Nikki da Costa: The Assisted Dying Bill gives carte blanche to private contractors

Nikki da Costa was Director of Legislative Affairs to two Conservative Prime Ministers, Theresa May, and Boris Johnson

In early March, the Times revealed that the government will pay private companies to end the lives of the terminally ill. Yesterday, it was confirmed that ministers will have complete discretion and all the power necessary to do this.

Sounds dystopian. But it was also a practical, hard-nosed, response of a government that must make workable Kim Leadbeater’s private member’s bill, while also trying to wrestle the NHS into shape and cut waiting lists.

Ministers, we were told, had “no in-principle objection”; repeatedly they’ve emphasised that the Government’s job is to make it ‘workable’, and ensure the bill provides an ‘adequate’ or ‘sufficient’ legal basis for providing these services.

As a result, multiple safeguards – such as assessments carried out by multi-disciplinary teams – have been discounted because they present ‘operational challenges’ for an overstretched NHS.

Now those concerns have grown to encompass the entire bill. To save the NHS and avoid undermining efforts to bring down waiting lists, we will contract out the responsibility to for-profit companies. And MPs must simply trust ministers to get on with it: detail that was meant to be provided in the last day of committee never materialised.

Instead, the Bill now provides ministers with complete discretion and flexibility in commissioning the services. It includes a sweeping Henry VIII clause granting broad powers for the “provision of voluntary assisted dying services” and to fundamentally reconfigure the NHS.

With a metaphorical flick of a backbench MP’s pen, a red line has been scratched through the NHS’ founding principles.

Ministers will no longer be under a duty to provide a Health Service which improves the physical and mental health of the people of England and Wales, and which prevents, diagnoses and treats physical and mental illness. The duty will expand to the provision of an NHS which assists in the ending of the lives of the terminally ill.

MPs will be asked to vote for this, and to accept that the Bill is completely silent on how services will be regulated.

As Danny Kruger pointed out in committee, the Bill contains a “great absence – a blank space” on delivery: who will provide these services, under what rules, and with what accountability? Labour’s Naz Shah shared palpable frustration: “we do not have any proposed model before us…this hasn’t been thought through. This isn’t right”.

From the Liberal Democrat benches, Sarah Olney was left to remark that promises to make things clear on how the service would be delivered had not been kept. As a result, she told the Committee: “parliament will be limited to a 90-minute debate on this issue, when these regulations are eventually made”.

In addition, MPs must swallow: that Clause 25 partially shields providers from civil liability for actions taken under the Bill; that Clause 29 exempts such deaths from coroner investigations; and Clause 30 stipulates that providers need only “have regard” to government-issued codes of practice – non-compliance doesn’t automatically trigger legal consequences.

Nor can they rely on independent oversight from the Chief Medical Officer – yesterday the Committee voted to assign that duty to a “voluntary assisted dying commissioner,” a figure embedded within the system, raising concerns they’ll be marking their and their team’s homework.

Even if you have no great faith in the NHS and would prefer a private sector provider – do you want to authorise the Government to do this completely unfettered by parliament?

I have no doubt that companies have already approached ministers offering to take this problem off their hands; the revenue may be significant and the overheads predictable. Estimates suggest 5,000 to 17,000 people annually might seek assisted dying in the UK. With fee estimates ranging from £3500 to £10,000 per patient, that’s a potential market worth a minimum of £1.8bn. Channelling this funding out of the NHS to private companies, legally set up to maximise profit and return to shareholders, risks turning a sensitive process into a transactional one.

This is not about distrusting private enterprise, just realism. Pursuit of profit can drive cuts – to resources, time, and attention.

A private provider under cost pressure might rush assessments; how deeply will they probe mental health or consider the risks of coercion? Will medical record reviews be thorough or reduced to tick-box exercises? Will patients get time to reflect, or face a conveyor-belt process? Could care be delegated to a substitute doctor – someone a little less busy, a little cheaper?

The Bill allows all this. And when it comes to those final moments when the drugs have been administered, will the terminally ill and their loved ones be fully supported, or will it simply be ‘adequate’?

The move has been compared to dentistry: independent contractors, perhaps small practices, providing NHS-funded assisted deaths alongside private deaths.

Yet dentistry itself highlights the pitfalls. NHS dental contracts reward activity (treatments completed) over patient-centered care, leaving quality and access uneven. How would this translate to assisted dying? A provider paid per procedure might prioritize throughput over holistic consideration of options.

The complete silence in the Bill and the push to privatize suggests a deeper truth: the UK isn’t prepared for assisted dying. The NHS lacks capacity to absorb this responsibility without compromising other services. Outsourcing feels like a shortcut to dodge hard choices – just as we are cutting corners in legislation and policymaking because that’s what’s required by the Private Members’ Bill process.

It is hard to accept that we are approaching this in this way, simply because of the luck of the draw in the PMB ballot, when it is the vulnerable that will bear the brunt of getting it wrong.