local authorities also hold statutory duties and records that might be directly relevant to an assessment of a person’s capacity and vulnerability. Without consultation, medical practitioners would simply not have access to that information.

Members should consider what that could mean in practice. A person seeking assisted dying might already be subject to safeguarding inquiries, capacity assessments or protective measures under existing law. However, if the co-ordinating medical practitioner would not be mandated to consult the local authority, those safeguards could theoretically remain unknown, which cannot be considered safe.

Amendments that were agreed to at stage 2 recognised the importance of multidisciplinary input by allowing referral to social services. I note that the member in charge of the bill, whose engagement on these matters I welcome, has stated his belief that the discretionary inclusion of social services would be a proportionate measure. However, I disagree, because I do not believe that leaving such a referral solely to the judgment of the co-ordinating medical practitioner would resolve the problem. Medical practitioners cannot reasonably be expected to determine whether social work input is required if they do not have the information or the training that is needed to identify safeguarding risks in the first place.

Evidence from jurisdictions that are examining similar legislation increasingly highlights the need for multidisciplinary assessment. The recent review by the assisted dying citizens jury and the review panel in Jersey concluded that clinicians alone cannot always identify coercion, safeguarding dynamics or complex capacity issues without input from professionals with expertise in social care and safeguarding.

The Parliament had a lengthy debate yesterday on the existence of coercion. We heard a range of views on the prevalence of coercion and the potential for coercion in other jurisdictions. Whatever side of that argument members may be on, we must try to avoid having confirmation bias, whether that is that coercion is not an issue or that it is a problem that cannot be overcome. If practitioners do not have the tools and resources to identify coercion, it will self-evidently be difficult to confirm that it is taking place at all.

As we all know, coercion is rarely obvious. It might not present as an overt force or threat, and it might instead appear through subtle family dynamics, emotional dependency, financial pressure or, as was mentioned earlier, an internalised belief that one’s life has become a burden.

Coercion can also be systemic. Societal narratives about the cost of care, the strain on families or the value of independence can shape a person’s decision in ways that are deeply powerful and extremely difficult to detect in a purely clinical assessment. For that reason, safeguarding against coercion requires multidisciplinary scrutiny.

My amendment 171 would establish a simple but essential safeguard, which is a duty for the co-ordinating medical practitioner to consult the local authority and ensure that relevant information about safeguarding, capacity assessments or existing statutory processes is taken into account.

If members do not think that coercion is a major issue, they should know that the amendment would give added peace of mind to those who believe that it is. If members are concerned about the costs of such a proposal, I would note that, in most cases, it would amount to a simple background check. If nothing is found, there would be no need for further social service involvement. However, if something is found, would that not make the proposal worth while? Is that not what we are trying to identify?

This may also lead to arguments about resource implications. However, I want members to note that the Scottish Association of Social Work, Social Work Scotland and the Scottish Social Services Council welcome the amendments. In fact, they insist that we vote for the amendments today, which I will come back to. They welcome the additional work—minimal as it would be—because they believe, as I do, that our primary consideration should be safety, not finance.

Another argument is about autonomy and whether someone would wish for a social work referral. I do not believe that the amendment would impede a person’s autonomy, as a person’s choice can be truly autonomous only if it is made free from coercion, free from hidden pressures and with full understanding of their circumstances. Ensuring consultation with social work services would allow medical practitioners to make decisions with the fullest possible picture. That would strengthen the integrity of the process—

I thank the member for that intervention and for taking the opportunity to put on the record what he wanted to. I recognise what he said at the end of his intervention, and I will come to that.

Without the safeguards that are being proposed here, we risk creating a system that overlooks the very protections that Scottish law has spent decades building up.

Members may differ on the principle of assisted dying—we can hear that in the chamber—but surely we can all agree that, if the law is to exist, it must operate with the highest standards of safety, scrutiny and care. When Parliament legislates on a matter of life and death, we must do so with the full weight of our safeguarding system behind us.

As Paul O’Kane mentioned, a joint briefing to MSPs that was circulated by the Association of Palliative Care Social Workers, the Scottish Association of Social Work and Social Work Scotland, states that, without support for amendment 171, the bill would not reach a minimum safe threshold from a social work perspective and would be unsafe for the people of Scotland. In addition, the chief executive of the Scottish Social Services Council, Maree Allison, has specifically said that amendment 171 is the most direct way to ensure that the bill aligns with existing safeguarding frameworks and avoids preventable harm.