It would be completely wrong to leave out of this account the terrific work of the hospices. I remember going to a hospice in Edinburgh and meeting a lady who said to me, “If you have to die, this is the best place to do it”. My noble friend Lord Howard of Lympne is president of the national hospice body and I am sure that he will have more to say on this than I. It is also important to notice the need for palliative care, not only for cancer patients, where there is a degree of concentration on that, but also for people with heart disease and other illnesses which require specialist treatment.

I am particularly concerned with the area of giving palliative care to people in their own home in remoter areas far from centres, which is extremely important. Hospices have developed a way of dealing with these points in their own areas; the help of the Macmillan nurses in particular in that connection is very important. However, we know that it is difficult enough to get GPs in these areas, never mind elaborate palliative care. On the other hand, the palliative care may be done by instruction and principle, and the nurses are certainly vitally important in that.

One of the problems that exists in the general area of palliative care, particularly as between hospitals and your own home or a hospice, is the social care and funding of the service of health as distinct from the mode of funding social care. The problem of elderly people receiving palliative care in hospital who could have it equally and more comfortably at home has to do to some extent with that divergence of funding. It is a difficult issue, which I hope in due course may be addressed. It is disappointing to see people kept in a hospital bed at considerable expense when they want to be at home and—with the arrangements that can be made there—are fit to go home, simply because a care plan or whatever else you like to call the arrangements has not been made. They can therefore remain in the hospital for an unnecessarily long time.

The practical steps that are indicated in the Bill by the noble Baroness, Lady Finlay, are extremely valuable and important, and must go some way to achieving the aim which her Bill sets out to achieve. I congratulate her very warmly on that.

1.14 pm

Lord Crisp (CB): My Lords, I, too, congratulate the noble Baroness on introducing this Bill and on her very eloquent speech, in which she drew out all the essential points.

The provisions of the Bill are important in themselves but the Bill is also important in raising issues of dying with dignity and good care at the end of life, not all of which, of course, can be legislated for. However, it is significant in another way in that it is about some of the wider changes in priorities in health that are beginning to take place. We are beginning to see both globally and nationally much more focus on disability and on mental health, which I am pleased to see is keeping the Minister busy in this House. There is much more focus on social care, on care more generally and on what are called non-communicable diseases or long-term conditions,

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where the task is not to produce curative effects but to help people to live with disability and limitations. As the noble Baroness, Lady Finlay, said, it is also about quality, care and costs.

There are things that all those emerging or renewed priorities for health have in common, and I want to mention three of them. The first is the very strong individual, and indeed family, focus. The point has already been made that palliative and end-of-life care needs to be about what individuals want. It is not just about offering a menu of choice; as the noble Lord, Lord Davies, said, it is about control. I am reminded of my father, who, in the last year of his life in his 90s, discharged himself from hospital against the advice of the medical staff. I was quite sure, as I believe were the medical staff, that that act of rebellion—or, if you like, bloody-mindedness—was very good for his morale and probably affected the length of time that he subsequently survived. Therefore, this is about control as well as about a menu of choices, but it is also about families.

Although I agree with the provisions of the Bill, it is a question not just of having a professionalised death but of people being a bit more willing to talk about death, having those sorts of conversations and thinking about death in a much wider way. I am aware of the important point made by the noble Baroness, Lady Hollins: that the person who is dying dies but there is often a serious aftermath, which I guess all of us know something about.

The second important point is variation, and it keeps coming up. We have some absolutely excellent practice—I am sure we all wish to congratulate the UK on coming top of the palliative care table in a recent Economist Intelligence Unit survey—but we also have some awful care. Therefore, it is important to manage variation. The other point that needs to be brought out here is that we need to understand who misses out. We often talk about averages and so on in healthcare but we need to know who is likely to miss out by disaggregating the data and gaining an understanding of whether it is men or women, poorer people or less educated people. Interestingly, in palliative care there is some evidence that one of the groups that seems to miss out is the very elderly—the over-85s. Again, this is a global issue. In the recently agreed sustainable development goals, the great phrase was “Leave nobody behind”, and that must be true of where the noble Baroness, Lady Finlay, is taking us with palliative care.

My final point, which joins up all these emerging priorities, concerns technology—not just assistive technology, pharmaceuticals and so on, which are all extremely valuable, but IT and communications technology. My noble friend Lady Lane-Fox, who is not able to be in her place today, is happy for me to say that her new organisation, Doteveryone, believes that digital health and new technologies can radically transform services. Importantly, Doteveryone will be working on a project focused on older people at the end of life, reaching those traditionally seen as the most excluded—the over-85s. It will be very interesting to see where that project takes us.

I want to make a couple of specific points. First, I know that we have all been lobbied about children’s palliative care. We have not really mentioned it so far

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in the debate, although I do not know whether others will raise it. It seems important that there is some reference to the particular and specific needs of children when we talk about palliative care.

Secondly, I agree very strongly that this is about all health and social care workers; it is not just about the specialist few. It is about everyone understanding this holistic approach to care.

Finally, in her opening remarks the noble Baroness, Lady Finlay, said that it is time to act and that the Bill is about saying, “These are some mechanisms to make something happen”. That is very important in the context that she and others have articulated—that improving quality is very often about eliminating waste and wasteful procedures. Getting it right and therefore improving quality in many cases also has a beneficial effect on costs. For all those reasons, I very much support the introduction of the Bill to this House.

1.20 pm

Lord Howard of Lympne (Con): My Lords, I declare my interest as chairman of Hospice UK, the umbrella organisation for all hospices in the United Kingdom.

The concept of a good death has, in recent years, been increasingly recognised, and recognised as something that should be available to all. This Bill will go some way towards achieving that objective in this country, and I add my thanks and congratulations to the noble Baroness, Lady Finlay of Llandaff, for bringing this forward.

The Economist Intelligence Unit survey, which placed the United Kingdom top of the 80 countries surveyed in terms of the quality of their palliative care provision, has already been referred to. It is worth noting that the previous survey carried out by the Economist Intelligence Unit, in 2010, five years ago, reached a similar conclusion—the United Kingdom was again rated as the best in the world. I hope that I can be forgiven for emphasising the contribution of hospices to that achievement, and I am grateful to those who have already spoken in the debate who have expressed their appreciation of what the hospice movement does. It is a movement, of course, that started in this country. People still come from all over the world to see how we do it. I am proud to stand here and say, without any fear of contradiction, that the care provided by hospices, both in hospices and for people who die at home looked after by hospices, is second to none. The recent ONS survey found that 85% of bereaved people whose relatives had died in a hospice or at home looked after by a hospice thought that the care they had received was “excellent” or “good”. The Care Quality Commission has rated more than 90% of hospices “good” or “outstanding”. In yesterday’s debate, the Minister referred to the observation of the chief inspector of the CQC, who said:

“I know from what my inspectors are finding”,


“hospices provide amazing care and support for people at the end of their lives”.

To take up a point made by the noble Lord, Lord Crisp, hospices do not deliver professionalised care. Of course many of the people who work in hospices are professionals, but there are very many volunteers too. To illustrate

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the difference between hospices and hospitals, I tell the story of a man who was very reluctant to go into a hospice. Eventually, he was persuaded to by his family. When he got there, the first thing they said to him was, “Is there anything you really want?”. He said, “The one thing I would really like is a bowl of porridge”, and, within half an hour, he was provided with a bowl of porridge. With the best will in the world, no one can imagine that happening in any of our hospitals.

The ratings for hospices, which I have mentioned, are far superior to those that hospitals receive. So I repeat today my call to the Minister for help in reducing the number of people who die in hospital. Most people do not want to die in hospital—they do not need to die in hospital and they should not have to die in hospital. It would actually save the NHS money if these people were not in hospital but were transferred instead to hospice care. Many hospices work closely with the NHS trusts in their areas to achieve this. One example was quoted by my noble friend Lord Farmer in yesterday’s debate. We want to evaluate the best way of doing this so that we can put forward to the Government the most effective arrangements for taking the 50,000 people a year who currently die in hospital out of hospital and into hospices or hospice care at home. To carry out that proper evaluation would cost what in this context is the paltry sum of £250,000. I repeat my call to the Minister to make that available.

I particularly welcome the provisions in the Bill which would place a duty on clinical commissioning groups in relation to the funding of palliative care. Three-quarters of hospices have had their NHS funding, which on average provides only a third of their costs, either cut or frozen in 2014-15. The record of hospices in meeting the shortfall from charitable sources is breathtaking. Collectively, 200 charitable hospices in the UK raise £1.9 million a day from local charitable sources. It is an extraordinary achievement, but if that shortfall is increased, as it has been, it will be increasingly difficult for hospices to continue their successful work.

Finally, I draw attention to the briefing that we have received—I hope, in time—from Together for Short Lives, which looks after babies, children and young people with life-threatening conditions and is affiliated to Hospice UK. It has asked for some amendments to the Bill which no doubt we will return to and which I hope will receive sympathetic consideration when we get to Committee stage.

The Economist Intelligence Unit survey quoted the words of the national director for hospice care at Hospice UK. She said:

“The things that make a better death are so simple … It’s basic knowledge about good pain control and conversations with people about the things that matter”.

This Bill will help bring about a better death for many people. On behalf of the hospice movement, I whole- heartedly welcome it.

1.26 pm

Lord Howarth of Newport (Lab): My Lords, it is a pleasure to follow the noble Lord, Lord Howard of Lympne, whose work on behalf of hospices I admire just as I admire the hospices themselves. I add my

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congratulations and thanks to those offered to the noble Baroness, Lady Finlay of Llandaff, for tabling this Bill, which I fully support.

I shall start by talking about the needs of children in palliative care, responding to the urging by the noble Lord, Lord Crisp. I am sure that all noble Lords have received the briefing from the admirable charity, Together for Short Lives, which tells us that, in the United Kingdom, some 40,000 children live with life-threatening or life-limiting conditions.

Children’s palliative care is different and needs to be different, if only for one important reason: because it may well, sadly, be needed for the whole of a child’s life. Yet the availability of resources for children’s palliative care is even more inadequate than it is for adult palliative care. Clinical commissioning groups contribute on average 10% of the cost of children’s hospices compared to 30% of the cost of adult hospices. Thirty-five per cent of children’s hospices had their funds frozen between 2013 and 2015 and 23% had their funding cut. Some families in remote rural areas have no access to specialist children’s palliative care. There is a dearth of people with the skills and knowledge to care for children who suffer from complex and life-threatening conditions.

The Health Select Committee noted also that a wide variety of childhood conditions can cause death before adulthood. Many of them are rare and, therefore, the requirement for diversified specialist care is all the greater. A Royal College of Nursing survey in 2015 found that nearly a third of children’s nurses said that they did not have the resources to deliver adequate care in a home setting, which of course is what most families want; and 31% of nurses acknowledged that they lacked the confidence to discuss end-of-life issues with children and their families.

The RCN calls for a greatly increased number of undergraduate training places to address what it describes as,

“massive gaps in children’s nursing”.

Only 17 community children’s nurses were due to qualify in 2014-15. Many consultants in this field are approaching retirement; too many are not trained to level 4. The training of general practitioners in paediatrics and in physical and mental healthcare for children needs to be improved. There is a 15% vacancy rate among children’s social workers. The commissioning of children’s palliative care is patchy and inconsistent, insufficiently integrating the various disciplines and agencies that need to be involved. The Bill addresses this range of problems. I do not know whether the noble Baroness intends in due course to provide model guidance, but guidance would be preferable to amendments to the Bill.

As to the predicament of children who are bereaved or face bereavement, the Childhood Bereavement Network, to which the noble Baroness, Lady Hollins, referred, has again briefed us extremely helpfully. Its 158 members are supporting children before and after bereavement. The network estimates that some 30,000 children under 18 lose a parent each year and, of course, more lose a sibling or a grandparent. It is a very sensitive issue and it is very difficult for children, parents and professionals to communicate in these situations.

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Gillian Chowns, writing in Bereavement Care and reporting on her research among adolescents facing the death of a parent from cancer, quotes those children. We hear their own voices describing their struggle with their isolation, their anxiety—who is going to care for them when a parent is gone? They want to know the full truth and they need the opportunity to release strong emotions. All such children should have access to well-organised support, proper information, a plan as to who is to do what, and advice and support for other family members, carers, their peers and their teachers. Only 65% of local authorities have an open-access service for bereaved children and most of those services are provided by the voluntary sector through charities such as the wonderful Winston’s Wish.

As the noble Baroness, Lady Hollins, also mentioned, children who suffer bereavement typically face worse outcomes in their future lives, including earlier mortality, mental health problems and entanglement with the criminal justice system. It is not only better but cheaper to ensure that these children come through the emotional crisis of losing a parent or someone important to them without being traumatised.

Many noble Lords will have read the beautiful book by Atul Gawande, Being Mortal, in which he argues that the role of those caring for the terminally ill is not to fight death to the ultimate but to ensure well-being—to ensure what the noble Lord, Lord Howard, called good deaths.

I will make one final point. The arts have an important contribution to make in palliative care. Music therapists, storytellers and those practising other art forms are able to help terminally ill people to prepare mentally, emotionally and spiritually for crucial transitions; to turn depression into hope; to have a sense of agency; to integrate feeling with cognition and sensation; and to gain insight and a sense of meaning and value in what would otherwise be a deeply unhappy and traumatic situation. The arts provide a safe opportunity to organise intense, confusing and contradictory thoughts and feelings; to find self-expression; to share important information that has previously been too difficult to talk about; and to mitigate isolation.

1.34 pm

Lord Maclennan of Rogart (LD): My Lords, it is a privilege to follow the noble Lord, Lord Howarth, who focused very much on the area I intend to speak about, which is children. I am grateful to the noble Baroness, Lady Finlay of Llandaff, for bringing forward this Bill because I believe that the best palliative care is helpful to families as well as to dying people. We need to spread this form of care, which at its best can be very good, across the country.

The Royal College of Physicians points out that only 21% of sites have access to face-to-face palliative care seven days a week, which is a recommendation that has long been advanced. It also shows in its National Care of the Dying Audit—Hospitals, which was completed in 2014, that mandatory training in care of the dying was required for doctors in only 19% of trusts and for nurses in 28%, despite national recommendations that such training should be provided. That is not satisfactory and this Bill should help the position considerably. The audit also mentions that

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53% of trusts have a named board member with responsibility for care of the dying, but 47% do not. That seems unacceptable, and I hope that it will be taken into account in the implementation of this Bill.

The clinical reader in palliative medicine at Oxford University, who no doubt sent his letter to most Members of the House, points out that there needs to be an awareness that palliative care is a form of emergency medicine and intensive care. It needs to be proactive to prevent crises as well as reactive to cries for help, and that sensitive communication skills embedded within a holistic approach is key to quality palliative care.

On the issue of children, we have had an extensive and thoughtful briefing from the charity Together for Short Lives. It is somewhat disturbing that the number of children with life-threatening and life-limiting conditions has gone up from 30,000 10 years ago to 40,000 today. It is clear that we need to be specific about how to help children and young people. The noble Lord, Lord Howarth, was very specific and I embrace what he had to say. However, we have heard that between 2013-14 and 2014-15, 23% of children’s hospices have had their funding cut as a result of financial restrictions on NHS commissioners. I hope that that will be noted by the Government and that their response will be positive. The treatment for young people with the expectation of short lives is clearly different from that for older people reaching the end of their normal lives. It requires specialist education, and I hope that that will be considered. The professional skills, experience and competencies needed to care for children and young people are not adequate, and should be a necessary part of the education of nurses and doctors.

1.39 pm

Lord Suri (Con): My Lords, not long ago I made one of the most difficult choices that I have been asked to make in this place. I speak of voting against the Assisted Dying Bill, sponsored by the noble and learned Lord, Lord Falconer. I voted against it because I believed that it was an absolute affront to our creator to take our own lives. I felt this self-murder to be a crime against nature and I could not support the state allowing it to happen. This all informs my view on the legislation that has been set before us. While those who are in intense pain may wish to kill themselves, they must also be allowed to access the services that could help them maintain their dignity despite their suffering.

This Bill will ensure that those with complex needs will be able to get support and will focus end-of-life care back on the patient. The case studies explored by the Parliamentary and Health Service Ombudsman show how badly some people have been let down at the end of their lives. I am not for one moment criticising the work done by the health service. I have used the NHS for many years, as have my family. I have been lucky enough to see its excellent work up close.

It is the systems of end-of-life care that are to be reformed through this Bill, not the people. On reading the report, what struck me was how unclear the instructions for communication were at this critical stage. One subject, Mr N, suffered unnecessary pain

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due to a lack of clear instruction for co-ordinating a response between specialists. This will be remedied by the new requirement for a single point of contact, as proposed in the Bill. The new responsibility that the CQC checks the provision of palliative care during inspections will also serve to uphold standards, as will the requirement for medical professionals to receive additional training in pain control and communication.

As ever with new legislation, there will be sceptical voices demanding to know how we will pay for it. I agree with the noble Baroness, Lady Finlay, that this Bill, if implemented properly, can save money. Promoting better standards of care and making the decision-making process more streamlined will save the time of our medical professionals and generate efficiencies that can be harnessed.

I urge this House to think of the gigantic human cost involved. To lose a relative is a devastating emotional blow in itself but to see them die in agony, devoid of the dignity with which they were born, is even more crushing. The considerations of the families are, to my mind, enough to justify the passing of this Bill. For that, and the other considerations, I urge noble Lords to approve this Bill.

1.43 pm

Lord Warner (Non-Afl): My Lords, as this is the first time on which I have spoken from this position in the Chamber, perhaps I could clarify my status. I am not a Member of the Cross-Bench group at this stage but a non-affiliated Member of your Lordships’ House. Let me reassure your Lordships that I have not had a personality transplant because I speak from this place—some may say that that is a shame.

One of my long-established views is to improve the end-of-life experience and, in particular, to give people more choice on how and where they end their lives with the maximum dignity. Clearly, good-quality, affordable and accessible palliative care is an important part of the end-of-life choices we should all be able to exercise when our time comes. That is why I strongly support the Bill and warmly congratulate the noble Baroness, Lady Finlay, on her initiative in bringing it forward.

I have no problems with the Bill’s structure and I very much support the points made by the noble Baroness, Lady Finlay, and others about the need to tackle the huge geographical variation in access to good-quality palliative care. However, I will explore in more detail a particular aspect and think about bringing forward amendments in Committee. I hasten to add that the issue I shall raise is not assisted dying. I still strongly support legislation on assisted dying along the lines of the Bill proposed by the noble and learned Lord, Lord Falconer. I gently say to the noble Lord, Lord Suri, that good palliative care is a partner with choice on assisted dying. They are not rivals, but part of the end-of-life choices that many people would like to have.

That brings me to the area I would like to strengthen: the choice to die at home, or the place that people regard as home. I have a Private Member’s Bill on this, the Right to Die at Home Bill, which is unlikely to be

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reached in this Session. As drafted, my Bill does not sit well with this Bill. It is no purpose of mine to damage this Bill by trying to force it into the structure of my Bill.

Here I turn briefly to the excellent briefing from the End of Life Care Coalition. The bull point to emphasise is one made by a number of other people: about 50% of people in the UK continue to die in hospital, despite this being the place where most people would least prefer to be. It is also the most expensive in care cost terms and is rated substantially lower than care at home, in a hospice or in a care home. We have achieved something quite remarkable in this country. Each year we allow half the people who die to do so in the place they least want to be, which provides the least acceptable care and is the most expensive for the taxpayer. That is no mean achievement when the NHS is in such a parlous state financially and needs to care for far fewer people in hospital.

I want to explore with the noble Baroness, Lady Finlay, how we might frame an amendment that captures the spirit of my Bill without damaging the structure or purpose of hers. After a helpful discussion with the clerks, I think that this might be done by giving patients a right to receive palliative care at home right up to the point of death. I believe that this would effectively provide people with an effective right to die at home or the place they regard as home. It would help to change some of the cultural and professional problems that we have in this area, which a number of other people have drawn attention to, in particular the noble Lord, Lord Crisp. It would prevent what happened to my father, who was discharged from a hospice to die in hospital—in my view, quite unnecessarily. I have an instinctive feeling that that is going on from time to time in some parts of the country, apart from for the people who get to receive hospice care.

Before I sit down, I shall touch briefly on money—a subject that I know is dear to the heart of the Minister. Allowing more people to die at home will save the NHS money, but some of those savings—this is a point I want to emphasise—will have to go to boost social care, which is still scandalously neglected by all the political parties. Macmillan has shown that palliative care delivered to people’s home is about a third of the cost of that delivered in an institution. Let us have a bit of sensible, integrated public policy-making. I hope that we can give this Bill a prompt passage.

1.49 pm

Lord Cavendish of Furness (Con): My Lords, it is a pleasure to follow the noble Lord, Lord Warner. I have always listened to him with great respect and, however he describes the seat he is in now in this House, I will continue to do so. I wish him well. However, I regret that, along with the noble Lord, Lord Davies, he chooses to keep alive the question of the Assisted Dying Bill following the rather conclusive vote in the other place recently.

I can only guess at the amount of work that goes into drafting a Bill such as this. I pay tribute to the noble Baroness, Lady Finlay, not just for this Bill but for all the pioneering work that she does for palliative care in the widest sense. It speaks volumes for the

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cause as well as the high regard in which the noble Baroness is held that so many of us are mustered in your Lordships’ House this Friday afternoon.

In the time available to me, I want to make three points: one general and two specific. I need first to declare an interest. Referring noble Lords to the register of interests, I merely say that whatever small value I might add to the debate stems from a very close involvement with St Mary’s Hospice in south Cumbria since its inception some 25 years ago. What a long way we have come since then, but there are still pockets of ignorance. I still occasionally hear a doctor saying that palliative care is no more than common sense—just give the patient a jab of morphine. I still hear people in care homes claiming that they can do the job as well as hospices. But death, dying, loss, grief and bereavement have been largely demystified in the last 10 years or so. They are discussed much more openly than they used to be. I look forward to what has been described as “the cultural aversion to talking about death” being entirely a thing of the past, a point which was eloquently made in the powerful contribution of the noble Lord, Lord Crisp. The culture is changing and changing for the better, even if we have a long way to go.

Earlier this month I participated in a conference organised by the Cumbrian hospices, with which the right reverend Prelate the Bishop of Carlisle is associated. In the morning we heard from, among others, Professor Allan Kellehear. In a compelling talk delivered with blunt Australian succinctness, he emphasised that responsibility for all end-of-life issues lay with everyone—with all of us. He called for leadership in the community to achieve these goals.

In this connection I think it is worth my saying that when we started at St Mary’s all those years ago, I felt that we should never look for, or accept, more than the cost of the clinical costs which we were incurring, which was then, and remains, I think, about 30% of the whole. Of course, it was a very long haul, with great financial crises along the way and some quite difficult moments, but the result was real ownership by the community. Huge benefits flowed from that ownership. It attracts money, as the noble Lord, Lord Howard, mentioned, and it attracts volunteers. The staff develop a sense of accountability to their local community and feel proud and happy to have that. It gives the trustees confidence that they are no longer alone in carrying the financial burden. In a very real sense ownership is shared. My contention is that this sense of community ownership adds force to the aims of this Bill. A group of local worthies asking for something is one thing, a united community demanding it is quite another, and by magnitudes more powerful.

The afternoon session of the conference was dedicated to motor neurone disease. Three MND spouses spoke to us with huge courage and answered our questions. Two of the suffering partners were living and one had recently died. We heard moving and harrowing tales of living with this awful condition. We heard that the NHS provision was excellent but we also heard, with great sadness, that the agency provision, as reported, was absolutely shocking, with untrained, underpaid, overworked and unreliable staff; and always in a great hurry.

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I subsequently spoke to the husband of a wonderful and inspiring neighbour who suffers from MND. He confirmed that their experience with the local NHS was excellent but that the care provided by the agency carers was deplorable. I hope and believe that this experience is not universal but I wonder whether such companies will fall under the provisions of this Bill. Perhaps my noble friend the Minister will be able to comment when he responds on the position of agency staff in general and whether or not it applies to the Bill before us. The same gentleman also told me that the generous provision of equipment was withheld from his wife on the grounds that she was over 65 when diagnosed. If that is correct, it seems very unfair and arbitrary. Again, I wonder if my noble friend could help with this. I have not given him any notice of this question but I would be very grateful if he could write to me.

To my mind, the advances in palliative care and the progress of the hospice movement in my lifetime rank among the great achievements of this country. That there is powerful demand for the best palliative care to be universally available is not unreasonable. The Bill represents another milestone in the long march towards that goal. It deserves our wholehearted support.

1.55 pm

Baroness O'Neill of Bengarve (CB): My Lords, this is a Bill on the right topic—on assisting the dying. That term has been used recently for a quite different Bill which was aimed at only a very narrow number of those who sought death and was about assisting their suicide. Here we have something that speaks to the many who die each year. So it is the right topic—and quite necessary.

It is also the right time, as the demography shows. We are going to have more deaths each year in the fairly near future. That may sound depressing but it arises out of a rather happy fact. Currently we have about half a million deaths in England each year, about 30,000 in Wales and about 55,000 in Scotland—so in round numbers, 550,000. The figure that has been referred to of 350,000 is the number of so-called expected deaths. But that figure of 550,000 will rise. Although we are all living longer, this increase in life expectancy is not a promise of immortality for any of us. The number of people who are likely to die is projected—it is only a projection but it is significant—to rise over the next 20 years to about 670,000 per annum in England, Scotland and Wales. That is a big increase on 550,000.

Every death will be sad in its own way but every death could be well or badly managed and it is clear that we know how to do it well in this country. The finding of the Economist Intelligence Unit is very reassuring in that respect. As my noble friend Lady Finlay of Llandaff said, the problem is the patchy availability, not the standard that we reach in many cases—not just exceptional cases. The quality of the best is excellent but it is availability at the time of need that is very bothering.

Unsurprisingly, availability at the point of need is less good for certain communities in the inner cities and for certain ethnic minorities, but I have personal experience of the fact that it is less good in many

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places that do not fall into those familiar categories. My brother died in leafy West Sussex. He was a well-organised person and when he knew he was dying, he contacted the local hospice and made arrangements to die there when the time came. When the time came and my sons and I could no longer look after him at home, I rang the hospice. They said, “Oh yes, we can take him in three weeks”. As he observed to me, “I shall be dead then”—as he was. We then turned to the GP, who was about to go on his Christmas holiday, and arranged admission to a care home. I cannot fault the standard of care given in that care home but the staff were not permitted to increase the dose of painkillers above what had been prescribed initially. It was Christmas weekend. He died on the day of the tsunami, in very great pain.

The continuation of that sort of event tells us that we are not doing it right at present and that it would not be complex to improve matters. Among the Bill’s many sensible provisions, those that focus on the unavailability of adequate pain relief at the point of need are particularly important. Pain comes in waves, as many people know. It does not wait for working hours, the end of bank holidays or for other events. He died with good care but appalling pain relief.

The problem is not that we do not know how to do it or that we cannot afford it—it would save money. It is a question of a will and a way, and this Bill points the way. I hope we can support it on to the statute book.

2 pm

Lord Haskel (Lab): My Lords, in the years that the noble Baroness, Lady Finlay, has served in your Lordships’ House, she has been a fighter and a champion for better palliative care, particularly in her home country of Wales. As a result, Wales has a system of seven-day specialist palliative care which many organisations say is good and successful, and when the noble Baroness wants to bring this to us here in England, we should sit up and take notice.

As the noble Baroness explained, here in England it is up to the clinical commissioning groups to allocate resources to palliative care departments in hospitals or to buy it in from hospices and other organisations—not only beds but their expertise. Apparently there are many guidelines, and many separate agencies—as well as doctors, nurses and the carers themselves—are involved. There are new ways of controlling the pain, as the noble Baroness, Lady O’Neill, just told us about. The Bill seeks to bring order and lay down a more comprehensive approach. The Care Quality Commission is required to examine and evaluate this. This requirement for better care, better organisation and better targeting surely must be welcomed because, as the noble Baroness, Lady Finlay, said, the variation between what is done and what should be done is quite large. This month’s report from the Economist Intelligence Unit points out that such improvements in end-of-life care need not cost more—it just has to be managed and organised better, which is what the Bill seeks to do.

I therefore welcome the Bill; but does it go far enough? For my part, I would welcome a clearer framework for people approaching the end of life to

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make their own decisions. Other noble Lords have referred to this. The Bill refers to advance decisions to refuse treatment and the Mental Capacity Act, but conversations and discussions need to start early. The Bill deals with patients once they have been confirmed as being end of life. But would discussions and earlier identification not help? That would enable more input from the patients themselves, so that people can have the end-of-life care that they wish for and which is right for them. I welcome the briefing from Compassion in Dying—yes, it did arrive in time—which supports, and even provides, advance decision forms. Can the noble Baroness, Lady Finlay, say how her Bill will help earlier identification and help people to make choices for end-of-life care and know that their choices will be respected?

I congratulate the noble Baroness on the Bill. The changes it proposes and the standards it lays down for the best palliative care possible deserve the support of all noble Lords.

2.04 pm

Lord Elton (Con): My Lords, I begin, as we all do, with thanking the noble Baroness and congratulating her on getting this slot. I also thank her for the enormous dedication, expertise and persistence with which she has pursued this task—this calling—of easing the way out of this world for so many hundreds of people. I should say that I come to this debate as a learner, not as a teacher. I am far from certain that I have grasped all the issues—I have certainly not grasped the final solution—but I would like to make a couple of observations and one suggestion.

My noble friend Lord Crisp was advocating greater openness in discussion about death. I reflect that, to initiate that, you need a largish community with a high average age containing a number of medical professionals and a scattering of clergy. Indeed, here we are, doing what he asked.

My interest and motivation, apart from that which all of our age share, comes from having contrasted the experience of a close friend of mine, whose death at home I observed, wonderfully supported by the local palliative care team, and a report from another friend of an appalling end of life where the person was for several days in such pain that, whenever the person was conscious, the bed was vibrating. That is an inequality which is absolutely insufferable in a civilised society.

Two images float into my mind that suggest how compassion enters into this. The first is the telephone answered after midnight for the noble Baroness, Lady Byford, when her husband was dying. The other was the bowl of porridge mentioned by the noble Lord, Lord Howard of Lympne, brought to a man coming from a hospital into a hospice and, I fear, on the way out.

The number and diversity of people involved in evolving a proper, coherent service seems to me one of the biggest difficulties, and there is the question of establishing communications between them, one with another. We are talking about professionals, who have the royal colleges, and clinicians, who have endless conferences around the world, all of them highly productive, but we are also talking about non-professionals, non-clinicians

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—care workers, paramedics, sometimes policemen or prison officers, all of whom have been mentioned. There is no forum for them.

It would be wrong to try to attempt that in legislation, but an early focus of attention after the Bill either goes on to the statute book or does not ought to be how to remedy that. How good are communications between different clinical commissioning groups? Should there not be a central, national forum for them—perhaps there is, I do not know, I am a novice—in which each group or cluster of groups could exchange notes on their practice? From the evidence that we have been sent and the stories we have been hearing, practice differs violently between one area and another.

There should be an established, respected and, I think, independent but supervised forum that could begin to generate a corpus of accepted best practice that could be shared around the country—indeed, across the nations; we have three nations represented here, and how much other groups seem to be able to learn from the Welsh groups. This is the beginning of that process. How it gets carried down to the next level of the variety of people involved is for another debate, and certainly for someone more learned in these things than I am, but I hope that we can get the fertilising cross-flow of experience between groups to begin.

2.09 pm

Lord Quirk (CB): My Lords, of course I, too, must begin by joining those who have thanked my noble friend Lady Finlay for presenting Parliament with this authoritative and timely Bill. There can be no one in this House, no one in this country, so well qualified in the whole area of palliative care, and we can be sure that every single detail in Clauses 2 and 3 of the Bill, for example, addresses issues that have been expertly identified by my noble friend in her personal experience as a clinician.

About 500 years ago, Francis Bacon memorably noted:

“Men fear death as children fear to go in the dark”.

He was using “men” in the gender-inclusive sense, of course. But I wonder why pharmacological progress in pain management, especially in the last half-century, does not seem to have mitigated or reduced this primeval fear of death. Perhaps it is because so little is known or understood of the comfort and relief that can be afforded by the current standard of palliative care when it operates at its best. Why else is there this trickle of desperate folk to seek terminal help in Zurich? Why else does a steady majority in this country, identified by opinion polls, favour the assisted suicide advanced by the noble Lord, Lord Joffe, and, in recent months, persuasively, by the noble and learned Lord, Lord Falconer of Thoroton.

The sad fact is that those with a good knowledge of current standards in palliative care know also how “patchily”, as my noble friend said, a high standard of such care is available in this country. We should, of course, be proud of our enviable record in this field—proud to be voted this very year, 2015, as the best in the world, just as we were in 2010. We should be proud of such selfless trailblazers as Sue Ryder and Cicely

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Saunders. Indeed, one of my own proudest moments as vice-chancellor of the University of London came when both these ladies accepted honorary degrees.

We can be proud, too, of our great charities, as the noble Lord, Lord Howard, noted. When in the late 1960s Dame Cicely approached Sir Isaac Wolfson, he and his trustees were enthused and began at once to join in the funding of this new wave of hospices. His son and successor as chairman, Leonard, later Lord Wolfson, was equally enthusiastic, as were a succession of trustees, such as the noble Lords, Lord Turnberg and Lord McColl of Dulwich, right down to the present, to the tune of many millions of pounds. The Wolfson Foundation has supported no fewer than 130 hospices across the UK, all reducing the fear Bacon spoke of, as, whether children or adults, we make our way into the dark.

Proud as we can be of this litany of praise and success, we have a very long way to go, and the rest of the world has relatively further still. Even in such a relatively well-provided area as London, the variation in provision from borough to borough is alarming. Such variation is gravely amplified when we look at the UK as a whole. In some quite extensive areas, patients seek in vain palliative care of the kind they need. This Bill specifies succinctly and authoritatively what needs to be done as a matter of urgency, and it surely deserves our wholehearted support.

2.15 pm

Lord Carlile of Berriew (LD): My Lords, I apologise to some noble Lords who spoke earlier, whose speeches I unavoidably had to miss. The noble Baroness, Lady Finlay, and I have stood side by side on the legislative battlefield on numerous occasions. I have always been willing to serve as her Baldrick, but when I use that comparison I do her an injustice because she is most certainly no Blackadder. Indeed, on all subjects, but especially on this one, she is very wise and knowledgeable, and I know that there are Members of your Lordships’ House other than myself to whom she has generously given private time when they have had issues around what we are talking about today. I support this Bill wholeheartedly.

This Bill is, of course, essentially about death. We should not have to feel gloomy about death in the way that seems so traditional in our country. I carry in my mind memories of my father’s death. I was lucky as I had a wise and wonderful father and his death was therefore a great sorrow to me. As I recall the last 24 hours of his life, every moment of which I witnessed, I can get almost a precise replay in my mind’s eye of everything that happened, everything that he said and all the thoughts that we exchanged before he was no longer able to speak, and it brings me great joy.

Today, 2,000 families in this country will face a death in the family. I wish that they could enjoy what I and, I believe, my father enjoyed on that day more than 25 years ago. My father did not want to die, but he was not afraid of dying. What occurred was almost the perfect end to life, but I am well aware that that does not happen everywhere.

Settings for death differ, and I have witnessed some of them. They include hospitals, nursing homes, residential homes and homes. I agree with the noble Lord,

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Lord Warner—wherever he cares to sit in your Lordships’ House—that if at all possible people should be able to die at home as long as home is the right place for them to die and the circumstances are there. Wherever possible, those circumstances should be provided. That is much of what this Bill is about.

Let us face it: in most cases death is predicted, at least within a relatively narrow timeframe. We prepare for birth over a period of nine months. We do not know exactly when the birth will occur, in most cases, but we are ready for it. We are ready to move as a family; we are ready to drop everything; we are ready to be part of a great family event at which we rejoice. I wish that we could do the same about death. In many cases, we can prepare for it and be at the side of the loved one who is departing from the family.

What has happened is that there has been almost a postcode lottery in relation to the way in which death is managed. In some parts of the country, provision has been very good and holistic; in other parts, and I have seen this too in my own family, it is, frankly, haphazard and disconnected, and you depend on the chance that there is at least one nice and sympathetic person present as the relative dies.

The Bill is about creating much wider knowledge and of creating training so that people are ready to deal with death. Dr Twycross, emeritus clinical reader in palliative medicine at Oxford University, wrote a very compact and telling letter to me about this. One of the things he said was that lectures are not enough, and that apprenticeships of an appropriate length and intensity are vital, particularly for doctors training to become specialists in gerontology, oncology, respiratory medicine, cardiology, neurology and pain medicine. I agree with him absolutely that training is about much more than lectures; it is about creating standards and knowledge. I believe that the noble Baroness’s Bill would help to achieve those high standards and good knowledge.

2.20 pm

Viscount Bridgeman (Con): My Lords, I am the last of many speakers today to congratulate the noble Baroness, Lady Finlay of Llandaff, on this, her latest contribution in her distinguished record of palliative care treatment in this country. I declare a non-pecuniary interest in having been for 11 years chairman of the hospital of St John and St Elizabeth in St John’s Wood, London, which, unusually for the hospice movement in this country, has within it St John’s Hospice, forming part of the same charity. In common with most other hospices of similar size—in this case, 22 beds—St John’s has contracts with a number of adjacent health authorities, in its case seven in north and west London. I have to say that patients who are near the end of their lives, whether they wish to spend their last days at home, in hospital or in a hospice, are liable to find themselves participants in a postcode lottery —rather surprisingly, in such a small area of London.

I shall give your Lordships some examples. Hospice at home is developed by many hospices. It is vital but it has administrative problems. Statistics show a slow but steady increase in end-of-life patients wishing to spend their final days at home. Some of the health

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authorities in the group pay for hospice at home but some do not. Some commissioning groups, which are the flagship of the innovations in the 2012 Act, pay great attention to palliative care but, regrettably, others—again, this is the experience of the hospice with which I am familiar—have palliative care low down on their list of priorities, a point that has been raised many times in this debate. Again, I refer back to hospice at home: here there are more than ever likely to be continuing problems of communication as most are elderly patients, many with varying degrees of dementia and of course in dispersed locations. In the catchment area of St John’s, several CCGs do not include in their team the post of palliative lead GP, a GP who, being especially experienced in palliative care, is ideally placed and qualified to ensure good communication with patients at home, and indeed good communication between hospice and CCG. Here again, some CCGs have this very important post and some do not.

A final example of the postcode lottery is the matter of contracts between hospice and health authority. In the St John’s group, only two out of seven health authorities have contracts for more than one year —in both cases, for three years. This is probably outside the scope of the Bill but the advantage to both parties is obvious with regard to long-term planning, and it is surely likely to be reflected in the treatment and facilities available to end-of-life patients with the right postcode.

How, therefore, is all this addressed in the Bill before your Lordships? I suggest that that very point I have sought to raise is addressed directly or indirectly in the Bill under Clause 2(2). In its 10 paragraphs there is in effect a series of minimum benchmarks of performance which I am confident should serve to raise minimum standards across the board and thereby go some way to eliminating the more glaring effects of the postcode lottery to which I have referred.

In conclusion, I must say a word about funding of the hospice movement, which has been referred to, particularly by my noble friend Lord Howard of Lympne. Traditionally the funding of hospices by Governments of all parties has varied widely, from 50% of operating expenses down to percentages in the 20s. The noble Lord, Lord Howarth of Newport, has of course referred to children’s hospitals, where funding is even lower than that. Therefore the shortfall has to be found from appeals and other fundraising events, and £1 million a year is probably the bottom-line requirement. I suggest that there is degree of cynicism on the part of government in all this. This is not a party-political point—it is common to all Governments. Every Government know that in the end virtually every hospice always gets its operating costs funded from somewhere.

I therefore say to the Minister: what a marvellous opportunity for the Government to show their appreciation for this marvellous movement, which, as the noble Baroness, Lady Finlay, has reminded us, leads the world, by at least raising across the board the average percentage of support which they are able to give.

2.26 pm

Baroness Scotland of Asthal (Lab): My Lords, first, I thank the House for allowing me to speak in the gap in support of the most marvellous Bill of the noble

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Baroness, Lady Finlay. She will know that I have been figuratively speaking by her side through all this, but rarely have I had an opportunity to add my voice, so I thank the House for that.

The expertise of the noble Baroness, Lady Finlay, has given us a great treat, because we have an opportunity to do that which will make a difference to so many. One of the tragedies, of course, is that so many of us fear death because of the possibility of dying in pain or alone. Yet each of us aspires to die with those who are with us, love us and care for us, and we hope to die without pain. The Bill, therefore, enables us to derive hope that those who will care for those in need at the moment of their death will have the skill and expertise to be able to give that which is needed. I agree with the noble Baroness, Lady O’Neill, that this is the right topic and at the right time. As the noble Baroness, Lady Finlay, said in opening, whoever a dying person is, whatever the time of day or night or day of the week, they will be able to receive high-standard care. That is the aspiration, and the Bill will help us to deliver it.

Both my parents died after having suffered a severe stroke and after a long period of illness—one for more than a year and the other shortly before that. Yet, as we have heard from the noble Lord, Lord Carlile of Berriew, for me it was the most extraordinary journey to go on with them. I saw strength, care and love, and I too will never forget that. However, both my parents did not die in this country but in the country of my birth, Dominica, where they had no benefit of the National Health Service, and where my family had in effect to create a hospice. I would like to see us here in the United Kingdom make sure that every individual has an opportunity to die not in fear but surrounded by those who love and care for them. The Bill will enable us to do that if we choose to do so. I hope that this House will choose to do that.

2.29 pm

Lord Hunt of Kings Heath (Lab): My Lords, the Opposition warmly welcome the Bill. I hope that it can make progress and get to the other place in time to get on to the statute book this Session.

Clearly, we have much to be proud of in palliative care—in the hospice movement, in particular, but also in parts of the NHS. However, the ombudsman’s five key themes make salutary reading. Frankly, in many places people are not recognised as dying and therefore the service is not responding to their needs. There is poor symptom control and poor communication. There are also inadequate out-of-hours services, poor care planning and delays in diagnosis and referrals for treatment. As my noble friend Lord Turnberg said in yesterday’s palliative care debate, there is no shortage of guidelines. An enormous number of guidelines is available; the conundrum is that they are not being implemented consistently. The question that we want to put to the noble Lord, Lord Prior, is: what can be done to ensure much greater consistency? I know that NHS England has established palliative care networks across England which are meant to support improvements in palliative care and share good practice, but I hope that the noble Lord, Lord Prior, will be able to report on progress.

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I also want to ask the Minister about staff training, which a number of noble Lords have mentioned. We often depend on many young doctors, nurses and care workers, but inevitably they may be ill prepared to deal with death. They certainly need support. I thought that the BMA’s submission to noble Lords on that was very interesting. It says:

“Caring for dying patients will always be difficult for doctors, regardless of their level of experience”.

It continues by saying that,

“doctors are not being equipped with the right tools to provide this care”,

and it refers to the review undertaken into the Liverpool care pathway, which,

“found that medical training in palliative care was inconsistent, and often inadequate, resulting in a large number of junior doctors feeling ill-prepared to care for dying patients at the beginning of their careers”.

That could also apply to nurses and other care workers. Again, I should like the noble Lord to say what the Government can do to get consistency in training.

My third point concerns leadership. The Health Select Committee in the other place recently said that evidence provided to the committee showed a clear lack of leadership at national level—at the centre of government —in relation to end-of-life care. It recommended that:

“The Department of Health and NHS England should ensure that end of life care is prioritised and embedded in future planning at all levels”.

Noble Lords have already mentioned the other recommendation concerning the identification of,

“named individuals who will be responsible for ensuring that the new approach to end of life care … is delivered nationally”.

Again, I ask the noble Lord whether the Government accept that recommendation.

The noble Lord, Lord Prior, in a very sympathetic response yesterday, put a lot of eggs into the CQC basket. Of course, we will have to wait to see the outcome of this work, but I was struck by the fact that he did not mention clinical commissioning groups. A number of comments have been made today about commissioning. Clearly, there is an inconsistency. We have to be honest and say that the capacity of CCGs to commission services is often very limited—they do not have the people with the expertise to do it. Does the noble Lord think that the situation might be better solved by having a national strategy in which a template as to what should be commissioned locally is required by CCGs? That would be entirely consistent with the terms of the noble Baroness’s Bill.

On funding—a point referred to by the noble Lord, Lord Howard, and the noble Viscount, Lord Bridgeman, in particular—there are two issues. One is the level of funding and the second is what I would call stability. The points on the level of funding have been well made, but my experience is that one of the problems—I speak as a supporter of Birmingham St Mary’s Hospice—is that hospices often do not know very much in advance how much they are going to get. Indeed, often they do not know until after the start of the financial year. I would have thought that one instruction that Ministers could give would be that hospices should be entitled to a three-year rolling contract so that they know exactly what they are going

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to get and can plan ahead. The figures given to them are, frankly, so low compared to the entire NHS budget that I do not believe it is unreasonable to ask clinical commissioning groups to do it. I think they often forget what it is like to be an organisation that is not certain of its funding. They get their funding—it might be tight but there is certainty of funding—but for hospices, there is no certainty of funding. At the very least, they ought to know and be able to plan ahead.

Time presses on, but I hope that the Minister will say that the Government are also going to accept the recommendations of the Health Select Committee on free social care, and I echo the point raised by my noble friend Lord Warner.

One thing I would ask the noble Baroness, Lady Finlay, is about the implications of the duty in the Bill compared to the general duties laid on the NHS in other Bills. If I were a Minister I would probably ask her what the hierarchy of importance is. I do not know whether we could explore this in Committee or whether the noble and learned Lord, Lord Mackay, and my noble and learned friend Lady Scotland might perhaps be able to help with an appropriate amendment in relation to that.

We wish this Bill well. I hope that we will have time for a proper Committee stage, as there are clearly a number of issues to be discussed. However, we wish to send this Bill on, with progress, to the other place.

2.36 pm

The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con): My Lords, first, I join with everybody else in thanking the noble Baroness, Lady Finlay, for raising this issue and bringing the Bill before us. She has a long history of passion, commitment and experience in this area, and we all recognise that. There seems to be violent agreement from all sides of the House on the substance of her Bill, and so I congratulate her on the support that she has garnered, which of course goes way beyond noble Lords in this House.

Before I address the Bill directly, I want to draw out three themes that have emerged out of the debate today. The first is that, despite the report from the ombudsman and some very upsetting individual stories, the UK does pretty well in this area. My noble friend Lord Howard referred to the report in the Economist. For the second time—the first being five years ago—out of all 80 countries surveyed, the UK came top, and that includes all the richer nations. We come significantly higher than most other European countries. In part, that is because the hospice movement in the UK has been extraordinarily successful. My noble friend Lord Howard referred to the CQC report. It is quite extraordinary that 90% of all hospices inspected have been “good” or “outstanding”.

However, in praising the hospice movement and the care that it delivers at home, let us reflect for a minute on how difficult it is to provide good-quality palliative care in a very busy acute hospital. It is true that they probably do not do it as well as it is provided in hospices, but, given the circumstances, they often do a remarkable job. My noble friend referred to the bowl

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of porridge that was provided in a hospice. I refer him to the Wrightington Hospital, where a lady coming near to the end of her life said that her one last wish was to see her horse. They brought the horse to the hospital and wheeled her down to see it. We do see these extraordinary acts of kindness and compassion in NHS hospitals as well. That is the first point that I would like to make: the UK does this pretty well.

Secondly, the most important point to come out of today’s debate is the patchiness of how we do it. Variation, I am afraid, is a problem that runs right through the NHS. The noble Lord, Lord Davies, went right back to 1946. Whether it is in end-of-life care, orthopaedics, stroke care or cancer care, there has been this level of variation since the inception of the NHS in 1946. The way that this Government have decided to try to confront this level of variation is through transparency.

It is a fact that, outside healthcare, the only way to drive out variation is through a market—we all know that. If you have choice and competition, they will drive out variation. It is much more difficult in an area such as healthcare, where there is such imperfect information and such imperfect choice. Our approach is to try to confront this issue of variation through transparency. It is not just through CQC reports but through having a much more open culture within the NHS. I say to the noble Lord, Lord Warner, that choice is also a key factor in that, where it is possible.

The third key theme to emerge from this debate is the importance of out-of-hospital care. Where we can deliver good-quality, safe care outside hospital, it tends also to be at lower cost. If it is at lower cost, we have more resources to spend elsewhere in the system. I say in response to my noble friend Lord Howard that I know that Hospice UK is in discussions with NHS England about whether it can help us deliver more care outside hospital. Other noble Lords referred to the huge importance of district and community nurses. Delivering out-of-hospital care to people who are at the end of their lives requires considerable expertise; you need district and community nurses on hand to administer pain relief and the like. In the case of my own mother, who died very recently in an NHS hospital, it was essential to have people there all the time who could adjust the level of pain relief, oxygen and the like.

Those were the three general points that I wished to make. I am afraid, however, that the Government cannot support the Bill and I will set out the reasons why. The most important reason is not that we disagree at all with the underlying intention of the Bill—we are in full agreement with it—but that we do not feel that primary legislation is the right way of tackling the issues raised because it could lead to unintended consequences. Most importantly, we feel that it attempts to deal with issues that, in the main, are best tackled by clinicians, ideally together with patients, carers and loved ones, based on a combination of the patient’s individual condition, preferences and the clinician’s professional expertise.

There is no other part of the healthcare system, be it cancer, stroke, maternity—the beginning of life as well as the end of life—where we have the mandated system that is proposed in the Bill. I will withdraw the

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following analogy if it is not fair. When the Liverpool care pathway was introduced—I was a huge supporter of it—there many parts of the country and many hospitals where it was implemented sensitively and where it contributed greatly at the end of many people’s lives. Yet, because in some parts of the system it became a tick-box solution where people were ticking the box and missing the point, I sometimes feel that a top-down, central directive, be it through legislation or from another source, can interfere with best-practice decision-making. That is the primary reason why we oppose the Bill.

However, there is a second reason—it is probably less strong, but it is strong nevertheless. It is that we feel that the Bill goes against the whole concept and principle of local autonomy that was established in primary legislation through the Health and Social Care Act 2012. I accept that clinical commissioning groups are still in their infancy—they have only been there for just over two years—but they are bound by a duty to commission health services based on the assessed needs of their local population, and palliative care is included in that stipulation. There is also concern that legislation on this issue as set out in the proposed Bill could stifle local innovation by NHS bodies, including commissioners, as they seek to improve the quality of care and provision.

As well as the responsibilities given to the local commissioning bodies, the 2012 Act also enshrines specific responsibilities for health education and training on Health Education England. This Bill would supersede those provisions, thus undermining the role and responsibilities of Health Education England, which works in partnership with local training and education boards to commission and deliver appropriate training and education.

I could go on and talk about what the Government are doing in this area, but that is the fundamental point and I should probably leave it there. We have huge sympathy for the underlying intent of the Bill.

Lord Elton: My noble friend has put local autonomy at the centre of his argument. If local autonomy results in unacceptable variations between localities, will the Government be on the look-out for this? It has only been running recently, as my noble friend says, but will he keep it at the forefront of his watch? If it increases or does not diminish, then something will have to be done about local inequalities.

Lord Prior of Brampton: My noble friend makes a good point. There is tension in the health service between local autonomy, local accountability and the National Health Service. There has always been this tension. We believe that in driving up standards it is best to have the local autonomy. However we must also have transparency so that we know who is falling behind and who is forging ahead. As to transparency at a clinical level, I was talking to a former president of the Royal College of General Practitioners recently—she comes from a different political background from myself—and she said that within the DNA of all doctors is a huge sense of competition: they want to deliver better care than the next-door doctor. That is true of surgeons probably more than anyone, but also

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true of GPs, physicians and hospitals, and increasingly it will be true of CCGs as well. My response to my noble friend is that we are embedding a much higher degree of transparency into the system and it is through that transparency that we will drive improvement by highlighting the best and the worst.

Lord Davies of Stamford: On the matter of transparency, does the Minister agree with my point that it is important that the commission should be transparent vis-à-vis the patient and that there should be a policy of full disclosure to the patient of the diagnosis, prognosis and any implications involved or deriving from changes in treatment or changes of venue from, for example, hospital to hospice or otherwise?

Lord Prior of Brampton: I accept and agree with that. One should not underestimate that even sophisticated, well-informed people put huge trust in their clinicians. How many of us, confronted with a difficult diagnosis, say, “What would you do?”. That is the question that most people put to their doctors. Of course individual choice is extremely important, but the role of the clinicians and the trust that we as patients put into them should not be underestimated.

In conclusion, let me reiterate how much we support the underlying intent of the Bill but that we do not believe that legislation is the right way to address the problems that the noble Baroness has outlined.

2.49 pm

Baroness Finlay of Llandaff: My Lords, I am most grateful to everyone who has spoken in this debate. They prepared for it carefully and highlighted the inequities in provision. I thank all those who support the Bill. I believe that patients and relatives out there, hearing that the Government do not support legislation that would drive up standards of palliative care provision, will be horrified. This has not been plucked out of the air. In Wales we have been doing this for seven years. It is a template as the result of a natural experiment between England and Wales. Through the Bill, we are trying to share best practice.

The Bill is indeed only skeletal. Since coming to this House, I have learnt that you do not put into a Bill what can go in guidance. The issues that have been raised by Peers over possible amendments I would certainly expect to see set out in guidance because that is the right place for them. The reason is that systems change over time, healthcare professional responsibilities change, and you do not want to be locked into something that becomes archaic.

This is not the Liverpool care pathway in another guise. In fact, I have to say publicly that we did not adopt the Liverpool care pathway in Wales because we predicted that it would run into trouble. We developed a slightly different, modified system of our own.

The principles of the Health and Social Care Act 2012 have to work out, and over time they will, but this Bill will not stifle innovation. In fact, it will make sure that there is innovation because research has set out in the Bill. It will make sure that those who provide specialist care have to keep up to date with what is going on and

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participate in research. No longer will they be able to duck out of it using all kinds of weasel words and excuses about wanting to protect patients from people who want to find better ways of care and thus improve it. Those people are called researchers who, like those at the Cicely Saunders Institute, have delivered most of the data to provide the transparency the Government want. I am greatly indebted, particularly to Dr Felicity Murtagh, Professor Irene Higginson and other colleagues there, who have provided me with an enormous catalogue of evidence to check out what is in my Bill.

As for consent and control, we already have the framework in place. No one should be treated against their wishes, so we have a framework that enables people to make advance refusals and statements of wishes. They can do it now, when they are well and long before disease strikes, and they can make changes if they change their mind. That is what the Mental Capacity Act 2005 is all about. It ensures that no one is treated against their will. I know that I now have an uphill struggle in trying to get it properly implemented, but it is a challenge that I take on willingly and I am humbled at being given the chance.

I am also alarmed at the thought of care being discriminatory against people on the basis of age and so on. As for people wanting to be cared for at home, I am cautious about anything that tries to put into legislation specific pathways of care because people change their mind. I have had patients change their mind about what they want and where they want to be in their dying moments—not about the place of care, but even about trying chemotherapy or asking for a second opinion about surgery. We have to be flexible all the time with our patients until they are dead because they may change their mind about what they want in the last few minutes. It may be a minor issue, such as whether the family is in the room or out of it, but those wishes need to be respected.

I am saddened that some have tried to link this Bill with the debate on the Assisted Dying Bill. The House of Commons looked at the proposal for physician-assisted suicide very comprehensively and has spoken very clearly. That Bill is unsafe and should not be brought back into either House of Parliament. It is actually an abuse of the House even to think about doing so. If people want assisted suicide, then go away and write a Bill that is safe, but do not saddle doctors in palliative care with it. They are the group that wants to provide better care and do not want to be involved in such a process. Those doctors also have the right to behave ethically and to do what they want for their patients; they do not want just to give in to demands.

I am also saddened that the Government have been so blunt; they will not even look at ways to improve the situation. We will watch the position over time. I hope that the Bill will have a Committee stage because I want to debate some of these issues further, and I also want transparency. But above all, I want every person dying in this country to be secure in the knowledge that they will get the care they need, but I am afraid that the response I have had today from the Government does not give me that assurance.

Bill read a second time and committed to a Committee of the Whole House.

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Advertising of Prostitution (Prohibition) Bill [HL]

Advertising of Prostitution (Prohibition) Bill [HL]

Second Reading

2.55 pm

Moved by Lord McColl of Dulwich

That the Bill be now read a second time.

Lord McColl of Dulwich (Con): My Lords, as noble Lords will know, I have previously introduced a Private Member’s Bill to address human trafficking on two occasions. I am very pleased that, after many debates over a good number of years, this House played such an important part in changing the law to bring in new offences on human trafficking and new mechanisms to provide support for victims. The Bill that I am bringing forward today addresses similar concerns to those Bills—that is, how to prevent harm to those who are in vulnerable situations.

I had the privilege of listening to hours of evidence on human trafficking, including as a member of the Joint Committee that examined the draft Modern Slavery Bill and as part of the all-party parliamentary inquiry, which ran from 2013 to 2014, on the laws in England and Wales on prostitution. As I said when I spoke on a similar subject on 1 December, the group published our report, Shifting the Burden, in March 2014. I encourage noble Lords to review its findings.

The inquiry reinforced for me the concerns I have had about the negative impact on individuals involved in providing sexual services and the circumstances in which they find themselves. I recognise that this does not apply to all individuals, but, as I said in December, the evidence I have seen indicates that the majority of individuals in prostitution today are victims of exploitation and violence of one form or another. I set out some of that evidence in my speech then, and I hope the House will indulge me if I repeat some of the arguments again as they are very pertinent to my Bill.

Multiple academic studies, including data compiled for the Home Office, demonstrate that the majority of people who sell sex are incredibly vulnerable and subject to real exploitation. For example, research has shown that homelessness, living in care, and debt and substance abuse are all common experiences prior to a person entering prostitution, which is sometimes reflected in the evidence received by our all-party group inquiry.

Many of those in prostitution have suffered abuse and violence in the home. Dr Max Waltman of Stockholm University notes that international studies have consistently found that,

“the majority of prostituted persons—somewhere between 55% and 90% … were subjected to sexual abuse as children”.

The 2012 study, which was carried out for the charity Eaves, interviewed 114 women in prostitution in London both on the street and indoors. Of the women interviewed, 50% said that they had experienced some form of coercion from a partner, pimp or relative, or through trafficking. The same study found that 32% of those interviewed had entered the sex industry before the age of 18. Other studies have found higher numbers than this. For example, the 2004 UK study found a figure of 52% entering before the age of 18.

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Numerous studies have found that between 50% and 95% of women in street prostitution are addicted to class A drugs. Professor Roger Matthews, an expert in prostitution law and policy has written:

“Street prostitutes frequently report that they work to support not only their own habit but also that of their boyfriend, pimp or partner. In some cases, male drug users/dealers will seek out female prostitutes as ‘partners’ since they make good customers and providers”.

The Eaves study I referred to also found that drug and alcohol misuse was not restricted to those in street prostitution, with 83% of their interviewees having a current or previous problem, which in a significant number of cases had begun or increased after entering prostitution. The evidence indicates not only that most people entering prostitution are vulnerable, but that the experience of prostitution compounds that vulnerability, putting them at risk of significant physical and mental harm. A comparative study of prostitution in nine countries, with more than 850 subjects, found that 73% had been physically assaulted. Some 61% of the women surveyed in 2012 by Eaves reported experiences of violence from buyers of sexual services.

Prostitution has also been shown to have a negative impact on people’s mental health. One comparative study in Glasgow looked at the mental health of female drug users, some engaged in prostitution and others not. The study found that those involved in prostitution experience more abusive incidents as adults and more mental health problems than those who are not. The authors concluded:

“Higher rates of adulthood abuse among prostitutes may explain the greater proportion of prostitutes than non-prostitutes meeting criteria for current depressive ideas and lifetime suicide attempts”.

The Council of Europe succinctly summarised my concerns in a parliamentary assembly resolution last year:

“Prostitution is a complex issue presenting various facets that should be taken into account. It affects the health of sex workers with consequences ranging from increased exposure to sexually transmitted diseases to higher risks of drug and alcohol addiction, physical and mental traumas, depression and other mental illnesses”.

However, it is not only the statistics that persuade me that the harms of prostitution are such that it can be seen as a form of violence against women and a dehumanising practice damaging for individuals and society as a whole. It is the stories of individuals who I have met that have been the most compelling. Earlier this week I had the privilege to listen to the powerful account of a woman who had been through prostitution and who now campaigns against sexual exploitation. She said the following:

“When you are prostituted, however you arrived there, you sign a social contract that comes with the highest cost; for the small print of this contract, the terms and conditions are harsh, disturbing and unjustifiable. So it would appear to most that we stand free on the street and yet everywhere we are in chains”.

She went on to say:

“It is my firm belief that every human is entitled to live a dignified life, and prostitution is the systematic stripping of one’s human dignity and I know that because I have lived and witnessed it, and it must no longer be tolerated”.

I agree with her entirely. The dignity and value of every individual person must be our priority.

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All these facts lead me to the conclusion that a reduction in the levels of prostitution is essential, and that this would positively impact not only those domestically but also individuals who might be trafficked into England and Wales in the future.

Noble Lords will remember that we have international obligations to reduce the demand for human trafficking in both Article 18 of the EU directive and Article 6 of the Council of Europe convention on this subject. Indeed, last year the European institutions advocated action to reduce demand for human trafficking and for prostitution. I am sure some noble Lords are thinking that we have covered all this in the Modern Slavery Act. That is, indeed, a fine piece of legislation but, as I said at the time, it did nothing to fundamentally address the demand for human trafficking for sexual exploitation—a very serious oversight given that, according to the NRM figures, sexual exploitation is consistently the most prevalent form of human trafficking in England and Wales.

My Bill before us today seeks to address some of that demand by preventing the advertising of prostitution. It does so by addressing an anomaly in the law on prostitution whereby it is currently illegal to organise or profit from prostitution by running a brothel or allowing premises to be used for prostitution and to cause, incite or control prostitution for gain, but it is not illegal to advertise those same services in newspapers or on the internet. As the Independent Anti-slavery Commissioner, Kevin Hyland, said to me yesterday, we would not accept adverts for a stolen bicycle or for illegal drugs and yet many prostitution adverts contain clear indications of other offences by referring to the availability of several women and, when combined with reference to ethnicity, should at least raise suspicions of trafficking.

I am not naive enough to think that if this Bill becomes law all advertising for prostitution will cease. That is not the criterion by which we should measure its success. My goal is twofold: first, that the law will help to reduce the amount of advertising and thereby help reduce the demand for paid sex, and all the attendant suffering and exploitation that comes with it, and help us fulfil our international obligations to address the demand for paid sex; and, secondly, that it will send a very clear message that we as a society reject the culture of prostitution advertising which commodifies and dehumanises women.

It is for those reasons that I am bringing this Bill before the House. In so doing, I would like to draw the attention of your Lordships’ House to the fact that this proposal is not without powerful international advocates. The European Parliament has noted that,

“advertisements for sexual services in newspapers and social media can be means of supporting trafficking and prostitution”.

This connection was poignantly highlighted by the case of a family in Bolton jailed last month for trafficking and exploiting two women in prostitution. According to the Guardian newspaper report, the court was told that one of the traffickers,

“set up profiles for the two women on adult websites, and when clients called he and his father would tell the women what to say. The victims, aged 30 and 21, were forced to see up to five clients a day and worked ‘whenever the phone rang’”.

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The proposal to ban advertising of prostitution was recommended in a 2014 resolution of the Council of Europe parliamentary assembly. That resolution, which was passed by an overwhelming majority last year, states clearly that,

“trafficking in human beings and prostitution are closely linked … legislation and policies on prostitution are indispensable anti-trafficking tools”.

The resolution calls on Council of Europe member states to,

“ban the advertising of sexual services”.

My Bill meets that call.

The Purple Teardrop Campaign, the United Kingdom organisation committed to ending human trafficking, has a petition calling on Her Majesty’s Government to ban what it terms “sex for sale” advertisements, saying:

“Many ‘sex for sale’ advertisements are placed by traffickers and so contribute to the demand for sexually exploited women and children”.

I understand that more than 36,300 people have signed the petition to date.

My Bill is short and to the point. Clause 1 makes it an offence for a person to publish or cause to be published, or distribute or cause to be distributed, an advert for prostitution. Clause 4 ensures that the offence applies to a business as well as to an individual. Clause 5 defines an advert as,

“every form of advertising or promotion, whether in a publication or by the display of notices or posters or by the means of circulars, leaflets, pamphlets or cards or other documents or by way of radio, television, internet, telephone, facsimile transmission, photography or cinematography or other like means of communication”.

Clause 2 sets out that the punishment would be a fine, the level of which would be set by the Secretary of State. Clause 3 provides a defence that the person,

“did not know and had no reason to suspect that the advertisement related to a brothel”,

or prostitution.

This is a modest but important Bill and I urge noble Lords to give it a Second Reading. I beg to move.

3.11 pm

Baroness Butler-Sloss (CB): My Lords, I congratulate the noble Lord, Lord McColl, not only on the Bill but on the enormous amount of hard work and campaigning he has done over many years in his efforts to combat modern slavery and the trafficking of all people, including women, into this country. I am co-chairman of the All-Party Parliamentary Group on Human Trafficking and Modern Slavery and a trustee and vice-chairman of the Human Trafficking Foundation. In those capacities and personally, I very much support closing the loophole in the law and the purpose of the Bill.

As the noble Lord said, the sex industry includes many victims of sexual exploitation, including many who are trafficked to this country. I have a vivid recollection of going to a Romanian prison where I met a number of traffickers who were serving long sentences. One of them was very proud of what he had done. He ran a very big network across the whole of western Europe, mainly in Spain, but he was happy to tell us that he had brought a lot of women—from

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Romania, mainly, but also from Bulgaria and other eastern European countries—to the United Kingdom for the purpose of prostitution. He said, and it was quite patently untrue, that they were all very glad to be doing it. But I knew from going to Romania on several occasions that many of them were in fact victims of trafficking working in this country and other parts of western Europe.

I support any measure that will reduce the opportunity for those who are sexually exploited to be identified and to be working. But I had a very interesting email from the opposite point of view. In fairness to the people who sent it, I thought I should spend a moment or two on it. The National Ugly Mugs, or NUM, and the UK Network of Sex Work Projects, or UKNSWP, are opposing the Bill. One of their main reasons is that the impact would be the criminalisation of legally working sex workers, mainly in the escort industry. This, they say, is very unfair. They say it will give additional work to the police but they also say it is not enforceable. They say that there are benefits from advertising because it gives them the opportunity to identify and give support to sex workers. They also make the fascinating point that there is a danger that what they call responsible owners of escort advertising will be warned off and less responsible people will take over the advertising for sex workers. My example of the Romanian in the prison in Romania, working the whole of western Europe, makes me think that there are pretty irresponsible and very well-heeled workers running escort agencies—I have no doubt about that. I do not accept what those organisations have said but thought that, in fairness to them, since they have taken the trouble to email me, I ought to give your Lordships at least some of their point of view.

I very much support the Bill. I had not appreciated that advertising for sex workers was still legal. I hope the Government will listen to what the noble Lord has said and support the Bill.

3.15 pm

The Lord Bishop of Derby: I too congratulate the noble Lord, Lord McColl, and thank him for introducing the Bill and for his important work in this important area. I will make a couple of points about the context and about the issue that we are debating. First, there is the scale of it. I was at a lecture on Saturday where somebody explained that demand for the purchase of sex increased enormously in the 1990s with the increasing availability of online pornography. The statistics went from one in 20 men buying sex to one in 10. That is a massive increase in the market. In its briefing paper, the Institute of Economic Affairs almost celebrates that by saying that it is a business worth £4 billion a year. This is not about money or business; it is about abused and oppressed human beings. As the noble Lord, Lord McColl, says, it is part of an increasing scenario of violence against women in our society and treating women as commodities that can be bought and sold.

This very week, some of my colleagues who work with prostitutes in Derbyshire visited a prostitute who advertises her services on the internet. This week, she was visited by somebody through that advertising and horrifically assaulted. Advertising can be an avenue

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for people to attack and abuse very vulnerable women, with horrific consequences. Because many of the women who are drawn into this trade are vulnerable, as the noble Lord, Lord McColl, said, we have to look at being consistent with our concerns about safeguarding. We are rightly concerned to safeguard vulnerable adults and children. Many of the women drawn into this trade are vulnerable in the most terrible way. Some time ago, I met a women here in London who was trying to escape from prostitution. The advertising that her pimp organises led to her being raped 10 times a day—the advertising provided the means for that to happen. That is the kind of human cost that we are looking at.

There are some issues about whether this is practical. I remind noble Lords that in the 19th century there was a lot of debate in this House and the other place about legislation to stop women and children being exploited in factories. At the time, one of the arguments was that you would never eradicate it. Of course it never was eradicated—it still is not—and some families really suffered. The point of the legislation then, as with this modest proposal now, is about what kind of marker the state should put down to say how we value people and how we want to protect them. This would be a powerful marker in a world that is obsessed with and dominated by advertising. I would be interested if the Minister has any comment on what kind of marker the state should put down through this proposal.

Another issue is what it says about the health of society when sexual services are advertised so freely in the press and on the internet. All the research shows that the great majority of men who use the services of prostitutes are either married or in stable relationships. Think of the cost to our society of relationships that are so unstable and immature that all this is going on. The cost is enormous. Should we not be trying to go back a bit to look at what is fuelling this demand? What is happening in the upbringing of boys and young men so that, when they grow up and become older, they patronise this kind of industry?

Advertising, if it is allowed, normalises that kind of behaviour. It normalises being able to buy a woman for sex in a very unequal power relationship. There is nothing equal about it. To allow advertising normalises buying a woman for sex.

Also at the conference on Saturday, I was with a woman, a former prostitute, who talked very movingly about being drawn into a world of fantasy. People who respond to the adverts come into a world of fantasy. She said: “The tragedy was, nobody asked the right question about me. They just wanted me to play along with a fantasy world that everybody thought was fine”. Underneath, she was hurting, she was heartbroken, she was frightened, she was being abused, but nobody asked the right question. Is it mature and right to allow human beings to escape into these fantasy worlds at such terrible cost to fellow human beings?

My last point, on which the Minister may want to comment, is that a lot of this advertising is enabling organised crime to flourish. We need to look at the link between organised crime and advertising for illegal activities to take place. I hope that we will support the Bill.

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3.20 pm

Lord Davies of Stamford (Lab): My Lords, I start by saying that I totally share the horror of the noble Lord, Lord McColl, and the whole House, at the ideas of violence, exploitation—I think that he had in mind living off immoral earnings—intimidation and, although he did not mention it, rape, having sexual intercourse without consent. These are real horrors. We have pretty strong laws against them with pretty strong penalties, but if the noble Lord can make out a case to strengthen the penalties or enforcement, I may well be with him. I do not think that he has made a case that the solution is to criminalise prostitution itself. I am quite certain that he has not made a case that the right way to criminalise prostitution is to do it on the back of this Bill, which is ostensibly about something else.

In my view, legislation should always be open, overt, frank and transparent. It should not be carried surreptitiously, casually on the back of some other Bill. It is very important that the whole House, the other place and the public have a chance to think through the long-term consequences of new legislation, particularly radical legislation of the kind that the noble Lord proposed in his introductory speech, which is criminalising prostitution itself. A lot of perverse consequences would flow from that. The noble Lord shakes his head, but we must be in a position to consider those consequences specifically in relation to the proposal that he has now made to the House to abolish prostitution, not the proposal in the paper that he has put forward, the Bill, which is simply to criminalise advertising for prostitution purposes. There is a lack of frankness in that approach of which I strongly disapprove.

My view about legalising or criminalising prostitution is, above all, based on a fundamental principle, which is that set out so lucidly by JS Mill 150 years ago, which I think is dear to the hearts of everybody who believes in freedom. That is that the state should not restrict the freedom of any citizen except to the extent required to protect the freedom of others. It flows directly from that that acts in private between consenting adults are no concern of the state or of the law. You violate that principle at your peril.

I recognise that virtuous and respectable people, in the interests of reforming society, as they see it, are always trying to encroach on that principle. The worst case was the introduction of the legislation in the 1880s criminalising homosexuality, which continued on our statute book for 80 years. In my view, we should never have violated that principle. I would be against it even if the pragmatic arguments ran in the other direction, but actually, I see several pragmatic arguments which run very much against the idea of criminalising prostitution. In the time I have, I will mention just three.

One is a definitional problem, whether it has to be dealt with by Parliament or by the judiciary in the courts. I fear that it does not sound very romantic or edifying to say so, but I suspect that quite a lot of relationships—far more than we like to think—have some element of material interest in them. It would be extremely difficult to decide whether the material or

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monetary interest was decisive in one particular case. The law would make an awful fool of itself if it specified that if you hire someone for sex for a night or a weekend, you are committing a criminal offence, but if the relationship, including the financial relationship, continued for months or years, you are not—in other words, that a crime, if continued long enough or repeated frequently enough, ceases to be a crime. That would be a novel jurisprudential notion.

Equally, the law would be pretty stupid if it ended up specifying that if you pay for sex with money—cash or specie—it is a criminal offence, but if you pay by means of a diamond brooch, it is not. The law would be held up to equal ridicule and there would be a considerable sense of injustice if you targeted the poor prostitute and perhaps the relatively poor client of the poor prostitute and left the wealthy man and the successful and wealthy courtesan to enjoy themselves without let or hindrance. That would be a mistake. So the definitional problems are real, and the noble Lord needs to address them, if he wants to take further his project of abolishing prostitution by law.

Then there is the issue of the strain on the criminal justice system and particularly the police. We know that the Government are cutting police numbers in drastic fashion, which I personally think is an utterly irresponsible policy that we and even they will ultimately regret. That aside, can you imagine what would happen if the police had responsibility for chasing up every act or alleged act of prostitution in this country? Here for once I do feel that I am not speaking alone. I should be very unamused if I was told by the police that they did not have time or resources to investigate the burglary of my house because they were launched on a much more exciting case, because Snooks was alleged to be having sex with Fifi and money might be changing hands. We want to think very carefully about that aspect as well.

Thirdly, there is the whole issue of the prohibition effects. We all know what prostitution is conceptually. The exchange of money for sex or sex for money is the confluence of two powerful forces in human nature: the desire for sex and the desire for money. If there are more powerful forces in human nature, I am not quite sure what they are, and if you try to dam the tide against them you may have some very perverse effects. The Americans did that with prohibition, but I fear that the two forces that I have just mentioned may be even more ubiquitous and powerful than the desire for alcohol. So you get the same effects; you create a whole new seam of rich potential profits for criminals involved in the intermediation which obviously would be necessary if you criminalised prostitution. It is quite easy to envisage all sorts of opportunities for criminal activity, racketeering and so forth, such as happened under prohibition.

If you prohibit by law something that has been going on for a long time and for which there is a structural demand and existing supply system—we are told that it is quite pervasive; I have not seen these websites myself but I have heard about them and I gather that there are an awful lot of them—you will force a raft of people overnight to change their habits or give up their livelihoods or become criminals. There are

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enormous social implications from doing that which have to be thought through. None of this has been thought through on this occasion.

Finally, there is one extraordinary anomaly—an ironic contradiction at the heart of the noble Lord’s Bill. He set out his intention essentially to defend women in this matter, and I have some sympathy with that: but he then brings forward a Bill that criminalises advertising. But advertising is always paid for by the supplier, not the customer, and the suppliers on these occasions are largely women. So the only people who would suffer criminal sanctions as a result of the Bill becoming law, if it ever did, would be the females involved in prostitution, and not the males. That seems to me an extraordinarily perverse outcome, and I hope that the noble Lord will think a little bit further about this Bill before taking it further.

Lord McColl of Dulwich: Before the noble Lord sits down, could it be by some unimaginable stretch of the imagination that he has come into the wrong debate? We are not talking about criminalising prostitution—we are talking about advertising.

Lord Davies of Stamford: The noble Lord’s Bill, as I have just said, talks about advertising—but, as I have also said, it seems not to be his real agenda. He made it clear in his own introductory remarks that what he intended to do was to abolish prostitution, and that this was just one of several legislative instruments that he has had in mind with that particular intention. I do not think that he can get away from the fact that his introductory speech was all about criminalising prostitution and that that was his preferred solution to the problems of violence and exploitation which he started off with.

Lord McColl of Dulwich: The noble Lord reminds me very much of part of the Queen’s speech—I refer to the Queen’s speech in “Hamlet”, when she says:

“The lady doth protest too much, methinks”.

Lord Davies of Stamford: The noble Lord has brought forward a Bill which is a bit of a false prospectus. If he had talked about advertising, we would all understand that we were simply limited to talking about advertising. In actual fact, every economic activity involves advertising, because every supplier has to have some way of communicating with his customers or potential customers. So you could say that if you ban advertising you ban the activity that is advertised, anyway. We did not get into any of that at all, and I think that—

Baroness Butler-Sloss: My Lords—

Lord Davies of Stamford: I shall give way in just one second, after I finish my sentence. The noble Lord has brought forward a bill of goods that is not exactly, when you open up the content, what you find on the label outside.

Baroness Butler-Sloss: Before the noble Lord sits down, perhaps I may calm this a little. I have absolutely no intention of supporting the abolition of prostitution for a number of practical reasons. It is one of the oldest businesses in the world, and it is likely to go on

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regardless of what Parliament might say. I am here today, when I would much rather be at home, to support a Bill which deals exclusively with advertising. I did not really hear a word in what the noble Lord about advertising and its evils in relation to victims of trafficking and sexual exploitation. That is my line, but the noble Lord, for some reason—and I found it very difficult to understand what he was saying—seems to think that support for the Bill is support for the abolition of prostitution. They are separate subjects in today’s debate.

Lord Davies of Stamford: When I read the Bill, I thought that it was slightly curious because, for the reasons I have just set out, if you succeed in abolishing the right to advertise, you kill the economic activity underlying it—and therefore, surreptitiously, there might be an intention to abolish prostitution, not directly by coming to the House with an explicit Bill to do that but indirectly as a result of the Bill before us.

I have to say in all honesty that the introduction speech of the noble Lord, Lord McColl, confirmed me in my suspicion that that is his long-term agenda—but we shall all have to read Hansard and make our own judgment on the matter.

3.31 pm

Baroness Gale (Lab): My Lords, I thank the noble Lord, Lord McColl, for introducing this important Bill, which I fully support. I am very pleased that he has brought it to the House today. I believe that there is a very strong case for this Bill on three counts: first, it corrects the obvious anomaly in our law that it is currently illegal to organise or profit from prostitution by running a brothel or allowing premises to be used for prostitution and it is also illegal to cause, incite or control prostitution for gain, but it is perfectly legal to advertise—so there is an advert, but if you respond to the advert, you are committing a crime.

Secondly, prostitution has, as we have already heard, far-reaching negative effects on the majority of those involved in selling their bodies and on society as a whole. The noble Lord, Lord McColl, has provided a detailed overview of the evidence that explains why the Bill is necessary. I shall highlight the overwhelmingly exploitative nature of prostitution by citing three stories from south Wales that were told this year in a powerful documentary called, “Selling Sex to Survive”. The programme looked at prostitution in Newport, Cardiff and Swansea. It featured Emily. She once had a happy home, but life trauma led to a breakdown, which resulted in her turning to drugs and prostitution. She said, “Working on the streets, there’s lots of money, lots of drugs, lots of fun, lots of boys, but it’s a horrible, horrible, life”. Another woman said, “You get customers that used to pay £30 to £40 but now it’s £10 all in”. She wants to escape prostitution. Then there was brothel worker, Sorina, who earns enough money in Wales to support her family in Romania—but it comes at a big human dignity cost. She said, “In here, in this job you must be a very cold woman, without thinking, without heart, without nothing”. Imagine basing your life on that: no emotion and no involvement. These stories show how awful, in most cases, it is for women in prostitution.

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Thirdly, the Bill is important because it helps us fulfil our international obligations to address the demand for paid sex in relation to trafficking and prostitution generally. As the noble Lord, Lord McColl, noted, we have international obligations to reduce the demand for human trafficking under Article 18 of the EU directive and Article 6 of the Council of Europe convention on this subject.

Given both our international obligations to address demand and the fact that, according to the national referral mechanism, trafficking for sexual exploitation is the most common experience for victims of trafficking in England and Wales, it seems rather strange that the Modern Slavery Act has nothing to say about the demand for paid sex, even though it addresses the demand for other forms of trafficking through its supply chain provisions. So this Bill will help us rise to the challenge and demonstrate that we are taking our international responsibilities seriously. It will help reduce demand for paid sex and the suffering associated with prostitution.

It will also involve our society sending a clear message through its laws that it does not want to facilitate the celebration of what is an overwhelmingly exploitative practice through advertising. Enforcement will require the provision of some resources but, given the overwhelming evidence of the exploitative nature of prostitution, taking this step is necessary to challenge the exploitation of, in the main, women. Our international and moral obligations mean that we must take action.

I end with a quote from the organisation Against Violence and Abuse, which stated:

“Over 50% of women involved in prostitution in the United Kingdom have been sexually assaulted, and at least 75% have been physically assaulted at the hands of pimps and punters. Women in street prostitution are 18 times more likely to be murdered than the general population. These terrifying statistics demonstrate the need for more comprehensive legislation preventing the exploitation of women through prostitution. It is, therefore, my opinion that the very least this government should be doing is explicitly prohibiting the advertising of prostitution, as Lord McColl’s Bill so nobly argues”.

I am sure that the Minister is listening closely, as he always does, to what the House is saying today, and I hope that he will be in a position to support the Bill.

3.37 pm

Lord Morrow (DUP): My Lords, I support the Bill proposed by the noble Lord, Lord McColl. I believe that addressing the demand for paid sex is one of the key challenges of our society today. It is a great disappointment to me that one of the longest-standing forms of exploitation has yet to receive the same attention and focus as modern-day slavery. I speak, of course, about prostitution.

As noble Lords will be aware I recently helped to take a Bill to address human trafficking and exploitation through the Northern Ireland Assembly. In the course of that process I engaged in extensive consultation, read a large amount of evidence and spoke to a great number of experts in this area. I spent hours talking with groups such as Women’s Aid in Belfast, which supports victims of trafficking and sexual exploitation, and Ruhama, a charity from the Republic of Ireland that supports women exiting prostitution. I visited

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Sweden and met police officers and anti-trafficking experts who explained to me the principle and the practical impact of their laws banning the purchase of sex. Most importantly, I met survivors of prostitution.

If I am honest, when the idea to criminalise paying for sex was first suggested I was far from sure. However, after meeting survivors and then carefully studying the evidence, I was more than convinced. The scale of the evidence demonstrating the vulnerable position and terrible experiences of the vast majority of people involved in prostitution requires us to take action. I recognise that that is not the case for every person, but from all the evidence that I read and all the people I spoke to, the voice of the most vulnerable was the most compelling. At the end of the day, we as legislators have to make a choice when considering prostitution. Do we act out of primary regard for the vulnerable majority or the privileged minority? I am very clear that it should be the former. That is why I strongly agree with the noble Lord, Lord McColl and disagree with the noble Lord, Lord Davies, that we must seek to reduce demand for prostitution.

While the noble Lord, Lord McColl, has done exactly the right thing in identifying the need to engage with demand for paid sex, the Bill does not go far enough. Rather than just focusing on advertising, a more effective way of tackling demand and attendant exploitation would be to make it an offence to purchase someone for sex. That legislative solution goes right to the root of the problem, and I am delighted to say that more and more countries are now turning to it.

Most recently, Lithuania has just changed its law, and the Republic of Ireland is currently in the process of changing its law. In Northern Ireland the decision to address the demand for paid sex through criminalising the buyer was not a decision taken lightly. The issue was debated at length, and ultimately was supported by 81 out of the 108 Members of the Northern Ireland Assembly and, significantly, by Members across the political divide, both nationalists and unionists. We must make it illegal to buy sex, because that will be the most effective way to reduce demand—which is in turn the most effective way to reduce the harm of exploitation.

Evidence from interviews with those who buy sex indicates that criminal sanction would be the most effective deterrent. Moreover, independent analysis of the long-standing employment of this approach in Sweden and Norway demonstrates that banning the purchase of sex can reduce levels of prostitution and curb trafficking. The independent evaluation of the Swedish law found that street prostitution had been cut in half as a,

“direct result of the criminalisation of sex purchases”,

and there was no evidence that the decrease in on-street prostitution had led to an increase in off-street prostitution.

We must reject the tacit acceptance of prostitution in our society. That acceptance may not take the form of openly promoting commercial sex—it might even acknowledge that prostitution is a harmful practice—but if we continue to say that it “has always been with us and will never be eliminated” or seek only to make the practice of it a little less dangerous, in effect we support

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its continuation. The only way to reduce the harm of this ancient form of exploitation is to reduce the demand that perpetuates it.

Having explained why the noble Lord, Lord McColl, is absolutely right to propose that we address demand for the overwhelmingly exploitative practice of buying people for sex, while suggesting that I think criminalising demand is the most effective way of doing so, I want to be very clear that I regard the proposal in the Bill to constitute a very important step in the right direction. Making it illegal to publish adverts will mean that the law no longer permits the promotion of prostitution. It will send the message that promoting exploitation is not acceptable, and will reduce access to prostitution—both of which can play a role in reducing the demand that fuels the trade. I was very interested to hear the noble Lord, Lord McColl, say that the anti-slavery commissioner says that the current anomaly in the law needs addressing. That is important, and we would do well to pay attention to his concerns.

I heartily congratulate the noble Lord, Lord McColl, on tackling an issue which is too often pushed to the margins because it is too difficult, and give the Bill my fullest support. I very much hope that the Government will take the overwhelmingly exploitative nature of prostitution much more seriously and recognise that this Bill provides them with an effective and timely means of doing so.

3.43 pm

Lord Kennedy of Southwark (Lab): My Lords, first, like other noble Lords, I congratulate the noble Lord, Lord McColl of Dulwich, on securing a Second Reading of his Bill. He raises a serious issue with his Bill before your Lordships’ House today. It proposes to make it an offence to publish, distribute or cause to be published or distributed advertisements which advertise a brothel or the services of a prostitute, and thereby deals with an anomaly, as the noble Lord himself outlined. The right reverend Prelate the Bishop of Derby is right to say that allowing advertising gives the appearance of normalising this activity, which is a front for organised crime. The noble Lord’s Bill provides a defence in cases where the publisher was not aware and had no reason to suspect that an advertisement related to a brothel or the services of a prostitute.

The consequences for communities and people from the effects of prostitution can be devastating: violence, extreme violence, even people being murdered, as we see all too often in the media. One recalls the terrible events in Bradford. The right reverend Prelate rightly talked about the vulnerable women who are drawn into this trade and are terribly exploited. People who are trafficked and effectively become slaves are treated utterly appallingly. The noble Lord, Lord McColl of Dulwich, made reference to that, as did the noble and learned Baroness, Lady Butler-Sloss, who talked about traffickers and people whom she had visited in Europe.

People involved in prostitution have serious problems with drugs and alcohol abuse, and their lives are utterly destroyed. As we have heard today, more than 50% of the people in this trade are coerced into it. I agree with the comments of my noble friend Lady

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Gale, who outlined the despair of women who work as prostitutes and said how important it is to develop international obligations. In addition, local communities can be destroyed by the effects of prostitution. There is important work to be done by various agencies to tackle its causes and effects. People who are abused and exploited need help and support from health, welfare and other organisations in order to exit prostitution. There needs to be a partnership approach with local authorities and non-statutory agencies to help people to find a route out.

In recent years, there has been a slight increase in the number of prosecutions of those who control prostitution. That is welcome but much more needs to be done. The noble Lord’s proposal is specific and focuses on advertising the trade. He was clear in stating that it is all about violence. The Bill—which I hope will progress further—seeks to disrupt these activities by making it an offence to advertise such services. This idea has been put forward before but no progress has been made. Certainly as far back as 2010 my right honourable friend in the other place Harriet Harman suggested a similar approach, and other colleagues and other campaigns have also called for action along similar lines.

I want to make a few general remarks about how we handle Private Members’ Bills, of which this is the third today. We will give this Bill a Second Reading and then it will be moved that it be committed to a Committee of the Whole House. Last year, I said to the Clerk of the Parliaments, “We have all these Private Members’ Bills. They are really good Bills putting forward really good ideas but they often go no further than Second Reading. Why can’t they go into Grand Committee, as other Bills do?”. I was told that it is perfectly possible for that to happen. Therefore, I ask the Minister and the government Whip to take that suggestion back to the Chief Whip for discussion. I think that we could make much more progress on these Bills if we had a sitting in the Moses Room, looking at the details in Committee. We are missing an opportunity there.

I again congratulate the noble Lord, Lord McColl, on putting this issue before the House today. He is seeking to disrupt the activities of the people who control the trade and deal in violence, abuse and misery. I hope that the noble Lord, Lord Bates, will give the noble Lord a positive response, as it would be good to see the Bill make further progress in your Lordships’ House.

3.47 pm

The Minister of State, Home Office (Lord Bates) (Con): My Lords, I join all other noble Lords in paying tribute to my noble friend Lord McColl. As someone who is passionate and informed in trying to improve and reform our society, he epitomises all that is good about this House. Of course, he is the principal architect of the Modern Slavery Act, which has now come into effect. As the right reverend Prelate the Bishop of Derby rightly observed, those who are trafficked are often trafficked in connection with prostitution, and therefore, that legislation will be effective in tackling this problem.

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Before I come to the details of the Bill, I want to set out what the Government are doing in this important area. I will then make a few comments on the practicalities of the Bill and talk about where we go from here.

First, I make it absolutely clear that we are committed to tackling the harm and exploitation that can be associated with prostitution. We believe that people who want to leave prostitution should be given every opportunity to find routes out of it. Like the noble Baroness, Lady Gale, and the noble Lord, Lord Kennedy, I pay tribute to all those organisations that work in the field of prostitution helping people to find a way out of this lifestyle.

Regardless of the legal position of prostitution in the UK, the law on rape and sexual assault is clear and unequivocal. We expect every report of sexual violence and rape to be treated seriously from the time it is reported, every victim to be treated with dignity, and every investigation and prosecution to be conducted thoroughly and professionally. This is a core strand of our wider work to eradicate violence against women and girls.

We recognise that prostitution is a complex issue that can impact on individuals and communities in different ways. Local areas and police forces are in the best position to identify and respond to the issues around prostitution in their area.

We all recognise the harm and exploitation that can be associated with prostitution. I assure the House that the Government are absolutely committed to tackling those harms. We are working across government and beyond to tackle exploitation in all its forms. This vital work is underpinned by rightly ambitious strategies focused on violence against women and girls, modern slavery and child sexual abuse.

In March this year, the previous Government outlined progress in tackling violence against women and girls over the period of the last Parliament. Our commitment continues. The previous Government ring-fenced £40 million to support victims of domestic and sexual violence—£10 million per year—and this Government are continuing that funding to April next year. In addition to that £10 million, the Government have provided an uplift of £7 million for services specifically for victims of sexual violence, and an additional £13 million for domestic abuse services, including refuges. We are currently developing a refreshed version of our strategy to be published later this year. This will set out how we will meet our manifesto commitment to provide a secure future for refuges, female genital mutilation and forced marriage units, and rape crisis centres.

Noble Lords will be aware of our concerted efforts to tackle modern slavery. Indeed, many were instrumental in their support for the Modern Slavery Act, including the noble and learned Baroness, Lady Butler-Sloss, and the right reverend Prelate. The Bill received Royal Assent in March and brings in a range of powers and measures to prevent exploitation and support victims.

Our Modern Slavery Strategy, published in November 2014, sets out the wider non-legislative work under four headings, the first of which being to pursue the organised criminals and opportunistic individuals behind the modern slavery trade. On this point, the noble and learned Baroness spoke of the people she visited in a

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prison setting in Romania who were responsible for trafficking. I hope that such people would now be captured, either under the Serious Crime Act or the Modern Slavery Act. That is, of course, something that ought to be clamped down on, and the proceeds of crime, which that person was benefiting from, would be taken from them.

Tackling child sexual abuse and exploitation is a top priority for the Government. The Home Office is leading on a cross-government programme to deliver the commitments departments made in the Tackling Child Sexual Exploitation report and the national group action plan. That includes recognising child sexual abuse as a national threat in the strategic policing requirement.

I now turn to the specific proposals in the Bill. Noble Lords will know that existing legislation regarding prostitution is contained in a number of Acts and has developed over time. The acts of buying and selling sex are not illegal in themselves—a point that the noble Lord, Lord Davies, made very clear. However, certain exploitative activities are specific offences. These include the running or managing of brothels, for example, or controlling prostitution—the point that the noble Baroness, Lady Gale, began with. In this context, noble Lords will be aware that it is already against the law to advertise activity that is itself illegal; for example, sex with trafficked individuals or those under the age of 18. This reflects a widely accepted emphasis on protecting the vulnerable. In terms of public nuisance, it is illegal to place advertisements relating to prostitution around public telephones.

The Bill proposed by my noble friend Lord McColl would go significantly further, by prohibiting all forms of advertising for prostitution, including online. It is a proposal that deserves our attention today. I do not want to reopen the debate that took place across the Floor of the House on the wider issue of prostitution. It is clear that the issues raised in this Bill are specific but that, at the same time, they must be seen in that wider context. The noble Lord, Lord Morrow, quite rightly drew attention to his own experience from the legislation in Northern Ireland, where it is a devolved matter and where they are entitled to take such an approach. I put on record two points which are material: first, the Government will follow closely the experience in Northern Ireland as that legislation is implemented; secondly, referring to my noble friend Lord McColl’s conversation with the Independent Anti-Slavery Commissioner, the whole point of having such a commissioner is that he is independent. I take seriously what he has said to my noble friend and will follow up on it.

Notwithstanding these contested issues, there is a practical point to make on the application and enforceability of a prohibition on advertising. Noble Lords may be aware that most advertisements for prostitution are not explicit—they are couched in euphemisms, which are difficult to disentangle from non-sexual services; for example, reputable massage services or saunas. It would also be difficult to apply the legislation to advertisement on the internet, which can be hosted overseas, as we are experiencing in other areas of legislation.

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The Government’s first priority in this area is public safety. For example, the Home Office has worked with the UK Network of Sex Work Projects to support the establishment of the National Ugly Mugs scheme, to which the noble and learned Baroness referred. This is an innovative mechanism whereby people involved in prostitution can make reports and receive alerts about incidents that have been reported to the scheme. Alert information is also fed to police forces, regional intelligence units and police analysts. We are pleased that the evaluation of the scheme shows that it has been successful in increasing access to justice and protection for those involved in prostitution.

Our focus on safety applies also to legislation: when considering legislative changes, we must consider carefully whether we are confident that they support the safety of the people involved in prostitution. For example, I am aware of communications that noble Lords may have received—they have been referred to—from the UK Network of Sex Work Projects setting out its concerns, particularly about criminalising and further marginalising an already vulnerable group, thereby exposing them to potentially greater risk or harm. I would be happy to discuss with my noble friend Lord McColl and other interested Peers the evidence of the extent to which such changes to the legal, and by extension ethical, position of buying sexual services would reduce harm to those involved.

While the issues around prostitution are complex and contentious, as we have heard today, we expect every report of violence to be treated seriously. In this context, it is important to reflect on the increased reporting rates for these terrible crimes, showing that, increasingly, victims have the confidence to report and can access the support they deserve. That is to be welcomed.

I recognise that at the heart of this Bill are the noble Lord’s genuinely held concerns for the welfare of those involved in prostitution. He has made those clear in his considered presentation of his proposed Bill today. I thank him and other noble Lords for their thoughtful contributions not only to this debate but to much of the Government’s work to tackle exploitation in all its forms, whether it be modern slavery, child sexual abuse or violence against women and girls. I am proud of the progress that we are making on a cross-party basis and we will continue to consider effective approaches.

In their present form, my noble friend’s proposals would have a number of legal and practical implications, which I am happy to discuss with him, that were perhaps not intended. However, we recognise his sincerity and desire to protect from harm those who are involved in prostitution and to offer people captured and trapped in that world a way out to a better and more healthy life for them and for society as a whole.

Lord Kennedy of Southwark: My Lords, the noble Lord made a point about the practicalities and that is the point I made generally about the Bill going to a Grand Committee. With this and other Bills you can sit there for a day and work them out in great detail and get things moving forward. It is a missed opportunity.

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Lord Bates: That is a fair point. It is for the usual channels and my noble friend Lord Gardiner, the Deputy Chief Whip, is the perfect person to hear those representations. I am sure he will consider them carefully and respond to them in due course.

4 pm

Lord McColl of Dulwich: My Lords, I thank all those who have taken part in this debate and the Minister for his kind remarks about me. However, I should like to draw attention to the amazing work that has been done by the noble and learned Baroness, Lady Butler-Sloss, the right reverend Prelate the Bishop of Derby and the noble Lord, Lord Morrow. A big team has been at work.

It has come through clearly in this debate that advertising facilitates the exploitation in prostitution of people who are trafficked and some who are not. I shall not respond directly to the remarks made by the noble Lord, Lord Davies, because they do not relate to this Bill. However, I should like to address briefly one point that he raised. He suggested that my Bill will further criminalise women who are placing adverts. The Bill was drafted with the intention, courtesy of Clause 1, to address those who facilitate and publish the advertising, such as newspapers and website operators. I shall certainly look into the question further and if I receive legal advice that Clause 1 could be interpreted to apply to an individual placing an advert rather than only to the entity publishing it, I shall certainly look into bringing an amendment in Committee.

Lord Davies of Stamford: I was guided in my remarks by the phrase in the first line of the noble Lord’s substantive Bill:

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“A person who publishes or causes to be published”.

It seems to me that inevitably the supplier of prostitution services would be causing to be published any advertisements that appeared on her behalf.

Lord McColl of Dulwich: I shall certainly take legal advice about that and see whether we can tighten things up later on.

The Minister referred to the importance of minimising the harm of prostitution and I agree that we want to do all we can to reduce the harm experienced by people in prostitution. Indeed, that is the aim of reducing demand. By addressing the proliferation of advertising and reducing the demand it fuels, we can reduce levels of prostitution and thereby reduce the harm that is caused.

We should of course be working with the police, the courts system, the NHS and social services to try to prosecute those who commit acts of violence against people in prostitution and to help people access support to exit prostitution and build a new life for themselves. However, unless we address the demand, for each person who is assisted out of crisis, another will take their place. We need to look at the bigger picture.

I find myself in a rather difficult position because there is much I would like to respond to but we are out of time. I should like to put on record that I completely reject the suggestion that the Bill is unenforceable or that it will make life more dangerous for people in prostitution. I feel very frustrated that time does not allow me to explain why.

Bill read a second time and committed to a Committee of the Whole House.

House adjourned at 4.04 pm.