Seòmar agus comataidhean

Ms Thomson, I have sat where you are in relation to a number of bills and I have happily torn into the FMs that have been presented to us. It is not until you sit down and try to do one yourself that you realise how perilously difficult it is. Even when there are comparator jurisdictions that have passed similar legislation, simply lifting and shifting the figures from those will not work for a variety of reasons. The model of the legislation may be a bit different, the delivery of the health and care system may be very different, or there might be wider differences such as the ones that Mr Mason referred to.

The financial memorandum is a best stab at coming up with figures that are as accurate as I can make them, based on reasonable assumptions. As I said in answers to the convener and Mr Mason, it is an unusual situation for a financial memorandum. If the figures are out—either lower or higher—the cost will go up or down, but the savings that may go alongside that will also go up or down.

Mr Marra’s point about going for ranges is a reasonable one. On reflection, I think that coming up with wider ranges might have been more helpful to the committee and might have reflected the fact that we are feeling our way. As I said, a number of those who responded to the committee made reasonable claims that there is usually an underestimation, but they have not necessarily gone as far as setting out what they think a more reasonable figure would be and what that would be based on.

I respond by saying that the proposals lean heavily on clinician judgment. At the moment, we trust clinicians to make a range of decisions, including those at the end of life. The proposals that I have set out in my bill would make for the most heavily safeguarded end-of-life option that there is—not least the requirement for not one but two clinicians to be involved in the diagnosis and the assessments.

Ascribing motives to medical professionals in the way that Care Not Killing has suggested is unfair and unhelpful to the debate that we need to have on these issues. As I said in my opening statement, I acknowledge that savings will be made when treatment that would otherwise have been given is not required or delivered, but that is not the motivation behind or the objective of the bill.

At the moment, decisions are being made to move patients from curative pathways to palliative pathways, and they are made in the patient’s interests and in discussion with the patient—they are led by the patient’s interests. Such moves may end up being less costly—it depends on the treatment that is given—than was the case with the pathways that the patients were previously on. However, I do not believe that medical professionals are taking such decisions, or advising patients on them, on the basis of cost savings.

We may come on to this in questions about investment in palliative care, but I note the evidence that the Health, Social Care and Sport Committee has been hearing in its evidence sessions over recent weeks. Last month, witnesses made the point that what they have seen in Australia is increased engagement with palliative care, because the discussions that are required as part of such a process—as I am looking to establish under my bill—have been activating such engagement in a way that has not always happened.

That reflects the point that the additional safeguards that my bill will introduce can help to provide a degree more transparency and robust protection around things that are currently legal. That includes the withdrawal of treatment and the issue of double effect, which relates to managing pain in the certain knowledge that palliative sedation can increase the risk of accelerating death.

At the moment, we ask medical professionals to operate in a relatively grey area, often without the input of patients, and more often than not with the involvement of families. Whether or not there are cost savings, I do not believe that medical professionals, who we trust to make such judgments, would be motivated in that way. Protections are in place to guard against such an outcome.

Yes.

Most have some sort of timescale. I think that it is 12 months in Queensland, whereas it is six in Victoria. In others, there is a difference between neurological conditions, in which there tends to be a longer timeframe for prognosis, and other conditions.

Thank you, convener, and good morning. Before I begin my statement, it will be helpful if I declare some relevant interests. I receive funding for an additional member of staff from three permissible donors—Friends at the End, Dignity in Dying and the Humanist Society Scotland—and the support is currently for a staff member one day per week. The Humanist Society Scotland also funds the development and maintenance costs of the domain and the hosting of a website that I use to publish materials relating to the bill—that was, ostensibly, prior to the formal introduction of the bill. Dignity in Dying paid the costs that were associated with my visit to California as part of a cross-party delegation of MSPs that met various organisations and individuals in relation to the state’s End of Life Option Act, and I refer members to my entry in the register of members’ interests for more details on that.

Members will be aware that I formally introduced the Assisted Dying for Terminally Ill Adults (Scotland) Bill in Parliament in March this year, following the usual members’ bills process, with the support of the non-Government bills unit. The bill aims to allow mentally competent terminally ill eligible adults in Scotland to voluntarily choose to be provided with assistance by health professionals to end their own lives.

The approach that I have taken in the bill and related accompanying documents is purposefully quite different from that taken in previous proposals and bills on the issue that the Scottish Parliament has considered. The approach and the estimated number of people who may request assistance reflect the bill’s provisions and the form of assisted dying. In effect, I am legislating to allow a relatively small cohort of people who request assistance to end their own lives to be provided with such assistance.

There have been suggestions that the numbers involved and, likewise, the costs will be higher than anticipated. However, the jurisdictions where numbers are significantly higher either do not have comparable legislation to the bill that I have introduced or have notably different circumstances from those in Scotland, and the financial memorandum reflects that.

My intention from the outset was to introduce a bill that would make it legally possible for terminally ill adults, if assessed as eligible, to be provided by willing health professionals with assistance to end their own lives. I wanted a bill that detailed, as far as possible and within the Scottish Parliament’s competence, the process that is involved before, during and after. The financial memorandum reflects the approach that is taken, the bill’s provisions and the limitations that the accompanying documents acknowledge.

To be eligible, a person must be terminally ill, aged 16 or over, have been a resident in Scotland for at least 12 continuous months, be registered with a GP in Scotland and have the mental capacity to make the request. A person must have had health and social care information and options—for example, about palliative and hospice care—and information about assisted dying explained to them prior to making a final decision. A person must also make the decision of their own free will, without coercion or pressure, to the reasonable satisfaction of healthcare professionals.

The bill will establish a lawful process for an eligible person to access assisted dying that I believe to be safe, controlled and transparent. The process broadly involves a person stating that they wish to be provided with assistance to end their own life and being assessed for eligibility by two doctors, acting independently of each other. If assessed as eligible, a person can give a further indication that they wish to continue and then be provided, at a time of their choosing, with the substance for self-administration to end their own life.

I believe that that will give people a choice and enable them to avoid the existential pain, suffering and symptoms that can be associated with terminal illness. In turn, it will afford them autonomy, dignity and control over the end of life.

The bill will make it lawful for a person to voluntarily access dying if they meet the criteria as set out in the bill and for willing health professionals to assist in that process, while continuing to ensure that assisting death outwith the bill’s provisions remains unlawful.

The bill also provides that no one is compelled to participate directly in the process if they have a conscientious objection to doing so. The provisions ensure that relevant data and information is collected, processed and published in annual reports to aid transparency and understanding. In addition, there will be a requirement for the legislation to be reviewed after five years. That will afford the Scottish Parliament, health and care professions and wider society an opportunity to take stock of the practical experience of assisted dying.

The financial memorandum—for the first time with any piece of proposed legislation on this subject in the UK—attempts to estimate the costs and savings that would be associated with implementation and the impacts of such legislation as far as it was felt reasonably possible to do so. That was done in the absence of any precedent for similar enacted legislation in the UK, and with often very little relevant or meaningful data—or, in some cases, none.

The approach that is taken in the financial memorandum is based on an estimation of the potential annual number of people who will request an assisted death and the number of people who will go on to self-administer a substance and end their own life. Estimates are provided for the first year in which assisted dying will be available, and the financial memorandum projects the figures over 20 years. Comparable data from Oregon in the US and Victoria in Australia was used to inform those estimates. On the basis of the assumptions and methodologies used in any available meaningful data, estimates for possible costs to the Scottish Administration and for health and care services in Scotland are provided.

The memorandum acknowledges that the legislation is likely to result in savings as well as costs, and that, broadly speaking, it is expected to be cost neutral. That is because a cost is associated with the processes that are involved in a person being assessed and potentially provided with assistance to end their own life, such as clinical and associated administration costs, and because there is a commensurate cost saving from a person no longer receiving care for however long they might have lived.

International evidence indicates that case numbers are likely to rise annually, certainly in the initial years of assisted dying being available. Therefore, to give an indication of how rising case numbers could affect costs and savings, the memorandum gives estimated figures for year 1 and then on-going costs until year 20.

Following the publication of the memorandum, it came to my attention that table 3, which sets out estimated costs to health services, and table 4, which sets out estimated overall costs, conflated some of the year 1 and on-going costs and year 20 estimated costs. I subsequently wrote on 17 June to this committee, as well as to the Health, Social Care and Sport Committee, to amend and present some of those costs more accurately and clearly. I wrote again to both committees on 14 October to note two other minor discrepancies.

The net effect of the issues that are noted in those letters is that the upper-end total estimated costs of the bill are £4,036 higher than those that are estimated in the financial memorandum. Although they are relatively minor, I extend an apology again to the committee for those errors.

I read with interest the 22 responses that you received to your call for views, and I thank all of those who took the time to respond. I note that NHS Fife, which was the only health board to respond, considered the estimated costs in the memorandum to be reasonable and the bill to be broadly cost neutral.

I welcome the acknowledgment across many responses, including from those who are more critical of the financial memorandum and of the proposal for assisted dying, that attempting to estimate costs in this area is extremely challenging and complex, because of a lack of meaningful data and/or precedent in many of the relevant areas.

I noted the issues that were raised in other responses, such as the suggestion that the case numbers are underestimated. I acknowledge that different assumptions can be made and methodologies used that would result in different estimates. Depending on which assumptions are made, one could estimate the cost to be higher than the memorandum does, or indeed to be lower. Frankly, none of us knows exactly how many people might wish to begin the process and how many might go on to be provided with assistance, and one could make a range of different but incompatible estimates. I am satisfied, however, that the assumptions that are made and the methodology that is used in the memorandum are evidence based, that they reflect a justified midpoint of the extremes of opinion and that they provide a reasonable estimate of likely numbers.

I also note the comments that the potential costs associated with areas such as training and the provision of support or guidance have been underestimated or excluded. I accept that some organisations and individuals have different thoughts on some of the issues. However, the estimates that are set out in the financial memorandum are based on available evidence, practice and expectations.

In relation to the comments about potential savings, I reiterate that, although some savings are likely, saving money is not and never has been a policy aim of the legislation. The bill is about giving terminally ill adults a choice to end their own life if they wish to and are eligible to do so, not to save money.

Thank you for your patience, convener. I look forward to answering questions from you and committee members.

Tavish Scott almost picked up the question that I was about to ask. In the conversations that I have had with the sector over a number of years, its particular message has been that it is doing as much as it can, if for no reason other than the enlightened self-interest that Ben Hadfield set out. The question is, where does the drive for innovation come from? Is it sector wide, or does it come from individual companies trying to steal a march on their competitors?

Moreover, how does it sit as far as international comparisons are concerned? It is routinely suggested that the Norwegian industry operates at a higher level than or does things differently from the Scottish sector. I appreciate that the environment and the circumstances for operators here might be different to those in the Norwegian sector, but it would be helpful to understand how the drive for the research and the innovation that Tavish Scott talked about gives some confidence that, in a changing environment, we will continue to see significant investment to improve, rather than a message of, “We’re doing as well as we can—look how well we’re doing,” which I think can come across to some as smacking of complacency. I think, therefore, that a description of how that research and innovation works and what the international comparators are would be helpful.

I recognise that the make-up of the industry is such that you would expect that to take place. I am just curious as to whether techniques, approaches and technology are being deployed in Norway, for example, that are not being deployed here. If so, is there a rationale for that? Do circumstances mean that such things would not necessarily work in the same way?

Thanks.

I do not believe that I have any interest relevant to today’s proceedings.

Unlike Miles Briggs and Stuart McMillan, who are trying to crowbar certain visitors out of the bill, I am trying to shoehorn some visitors into it. It is worth putting on the record that the levy will work only if there is sufficient local flexibility that recognises the different ways in which tourism operates in different communities and at different times of the year.

Fundamentally, there needs to be fairness and equity in relation to the way in which the bill applies. As the Convention of Scottish Local Authorities has pointed out in its briefing, cruise traffic is now a significant and growing part of the tourism economy. As the bill stands, there is a risk that tens of thousands of visitors will be exempt from paying the levy.

At a local level, in places such as Orkney, where cruise traffic brings in a significant proportion of the tourist visitors who come to the area each year, there is a risk that, without being able to apply the levy to cruise traffic passengers, the viability of the levy will not be sustainable because the revenues that are raised otherwise would not allow the administration of the levy to wash its face.

In applying the levy to some but not to others, particularly in such a significant part of the tourism sector, local authorities might risk losing public confidence in what they are doing. It is an invidious position in which to place them.

I know that there are issues of competence in relation to applying the levy to cruise traffic. I am grateful to the minister for the engagement that I have had with him in recent weeks. I know that discussions are on-going with local authorities through COSLA on how they get around the issue, but I thought it important at this stage in the scrutiny of the bill at least to allow a debate to take place so that the minister could put commitments and assurances on the record, and to allow colleagues who have similar concerns or issues in relation to their own parts of the country to put those on the record. I look forward to hearing what they have to say.