Mental Health Bill [HL]
Wednesday 6th November 2024
(1 month, 2 weeks ago)
Lords ChamberRead Full debate Mental Health Bill [HL] 2024-26 Read Hansard Text
Mental Health Bill [HL]
Monday 25th November 2024
(3 weeks, 5 days ago)
Lords ChamberRead Full debate Mental Health Bill [HL] 2024-26 Read Hansard Text Watch Debate Read Debate Ministerial Extracts
Baroness Merron
That the Bill be now read a second time.
Relevant document: Report of the Joint Committee on the Draft Mental Health Bill, Session 2022-23. Welsh legislative consent sought.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, it is an honour to move the Second Reading of the Mental Health Bill—a Bill which Members of both Houses have been waiting for and working on for some considerable time.
There is much consensus that our mental health laws are not fit for the 21st century. Many elements of the Mental Health Act 1983 are outdated. Its operation is associated with racial disparities and poor care for people with a learning disability and autistic people, and it fails to give patients an adequate voice. Modernising the Mental Health Act is a vital manifesto commitment for this Government, so I am proud to introduce reforms that will ensure that care is appropriate, compassionate and effective; give patients more say over their care; improve support to help patients understand and exercise their rights; and protect the safety of the public, staff and patients.
The wait has been too long. I know that a number of noble Lords were involved when the Act was last amended substantially in 2007, but, although attitudes to mental health have, thankfully, changed since then, the law has not kept up. The Bill is the product of the combined effort over some years by Members of both Houses and many outside Parliament, and all parties have rightly come together to support it. Sincere thanks are due to many, but I will highlight just a few, starting with Members of your Lordships’ House who served on the pre-legislative scrutiny committee in 2022: the noble Baroness, Lady Buscombe, as chair, as well as the noble Baronesses, Lady Barker, Lady Berridge, Lady Hollins and Lady McIntosh of Hudnall, and the noble Lord, Lord Bradley. All have given a huge amount of time, expertise and energy, which has informed and motivated this Government to strengthen the Bill. I confirm that we have improved the previous draft Bill by heeding the committee’s recommendations to include guiding principles and advance choice documents in this revised Bill.
I pay tribute to the former Prime Minister, the noble Baroness, Lady May, whom I had the pleasure of meeting earlier today with the Secretary of State. The noble Baroness, Lady May, identified the need for modernisation and set up the independent review of the Act in 2017. Without this, we would not be here today. I thank the independent review chair, Sir Simon Wessely, and his vice-chairs, including the noble Baroness, Lady Neuberger, who made the case for change and provided the blueprint to follow. I know they will continue to be champions for reform. I also thank the many stakeholders and parliamentarians who have engaged with us ahead of Second Reading and over the years, and those with lived experience, who have bravely told their stories.
The Bill will complement other major reforms that this Government have announced. The Budget announced £26 million to be invested in new mental health crisis centres to reduce pressure on accident and emergency departments. To cut mental health waiting lists, we will go further still, recruiting an additional 8,500 staff. As part of our mission to reduce the number of lives lost to suicide, these NHS workers will be specially trained to support people at risk. We will improve support for young people, with walk-in hubs in every community, making support workers more accessible to children, and a specialist mental health professional based in every school. The NHS has asked every provider of mental health services to review its offer for serious mental illness. By focusing on early intervention—prevention is the key—we seek to prevent people reaching crisis and to reduce the need for detentions in the first place.
I turn to what the Bill seeks to achieve. The Mental Health Act is there to protect people. Its core purpose is, and will remain, to be able to intervene, detain and treat when someone is so unwell that they present a risk to themselves or others. The overall aims of these reforms are to improve the care and treatment of people with severe mental illnesses when detained under the Act, to improve patient outcomes and recovery, and to protect the public, patients and staff. The existing Act confers certain rights on people who are detained, including the right to appeal their detention at a tribunal and a right to an advocate as well as to a medical second opinion in certain circumstances. The Bill seeks to strengthen and expand these rights. It will require the inclusion in the statutory code of practice of the new and revised guiding principles recommended by the independent review, which in turn informs professional practice around the Act. By doing this, we aim to improve things for patients and support a change in culture.
We are strengthening and clarifying the detention criteria to make clear that people will be detained only if they pose a risk of serious harm to themselves and/or others, and if there is a reasonable prospect that they will benefit from the proposed treatment. We are reforming the use of community treatment orders—CTOs—to reflect the revised criteria, to increase oversight and scrutiny of decision-making, and to improve the transfer of patients under a CTO from hospital to community services. We are also introducing statutory care and treatment plans for patients detained under the Act, except when under very short-term sections, to provide a clear plan for a patient’s recovery and a path to discharge.
Where the patient’s voice has previously been unheard, the Bill will place them at the centre of their care and treatment. We are introducing a new clinical checklist requiring clinicians to, as far as possible, involve patients in decisions about their care and to take their feelings and wishes into account.
We are making sure that patients know they can create an advance choice document and that appropriate support is available to help them do so, allowing those at risk of detention under the Act to outline their wishes and decisions while they are well. This document helps them retain control over decisions about their admission, care and treatment if they later become too unwell to communicate these preferences. Last week I saw and heard about the differences that these can make on my visit to the South London and Maudsley, where the words of welcome from service users about these measures highlighted the contribution that advance choice documents can make, particularly to tackle racial inequalities.
We are allowing patients to choose a nominated person to look out for them and their interests when detained and will be increasing their powers. The independent mental health advocacy service was a notable success of the 2007 reforms to the Act. It is a thriving sector, with advocates and volunteers working for excellent organisations such as VoiceAbility, making sure that people are involved with decisions about their care.
We are now looking to expand these services in two ways. First, we are making sure that patients who come into hospital voluntarily can access an advocate to help them understand their rights and be involved in decisions about their care. Secondly, for detained patients, access to advocacy will be on an opt-out basis, ensuring that patients are proactively offered this support when detained to improve advocacy uptake among detained patients.
I know only too well that noble Lords are acutely aware that for some people with a learning disability and autistic people, detention is both non-therapeutic and unnecessarily long. In order to better meet people’s needs in the community, we will limit detention so that people with a learning disability and autistic people can no longer be detained beyond 28 days, unless they have a co-occurring mental health condition that requires hospital treatment. This will affect only civil patients. Hospital will remain an option for those in contact with the criminal justice system, where the only alternative to detention in hospital is prison.
For people with a learning disability and autistic people, the right measures and support are very much needed alongside this change. That is why the Act will require that when people are detained, there is a care (education) and treatment review to be given due weight in decision-making. We are also creating new duties on commissioners to hold registers to help manage the risk of people going into crisis and being detained, and to better meet the needs of people through appropriate community services.
I am grateful for the work of the Ministry of Justice Minister, my noble friend Lord Timpson, and his department, to improve access to mental health care and treatment for people in the criminal justice system. The Bill will end the use of both prison and police cells as places of safety. It will end the use of remand for own protection under the Bail Act where the court’s sole concern is the defendant’s mental health.
We will introduce a statutory 28-day time limit for transfers from prison and other places of detention to hospital when a person requires treatment for their mental health under the Act. We will also introduce a subset of conditional discharge, called supervised discharge, to support the small number of restricted patients who are no longer benefiting from being in hospital.
We are aware that there have been concerns about public safety and are therefore ensuring that our reforms do not weaken the ability to detain people who could pose a risk of serious harm to themselves or others. I assure your Lordships’ House that these reforms do not change the core function of the Mental Health Act. Clinicians will remain able to intervene, to detain, and to treat whenever someone with severe mental illness presents a risk to themselves or others.
We are confident that this is the right package of reforms. However, the Bill further strengthens the measures in respect of public protection. The Bill improves on the previous draft Bill by: first, accepting the Joint Committee’s recommendation to remove “how soon” from the new detention criteria, making sure the Act cannot be misinterpreted to mean that a harm must be imminent to justify detention and early intervention; secondly, introducing a new requirement for the responsible clinician to consult another person when they are making a decision about whether to discharge a patient; and thirdly, strengthening the code of practice’s guidance on discharging patients and promoting the need for discharge planning tailored to the individual needs of patients and their circumstances. We will consult on changes to the code.
I am very grateful to noble Lords across the House for their ongoing support for and interest in the Bill. It has been a long time coming, and I know that we all want to get this on the statute book, which is why it is a priority piece of legislation for this Government. There has been a failure to reform, but today we begin to change that. I look forward to what I know will be a collegiate and constructive debate, which many will follow—inside both Houses and outside. I beg to move.
Earl Howe (Con)
My Lords, I begin by extending my gratitude to the noble Baroness, Lady Merron, for introducing the Bill into your Lordships’ House and for her very clear exposition of its contents. It is a Bill that we on these Benches warmly welcome. That welcome should not come as a surprise because, as the noble Baroness said, the Bill before us is the successor to a draft Bill prepared by the previous Government, a draft that owed its origin to my noble friend Lady May, on whose watch a review of the 1983 Act was initiated some seven years ago during her time as Prime Minister. Much of what we see laid out here is the product of diligent work carried out by Professor Sir Simon Wessely and his review committee, as well as the Joint Committee of both Houses, so ably chaired by my noble friend Lady Buscombe.
The passage of the Bill presents us with a golden opportunity to address both the current state of mental health provision and the law that governs it. The last major update of the Act took place in 2007 under the previous Labour Government. That may not sound like a long time ago but, as we shall no doubt hear from others, experience gained in the intervening years has taught us that a further update is indeed warranted if we are to ensure that the Act remains relevant and appropriate, and that its powers are proportionate.
Wherever the state uses its powers to deprive an individual of their liberty, the necessary safeguards must be in place so that those powers are used sparingly, proportionately and with the highest regard for human dignity and autonomy. That is why the Bill is so important. Since the last set of changes to mental health legislation in 2007, the number of people being detained under the Mental Health Act has grown exponentially. In fact, since 1983, the numbers have nearly doubled to a total of over 52,000 new recorded detentions between 2023 and 2024.
Within that total, we have also seen a stark disparity in the classifications of those being detained. Black people are 3.5 times more likely to face detention under the Act. Shockingly, to my mind, there are currently over 2,000 people with autism and learning disabilities detained in mental health hospitals across the country. I was equally shocked by the realisation that people with autism can be detained even if they do not have a mental health condition, leading to disproportionate, burdensome and wholly inappropriate treatment.
These issues occupied centre stage in the Wessely review, which proposed the formal recognition of four key principles that should from now on govern both theory and practice in this area of the law. The principles are: choice and autonomy; least restriction on liberty; therapeutic benefit; and the person as an individual. The previous Government fully accepted these four principles and—giving life, as it were, to those principles—the draft Bill set out to make a number of important changes. It strengthened the rights of patients with a learning disability, it gave patients greater autonomy in choosing how they wish to be treated, it introduced duties on commissioners to better understand and support people with a learning disability or autism, who may be at risk of crisis, and it sought to update community treatment orders, which are one of the key drivers of racial disparities in the numbers of people subject to restrictions under the Act.
It is therefore very pleasing indeed to see this Government’s firm commitment to enacting exactly these reforms, and I, for one, hope that as the Bill proceeds, we can come together as a House to implement and, where necessary, improve this hugely beneficial set of changes.
With consensus as the thread that, happily, we expect to run through our consideration of the Bill, there are nevertheless certain themes within it that are likely to require our particular attention. The first of these is community treatment orders. CTOs were first introduced in the Mental Health Act 2007. The Joint Committee on the earlier draft Bill was very clear that CTOs had been widely overused and that they are one of the leading causes of the racial disparities that I referred to a minute ago. The Bill before us makes a number of changes to the criteria governing the use of CTOs, all of them designed to support two of the key principles in the Bill: those of least restriction and therapeutic benefit.
As far as they go, these changes are desirable. However, the Bill stops short of including the full suite of recommendations made by the Wessely review. The Centre for Mental Health has raised this as a key concern. It points out that there is still no persuasive evidence of the benefits of CTOs. Against that background, it argues that a number of checks and balances are needed on the use of CTOs in future, over and above those already in the Bill. In particular, it notes that the committee recommended a full statutory review of the use of CTOs to report within a fixed timeline, which, on the face of it, is the least that we should be doing. I think we will want to debate in Committee why the Government have not felt it appropriate to go as far as the Joint Committee and the independent review recommended in this area.
The next important theme is children and young people. According to NHS data—and this was highlighted by the noble Lord, Lord Darzi, in his recent review—932 children in mental health units were subject to restrictive interventions in 2023-24. In total, more than 84,000 restrictive interventions were carried out on these children, which is a 51% increase from the year before. This is the highest number of restrictive interventions recorded since figures were made available in 2019, and that is despite the number of children in mental health units appearing to decrease.
We have a duty to use the Bill as an opportunity to identify ways of reducing such restrictive interventions and using them more humanely and more proportionately. Two years ago, the Government launched the Oliver McGowan training for NHS staff to help them better deal with young patients with autism. Noble Lords may remember that this was in response to a truly harrowing and appalling set of occurrences that ended with the death of a young man. It is fair to say that the case shook the health service to its core. I believe we have in the Bill the opportunity to take forward those lessons so as to protect children who may be at risk from unwarranted detentions.
The independent review and the Joint Committee had much to say about how treatment of children under the Mental Health Act could be improved. Unfortunately, by no means all those recommendations have found their way into the Bill. One such omission relates to the inappropriate placement of under-18s into adult wards or facilities that can sometimes be miles away from their home. The Joint Committee found that in each of the years 2016-17, 2017-18 and 2018-19, over 1,000 children were placed out of area, and that in 2020, 21% of children and young people were placed as in-patients more than 50 miles from their home.
It is perfectly obvious that being taken to an unfamiliar environment in a place far away from friends and family is almost guaranteed to exacerbate the issues young people face when experiencing a mental health crisis. On top of this, data from the Care Quality Commission showed that in 2021, 249 children and young people admitted for mental health treatments were housed on adult wards for more than 48 hours, some for a good deal longer than that. These are uncomfortable figures; I hope noble Lords on all sides of the House will want to ensure that, through this Bill, we take all possible steps to bear down on the scale of these problems and strengthen the protections afforded to children and young people.
One of the core themes that has remained prominent throughout the process that has led to this Bill is that of choice: giving patients as great a degree of autonomy as possible in how they are treated and maximising their ability to determine what happens to them if they are detained. In that regard, I think the Bill succeeds on many counts, but one measure recommended by the Joint Committee was that there should be a statutory right to an advance care document for every patient who has been or may be detained under the Mental Health Act. The Bill, as it stands, does not follow up on this recommendation. Instead, it places a duty on NHS England and integrated care boards to make information regarding such documents available to patients. I do not doubt that this is a beneficial reform, but we should debate whether it goes quite as far as it usefully might. Guaranteeing patients and service users the chance to state and record their preferences for care and treatment plays directly into the key principles of choice, autonomy and treating every person as a rounded individual—so what are the barriers to doing that?
There are a whole host of detailed issues which we will need to cover in Committee. The final, major area I want to touch on is that of the role played by the police. Inevitably, circumstances arise in which the police are required to become involved with people who may be a risk to themselves or to others. There is a strong feeling that encounters with the police are far too common for people with mental health conditions. As the independent review and the National Police Chiefs’ Council have pointed out, the presence of the police in situations where a mental health issue poses a risk of serious injury or death can be counterproductive. In its written submission to the Joint Committee, the Metropolitan Police stated that:
“Our officers simply cannot provide the specialist care needed, exposing both patients and officers to extreme risks”.
The NPCC has also expressed its concern that the role of the police in mental health pathways must be reduced.
It is welcome that the Bill goes some way to addressing this. Clause 46 removes police stations and prisons as places of safety, thereby preventing patients experiencing mental health crises from being locked up inappropriately. However, there is a potential knock-on effect that we should talk about in Committee. Well-intentioned as the provision is, it could well lead to a rise in people being admitted to accident and emergency departments, escorted by the police, and having to wait in crowded spaces with the lack of the necessary, specialised facilities until they can be assessed by clinicians. In this environment, the risk of harm could well be multiplied. We need to ask how this risk can best be mitigated. I fear that any realistic answer will need to involve resources, by which I mean taking steps to ensure that the requisite arrangements are made for NHS trusts to deal with an increase in the number of mental health patients being admitted to hospitals as places of safety. This is not an easy set of issues, but it is a subject that we cannot duck.
Parliament must see to it that wrongful, inappropriate and untherapeutic detentions of those undergoing a mental health crisis are brought to an end. The Bill provides us with a necessary and welcome opportunity to transform the treatment of those with mental health conditions and to bring both doctrine and practice well and truly into the 21st century. Along with my noble friend Lord Kamall, I look forward to working with the Minister and with noble Lords on all sides of the House to scrutinise and—where we can—improve the Bill’s provisions. Many thousands of the most vulnerable members of our society are depending on us to do so.
Baroness Barker (LD)
My Lords, I declare an interest as a member of an advisory panel for Rethink Mental Illness.
The House of Lords is an institution that is frequently criticised. Those of us who are often called on—not least by schoolchildren—to defend it often find ourselves having to give examples of work it has done which would not have been done by anybody else. As a veteran of the pre-legislative and post-legislative scrutiny of the Mental Capacity Act, the pre-legislative scrutiny of the Mental Health Act 2007 and all the various bits of subsequent legislation, I think that we have arrived at the point with this piece of legislation where we can make a defensible case for the unique contribution of this place to legislative progress. As the noble Baroness, Lady Merron, was generous enough to say in her introduction, there are a lot of us in this place who have got form on this. Specifically, there are an awful lot of us who have detailed knowledge of all those bits of legislation and of the workings of the 1983 Act.
If the noble Baroness will not mind me saying, we come to these pieces of work in two minds. It is great to have the opportunity to go back, look at what we did in the past and rectify some of the mistakes. However, it is always also deeply frustrating because, in truth, here we are again putting another patch on the 1983 legislation. We will never get the mental health system that we so badly and desperately need until we do more than that.
Having said that, along with other noble Lords, I congratulate Sir Simon Wessely and his team, and specifically the working groups that worked with him. If any noble Lord who has been inundated with briefings from all the interested parties, as we all have been, is ever in doubt about a subject, they should go back to the report of the working groups to understand how people have arrived at their conclusions and what we should perhaps strive for. I say that as the person who sat here night after night during the passage of the 2007 legislation, arguing for an advance choice document against a lot of entrenched opposition, not least from practitioners. It is really important that we use the privilege of our position—I mean that: privilege—to work away at this legislation as we did with that so that, perhaps uniquely, we can make some progress.
Those of us on these Benches will support anything that makes clinicians have to be more accountable and transparent in their work. We can have any legislation we like but, until such time as we call decision-makers to account, we are not going to get anywhere on behalf of people who are detained. They may be detained for their own good. They may be detained for the safety of others, but they are none the less detained. Their opportunities to challenge the decisions made are quite rare. As ever in this House, in the end, when we are coming to a decision, we always have a duty to defend human rights. Human rights legislation exists to defend the people that nobody in society likes. Quite often, that means the people subject to this legislation.
On the issue of principles against the Bill, having gone through the Mental Capacity Act, and having then subsequently reviewed it and its implementation, with serried ranks of professionals coming in to tell us that they just ignored the principles which had been in that Bill since the beginning, I am not overjoyed that they are going to be stuck into a code of conduct. This will surprise the noble Baroness, Lady Merron, not a lot. I do not honestly think it will make any difference at all. They are very good principles but, unless and until they are in the Bill and practitioners believe that their decisions will be judged against them, they will be useless.
Lots of other people can speak about learning disabilities far better than I can. I want to say just two things. First, the noble Earl, Lord Howe, talked about training professionals in relation to young people. Increasingly, people are diagnosed with learning difficulties, and particularly autism, as older adults. We should listen to what the noble Baroness, Lady Hollins, has been telling us for years and require all mental health practitioners to have training in the diagnosis of learning disabilities and autism. That is the one thing that would make a swift and tangible difference in this area.
Secondly, the alignment—or non-alignment—of the Mental Capacity Act and the Mental Health Act has been problematic. We have known about that for more than 20 years. To everybody who knows about it, I simply say “Bournewood gap”. To those who do not, I say that the two pieces of legislation are built on completely different bases. Two people, sitting side by side, can be treated according to one or the other depending on who is in the room at the time. If you get banged up under one, you have quite a lot of rights; if you get banged up under another, you do not. I understand why Sir Simon and his team thought that it would be too long and too difficult a job to sort this out. It was much better that we carried on to do some of the more urgent things in this Bill, but we have to go back and do it. Other jurisdictions are going down that path.
The one thing that the noble Baroness and the Government have to do is give a commitment that they will monitor that and, upon the passage of this Bill, put in place a system of funded research about the change to bring in what is known as fusion legislation. If we do not, we will just consign a load of people to being wrongfully treated, so I hope that she will do that.
In a similar vein, Dr Lucy Series and Luke Clements, who are academics and practitioners who have worked on this for a long time, sent us a briefing that explains in characteristic detail the deficiencies that arise under Section 73 of the Care Act 2014. It means that people who are being treated in private settings, even though their treatment was commissioned by the NHS, are not being properly protected by the Human Rights Act. They have written a very short but effective paper for us, and I simply ask the noble Baroness to commit to a meeting of interested Peers—there are a number of us—with Dr Series and Luke Clements, so that we can deal with that. Can we stop treating people differently just because of the person or organisation that happens to be providing their care?
On CTOs, we are not allowed to wear T-shirts in here but, if we were, I would be sorely tempted to wear one that reads, “Told you so”, because we did. In 2006-07, we sat here night after night saying, “You are telling us that this is not going to be used very often or used disproportionately against some people. That is not true, is it?” It really was not. Because of that and the racial disparities, I and others were for a long time of the view that CTOs really should go because they were enabling bad practice by practitioners. What changed my mind was listening to patients and their families, because there are a small group of people for whom CTOs work, are the least restrictive option and are beneficial. We should therefore keep them. I am reluctant to admit that, but we really have to change all the processes around them to make sure that practitioners are sticking to the intention.
Advance choice documents are another “I told you so”. I am so pleased that they have done what enlightened practitioners said they would back in 2005-06; they have improved care for people. I am indebted to the noble Baroness, Lady Finlay, for telling the joint scrutiny committee about the work that was done in the field of palliative care to make sure that advance choice documents are electronic, and therefore more widely available, and to minimise excuses on the part of practitioners: “Well, I didn’t know about it”. A team from King’s has been looking at that. I hope that, during our discussions, we can go into that in greater depth. I do not quite know how that will work, but it is important.
On prisons and police stations, we were very lucky in the joint scrutiny committee because one of our members was an A&E doctor so we talked about this quite a lot. The truth is that people will still turn up in A&E because the lights are on. That is where people in distress will go. There will also be people who, faced with somebody who is having an episode, still call the police, because they are frightened and do not know what to do. During the passage of the Bill, I hope that the Minister will explain how £26 million will deal with what is quite a big problem and that we look at the transition to the police stepping back to leave everybody else to deal with people who, at the point they meet them, are very ill and disturbed and who need help.
Finally, some of us argued strongly for a mental health commissioner. That was not because we wanted another commissioner—we have lots of commissioners for things already—but because we were trying to deal with a key issue. We do not have a system of mental health care or joined-up services. We have episodes of care, some of which are very good at the time but do not work together as a system. After the hours that we have sat in this place and looked at the various different bits of legislation in great detail, we do not understand why we lock up more people, year on year, and what the best use is of the resources available—they are not infinite—not only to deal with people who are experiencing real crises and trauma but to ensure that we use the best of what we have to put as much as we can into services that are also preventative.
It is a great privilege to be in this House. It is an enormous relief that we can do our work in great detail and largely away from the pressure of headlines, which I know people in the other place always feel whenever there is a failure. It may well be that, during the passage of the Bill, something in the media changes the national mood on this, but our job, privilege and responsibility is to think of the people who are in the worst possible place under this legislation and to do the best possible job that we can for them to make sure that we get the best out of this legislation.
Baroness Watkins of Tavistock (CB)
My Lords, it is a pleasure to follow the previous three speakers. I declare my interests as a non-executive member of the NHS England board and 45 years as a registered mental health nurse.
I warmly welcome the long-overdue reform of the Mental Health Act and congratulate the new Government on bringing it swiftly in their term. I appreciate the opportunity that the Minister has taken in holding discussions about the Bill prior to Second Reading and offering to consult further about potential amendments to strengthen and clarify particular sections. Modernising the 1983 legislation provides a real opportunity to reduce injustices in implementation and provide equitable support for people suffering from a mental health crisis, giving them more autonomy and choice and including a new right for service users to choose a nominated person to advocate for their interests.
First, I am pleased that the Bill aims to end the unnecessary detention of those with autism or learning disabilities, yet I share the concerns of the Royal College of Psychiatrists and other professional bodies that further clarity is needed around assessment and treatment. For many, the proposed 28-day limit for assessment may not be long enough to reach a comprehensive diagnosis, especially considering that those with autism often present with additional complexities. It may be difficult to admit, assess and support some patients within the time limit outlined in the Bill, risking recurrent use of overstretched A&E or admission and detention under Part III of the 1983 Act should there be safety concerns. The NHS Confederation drew on the example of New Zealand, where similar changes to mental health legislation saw a temporary increase in patients being sent
“to prison, left neglected in the community or admitted to forensic facilities as secure patients”.
Failing to allow for thorough assessment may worsen mental health care provision and further racial inequalities, as currently Part III detentions disproportionally affect black men.
To combat this, an emphasis on continuity of community care would cut the number of people admitted for an assessment, while ensuring that patients remain safe within the community, yet there is a chronic lack of community-based workers, with a third of all nursing vacancies being in mental health services. I therefore ask the Government to provide clarity on how they will ensure that those who, in the past, would have been detained for assessment and treatment will still be able to obtain a full diagnosis and the support that they deserve, preferably without hospital admission. Careful consideration of workforce planning in the community for social work and allied health professions, as well as psychiatrists, general practitioners and nurses, should form a significant part of the preparation for this Bill’s implementation; then patients and cares could more often be appropriately assessed, treated and cared for by both mental and physical health services, in community and primary care settings, thus avoiding admission.
The Bill offers an opportunity to improve support for those under the age of 18 who are admitted formally under the 1983 Act, yet it is estimated that 31% of under-18s are—thank goodness—admitted informally to hospital for assessment and treatment. I fully support the introduction of new statutory care and treatment plans, but I ask the Minister if they could be extended to those admitted informally, if it is a correct solution.
The Government are right to state that these plans will encourage patients to engage with treatment towards their discharge and beyond. Care and treatment early in a person’s life provides better outcomes than later intervention, so extending these plans to the significant number of informal patients aged under 18 could provide a solid foundation for later life. Additionally, ensuring the availability of quality community services would also reduce childhood detention. I therefore ask the Government to confirm their plans to encourage this early intervention via both the community and the care and treatment plans.
The Bill would be strengthened if it were to improve the environment for young patients. I will not repeat what has been so ably explained by the noble Earl, Lord Howe. However, we really ought to move to a statutory requirement that young people are not allowed to be kept in adult wards for treatment in crisis, or treated miles from home.
There must also be an exploration of the place of parental responsibility before the Bill is finalised. The introduction of a “nominated person” as well as “advance choice documents” are commendable steps to improve agency for those detained under the Mental Health Act. Some young people will choose not to include their parents for either of these. I therefore ask whether the Government can provide clarity as to how this will function with expectations of parental responsibility.
Healthcare professional bodies support the principle of ensuring that prisoners with severe mental health conditions are swiftly transferred to hospital, where they can receive proper treatment, but I have questions of practicality for the Government. What is the plan to ensure capacity in the in-patient sector? What happens to those who clearly cannot be properly treated in the in-patient sector, or who are a significant danger to others on the ward? As a former ward sister, I know that this is a real question from people working in those environments at the moment.
Will there be an assessment at the end of a patient’s treatment to determine whether they are recalled to prison or given a community treatment order if it is safe to do so and better for their mental health? I would welcome working with the Government to get clarity on this issue, particularly in relation to a code of practice.
As I have already said, continuity of care in the community will be essential to prevent unnecessary detention and to provide support to patients after detention. I therefore ask the Government to clarify the implementation timetable for the Bill in order to ensure that current staff have time to receive the development needed and that the necessary new staff are recruited.
I ask too whether there should be a research investigation into safe staffing ratios in the community. The Royal College of Nursing is calling for a maximum caseload for mental health community nurses to ensure that community treatment orders are conducted properly and that nurses can assist in preventing crises, but very little research into this ratio issue has been done outside in-patient facilities. It seems right that research and planning be done to ensure that the community can help fulfil the Bill’s admirable aims. A recent paper by King’s College refers to “frugal innovation” in healthcare. Investing properly in community care will reduce the costs overall.
I trust that the potential shortcomings of the Bill as it stands can be amended and/or resolved through the code of conduct to ensure that it is future-proofed and significantly enhances mental health service provision for patients, which is the aim of His Majesty’s Government, the vast majority of Members of this House and healthcare professionals themselves.
The Lord Bishop of London
My Lords, I am grateful to be able to participate in Second Reading of this important Bill. It is a privilege to follow the noble Baronesses, Lady Barker and Lady Watkins, who have a real breadth of experience in this field. I too welcome, along with many noble Lords, the reform of the Mental Health Act, which is long overdue.
The noble Earl, Lord Howe, highlighted the over-representation of minoritised communities detained under the Act but also placed on community treatment orders. Some groups are also more likely to be detained through contact with the criminal justice system or emergency departments. It is important to remember that we are speaking about these inequalities in the wider context of health inequalities; some groups present to health services far later, when their symptoms have worsened. The Royal College of Nursing notes in its briefing that mental health services are
“not seen as accessible to all communities”,
and that:
“Many black men have a first interaction with a service via the police during a crisis”.
Many of the organisations that have helpfully sent briefings ahead of the debate have acknowledged that the legislative actions available to address this issue are limited. The Minister highlighted the advanced choice directives, which are a welcome step towards this. As the Joint Committee on the Draft Mental Health Bill notes, this is important for those who have experienced trauma, disempowerment and discrimination.
Data collection has also been discussed during scrutiny of the Bill. Although data collection is improving, capturing more complex data on ethnicity is important when looking at health inequalities in this way. In much of the work I have done on health inequalities with the NHS and faith groups, ethno-religious identity is significant if communities are to be better understand at an ICB level or higher how to reduce inequalities.
It is also important that, in evaluating the changes to the Act, the Secretary of State has the appropriate data to do so. What steps are the Government are taking in the Bill or in other ways to mandate this kind of data collection, so that racial inequalities are monitored?
The Royal College of Speech and Language Therapists also emphasises that communication considerations are important to the Bill. In my experience, some faith communities find it very hard to discuss mental health, and that is made worse by the biases and discrimination they meet when they seek help. The patient and carer race equality framework is to be welcomed as the first ever anti-racism framework for mental health trusts and service providers. In order to assist in this, the Royal College of Nursing has recommended that mandatory training on equalities be given to all working under the Mental Health Act. As I often say in this place, faith literacy is an essential component of that.
Much of this is still about trust and culturally competent care. It is critical that services be accessible and effective for people with different traditions, cultures and faiths. Empowering patients to offer their data is as important as mandating that it be collected.
Many briefings note that the Bill will be effective in reducing racial discrimination and health inequalities only if there is investment in community services and other actions. Not everything we can and should do is medical; the involvement of the voluntary and community sector is also crucial.
I welcome the provisions in the Bill to restrict the long-term detention of autistic people and those with learning disabilities. I support the Joint Committee on the draft Bill’s recommendation of clearer duties for ICBs and local authorities to develop robust community services and social support.
I pay tribute to the work of the work of the noble Baroness, Lady Hollins, and the independent care and treatment review programme to expose the serious harm and trauma inflicted by the use of solitary confinement, detention and long-term segregation in mental health and specialist learning disability hospitals. I too support the comments made by the noble Earl, Lord Howe, with regard to young people.
The right reverent Prelate the Bishop of Gloucester is the lead Bishop on prisons for the Church of England, and she apologises for not being in her place. She and I commend the Government on bringing forward the long-overdue provisions to end the use of prisons and police cells as places of safety. The right reverend Prelate has told me that last year more than 300 people suffering mental health crises were taken not to a hospital but to a police station. According to the recent report from the Chief Inspector of Prisons, the average time to wait to transfer mentally ill patients from prisons to hospitals is 85 days—almost three months. We welcome the statutory time limit of 28 days, but I highlight, as other noble Lords have, that if this is actually to happen, it needs to be resourced. As the noble Baroness, Lady Watkins, highlighted, there is a question of resource not just on this point but for much of the Bill.
Shortages of mental health nurses and doctors impact on those detained under the Mental Health Act and in the community. The learning disability nursing workforce in the NHS has dropped by 44% since records began in 2009. Investment in the workforce will be key to the success of the Bill. Community services can be developed and resourced only as far as the NHS, local authorities and directors of adult social care are supported to do so. I welcome the Bill and look forward to following its passage and working on what is an extremely important reform.
Lord Touhig (Lab)
My Lords, I refer the House to my interest as a vice-president of the National Autistic Society, a role I share with my good and dear friend, the noble Baroness, Lady Browning.
I welcome the Bill. It has been a long time coming, and I passionately hope that it will allow us to end once and for all the myth that autism is a mental health condition. Autism is most definitely not a mental health condition, and our failure to address this has meant decades when autistic people have been wrongly incarcerated, often in appalling and degrading conditions, and robbed of their human rights. More than 2,000 autistic people and people with a learning disability are in mental health hospitals in England, a point made by the noble Earl, Lord Howe, in his opening remarks. The National Autistic Society tells us that 68% of these people are autistic.
Some 93% of autistic people and people with a learning disability in mental health hospitals are detained under the Mental Health Act 1983. The average length of stay is five years, but for a great number of autistic people the detention lasts for decades. Professor Sir Simon Wessely’s review of the Mental Health Act in 2018 found that the experience of detention was often damaging and traumatic. The Bill includes measures to improve care and support for autistic people, reducing reliance on hospital-based care. That certainly is good and is welcomed.
However, there are aspects of the Bill that concern me, and I have had a chance to discuss them with my noble friend the Minister. I have been fortunate to have had a number of fruitful meetings and discussions with a team from the Autism Centre of Excellence at Cambridge and, as a result, they and I share some concerns. First, the Government have said:
“For those with a learning disability or autistic people, the act will be amended to place a limit of 28 days for which they can be detained unless they have a co-occurring mental health condition”.
My noble friend mentioned this in her opening remarks. I stress again that autism is not a mental health condition, but given that eight in 10 autistic people experience mental health issues, without the right safeguards there must be concern that the new provisions could simply lead to a continuation of the current intolerable situation. I hope my noble friend, who kindly met with me recently to discuss these matters, will seek to assuage my fears on that point.
The Government have also said:
“Police and prison cells will also no longer be used to place people experiencing a mental health crisis … Instead, patients will be supported to access a suitable healthcare facility that will better support their needs”.
The right reverend Prelate referred to this in her remarks. The Lampard Inquiry was set up to look at more than 2,000 deaths of people in in-patient mental health facilities, specifically in Essex, and it is believed that many of those who died were autistic. I say to my noble friend that it would be wrong to assume that simply switching the location where autistic people are detained is going to achieve a much better way of protecting them.
The Government have also said the reforms will
“introduce statutory care and treatment plans”.
I share the Cambridge centre’s belief that every autistic person who needs support should have access to a statutory plan to enable them to get the help they need. It should not take an autistic person falling into crisis and being detained in a mental health hospital for such support to be provided, as is often the case today. Autistic people who are at risk of falling into crisis should have a similar right to such plans to prevent in-patient detention becoming a risk in the first place.
A focus on prevention would be in line with Wes Streeting’s idea of reforms of the National Health Service. It is recognised that the current system does, in fact, have a range of provisions, legal rights and safeguards that should, in theory, have reduced the number of people detained in in-patient mental health services. But published statistics show us that this has not happened, with thousands of people still inappropriately detained, so I ask my noble friend to consider these concerns as the Bill passes through the House in Committee and so on.
There is a danger of allowing, even unintentionally, the creation of a critical gap between what happens at a policy and legislative level and what happens on the ground. Without reckoning with this gap and setting up measures to ensure that what is said by government turns into real action on the ground, these reforms will not change the decades-long scandal of thousands of autistic people being detained inappropriately. To do this will require clear measurement, consistent and regular accountability and the necessary funding to enable the National Health Service and other agencies to deliver the hoped-for change that we need from this Bill.
Baroness Buscombe (Con)
My Lords, it gives me enormous pleasure to speak in this debate. For me, this legislation is above politics: it is a real opportunity for constructive opposition. I welcomed the call in July from the Secretary of State for Health, Wes Streeting MP, asking whether I would support the Bill and assist in its progress. Yes, there are some aspects of the Bill on which we on these Benches will wish to press the Government. However, our view is that it is overdue and critical for so many people who have felt misunderstood and suffered serious neglect for too long.
I feel lucky to have chaired the Joint Committee on the Draft Mental Health Bill. Everyone on the Committee apart from me had professional and practical expertise and experience and/or powerful personal experience and knowledge through friends and families. We received evidence from more than 50 organisations and many people who were service users, to whom we remain eternally grateful. We had many hours of strong debate and always managed to find a way through. Results sometimes involved compromise but were also consensual. I thank each and every member for their invaluable contributions, together with our advisers and the brilliant Alex Ruck Keene KC for his extraordinary drafting skills. I also thank the clerks and officials who worked skilfully against a very strict timetable.
I pay tribute to all our medical staff who work in this complex and, in many ways, challenging field of medicine. My sincere admiration for them, and the difficult choices and decisions that they must make, knows no bounds.
A key point for me—I speak as a lawyer—is that so much that directly affects the well-being of patients must be improved, not necessarily by legislation, which can hamper positive change, but through a step change in culture in order to genuinely value every individual and improve their life through choice, dignity, support and advocacy. The Bill seeks to address that, although it lacks a key tool: the use of technology and the drive for data, which I urge the Minister to consider.
The process of amending the current Act speaks volumes. Would that we could have torn up all the current Acts and started again with a fused approach to treating mental health, but we were persuaded that that would just take too long. It has taken too many years to get this far, and now change is urgent.
I have time to touch upon just a few of the many aspects of the Bill. It is right that the Government have agreed—here I say to the noble Baroness, Lady Barker, that we have good news—to embed in primary legislation what I call the Wessely principles: choice and autonomy, least restriction, therapeutic benefit, and the person as an individual. Each principle should be tested against the implementation of current proposals, future reform and change to ensure that patients as individuals remain the heart of the matter.
Least restraint is a key reason for reform, although in practice it is a difficult balance to strike. As the Wessely inquiry report makes clear, as a society we now benefit from a greater understanding of mental health. However, at the same time society has become much more risk-averse. Much of our debate centred around the need to address all avenues of least restraint, particularly given the current inequalities of outcomes, against the risk of unintended consequences for the protection of society and the therapeutic benefit of the patient.
To apply the principles, we need the data to track every patient and their outcomes. I remain appalled at the lack of information and communication across the NHS, which has a negative impact upon so many lives. Each time a person is moved, they are registered as a new patient. How much does that contribute to flawed data and poor outcomes? I urge the Minister to look at that.
A key missing element is technology, as I have said, and I do not mean some clunky, one-size-fits-all NHS-wide system. In short, we need to swiftly develop a national dataset to allow for real-time monitoring and accountability, evaluating variation and inequalities, understanding medium- and long-term trends and informing future policy decisions.
For choice, dignity and autonomy, we recommended a statutory right for patients who have been detained under the Mental Health Act to request an advance choice document to be drawn up and recorded in a way that is accessible digitally. There is no mention of digital in the Bill. Instead, it introduces duties on integrated care boards, NHS England and local health boards in Wales to make arrangements so that people at risk of detention are informed of their ability to make an ACD, a written statement, and be supported to make one.
Our report referenced the potential for creating ACDs via an app, similar in some ways to one already working for end-of-life palliative care, to support all patients. Simply put, it is a no-brainer and transformative, easily accessed by anyone, either on a mobile phone or even on a patient’s clothes, so that when that person is in crisis there is an instant critical guide to who that person is. That would greatly assist the police, if they are in attendance, and those in A&E. I am hopeful that this approach and other smart, cost-efficient moves will be in the code of practice.
The implementation of reform requires constant oversight. We recommended the appointment of an independent mental health commissioner with overarching responsibility to ensure consistency of delivery of the Government’s priorities for patients across England and Wales. This is not about the Government losing control; on the contrary, it is about an overarching small body with the ability to focus upon consistency across the whole sector, ideally using digitised national data to track and monitor the implementation of the reforms over a period of years, working with the associated NHS bodies to promote better outcomes. I ask the Minister: who else will do that?
Furthermore, we must address unacceptable racial disparities and inequalities, particularly among black men, who, as we have heard from my noble friend Lord Howe, are three and a half times more likely to be detained under the Mental Health Act and seven times more likely to be placed on a CTO. But how is that data collected and verified? Indeed, the facts could be worse. Our report was clear that better outcomes would be achieved and inequalities reduced if each health organisation introduced culturally appropriate advocacy and appointed a responsible person to collect relevant data and publish and oversee policies to address these inequalities. A mental health commissioner could ensure that that was done.
Mental health services currently operate in a static world. What happens when someone has a crisis far away from their local authority? We heard on a visit to SLaM in Lambeth that patients sometimes travel miles to Lambeth when on a downward spiral to receive, in their view, better treatment there than within their local authority. That is another reason to have accurate data.
Another critical area is children and young people. Issues highlighted in our report, including the role and profile of nominated persons, detention in adult wards and conflict with the Children Act, must be clarified and assurances given to families and their young. Investing in and building the right community support and action plan for people with learning disabilities and autism no longer detained under Section 3 is critical, as is monitoring the outcomes for those with learning disabilities and autism who may be at risk of being detained under the Mental Capacity Act or through the criminal justice system instead. This is an area where our committee had a strong debate, concerned about unintended consequences that might impact on the patient and/or society at large if the right protections, including safe spaces, were not in place. Are the Government content that they have achieved the right balance?
I feel I must record—because I want to be helpful to the Government—that our committee had one opportunity to put some of the crucial questions to, and test the opinions of, around 18 officials from the DHSC and the MoJ who had worked on the Bill for four years. That meeting was cut very short because one official said she had to collect her child from school, so all 18 walked out. That must not be allowed to happen again.
Priorities must be set for the implementation of the many proposals, and there needs to be a significant increase in capacity right across mental health services, all of which requires enormous investment. I wish the Government, particularly the noble Baroness, Lady Merron, well.
Baroness Murphy (CB)
My Lords, this is a long-overdue Bill, as many have said, and I hope it will progress through the House as quickly as possible. Quite why it has taken six years for Sir Simon Wessely’s report to be acted on, I am not sure, but I am particularly pleased that we have got advance directives in, even if in a slightly watered-down form.
However, there are some rather troubling changes that have been squeezed in recently for reasons that are difficult to understand, and I shall want to explore those in Committee. There are differences between the criteria for Parts 2 and 3 of the Bill, for example, which is bizarre, and I am scared that the changes in relation to learning difficulties and autism, in spite of all the good intentions, will be extremely difficult to implement. Throughout the Bill, there is an assumption that if you change the legislation, it happens, but we know very well that it does not—it takes years to implement—so I am concerned about that overall. Having said that, I will remain on the theme that the noble Baroness, Lady Barker, picked up. We will leave the rest until Committee, where we are going to have very detailed debates.
It is now 20 years since I came into this House with the certainty of the optimistic new girl that we would see a new mental health Bill that addressed the deeply flawed legislation that we had been living with since 1959, but I am pretty sure now that I shall leave the House having seen no fundamental change. I am ashamed that in England and Wales we are falling so far behind many other countries, when we used to be in the advance in devising mental health law that was fit for purpose. Scotland is 20 years ahead, as is Northern Ireland.
I was told back in 2017 by Simon Wessely and others that it would take 10 years to develop a unified mental health and capacity Bill. If we had started then, we would be almost there by now. We tinkered with the 1959 Act in order to produce the1983 Act. We added a new Mental Capacity Act in 2005 that cut across mental health legislation. Then we added the ludicrously undeliverable deprivation of liberty safeguards and added tiers of bureaucracy to an already overburdened system, all reducing the time for clinical and social care professionals to spend with patients as they had to spend more time filling in forms. The new Bill makes no attempt to address the complicated relationship between the 1983 and 2005 Acts or how they are meant to be used for individuals, and this is particularly difficult for patients with learning disability and mental disorders and also older people with dementia where people are tossing up which Bill is going to be used. It is clinically ridiculous.
I would have liked to see a Bill that addressed all mental health and capacity issues, putting capacity for decision-making at its heart, consistent with the United Nations Convention on the Rights of Persons with Disabilities, which we currently contravene and have done since its implementation by the UN in 2008. The human rights implications of the current Bill are profound. It does not address the fundamental rights of thousands of mentally ill people, primarily because of the absence of having decision-making capacity at its heart. We accept that patients with physical disorders can make decisions that may be seriously detrimental to their health or safety. In contrast to this, in mental health law capacity plays little or no role in decisions to initiate psychiatric treatment against a patient’s wishes. The criteria for the involuntary treatment of mental disorders fails to respect the autonomy of the patients. The key considerations are the presence of a mental disorder and risks to the patient’s health or safety. For persons with physical disorders, their personal values are given dominion. Those with mental disorders are not accorded this privilege in this Bill, even though we make such a meal of it in the Mental Capacity Act 2005. There is an underlying assumption that mental disorder necessarily entails an inability to make sound or rational judgments, but even among the most ill patients—those admitted to acute psychiatric wards—40% to 60% retain capacity.
People with mental disorders are unusual in being liable to detention, usually in hospital, because they are assessed as presenting a risk of harm to others before they have actually committed an offence. This constitutes a form of preventive detention that is selective. We spent some time in this Chamber a couple of weeks ago debating indeterminate sentences for people in prison thought to pose a continuing risk in the community. There was widespread agreement here that it was an iniquitous thing. And yet mental health law allows the detention of those with mental disorder on the basis of risk alone. How can that be justified? There is no evidence that risk is easier to assess in those with mental disorder or that violence is more predictable in this group, and it is an expression of the prejudicial stereotype that people with mental disorder are intrinsically dangerous, contrary to research evidence.
This does not mean that people’s dangerousness is unimportant. If it is reliably linked to an individual’s mental disorder, then, if the person lacks capacity, involuntary treatment may be justified, but if the patient has capacity, protection of the public becomes the sole interest. I do not deny there are problems with a capacity-based regime. Many people think you have to fudge the decision, but I would say it was because they do not understand the fundamental ways to assess capacity and the full influences on it.
One of the aims of this Bill is to reduce sections. The number of new sections, as we know, has rocketed again. Last year, there were over 52,000 sections, a further 5,000 or so placed on a community treatment order, and 140,00 people on mental capacity deprivation of liberty safeguards. If the aim of the new Act is to reduce detentions, I cannot see how. The discharge rate from tribunals has reduced from 25% in the mid-1980s to about 6% today. How is it going to happen exactly under this legislation?
I do not see how the overrepresentation of black people in the detained population is to be addressed by this Bill. We need a completely different new way of assessing people and allowing people to get access to services that are sensitive to their needs, providing something that they want to access. I cannot think that there is anything new in this Bill which reflects new thinking that is going on about how you encourage people to access services when they first begin to feel ill.
The Bill has nothing to say about restraint and seclusion. It does not address the hundreds of people in the prison system and their non-consensual treatment except to speed up those that are suitable for transfer. The majority of the mentally unwell will never even be considered for transfer, but they have terrible problems which impact on the prison system tremendously.
Finally, it is now 14 years since the Mental Health Act Commission was abolished and replaced first with the mental health commissioner and now by the totally inadequate low-profile CQC, which has no legally qualified members and no mental health representation at executive board level. Whereas the former chair and vice-chair of the commission had direct access to the Secretary of State for Health, as I am sure the noble Baroness, Lady Bottomley, will remember—she got tired of seeing us, I should think—mental health does not now appear to have the same direct influence. Perhaps it is not surprising that mental health appears only on the government agenda when there is some crisis that has been brewing for years or, as now, after meandering for years through our scrutiny and committee systems.
I have had my say. I am not going to raise this issue again. I felt I had to say it once. I will throw myself into Committee with enthusiasm and hope we can get this Bill through, but I do hope that one day we will get the mental health and capacity legislation that we really need.
Baroness May of Maidenhead (Con)
My Lords, it is a great pleasure to be able to contribute to the Second Reading of this very important Bill, albeit, as other speakers have already said, a Bill that has been too long coming. I wholeheartedly welcome this Bill and I thank the Government and commend them for bringing it forward so quickly in their term of office. I also thank the noble Baroness the Minister and the Secretary of State for the meeting that they held with me earlier today. Like others, I also want to look back and thank Professor Sir Simon Wessely and his team—including, not least, the noble Baroness, Lady Neuberger—for the invaluable work that they did that has led to the Bill before this House today. I want to say a particular thank you to those with lived experience who were willing to come forward and inform and advise the review panel, but also the pre-legislative scrutiny work and at other stages too, so that the Bill could be based on real experience, not just on what politicians and, dare I say it, the civil servants thought would be the right thing to do. So I welcome this Bill.
When in October 2017 Sir Simon Wessely was commissioned to undertake the review, there were a number of reasons that led to that. The first was the one that the Minister has already referred to: the Mental Health Act 1983, which was in place for over 30 years, had had some amendments subsequently but was felt to be out of date. Society and clinical treatments had moved on, so there was a need to look at it. But, for me, there was a more fundamental issue, which was the fact that so many people who found themselves in mental health crisis felt that, somehow at those points of crisis, they were people to whom things were done, to whom society did things, rather than people who were able to be part of and involved in that decision-making—they lost their human dignity in the processes that they went through. There were also issues about family members who were concerned that they were not listened to, when they felt that they knew when people were coming to points of crisis, or family members who felt that they were shut out from the discussions about their relative who was potentially at a point of crisis.
Then there was the overuse of detention. Reference has already been made, and I am sure will be made by others in this debate, to the racial disparity in the use of detention, a matter which should concern us all. There was also the question of the use of detention for those with autism and learning disabilities. All those issues underpinned the reason for looking at reviewing the Mental Health Act 1983.
The first point has been that issue about the loss of dignity and the way in which people in mental health crisis are treated. I hope that will be dealt with by those very first principles that appear in Clause 1. I draw particular attention to the fourth of those:
“The person as an individual”.
Under “Matters to be addressed”, it says:
“treating patients with dignity and respect and considering their attributes and past experiences”,
although I accept, as the noble Baroness, Lady Murphy, just said, that it is not enough simply to put it on a page of legislation. For that to be enacted requires changes of culture and attitude from all those who deal with people in mental health crisis.
Part of this sense, though, of people being able to feel that they are making decisions for themselves is the advance choice document enshrined in this legislation. I am sure that the Government will want to think carefully about the matters that it might encompass, and about its interaction with potential future legislation.
I want to pick up the issue of the nominated person. I mentioned families feeling that they are sometimes cut out but of course, as we know, sometimes for the individual with mental illness or mental health problems the nearest relative—that family member—might not be the most appropriate person to be their nominated individual. That individual may actually be somebody with whom—how can I put it?—the tensions can lead to increased difficulties for the person with mental illness, rather than reducing them. That ability to nominate somebody else as the person who someone wants to be there is critical. The noble Baroness, Lady Watkins, referred to this in relation to children but I think that, in general, it could create some tensions with family members who feel that it is their right to be that person alongside the individual in mental health crisis. Having said that, I believe that the nominated person point in the Bill is absolutely appropriate.
I want to focus also on the questions of detention. I have referenced how we need to look carefully at the inappropriate racial disparity in detention, but I also want to comment on the police issue. I am pleased to see the outlawing in the Bill of the use of police cells and prisons as first places of safety. This is of course the culmination of work in progress. There was voluntary work with the police and the health service, in 2012 and subsequently, to encourage and help them to ensure that the first person who someone in mental health crisis saw was not a police officer, and that they were not taken to a police cell as a place of safety. We then ensured that work in the Policing and Crime Act 2017, so that police cells could not be used as places of safety for those under the age of 18. The Bill takes it that bit further and it is absolutely right that it does—and right to do it for the individual who is in mental health crisis.
It is also right to do that for the police, because one issue that police officers themselves constantly made reference to me about was their fear and concern about being expected to deal with somebody who was in mental health crisis, when they had no training and no capability of knowing what to do in those circumstances. Of course, it is bad for the individual too if they are faced with somebody who has no actual understanding of what their condition is or how they should be dealt with.
Perhaps I may gently say to the Minister that in 2015 we put £15 million into providing alternative places of safety and in 2017 the Government put £30 million into providing them. This Government are now putting £26 million into providing those alternative places of safety. It is easier to say this from this side of the House, but the Government might wish to consider those figures, if I can put it like that. I also suggest to the Government that they consider alternative places of safety as not necessarily being a healthcare facility. Many places in the third sector are able to provide those facilities and the Government should look at that as well.
Finally, we also need those facilities to try to ensure that people are less likely to get to the point of crisis. If they are less likely to get to that point, they are also less likely to turn up at A&E because they are in crisis. That would be a win-win for the individual concerned, for the Government and for the health service.
Overall, I welcome the Bill. There are some very good provisions in it. As we have heard, it will be subject to detailed scrutiny in this House but it is no bad thing—I can say this now—that it started in this House. I welcome it and look forward to its passage.
Baroness Hollins (CB)
My Lords, it is a pleasure to follow the noble Baroness. I remind the House that I worked clinically as a psychiatrist for about 35 years and had been a consultant for two years by the time that the 1983 Act was introduced. I argued then, as now, that mental handicap, as it was called, had no place in legislation—although others disagreed. Profound changes in societal attitudes, alongside advancements in the understanding and treatment of mental illness, have occurred during my career. I agree with the noble Baroness, Lady Barker, and my noble friend Lady Murphy that fusion legislation really should have been considered.
There is no minimum age limit in the Mental Health Act, meaning that its provisions apply to children and young people as well as adults. The Joint Committee, of which I was a member, recognised their unique needs, saying that this is
“a crucial opportunity for the Government to strengthen the rights and protections for children and young people”.
We must never forget that the mental health of babies, children and young people is fundamental to the mental health of the adult population, and that we cannot legislate for the treatment of serious mental disorder without taking mental health seriously from the very beginning of each person’s life.
Psychiatry’s past has included some harmful and forced interventions, rather than the preventive approaches, early intervention and evidence-based treatments that are so needed. The Bill aims to safeguard dignity and autonomy, and ensure best practices for all, including people with learning disabilities and autistic people. A major current concern for me is that there are nearly 2,000 people with a learning disability and autistic people in psychiatric hospitals. Usually, that is because of a lack of individually tailored support and housing—they have an average stay of five years—and because of the shortage of effective treatment options in the community and lack of training for the wider mental health workforce.
My Heart Breaks, the report of a review that I chaired and which was published by the Government last year, shed light on the harrowing realities faced by many of the 100 or so of those 2,000 in hospital who are detained in long-term segregation at any one time. The systemic failures we found reflected a troubling overreliance on detention as a substitute for meaningful care, despite such detentions often lacking therapeutic goals, a pattern that unfortunately affects other patient groups as well, including those with personality disorders.
Historically, policy and practice have overlooked complex intersectional vulnerabilities, including learning disability, autism, gender, race, poverty and physical health issues. Marginalised groups, especially people from racialised communities, are detained more often. Trauma histories may be compounded by the excessive use of medication and restrictive practices which contain people, with an eye to safety, but disempower and just do not support recovery. People need better-adapted psychological therapies but are less likely to access them, and poorly co-ordinated discharge processes further trap individuals in a dysfunctional system. This violates people’s human rights and ethical care standards.
As a long-time advocate for people with learning disabilities and autistic people, for me, one of the Bill’s most significant reforms is the removal of learning disability and autism as stand-alone grounds for detention under Section 3, part 2. This change is complemented by new duties on health and care bodies to provide the community-based support and therapeutic approaches needed to prevent unnecessary detentions. But legislation alone will not provide better care; the right people in the right place with the right skills are needed. So the Bill introduces mandatory care, education and treatment reviews, which aim to create personalised care plans and facilitate timely discharges. Additionally, dynamic support registers are intended to track those at risk of crisis, allowing for early intervention before issues escalate. Advance choice documents could also be valuable for choice, safety and care.
The National Autistic Society, Mencap and several other charities have welcomed the Mental Health Bill as a step toward safeguarding the rights of individuals with learning disabilities and autistic people. All stress the need for robust support systems, including housing and social care. These are essential to prevent unnecessary admissions, emphasising that the Bill’s success depends on effective implementation, accountability and substantial investment in community services. They also request a new action plan to replace the Building the Right Support action plan. This is particularly urgent, given that targets to reduce in-patient numbers of people with a learning disability and autistic people have been repeatedly missed over the last decade, and only one in five integrated care systems have currently met the March 2024 target for reduction of in-patient numbers.
Can the Minister confirm whether a plan such as that being requested will indeed be co-produced and implemented with the help of people with lived experience, families, campaigners and relevant bodies, alongside the implementation of this legislation? Both the Royal College of Psychiatrists and the BPS have cautioned against removing autism and learning disabilities as stand-alone criteria unless there are substantial improvements, warning that this could divert unsupported individuals into emergency services or the criminal justice system. Easy to say, better not to do it—but we must use this as a lever to change the culture of care and support for these groups of people.
We do not want to risk criminalising people’s mental health needs, and we do not want to disproportionately impact already marginalised groups. I ask the Minister, what assurances can Government provide to ensure adequate funding to deliver minimum safe services in the community, such as early prevention measures, rapid response teams, crash pads and effective therapeutic approaches in the community? Indeed, could these alternatives be mandated?
Compulsory detention and treatment of individuals with personality disorders under Part 2 of the Mental Health Act is another issue. Personality disorders stem from relational difficulties and cannot be effectively treated in restrictive in-patient settings. Research shows that admissions without structured, evidence-based psychological interventions provide no benefits and can indeed worsen symptoms.
Why is Section 117 aftercare limited to Section 3? Social and health care should be integrated for all patients based on need, not the section they were detained under. For example, a financial crisis causing suicidal thoughts in a farmer might lead to a Section 2, when a social prescription might have been effective. After assessment, they will return to the same situation without appropriate support, such as legal or financial advice to resolve the crisis.
The new Mental Health Bill gives us an opportunity to address the stigma that shaped policy in the 1980s and create a legal framework which keeps pace with scientific advancements. We need to reframe our focus from risk management to supporting accessible, evidence-based community interventions, ensuring that care aligns with ethical and therapeutic principles and prioritises a rights-based, person-centred approach.
Our actions now will shape mental health care for the 21st century. Let us enact compassionate and progressive reforms that future generations will respect.
Lord Bradley (Lab)
My Lords, it is always a pleasure to follow the noble Baroness, Lady Hollins, with her expertise in this area. I declare my interests as listed in the register and am pleased to make a short contribution to this debate. It has been some time coming.
Following the excellent review of the Mental Health Act, initiated by the noble Baroness, Lady May, Sir Simon Wesley produced his report in 2018 and a draft Bill was published by the last Government, as we have heard. This was followed by detailed scrutiny by the Joint Committee of both Houses, which I was pleased to be a member of and which was so admirably chaired by the noble Baroness, Lady Buscombe. It was disappointing at that point that the deliberations were paused, but I was delighted that the new Government, following a manifesto commitment, immediately introduced this Bill, which everyone has welcomed today.
In the time available I will focus on only a few areas, the first of which is the proposed changes under Part 3 of the Bill—essentially, the interface between mental health and the criminal justice system. I am delighted that Clause 35 proposes a statutory time limit of 28 days for the transfer of acutely mentally ill patients held in prison to appropriate hospital provision. It is now well recognised that the prison environment and care capacity is detrimental not only to the prisoner but to other prisoners and the staff who care for them. I made a similar recommendation in my independent report to government in 2009, nearly 16 years ago—albeit with the perhaps unrealistic time limit of a 14-day transfer. Clearly, you have to be patient and persistent to achieve legislative change.
Secondly, on Clause 46 and the removal of police stations and prisons as places of safety, I made related recommendations back in 2009, and I am obviously now pleased that there is overwhelming recognition that both facilities are not appropriate as places of safety. Clearly, detailed examination of these proposals will be required in Committee to ensure that the wording delivers their intention. For example, when will the clock start on the 28-day limit?
Thirdly, for this to be effective, investment in alternative community-based healthcare provision will be required for places of safety, as will investment in liaison diversion services, to ensure that only those who need to obtain a place of safety. Otherwise, as we have heard, A&E departments will continue to be the default position, at huge cost to the NHS and to the police service. We also need additional acute mental health beds in every local area to ensure timely transfers and to make the legislative changes a reality.
There is also concern, well articulated by the Children & Young People’s Mental Health Coalition, that children and young people are still inappropriately placed in settings outside their local area, and on adult wards. It is imperative that the Bill strengthens safeguards against this and recognises the Joint Committee’s recommendation for stronger procedural requirements where such inappropriate placements are considered, including a requirement that such a placement is demonstrably in the child’s best interest.
There are many positive elements of the Bill, as the Minister clearly outlined in opening this debate, including improving the patient experience, improving patient choice and autonomy, and limiting the detention of people with learning disability and autistic people without qualifying co-recurring mental health conditions—all of which and much else, as we have heard, will be carefully considered in Committee.
However, I believe we need further debate on where the principles outlined by Simon Wessely are placed in the Bill. I am particularly disappointed that the Government have not currently accepted the recommendation to establish the role of a mental health commissioner and seemed silent on the issue when the Bill was introduced. As we have heard, the Joint Committee recommended that this post be statutorily positioned and that the mental health commissioner should be created with a number of roles, which I would like to briefly elaborate on.
The mental health commissioner should be a voice at a national level, promoting the interests of those who are detained and who are likely to be detained under the Mental Health Act, as well as the interests of their families and carers, raising awareness of their needs and challenging stigma and stereotypes. They should work in conjunction with the Care Quality Commission and other bodies to make recommendations on further reforming mental health law in the direction of more rights-led and fused legislation, such as we have heard on the Mental Capacity Act.
Critically, the commissioner should be a mechanism for tracking the implementation of the reforms in and associated with this Bill and other legal changes, essentially and particularly with the inclusion of the provision of data to understand how the Bill is operating. We saw the role of the commissioner as primarily to act as a watchdog to oversee the direction of travel for the key reforms in the Mental Health Act and mental health policy generally, overarching the whole government system. This has been supported by many organisations working in the mental health field, including the Centre for Mental Health, of which I am an ambassador. The centre added that, in addition to overseeing the reforms to the Mental Health Act, a commissioner could play a wide-ranging strategic role across all government departments.
Finally, I will say a few further words about resourcing and implementation, which will be crucial to the success of this legislation. Again, the Joint Committee recommended that the Government publish a comprehensive implementation and workforce plan alongside the Bill with key milestones detailing the implementation of the Bill and, crucially, how they link to milestones in the implementation of the NHS 10-year plan and other government initiatives. These should include milestones on workforce development, not only for mental health staff but allied health professionals, such as speech and language therapists. I declare my interest as honorary vice-president of the Royal College of Speech and Language Therapists.
The plan should also include milestones on training, advocacy and community care capacity, as well as on numbers of detentions, length of stay and, critically, reducing racial and ethnic inequality. There should also be a statutory duty to report annually to Parliament on the progress against these milestones during the implementation period. Disappointingly, unless I have misunderstood the Explanatory Notes to the Bill, the Government have so far offered only a financial assessment over a 20-year period, which is not at all coherent with the NHS 10-year plan.
However, in conclusion, I am very pleased that we are debating this incredibly important Bill now and in the coming weeks and months to try to ensure that we go a long way to producing a progressive Mental Health Act which is fit for 2025 and years beyond. I look forward to the Minister’s response at the end of the debate.
Lord Scriven (LD)
My Lords, it is a pleasure to follow the noble Lord, Lord Bradley, who was the MP for the constituency I lived in when I was a student. In those days, I campaigned against him, but, from listening to his speech today, I am sure that we will campaign together in Committee on some of the reforms that may be required in the Bill.
This Bill is a welcome direction of travel for mental health legislation in the United Kingdom, but it is only an extra stop. As other noble Lords have said, sometimes we have to look at the bus we are on—the underlying legislation. That bus was built when I was 17 years old, if we go back to the 1983 legislation, and it had its last MOT 17 years ago, in terms of its amendments. I believe that, although these measures are welcome, there is still a fundamental issue in terms of the basis of what we are traveling on. I understand the problems with that.
The questions we are really asking in this Bill are quite limited in the sense of the balance between individual freedoms and public protection when it comes to the detention of individuals. Because we look at such legislation infrequently, we must do our best in Committee to ensure that the balance is at its best and that, wherever we can, we take a person-centred, rights-based approach to this legislation. Having said that, there are some pleasing points in the Bill, including the tightening of the criteria for the detention and compulsory treatment of individuals. It is welcome that the four key principles are mentioned but it is a shame that they are not on the face of the Bill and are down as guidance only. It is important that those of us who really support the principles fight for them to be on the face of the Bill in Committee.
The advance choice documents are a welcome provision but, as many noble Lords have said, they need to be fully accessible 24 hours a day, 365 days a year to those who care for people who have given an advance choice document. I question why they are only for people aged 18 and over. If we are looking at Gillick competence, there are issues around those who are younger, who should be able to provide an advance choice document. I worry that they are not a right or a duty but are only to be given as a consideration.
I welcome the right to a nominated trusted individual but many people who have been involved in healthcare will know that it is not just about having that person as a right; it is about the way in which professionals listen to them and carry out the advocacy that they provide. I am not sure, as we start with this Bill, that the balance is correct; I believe that certain issues will have to be addressed in Committee.
I have also looked at the potential implementation of the Bill. It is always good to start with the impact assessment. It has in it some quite startling issues that I think we will want to look at in Committee. For example, community treatment orders are not meant to change for at least another seven years, but the implementation start is in seven years. The existing CTO regime will last for another seven years and, from the Government’s impact assessment, it looks as though the new regime will start in seven years at the earliest.
I will come back to people with learning difficulties and autism in a second, but the implementation of the measures for them not to be held for more than 28 days and for other provision in the community to have to be available will be in three years’ time, according to the impact assessment. However, there is no money in the next two years to start to provide for those community facilities. It is as though they will come on stream the second the implementation date is reached; I question the Government’s planning on that and whether it is a realistic adaptation for people with learning difficulties and autism.
My passion and focus in Committee will probably be learning disabilities and autism, because they are personal to me. I have close family members who are loving and warm but very misunderstood by those who do not have a close relationship with them. It is scandalous that, in 2024, having those labels attached to you means that you could be detained under the Mental Health Act for more than 28 days. I welcome the fact that the Bill’s provisions will move away from Section 3 and towards Section 2 detention, but I worry that it will not stop detention of people with learning disabilities or autism. For example, DoLS will be used, because these people are misunderstood. The legislation in itself will not change what happens to them. Individuals who are seen not as a threat but as difficult will be detained. As other noble Lords have said, fused legislation needs to be used to ensure that those individuals are not detained using different pieces of legislation.
As other noble Lords have said, it is also worrying that people with learning disabilities or autism who are under a Section 2 detention or detained under the Mental Capacity Act will not have access to Section 117 community facilities. It is quite fascinating that the very things under Section 117 that need to be in place to ensure that these people are not detained are the very facilities that they do not have a statutory right to. That needs to be looked at in this legislation.
There are many things to welcome, but many further questions need to be asked and drawn out, particularly regarding some of the contradictions in different parts of the legislative process on mental health provision within the UK and around the rights-based approach, which the Government seem not to have in place. We will want to explore that as we go forward.
Lord Meston (CB)
My Lords, consideration of this Bill has been greatly assisted by the thorough scrutiny and analysis undertaken by the Joint Committee on the draft Bill and its compelling report, published in January 2023. Parliament will now need to look with care at its recommendations, including those not incorporated into the Bill as now presented, and the justifications for any omission.
The first question tackled in that report was whether what is now required is fundamental reforming legislation rather than another amending statute. If I may follow on from the noble Lord, Lord Scriven, the bus was not built in 1983; its chassis was built in 1959, and we are still dealing with it. The report states:
“The Mental Health Act 1983 is … forty years old. It has been amended multiple times over those years, making it hard to use even for experienced professionals. It is overly complex, especially where it interacts with the Mental Capacity Act 2005”.
For example, the committee noted:
“Attempts to both protect and empower children in these settings have resulted in a complex mixture of statute law and case law alongside the MHA that … makes assessing a child’s rights to access certain safeguards in this draft Bill complex and obscure”.
For essentially good and pragmatic reasons, as the noble Baroness, Lady Buscombe, explained, the Joint Committee did not wish to introduce further delay or uncertainty, so favoured the form of the Bill considered by it, which is now before Parliament. However, for the courts, tribunals, lawyers and all the other consumers of the legislation, the question will remain, as per the quote in the invaluable Mental Health Act Manual:
“If the Mental Health Act is to be modernised, is it appropriate to base the modernisation on a legislative structure that was established over 60 years ago by the Mental Health Act 1959? The process of bolting on multiple miscellaneous amendments to that structure over the years has resulted in an Act which is overly complex, confusing, and expensive to operate”.
Inevitably, those problems will be exacerbated when this Bill adds further amendments to the 1983 Act. It is therefore to be hoped that the Government will see the Bill, as the Joint Committee put it, not as
“the end—or even a pause—in the process of reform of mental health legislation”.
Meanwhile, the code of practice under the 1983 Act will need, and I understand will now receive, further revision and updating once the Bill is enacted to cover the stronger requirements of the new legislation and provide clear guidance to meet the needs of patients and for all those who operate the changes.
I turn to some of the Bill’s detail. It is certainly welcome that it recognises the real problem that too many autistic people and others with learning difficulties have been detained inappropriately and for far too long. It is also welcome that the Bill removes police stations from the definition of a place of safety in the 1983 Act. Inevitably, the police will continue to have to deal with disturbed and distressed people suffering a chronic or temporary mental health crisis, but these are people who should not be in police stations any longer than absolutely necessary, particularly if expert assessment or treatment are required.
It is to be hoped that the changes will relieve the police of some of the difficult decisions as to risk required under the existing code of practice, but, as others have said, these changes will not work without sufficient community alternatives. As the noble Earl said, it will not be helpful if they simply pass the problem on to an A&E department. I do not want to get anecdotal, but I had a brief admission to A&E. It was, happily, not long lasting, but it was extraordinary to watch the staff in that hospital cope with a very determined and disturbed man. Unfortunately, I did not see the end of that because, luckily, I was released. Nevertheless, it is a problem that needs to be thought about hard.
By contrast with the ethos when I started as a lawyer, all courts now strive to ensure that people are not defined by their mental health problems, even if it is not always possible to prevent those with mental health problems entering the criminal justice system or to divert them from it once they are in it. Professionals in that system need help to deal with these people and their problems. Therefore, the improved provisions for transfer of prisoners to hospital, including those detained under the Immigration Act, should be valuable, but will always depend on compliance with the code of practice, which requires the need for in-patient treatment for a prisoner to be identified and acted on quickly.
The same problems apply when the criminal courts consider sentencing options. The courts depend on the Probation Service and legal representatives to draw attention to the possible need for psychiatric reports and detention. Having sat as a judge in the Crown Court, I can convey the real exasperation of the judiciary when necessary reports are not available or when suitable hospital places cannot be found without further delay and hearings in an overloaded court system.
I turn to a different topic, which has been referred to. The Bill will implement recommendations about replacing the existing “nearest relative” with “the nominated person”, under the principle of patient choice and autonomy. I have some concerns about the selection and replacement of nominated persons, and the complicated provisions within the Bill. Now is perhaps not the time for that, and I will leave it to Committee, but it needs to be looked at again. In particular, there is a need to focus on the consultation, at the very least, and recognition of the legitimate interests of parents and others with parental responsibility.
On this topic, I question—although, again, I leave this to Committee—the continued use of the county court for applications to terminate appointments of nominated persons. The use of the county court is left over from the 1959 Act, at a time when there was neither a separate family court nor a Court of Protection. I suggest that these would now be better equipped to deal with these applications.
There are further points focusing on the needs of children, one of which has already been touched on. It was highlighted by Dr Camilla Parker in her evidence and will strike a chord with many practitioners. It concerns the overlapping factors governing capacity and competence, and the differing processes for assessment. Dr Parker observed that, even after 40 years, we do not have “clear and consistent criteria” for determining whether a child is competent to make a decision. It would be helpful to understand the Government’s current intention, particularly if formulating any statutory tests is not intended.
More fundamentally important is the location for the placement of children. This overlaps with the real problem, which has been highlighted repeatedly by the judiciary, the Nuffield Family Justice Observatory and the Children’s Commissioner, of the use of deprivation of liberty orders, or DoLS, and placing children in unregistered settings—not just adult wards but unsuitable, unregistered settings. Again, I will return to this in Committee.
Baroness Browning (Con)
My Lords, I declare an interest as a vice-president of the National Autistic Society, with the noble Lord, Lord Touhig, and as having some responsibility for family members on the autistic spectrum.
Like the noble Baroness, Lady Barker, I am a veteran of the Mental Health Act 2007 and the Mental Capacity Act. When I came to this place, I was pleased to be involved in the review of the Mental Capacity Act. This and other Bills of this nature would merit looking at, to see what happens after we legislate. My concerns with the 2007 Act were, primarily, community treatment orders. Looking at the Bill, I see that these are to be altered, but I still share the view of the charity Mind, which would like to see them abolished altogether. I hope that, as we go through Committee, we can make substantial changes to what we have in front of us.
I was also concerned about the deprivation of liberty generally and the situation for autistic people in relation to mental health services. I am still concerned, but I welcome the proposed changes for people with autism and learning disabilities, making it illegal to detain an autistic person or a person with a learning disability unless they have a coexisting mental health condition. Presently, of the 1,385 autistic people detained in mental health facilities, 93% are detained under the Mental Health Act—they are not voluntary patients.
I make no apology for making the case for autism being a special condition that needs to be treated differently to other conditions. I say that because, apart from the Mental Health Act, autism is the only medical condition that has its own Act of Parliament. That tells you that something about it is different from other conditions. In 2009, both Houses of Parliament passed a short but important Act, which was introduced by my friend the late right honourable Cheryl Gillan MP.
So what is it about autism that makes it so different that we should have special regard to it as the Bill progresses? I will first look at how autistic people come into contact with psychiatric services generally. Autism is, of course, a spectrum, so we are talking about a wide range of conditions. There is the old adage that, if you have met one autistic person, well, you have met one autistic person. Although we may look at commonalities among this whole group of people, they are all individuals and should be treated as individuals.
Autistic people come into contact with psychiatrists, although a wider range of people diagnose autism now. I give apologies immediately to the eminent psychiatrists in this Chamber, but, over 32 years in this House—and having taken up many cases and I hope assisted several Members with their casework—I have seen what can often happen if a psychiatrist does not understand autism or, even worse, receives a patient with an autism diagnosis from another psychiatrist but will not accept that diagnosis. That is shocking. So often, misdiagnosis can occur when somebody is admitted to a mental health institution but the psychiatrist will not accept that diagnosis and starts to rediagnose somebody, giving them medicated treatment that clearly does not work. I have seen the results of that.
I particularly remember—it is fixed in my mind—a young man who was a very good artist and whose autism diagnosis was overridden when he was admitted. The diagnosis was, “No, no—this is schizophrenia”. Interestingly, that is a common mistake. As each medication was applied and did not work, that young man’s ability to hold a paintbrush and produce the sort of work he produced before was completely diminished. So autistic people come into contact with psychiatrists, and my point about psychiatrists is that they must have specific autism training. There is a huge lack of psychiatrists generally but particularly psychiatrists with that type of training.
As the noble Lord, Lord Touhig, rightly said, although autism itself is not a mental health condition, people with autism can of course have a mental health condition or a learning disability. But, out in the community, if an autistic person needs medication of one sort or another—I am talking not about drugs that are used for psychosis but drugs to help control anxiety, which is a natural side-effect of autism—accessing the correct drugs through a psychiatrist is impossible in some parts of the country. It is very much a postcode lottery, because psychologists—whom autistic people are very often referred to—cannot prescribe. So, if there is no local psychiatrist whom a GP can refer you to, your only option is very often to pay to see the right person privately. If any of us had a cardiological condition, we would not expect to have to pay for a cardiologist to treat us. I believe the Bill should address access to appropriate—that word is used so often—care from trained and qualified people, whether psychiatrists, CPNs or whoever.
The other thing about autistic people that must be taken into account is that so many of them have sensory side-effects to their autism. There is a vast variety of side-effects, which perhaps may not seem important to people who do not experience them. They can be anything from lighting to noise, sound and the proximity of other people to them. These things need to be taken into account, like the things that have been said already: what a horror it is for any of us to be admitted to A&E now, but, frankly, it can produce very serious results for an autistic person.
I would like this Bill to produce the right training and the right services in the community. For autistic people, the downward spiral into very severe anxiety is there when community services are not provided. When I talk about community services, I am not always talking about something that will cost a fortune; it is actually the low-hanging fruit of low-cost measures. Sometimes it can be as simple as something that provides somebody—a child or an adult—with a friend: somebody with whom they can form a relationship. That does not cost a fortune. However, when money is tight—and we know money is tight—those are the first sorts of services that get taken away, and the downward spiral of an autistic person when these services are no longer provided or are not provided in the first place is what results in them needing to come into contact with the more serious mental health services that this Bill will address.
The noble Baroness, Lady Watkins, mentioned parental responsibility, and in this debate we have not yet mentioned lasting powers of attorney. These are powers for people who are able to sign them when they have capacity, which may well be a very useful thing when people are denied access to their relatives or carers. I hope we will include that in the Bill.
Baroness Fox of Buckley (Non-Afl)
My Lords, it is somewhat humbling and not a little intimidating to follow so many insightful speeches from those at the heart of the issue. For me, as a bit of an amateur outsider, I broadly welcome the Bill, with some reservations that I will pursue in Committee.
For Second Reading, I suggest that we should always remember the cultural and political context of our deliberations and indeed definitions—I will come back to that. We also need to remember the lessons of history: locking people up for mental illness has been mired in ethical and political scandal over many years. We all can cite the former Soviet Union, where political dissidents were labelled mentally ill, but even in democracies it was not until 1973 that the American Psychiatric Association voted to declassify homosexuality as a mental disorder—and let us not forget those unmarried mothers who were sectioned in the 20th century.
However, even with this misuse of psychiatric power, it is still possible to be a defender of liberty—such as myself, I hope—and yet acknowledge the need for some people to have their liberty restricted because of their mental health. Many years ago, when I worked for Mind, this was a very polarising debate; but I argued then, and continue to believe, that when someone is severely psychotic, manic or out of their mind, psychiatric coercion is not a violation of individual autonomy. That is because the subject at that point in time—“at that point in time” is key—is not autonomous in any moral sense.
However, is release not different? And that brings me to the issue of community treatment orders. Along with others, I too would like them to be abolished. The general problem of CTOs was well explained by Dr Ken McLaughlin is his pamphlet Escaping the Straitjacket of Mental Health. In it, he makes the point that, while the case for compulsion can be justified at the point of hospital admission, when the patient is likely to be in an acutely psychotic state, can compulsion be justified at the time of hospital discharge when the patient should have mental capacity restored? Prior to 2007 and CTOs, on leaving hospital, an ex-patient regained their full rights of citizenship, including the right to refuse medical treatment. The problem of being released with a CTO is that you return to the community as neither a patient nor a citizen. This hybrid state is troubling in terms of compromising civil liberties.
I tend to agree with the noble Earl, Lord Howe, and others: at the very least I question why the Bill will allow indefinite CTOs to occur. I agree with the Centre for Mental Health’s call for the safeguard of time limits, and then CTOs could be extended only if there was proof of proportionality for the individuals concerned.
The question of indefinite “coercive orders” inevitably reminds us of the plight of the almost 3,000 prisoners held indefinitely behind prison bars under the abolished and discredited IPP sentence. Many of these people are incarcerated in prisons precisely because their mental health has deteriorated as they have been refused release, even on licence; a sort of unacknowledged section is happening here. What is more, shockingly, a wide range of experts now blame this very sentencing regime as the cause of IPP prisoners’ mental distress. The hopelessness—“psychological terror”, as it has been described—of never-ending sentences has literally driven prisoners to lose their minds, and even their lives through suicide.
So, while I am delighted the Bill will remove prisons from the list of places of safety, how does it help IPP prisoners? They are deemed too mentally unwell to be released safely. Their illness is derived at least partly from a shameful state mistake, yet IPP prisoners are coercively detained indefinitely in institutions that the Bill would have the state now deem as unsafe for those with serious mental illness.
One case that has recently attracted headlines illustrates an IPP prisoner’s plight as it relates to the Bill. Forty year-old Thomas White has served 12 years as part of his indefinite IPP for a non-violent theft of a mobile phone in 2012. According to his psychiatrist, Thomas developed his religious hallucinations and psychosis as a direct result of being on an IPP sentence. His sister Clara has been campaigning for over a year to have Thomas transferred to a hospital, but his recent assessment appointment was cancelled due to staff shortages. Clara notes despairingly:
“We waited a long time to have Thomas assessed again by the psychiatrist. We more than likely won’t get the assessment again. The system is nothing but criminal—people like my brother are being seriously failed”.
James Frith, the Labour MP for Bury North, agrees. He said:
“Thomas’s indefinite imprisonment has had a hugely detrimental impact on his mental and physical wellbeing. Thomas should be a patient, not a prisoner”.
Hear, hear.
Things are little better for the general prison population. The annual report from the Chief Inspector of Prisons complains of high healthcare staff vacancy rates and chronic recruitment and retention issues. In that context, Richard Garside, the director of the Centre for Crime and Justice Studies, concludes that the provision in Clause 35 to introduce a statutory target of 28 days for transfer from prison to hospital, while welcome, feels aspirational rather than practically implementable in the current system.
The broader crisis of staffing and resources and whether it will hinder the Bill, as we have seen in jails, is also mirrored outside the prison gates. Many briefings that we have all received for this Second Reading query whether the Bill will deliver its promises as a consequence of such problems.
I will now raise a related concern. I think that overstretched mental health services are not just a question of resources but rather a consequence of a recent cultural trend: the problematic medicalisation of more and more aspects of the human condition. Ever greater numbers of people are being encouraged—often by Government-backed policies—to view normal, if adverse or perhaps painful, life events through the prism of mental illness. As a consequence, a greater number of people now demand expert pharmacological or therapeutic intervention.
Over recent decades, this huge increase in classification in the psychological realm has moved the job of diagnosis far beyond the field of psychiatry. A veritable industry of counsellors, therapists and psychotherapeutic practitioners now label an ever-expanding set of behaviours as mental ill-health. As the number of labelled conditions has grown, those reporting that they suffer from such problems has risen exponentially. The stats bandied around are eye-watering. According to the psychologist Oliver James, a third of the adult population shows sign of “psychiatric morbidity”. The problems of worklessness and sick leave, which the Government are rightly tackling, seem dominated by those who have removed themselves from productive work because of mental health-related problems.
Student Minds reports that one in three students experiences clinical levels of psychological distress, but as it is now claimed that students might suffer PTSD if exposed to certain literary texts, it is difficult to assess the clinical authenticity of the so-called mental ill-health epidemic among the young.
The main thing is that the pathologising of ever more aspects of life has unintended consequences, some pertinent to the Bill. For example, we risk reducing the time and resources available to those who desperately need professional help if the system is clogged up with inappropriate referrals and arguably overdiagnosed conditions.
Finally, there is a danger of confusing public opinion if the true horrors and tragedy of serious psychotic illness are relativised and given the same mental health moniker as unpleasant but mundane psychological challenges.
Lord Adebowale (CB)
My Lords, this has been a fascinating debate so far. It is an honour to contribute and to listen to so many learned Peers around the House. In fact, earlier on I detected an almost kumbaya moment around the agreement on some of the aspects of the Bill.
I declare my interest as chair of the NHS Confederation, which is a membership organisation representing health and care leaders in England, Wales and Northern Ireland. We have the privilege of having 100% of all mental health trust leaders in membership.
This debate is overdue, just as updating the Mental Health Act is long overdue. I could not help thinking, during the contributions of the noble Lords, Lord Meston and Lord Scriven, that if we were to go back to 1959, this House would be of archaeological interest before we got anywhere near where we have got to today—so we shall start where we are and continue to make the Bill the best it can be.
I should also point out that a member of my family is on the autistic spectrum, so I get it, just as people who have that experience also get it.
Organisations such as the NHS Confederation have warned that the success of reforms will be dependent on the wider infrastructure to support them. My first question to the Minister is: can she confirm that as well as the important measures in the Bill, we will see further details in next spring’s spending review and in the 10-year NHS plan about how patients and staff working in mental health will be supported in years to come?
The Bill is welcome, not least because it is intended to stop people with learning disabilities and autistic people from being detained long-term, unless they also have a serious mental health condition, but only when there is sufficient and appropriate community care in place to support them. It is clear, therefore, that a plan on how this capacity will be built up is vital; otherwise, people will continue to be detained inappropriately. Can the Minister provide more details on what the Government will do to ensure that we see that capacity is built up, so that people with learning disabilities and autistic people are able to benefit from the support that community care can provide?
Concerns have also been highlighted to me by many of our members and other organisations that the changes for people with learning disabilities and autistic people may unintentionally risk these groups falling into the criminal justice system due to a lack of community provision, as mentioned by the noble Baroness, Lady Watkins. This is similar to the changes in New Zealand she referred to, which led to people with learning disabilities and autistic people sometimes being sent to prison and left neglected in the community or admitted to forensic facilities as secure patients, as they were unable to be detained under its equivalent of the Mental Health Act.
I welcome the safeguards that the changes relating to people with learning disabilities and autistic people will be enacted only once sufficient provision is in place. Can the Minister provide more details on what the Government will do to ensure that capacity is built up so that people with learning disabilities and autistic people are not inappropriately—and indeed unintentionally—detained for many years, often far away from home and for very long periods?
The Government are committed to enacting the changes to detention regarding people with learning disabilities and autistic people only once sufficient community provision is in place to reduce the risk of these people falling into the criminal justice system. Again, can the Minister outline how the decision to enact this part of the legislation will be made?
The reforms that we are debating introduce duties on commissioners to ensure an adequate supply of community services to prevent inappropriate detentions in hospital, but without a funded plan to build up this provision, there is a risk that the proposed changes to the legislation will never be enacted, and people will continue to be inappropriately detained. Can the Minister say what measures the Government will put in place to help commissioners get it right at local level?
In addition, as the noble Lord, Lord Bradley, mentioned, referring to the 28 days, some people are very concerned that it is not long enough to complete a thorough assessment to identify whether patients with a learning disability or autistic people have a co-occurring mental health disorder, due to the complexity of what patients often present. Does the Minister acknowledge these concerns, and will she remain open to discussions with the sector throughout the passage of the Bill so that the views of those who work day to day with vulnerable people, as well as the views of people with learning disabilities and autistic people and their families, can be fed directly into the legislative process?
It is nice to note that many have referred to the stark racial inequalities in the use of CTOs, and wider concerns around their use. However, mental health providers and many professionals agree that they can be beneficial to patients as they can be the least restrictive option, and we welcome the Government’s commitment to reviewing CTOs. Can the Minister share details about the scope and timescale of this review?
The NHS Confederation has raised concerns about high vacancy rates across the sector, which are bound to impact on staff capacity. Again, can the Minister give assurances that this will be addressed as soon as possible, if not as part of this legislation then through the upcoming 10-year plan or the review of the NHS workforce plan? This was mentioned by the right reverend Prelate the Bishop of London, and indeed the noble Baroness, Lady Buscombe, whose points on data I also agree with.
The NHS Confederation has pointed out that more opportunities for patients to challenge their detention are likely to increase the number of tribunal hearings. This would require an additional 33% expansion of the in-patient responsible clinician workforce. Given that national consultant psychiatrist vacancy rates are currently around 10% to 15%, this will be very challenging. With the Government set to publish an updated long-term workforce plan for the NHS next year, as mentioned earlier, can the Minister give an assurance there will be measures in this plan to specifically tackle workforce shortages in mental health?
In referring back to the issue of racial inequality, the patient and carer race equality framework is the key vehicle in reducing the racial disparities that exist in the Mental Health Act and in wider services—which mean, for example, as we mentioned, that black people are far more likely to be detained under the Act or to be placed on a community treatment order than white people. The so-called PCREF is not part of legislation, but all mental health providers are expected to implement it. Concerns exist that the lack of understanding of the framework, as well as the lack of resources available, are hampering its implementation. Again, will the Minister consider using legislation to address these concerns?
Racial disparities are a significant issue, and the NHS Confederation has described the disparities in rates of detention of people from different racial backgrounds as unacceptable—I agree. For example, black people are more than three times more likely to be detained under the Mental Health Act. There is evidence that advance choice documents reduce racial disparities in the level of detentions. This led to many in the sector calling for them to be made statutory. Indeed, this was recommended by both the Mental Health Act review and the pre-legislative scrutiny committee which looked at the draft Bill. Can the Minister set out why advance choice documents will not be made statutory? Is she confident that measures in the Bill concerning such documents will help reduce those racial disparities in detention rates? There are very few evidential interventions that actually reduce racial disparities, so let us use the one that we know works.
The NHS Confederation has highlighted concerns that the new criteria for detention set out in the Bill—namely, that serious harm may be caused—need to be defined. If they are not, we risk inconsistency in how the definition is interpreted. Will the Minister come forward with a definition of what constitutes serious harm so that there can be no doubt about what this means in practice?
Funding for new mental health crisis centres announced in the Autumn Budget was welcome, but we need to see more funding provided for the NHS and mental health in the coming years. As the confederation has pointed out, successful implementation of the legislation we are debating will depend on ensuring that the workforce and resources are in place. That includes capital funding to improve the safety and therapeutic environments of in-patient wards. I have seen some shocking places, as no doubt many noble Lords have. Can the Minister say whether, alongside these much-needed reforms, we will see further funding for mental health in next spring’s spending review? I urge her to speed dial the Treasury.
The Government estimate the overall cost of the reforms to be around £5.3 billion for housing, health and social care costs and £313 million for costs to the justice system in England and Wales. The upcoming 10-year plan and next spring’s spending review are key opportunities for the Government to acknowledge what is needed to enact these reforms. The money for the NHS in the Budget was very welcome. I am a big fan of £22 billion for the NHS, but will the Minister give an assurance that further funding will be made available so that these reforms have the best chance of being effective?
The Government’s commitment to shift more care into the community is welcome because it supports better patient outcomes and is a more efficient use of funding. However, the NHS Confederation and I are among those who have pointed out that we need to make sure that the right provision is in place for that community care. Can the Minister provide assurance today that the Government acknowledge this, and can she set out the Government’s plans to ensure that we have this provision?
As the NHS Confederation pointed out recently, on behalf of our members, people with mental health needs and those with learning disabilities—
Lord Cryer (Lab)
Let me just point out that the limit of nine minutes is voluntary, but a lot of people want to speak.
Lord Adebowale (CB)
I know. I have two things to say and then I will finish, honestly. People with mental health needs, those with learning disabilities and autistic people are waiting too long for appropriate care and support. The mental health estate has also experienced years of underinvestment. Can the Minister give an assurance that alongside this Bill, the Government will use every opportunity they have with the 10-year plan and the upcoming spending review to ensure that we see further investment in care and support for those who need it and into the mental health estate?
Baroness Parminter (LD)
My Lords, it is a pleasure to follow the noble Lord, Lord Adebowale. I will not have quite as many questions for the Minister as he had, but I very much agree with what he says about community treatment orders, which I will return to at the end of my remarks. Like many other Peers, I welcome the Bill, which I hope will improve the treatment of people who are detained when they need to be, for their safety and other people’s, because they are in mental crisis. As others have said, it is a long time coming, and I very much congratulate the Government on bringing it forward so early in their term.
I am not an expert in the field, unlike just about everybody else in this debate, and nor do I have scars on my back from considerations of the legislation in the past. I come to it as someone with lived experience of the impacts of the deadliest of all the mental health conditions, eating disorders, and, in the context of the Bill, as the mother of a daughter who was sectioned aged 17. I know that sectioning is hard. It is hard for the individual: they are separated from their loved ones and the people who care, they cannot do what they want, and they are not where they want to be. It is hard for families and loved ones who are trying to navigate the system. But I know that sectioning works. It saves lives. It saved my daughter’s life when she was in the grips of an extremely vicious eating disorder. She was so malnourished that she could not even allow anyone to feed her by a nasogastric tube, and the state had to step in and save her life. She went to a hospital more than 100 miles away. She was initially restrained and then kept there for five months. We visited her and they kept her safe. At the end of those five months, we were able to bring her home. She was treated in the community by the NHS team, and we are grateful for that care.
I know that detention works, but as the noble Baroness, Lady Watkins, rightly said, we would need less of that detention if there were more provision of community services all around the country so that people could be treated quickly and appropriately. We know that will require more funding, and that was a point that the noble Lord, Lord Adebowale, raised very well. It will require a bigger workforce, and it will require those community services to support people when they need it.
It will also need more specialist beds, and these are particularly needed in the field of eating disorders. At the moment, there are only 251 NHS beds in our country and 198 in the independent sector of specialist adult eating disorder services. The Bill covers England and Wales, but there are no beds at all in Wales. Yet we know that they are absolutely needed. Beat, the leading charity for eating disorders, estimates that about 1.25 million people in this country have an eating disorder. Mental health eating disorder services are absolutely up to the gunnels and beyond, and since 2010 the number of hospital admissions for eating disorders has quadrupled from 7,000 to 28,000—so there is a real pressure point.
When my daughter Rose needed an eating disorder bed, one was not available. She was kept for a month on an adult general ward in the local hospital, where her condition deteriorated to the extent that she had to be sectioned. We need more of these beds. It is no good if we just spend all our time in this Chamber focusing on the particulars of this very small but important part of the Mental Health Bill, on detentions, if the Government do not also grasp the nettle about the need for more beds for people when they really need them.
The other worrying aspect about not having beds is that it stops the mental health law being applied in the first place. The 1983 Act insists that local areas make arrangements for beds in urgent circumstances. I was talking to Dr Ashish Kumar, the chair of the eating disorder faculty at the Royal College of Psychiatrists, who told me that
“even after two medical recommendations, clinicians are not allowed to apply the section because the tier 4 (inpatient unit) services do not offer them a bed. Hence this is a silent crisis—where these seriously unwell patients are not admitted to psychiatry wards or given the opportunity to have a legal provision of the MHAct applied … The whole legal provision is disregarded in a very high number of cases”.
Therefore, I ask the Minister to reassure us—in summing up today and, I am sure, in Committee—that the Government will put equal focus on ensuring that there is community provision for people with eating disorders to minimise the need for people to go into beds, and that there will always be sufficient beds for people with severe eating disorders who really need it.
I agree very much with the comments of the noble Lord, Lord Adebowale, about community treatment orders. It pains me to disagree with the noble Baroness, Lady Browning, for whom I have the highest regard, and with Mind. When we faced Rose being sectioned, the place we turned to for advice to understand the Mental Health Act, as parents literally pushed into it, was Mind and its fantastic website, and I pay tribute to it for that. But I believe that for eating disorders, community treatment orders can be very beneficial.
If you are sectioned for an eating disorder, it is because your condition is such that you are at risk. When you come to be released, you are at high risk, even if you have community support, of losing weight quickly and facing an urgent readmission. That is because the complexity and the tyranny of the eating disorder mean that the person cannot, of their own volition, maintain their weight. A community treatment order puts a boundary around the eating disorder in a way that a voluntary agreement could not, in that it makes it clear what will be the result and what will result in an in-patient setting.
Eating disorders are a really complex battle of control. The person with an eating disorder feels that they are completely out of control, but they are desperate for control. A community treatment order gives them control by not keeping them in a hospital, but it also gives them some sense of control through the terms of the order: they know what is going to happen. Let us not forget that it also gives some control to the community treatment team, who do not have to wait for a medical emergency in order to readmit if that is needed.
I contend that if it is done in the right way—in an open and consultative manner, with the intention of supporting that person to live in the community and access their community care—a community treatment order can be uniquely beneficial for people with eating disorders. It has the benefit of keeping that person out of hospital, and the restriction is on the eating disorder and not on the person. In Committee, I hope to carry on making the case for people with eating disorders and their carers, alongside the many other experts in this field, so that we can ensure that this welcome Bill is as good as it needs to be.
Lord Alderdice (LD)
My Lords, I am grateful for the opportunity to participate in this debate. I declare an interest as a retired psychiatrist and a fellow of the Royal College of Psychiatrists.
So much of what I will say comes from my experience of working as a consultant psychiatrist in Northern Ireland. This is particularly important because the legislation in Northern Ireland has always been different from the legislation on this side of the water. The 1950s’ legislation was referred to earlier. In Northern Ireland, the 1961 Act did not, for example, permit admission or detention on the basis of personality disorder. I will come to that in a minute because that foundational difference is of enormous importance.
I welcome this Bill, not because it is a perfect Bill and not even because the foundations of the Bill are particularly good, but because it is at least an improvement on the way things have been for some time. I welcome the four principles it identifies. There are choice and autonomy, a least restrictive approach, and therapeutic benefit—although, of course, this is a difficult one to assess in a short period, as the noble Lord, Lord Adebowale, has pointed out. It can be difficult to work out whether particular approaches to treatment are going to work in the short term. Often we need time. The fourth principle is treating the person as an individual, although again this is not as straightforward as it might appear.
As Dr Lade Smith, the president of the royal college, has pointed out, there are ways in which a piece of legislation such as this can be introduced. Although with plenty of resources there would be a good outcome, if there are inadequate resources the situation can be made much worse. It is not just that not enough resources do not make the situation sufficiently better; that can actually make it worse. For example, if a decision is made not to admit the most seriously ill patients to hospital, which is a very good principle, the consequence is that the people in the wards are even more disturbed and much more difficult to handle. Keeping the same level of staff makes it impossible to manage them because that number is not sufficient to deal with an increasingly toxic and non-therapeutic environment.
Changing from the most direct family member to a nominated person is very good. I entirely support it, but it is not without its consequences. If, before admission, the person is living with the family, but they decide to choose someone outside the family, the family may not be prepared to accept them back again. The nominated person may not be in a position to accept them either.
The truth is that none of us is simply an individual. We exist in the context of relationships. If we do not find ways of engaging with those relationships, simply operating on the basis of individual autonomy and human rights may actually create problems of its own. I absolutely agree that we should not admit disturbed people to police cells or to prisons, but if we do not provide sufficient alternative resources then either they are admitted to psychiatric units and other people who should be in those units are unable to be admitted because there is no room, or they are not admitted at all and things become worse.
This is a complex issue; it is not at all simple. There are unintended consequences. A whole list of colleagues have pointed this out: the noble Baronesses, Lady Murphy, Lady Hollins, Lady Buscombe and Lady May of Maidenhead, and the right reverend Prelate the Bishop of London. Almost anyone who has had direct engagement with the care of patients in these circumstances realises that there is a degree of complexity in dealing with them that a piece of legislation on its own will not resolve, especially if it is not legislation that requires the provision of resources—which, of course, this Bill does not. Doing something without resources can not only be unsuccessful; it can make the situation worse.
Are there better ways of dealing with this? Yes. The Northern Ireland legislation is much better. It is what was referred to earlier as fusion legislation. That is to say that it looks first at the question of whether a person has disturbance of mind and brain function and, secondly, at whether they understand the information relevant to decisions and appreciate the relevance of it. For example, a person who had delusional thinking would obviously not understand the relevance or appreciate it. It gets away from lots of the problems that this part of the country finds itself dealing with because of the separation of mental illness and mental capacity. Those two things were brought together in the Northern Ireland legislation. That was easier because, as I said earlier, personality disorder was never regarded as an appropriate basis for a formal admission in the first place.
As has been said by a number of colleagues, one of the difficulties that has to be dealt with when legislation is changed if that change is not fundamental—or, frankly, even if it is—is that the culture being operated in is one in which all the staff have been working for decades. Trying to change that is really difficult. One way of doing it is to take little steps. I regard separating out autism and learning disabilities as a positive step in the right direction. The noble Baroness, Lady Fox, is not in her place but I agree—perhaps unusually—with what she said about the overmedicalisation of problems of living. It is true in universities, where there are huge problems now in dealing with students. It is true in all sorts of areas. Every time someone has problems of living it is called mental illness: “I’ve got mental health, doctor”. We wish they did have mental health; that is what they do not have. That is why they have a problem.
All sorts of problems of living are now thought of as disturbance and disorder. That, in my view, is a serious mistake. I have to say that psychiatrists have made their own contribution to developing things in that way, but we have to pull back and look at it again. That is one of a number of very good reasons pointed out by noble Lords for why taking autism and learning disability out of that kind of package, and seeing them in a different way, is an important step in the right direction but—I come back to this again—as long as there is appropriate provision of resources. Without that, things will not go well and we will have unintended consequences.
Those who have produced this legislation and those who will scrutinise it have done and will do it with the best will in the world. They want to make things better and they are doing their best, but a funny thing happens in science: you produce a theory, do some work with it and then discover that it does not quite cover an issue, so you put in a little caveat. Then it does not cover that issue, so you put in another little caveat, and more and more. The whole thing becomes more complex until suddenly, one day, somebody says, “Do you know what? This is not the right theory”, and then there is a shift in understanding to a whole new way of thinking about it.
That is where we are with problems of this kind. We really need to make a paradigm shift. Your Lordships would expect me to say it but, on this issue, the approach that was taken where I was working in Northern Ireland is useful to explore, just as bringing together health and social care was useful. There are other useful things, such as advance choice, but there are so many that we could not possibly deal with them all in one debate. That is why we will be discussing them for quite some time.
Baroness Keeley (Lab)
My Lords, I am glad to take part in this debate in your Lordships’ House, after four years as a shadow Minister for Mental Health and six years on the Health Select Committee in the Commons.
In welcoming this Second Reading, I will speak about dealing with the inappropriate detention of autistic people and people with learning disabilities in mental health hospitals. Noble Lords, including those who served on the Joint Committee on the draft Mental Health Bill, understand that too many autistic people and people with learning disabilities have been detained in inappropriate facilities and for far too long. But we, as politicians and legislators, have not made the changes needed to stop this.
The Winterbourne View scandal and a series of other scandals since 2010 have shown abusive treatment meted out to autistic people and people with learning disabilities detained in inappropriate units. In 2011, following the shocking revelations made by journalists of the abuse to residents detained in Winterbourne View, which was rightly described as “torture”, the then Prime Minister pledged to close all inappropriate in-patient units by 2014. That did not happen. Since then, successive Governments have also committed to targets to reduce the number of autistic people and people with learning disabilities in in-patient settings and to prioritise housing and support in the community for those individuals. These targets have all been missed.
In 2021, the Commons Health and Social Care Select Committee, of which I was a member, completed an inquiry into this treatment. Commenting on the missed and delayed policy targets, the inquiry report suggested that “a more radical approach” was needed to unlock community provision for this group of people. Now there is a chance for reform but there are widespread concerns to raise with my noble friend the Minister that the measures in the Mental Health Bill will not be enough in themselves. While it is welcome that the Bill makes it harder to detain a person under the Mental Health Act on the grounds of autism or learning disability, there are widespread concerns, as we heard in this debate, that this could lead to people being held under alternative routes, including the Mental Capacity Act 2005 deprivation of liberty safeguards. We must guard against that happening.
In many cases, autistic people and people with learning disabilities are not being detained just because of the legal framework they are under. They get stuck for years in mental health hospitals because of the lack of support for them in the community. In too many cases, discharge planning is repeatedly delayed because those responsible see the needs involved as too complex or feel that there are no suitable care providers. I will mention two cases to illustrate this: a young autistic woman called Bethany, and Tony Hickmott.
When I first raised Bethany’s case in the Commons, she was a 17 year-old autistic woman with extreme anxiety, kept in seclusion in St Andrew’s hospital, Northamptonshire. In a cell-like room, she was fed through a hatch in a metal door. When her father Jeremy visited, he had to kneel at the hatch in the door to speak to her. Bethany was detained and held in seclusion despite an assessment that the hospital setting that she was in could not meet her needs and a recommendation that she should be moved to a community residential setting with high support.
The lack of funding for support in the community was clearly a factor. The Walsall Council officer responsible for her placement told Bethany’s father that her care had already cost the council £1.2 million. “To be frank,” the officer said to him, “Walsall could do with a breather”. Moving Bethany to a community setting would involve her local council paying £100,000 to £200,000 a year from the adult social care budget, instead of leaving the NHS to pay the much higher bill, which was £676,000 a year. It seems that Bethany was being held in isolation so that the local council responsible did not have to pay her costs, but the very high costs of her detention were then borne by NHS England.
I raised Bethany’s case numerous times in the Commons and she was at last discharged to live in the community. Fast forward seven years and her father talks about what a happy life his daughter now has, in her own property, with good support from a wonderful care team.
The outcome has not been as positive for Tony Hickmott, an autistic man with learning disabilities. In 2022, Tony had spent 21 years in a secure assessment and treatment unit and it looked as if he could finally move back to his hometown of Brighton, close to his parents Pam and Roy.
Tony had stopped meeting the criteria for being detained in a psychiatric hospital in 2013, but it was ruled that he could not be discharged from there because a suitable community placement could not be found for him. His parents applied to the Court of Protection in 2019 and, after a number of hearings, the judge ruled that Tony should be discharged from hospital to live in a specially renovated house with care from a brought-in provider.
This should have been a happy ending too, but it was not. Reports describe that Tony is now effectively barricaded into the bedroom, with the care staff in his home operating the house like a seclusion room. Tony’s parents, now in their 80s, are prohibited from taking him out into the community. He is held under the deprivation of liberty safeguards. I hope that Tony Hickmott’s care provision can be improved.
Much could have been done by Governments over the last 12 years to tackle this issue of inappropriate detention. The new Government now have the chance to change this. First, we must act to prevent new inappropriate admissions of autistic people and people with learning disabilities. Secondly, we must act to enable the discharge of the 2,000 autistic people and people with learning disabilities detained inappropriately in mental health units.
As we have heard in this debate, the average length of detention for this group is 5.4 years, with 355 people detained for more than 10 years. Mencap has estimated the cost of this care in inappropriate units for this group as £534 million a year. Detentions are often, as we have heard, far away from family and friends, with alarming reports of people from this group being overmedicalised, subject to physical restraint and shut away in isolation. All this is as traumatic for those detained as it is devastating for their families. As Mencap has said, its findings on the staggering cost of institutional care show that this is
“an appalling waste of public money on the wrong type of care”.
I hope that there is now a will to change this.
As I mentioned, there is first the issue of ensuring no new placements of autistic people and people with learning disabilities in those inappropriate mental health units. The Commons Select Committee inquiry report made recommendations on how this could be achieved.
Secondly, the issue of who is paying for care and community support must be tackled. I support the plea made by the noble Baroness, Lady Hollins, for an action plan to succeed the Building the Right Support Action Plan. The Commons Select Committee inquiry recommended that the Department of Health and Social Care should
“redesign the financial incentives … so that local authorities”
and local NHS bodies
“do not seek to ‘offload’”
the care of
“autistic people and people with learning disabilities onto the NHS or place these individuals in inpatient facilities”.
Tackling these issues of funding flows now needs strong cross-governmental action.
There are some further actions that could be taken to improve the mechanisms around this area of work. I thank the human rights lawyer Dr Oliver Lewis for his input. Currently, mental health tribunals are not considered useful in dealing with people stuck in hospital in-patient units. Tribunals dealing with cases for this group should be required to have a medical member with expertise in autism and learning disabilities. Working through the practical issues of achieving a discharge destination for people currently detained could be improved if mental health tribunals are given the power to compel a local authority or NHS body to find a discharge destination in the community or if the Court of Protection was used more to rule on discharge arrangements.
The Bill presents an opportunity to correct an oversight under Section 73 of the Care Act 2014 affecting human rights, which the noble Baroness, Lady Barker, raised earlier. I too thank Dr Lucy Series and Professor Luke Clements for information about the issues raised in the Sammut judgment. As we have heard, that is a ruling that means the Human Rights Act does not apply where mental health patients get Section 117 aftercare in private settings. There is a real concern about the broader implications of this for patients receiving continuing healthcare through private services, children in private social care, and even patients detained in private hospitals under the deprivation of liberty safeguards. This latter group could expand to include the numbers of learning disabled and autistic people who are detained in hospital under the deprivation of liberty safeguards because they are no longer eligible for detention under Section 3 of the Mental Health Act. I am sure it was Parliament’s intention to protect the human rights of vulnerable adults and children for whom the state arranges health and care services. I hope that my noble friend the Minister will agree to the suggested meeting with Lucy Series and Luke Clements to discuss that.
I hope that we can bring forward amendments as necessary to correct this oversight as well as to address the other issues I have raised.
Lord Crisp (CB)
My Lords, I too welcome the Bill. It is overdue and times have changed. People’s views and sentiments, and our knowledge, have changed over those years. I welcome the principles that seek to rebalance the way we handle these issues.
All this is in the context of a Bill that is about the safety of service users as well as public safety. I want to come back to the former but, very briefly, on public safety, I note that the bar for detention will be higher—there must be evidence that
“serious harm may be caused to the health or safety of the patient or of another person”.
The question is: what counts as evidence? Where is the place for the judgment of experienced clinicians? Is that evidence? Is the testimony of relatives? What is the definition of “serious harm?” I understand the need for transparency, but this is a very difficult area that will obviously need much more discussion at later stages of the Bill.
I also welcome the separation out of the care for people with learning disabilities and autistic people, the attention to the needs of people in the criminal justice system and, of course, the importance of tackling racial disparities.
We have had a lot of impressive briefings for this Bill. I will quote one of them, from Blooming Change. That was the one about children who had experience of the system. There were lots of issues about patient safety and quality of care. They talked about being injured during restraint, just being drugged and restrained and being scared all the time. There is a dreadful sentence there, which I will read out:
“Hospital makes you worse … going into hospital with one problem and then leaving with trauma, new behaviours, new diagnoses, assaults, PTSD – it’s awful”.
I noted the earlier comments by the noble Earl, Lord Howe, about the very large number—I think it was 52,000—of uses of restrictive interventions in the last year, and the comments of the noble Baroness, Lady Watkins, about this, and about the importance of children not being in adult wards. It seems to me that this is a great example of what we just heard from the noble Lord, Lord Alderdice, about admission making the situation worse. The idea was to put people into a ward, but, actually, it led to a deterioration of their condition.
If I think about the Mental Health Act, I understand why the review that a lot of this was based on was focused, but actually we cannot think about the Mental Health Act in a vacuum. Let me pick up two or three examples of that. The first one is that the very same Sir Simon Wessely asked me 10 years ago to look at the capacity of acute adult wards across England. I did so, and with a group we were in contact with every service in England and with consultants who were leading the admission and discharge of patients. One of the interesting findings of that was that something over 20% on average of discharges were delayed because of housing. Indeed, of all those units in England, only two had any links with the housing authorities. This seems to me to be a very fundamental point: if you are stuck in hospital, you may well lose your accommodation, which will lead to other problems. That is just one example of many wider social issues that need to be taken into account, even though we are focusing on something as narrow as the terms of the Mental Health Act.
There is also the impact on A&E, which the noble Baroness, Lady Barker, and the noble Earl, Lord Howe, referred to very early on about just shifting the problem if we are not careful: shifting it from one place to actually landing up in A&E, where there may not be liaison, psychiatry or anything else that will help with the problem.
A number of noble Lords deplored the lack of a wider Bill in which this would nest, but it is very clear that this needs to be implemented in the context alongside other changes that are already under way. There are some profound questions here about care and treatment. We have been very privileged to have heard from a lot of people who know a great deal about this, including a number of very distinguished senior commissioners who could give us insight, as well as parents who can give us remarkable insight and profound comments.
If you look at some of the statistics, healthy life expectancy for all of us has improved massively over the last 40 years, but the gap between life expectancy for those with severe mental illnesses and life expectancy for the rest of us has doubled since the 1980s and is now 20 years behind. If we also look at some other evidence, the NHS independent Mental Health Taskforce argues that outcomes from severe mental health problems have worsened in recent years, and others have argued that they flatlined for about 40 years and, in some cases, have deteriorated.
Various noble Lords have talked about the importance of the change in the model that we are talking about here, with much more focus on the community, much more focus on prevention and much more focus on thinking of this end to end, rather than just as isolated incidents involving isolated patients who do not have relationships with the rest of the world in that sort of model. It really seems to be fundamental that we get hold of those issues; even if they are not in this Bill, they need to be linked to an understanding that those changes may well come with the forthcoming 10-year plan and the implementation of this.
I want to touch on a wider point about the overmedicalisation of common problems. Here is another statistic: in the year to April, 8.7 million people received antidepression tablets—and that is just England, without counting anywhere else. The major problem in that area, apart from the overprescribing itself, is helping people to get off those drugs in due course, which is another example of where some of our current practices have been doing harm. We need a new emphasis on some of the social interventions that many noble Lords have mentioned and a new emphasis on patient safety.
Lastly, this is only legislation. It needs to be accompanied by a real implementation plan for the management of change because it cannot be treated in isolation. These other moves and other leaders are making change happen elsewhere. I very much welcome the Bill and look forward to the discussions about some of these important issues in Committee and beyond.
Baroness Berridge (Con)
My Lords, it was a privilege to sit on the Joint Committee to scrutinise the Bill, but it was disturbing to see for how long the legislation has been failing patients, their families and clinicians. I thank my noble friend Lady May, who is not in her place, for instituting the process and for placing a clear focus on the disproportionality faced by racialised communities. There is much to commend the Bill, such as the change in detention criteria, and statutory care and treatment plans, but it could still be improved.
The introduction of community treatment orders made a bad disproportionality situation even worse. The mental health factsheet accompanying the Bill says that black communities are seven times more likely to have a CTO than their white counterparts, although that is an improvement on the evidence to the committee, where we were told that it was up to 11 times, while Parliamentary Office of Science and Technology research states that it is up to 10 times. Whatever it is, it is too high. If CTOs are to remain, I hope the Minister will outline that proper research will be undertaken to understand what is causing that disproportionality.
While I welcome the changes to CTOs, I stand by the Joint Committee recommendation that they should be abolished for Part II patients; I stand with Mind on that. There are differing opinions on this issue now, and it would be useful to return to it in Committee. Because of disproportionality, the CTO issue is of particular importance to certain communities. However, I agree with the noble Lord, Lord Adebowale; we also heard about the informed research showing that advance choice documents are known to reduce detentions and reduce medicalisation when someone is detained. So, while I am pleased to see the advance choice document in the Bill, I ask His Majesty’s Government to consider that there should be a right to request that.
As the Bill goes through Parliament, I hope that the hard work of a smaller, often less-resourced group of activists for these communities will be appreciated. The work of the NAS and Mencap is exemplary, but sometimes those who are not able to shout the loudest are in the greatest need of our support. I am sad to notice that two of the provisions that are particularly important to racialised communities are being diluted.
One of the most important changes is that the outdated use of nearest relatives is being replaced by nominated persons who represent the patient and exercise relevant statutory functions. It is important to note the power that the nominated person has. It includes the power to order the discharge of the patient, unless of course a barring order is made. Ideally, the nominated person is chosen by the patient, but if they do not have capacity, that function is done by the approved mental health practitioner—AMHP. Those are welcome changes for most adults—I note the comments from the noble Lord, Lord Alderdice—but the Joint Committee’s report highlights that all is not clear with regard to the nominated person and children and young people.
The decision not to have a new piece of legislation is a particular problem. When the Mental Health Act 1983 was passed, it was envisaged that it would really apply only to children in the criminal justice system. To complicate matters, the Children Act 1989 was passed, with further amendments later on giving 16 and 17 year-olds the right to consent to medical treatment if they have capacity. Then came the Mental Capacity Act, which does not apply to under-16s but does if you are 17. Then Gillick competence was added to the mix. Yes, it is all rather fudgy, even before you add on the nominated person under the Act.
I will give a couple of examples. For the under-16s, under new Schedule A1, the nominated person must be the person with parental responsibility, but what of the situation of a special guardianship arrangement where the parents keep some residuary parental responsibility? Does the AMHP have to appoint the parents and the special guardian? That would set up quite a difficult arrangement for clinicians. Also, why does this schedule refer to a local authority being “willing” to act as the nominated person? Under the Children Act when there is a care order, local authorities have a duty to act when they have parental responsibility.
I turn to the 16 or 17 year-old who lacks capacity to appoint a nominated person. There is no mention at all of parents’ responsibility in paragraph 10 of that schedule, yet the young person might be living with them. So if the nominated person uses the powers of discharge, a process takes place for them to be discharged. You are relying on the mental health institution to remember that parental responsibility lasts until someone is 18 and to tell the parents that the patient is on their way home. That might not sound like a problem, but if you have got other, younger children in the household, it might be a risk to them to have that person back in the household. Also, a 16 or 17 year-old may be under a care order. Is the local authority going to be informed because it is going to be providing the accommodation? The schedule is silent on that. A common statutory mechanism is to mandate for particular circumstances like those of the under-16s but to have a presumption for other situations. So why not have some kind of presumption that a 17 year-old person with parental responsibility should be the nominated person if they are residing with them?
The previous Government accepted that after the independent review on children and young people more thought needed to be given. So will the Minister agree to have a meeting about children and young people with officials, interested Peers, and the experts in this field who are practising in this niche area of the Mental Health Act and the Children Act?
Children and young people are also in a vulnerable position if they have learning disabilities and autism and no co-occurring mental health illness. If they are in crisis and the parents need help, if there is no Mental Health Act provision, then what happens? We have heard about the use of DoLS under the Mental Capacity Act, but if you are 17 or 18 and lack capacity and are held under that, there is no Section 117 aftercare. However, if you are under 16, or 17 with capacity, you are not under the Act at all. Where does that leave you? That probably leaves you under the inherent jurisdiction of the High Court or, rarely, a care order. Only last week the Children’s Commissioner reported on around 1,000 children a year who are now under the jurisdiction of what is called a High Court DoLS order. Let us just say her report is not good news about that third provision to restrict a person’s liberty.
While the situation for those with learning disabilities and autism is currently shocking—and I marvel at the work of the noble Baroness, Lady Hollins—the Act could make a bad situation worse. This is also important to cover at the meeting that I have suggested and as High Court DoLS are a relatively new creation, it would be good to have there former members of the judiciary who have had experience of imposing those orders on children and young people.
I am disappointed not to see the recommendation from the Joint Committee of a mental health commissioner as part of the Bill. Since the Joint Committee reported, rare events have shown the danger to the public if mental health services fail. Often it is those who not medically trained but are friends and family who can see that someone is getting really unwell and needs help. Is it obvious to know where to go if you have tried the previous hospital and you have tried to use PALS? Do friends and relatives know that it is the CQC that they need to go to? The police have rightly stepped back in some respects in these situations. Not appointing a mental health commissioner is a missed opportunity as it is imperative that those people know somewhere to go to. While the Joint Committee’s report was not overt about this being a function of the mental health commissioner because it was before the events I have outlined, an emergency process such as this could well fit within their remit. It would be a one-stop shop. While there is a mental health homicide review under way, if there is the need to legislate, we could now be missing it. However, if His Majesty’s Government established a mental health commissioner whose functions could be by way of secondary legislation, the door to legislation remains open if that review suggests such measures.
Finally, I hope the Minister will inform your Lordships’ House that the Law Commission is being requested to look at whether, in England and Wales, we should be doing what the noble Lord, Lord Alderdice, recommended, and which is happening in Northern Ireland: the fusing of our mental capacity and mental health laws. This is a sticking plaster only on an area of law that badly needs a restart.
Baroness Neuberger (CB)
My Lords, I declare interests as chair of University College London Hospitals NHS Foundation Trust and Whittington Health NHS Trust, and as a member of the North Central London Integrated Care Board. I am delighted to be able to speak in support of the Bill today, which has been a long time coming. As noble Lords know, I was one of the three vice-chairs of Simon Wessely’s review. It seems a long time from when we published that in 2018.
I pay particular tribute to the noble Baroness, Lady Buscombe, and her team for their pre-legislative scrutiny, which did so much to clarify and to push the draft legislation nearer to what our original review had said, but your Lordships will not be surprised to hear that there are still some areas of concern. I say that as I pay tribute to the Minister for all her engagement, both formal and informal, with members of the review team.
The Government have published the impact assessment for the Bill, showing what they believe will be the costs of the improvements that we all wish to see happen, but have said absolutely nothing about how they will pay for all of this. If we are going to make these reforms work, we are going to need money in the system. Other noble Lords have said precisely that, notably the noble Lord, Lord Alderdice, and the noble Baroness, Lady Watkins, on the subject of staff. You have only to speak to people working in this field to realise that they are desperate for resources, beds and staff—particularly nurses—alongside alternatives to detention that provide real care and do not leave people on the streets. That goes back to the issue of community treatment orders, which we will no doubt come back to in Committee, because this is a really serious concern.
We all know that public finances are under huge pressure but I urge noble Lords, and particularly the Minister, to push as hard as possible for funding for these reforms and the mental health system as a whole. It really is needed and if we do not do that, whatever we legislate will make precious little difference to what happens. That is what we ought to worry about. It is also vital that this House notes the commentary from the Royal College of Psychiatrists whose president, Dr Lade Smith, warns us that these reforms must not make worse the racial disparities already associated with the use of the Act. We need to take heed of that, as many other noble Lords have said.
I want to thank some people in particular, notably Sir Simon Wessely, the chair of the review and, one might argue, the architect of these reforms, and my co vice-chairs Mark Hedley and Steven Gilbert, for their essential contributions. I want also to pay tribute to the Civil Service teams in the Department of Health and Social Care and the Ministry of Justice, particularly Matthew Lees, who put in huge amounts of hard work and showed astonishing devotion to the cause. Some of them have seen it all the way through.
We are delighted that the Bill includes the new guiding principles that we devised and recommended, as well as provisions to promote the use of advance choice documents; but as the noble Earl, Lord Howe, and the noble Baroness, Lady Berridge, have said, there is something very peculiar about the way this is framed. Advance choice is not given as a right to patients; it is a duty upon the ICBs. When we get to Committee, we need to push that one quite hard.
We also remain disappointed that the Government have not been able to include measures relating to our recommendation that the tribunal consider appeals from patients whose expressed preference for a particular kind of treatment has been overturned by doctors. We believe that that would be an uncommon occurrence; nevertheless, it is an important safeguard for patients’ rights—a right to be involved in decisions to do with your own care. I really hope that the Government will reconsider this proposal, ideally before we end consideration of the Bill.
We are living in a time of increasing tolerance and understanding of mental ill health and decreasing stigma surrounding it, but that is not what many people in the system experience. Many people are most distressed not by the detention itself but the way in which they are treated and made to feel helpless, ignored and stripped of their dignity and self-worth. That is why the review identified—and this is key—a clear gap when it comes to supporting and valuing patient autonomy. It is why we argued that we must move away from what we heard all too often: the default position of clinical staff rejecting what the patient wants. Many of the independent review’s recommendations therefore aim to shift the dial in favour of greater respect for the wishes, choices and preferences of patients. It was also clear that when people were—rightly, in their own view—being deprived of their liberty, they were also all too often being deprived of any say in how they should be treated. As one service user who was part of our core team told us when we started on this process:
“I am sure being detained saved my life, but did it have to be such a terrible experience?”
In one significant respect, the Bill goes beyond any recommendations that we made, proposing, in effect, to exclude learning disability and autism from the scope of the Act, except for short-term admission. Other noble Lords around the House have spoken on that; however, we were and remain concerned that exclusion from the scope of the Act might not solve the problem—although it should—but instead simply shift it elsewhere. The noble Lord, Lord Alderdice, I believe, was hinting at that too.
This Bill, unlike its predecessors—I am a veteran of 2008 as well—enters Parliament with a considerable level of agreement from all the political parties, professionals, media, the charitable sector, service user groups, and in particular stakeholders representing ethnic minority communities, although there are considerable worries.
So there are some concerns, and we know about that. I very much hope that the Minister will be able to meet once again with the team from the Royal College of Psychiatrists and with some user groups, particularly people with autism and other disorders who are expressing major concerns—all of us will have had some of those emails. I hope that that can happen as the legislation goes through, so that we can see if any further fine tuning can be done. But this is without doubt the right time—one might even say it is overdue—to modernise the Act, and I very much hope that the House will support it.
Baroness Ramsey of Wall Heath (Lab)
My Lords, today I will focus on those aspects of the Bill that concern children and young people with learning disabilities, autism or both. I also want to note that I found listening to the lived experience of the noble Baroness, Lady Parminter, very moving indeed.
My formal interest in this issue dates from my being the independent chair of NHS England’s children and young people transforming care steering group—for children and young people with autism and learning disabilities—from 2017-20, and before that as chair and non-executive board member of various NHS organisations. My close personal interest, however, is lifelong, as the younger sister of Patricia, who I mentioned in my maiden speech.
Patricia was born in a much less enlightened time than we enjoy now, with a learning disability that denied her expressive language and deemed her at the time of her early childhood in the 1950s as a mental defective under the then mental deficiency legislation. My brother Jim followed soon after. My younger sister and I came some years later, to our loving parents’ great joy, but neither she nor I ever lived with my sister Patricia, as she was taken away from our parents when she was seven—before we were born—to a huge and forbidding mental hospital near Birmingham, three long bus rides away from where our parents lived. They had to write each month to the hospital authorities for permission to visit, a maximum of once a month.
When our father died in 1990, my mother asked me to become Patricia’s co-guardian with her and gave me a box that he had kept containing all the paperwork concerning Patricia. The letters from my father asking for permission for Jim, my brother, to visit his sister once she was removed from the family home are heartbreaking to read, as he was always refused, even at Christmas time, because Jim was under 12. So Jim did not see his sister for years.
By the 1960s, these rules had relaxed, and my other sister and I were taken to visit one Sunday a month. I am ashamed to say that I dreaded those visits as a little girl—not because of Patricia, who I liked to see and spend time with, but because the heart of the hospital was a forbidding Victorian building where patients with mental health issues were kept. Sometimes I would hear screams and see figures trying to put their arms out of the tops of windows. At the side of the hospital for the learning disabled—by then called mentally handicapped—which was physically a much pleasanter part of the site, we would sit and eat with and cuddle our sister, who was always delighted to see us, especially our mother.
In time, my parents got a car, and my father would drive us to a café with Patricia. Sometimes we were made welcome, and sometimes not so much. My sister never went to school as she was 18 by the time the duty to educate children with learning disabilities came in following the 1970 Act. My mother found that heartbreaking.
As a child, I did not know that my parents were campaigning to get Patricia moved nearer home, hoping to take advantage of a more benign regime that was developing in the 1970s of long-stay campus-style hospitals where young adults with learning difficulties could live, still under NHS care but with fewer restrictions on the number of visits and more activities for patients—later residents. Eventually, my parents were successful, and those were happier years, with much more contact and my sister being able to visit the home that she had not grown up in.
After my father’s death I took up the campaigning mantle from him to make sure that Patricia genuinely benefited from the latest initiative: care in the community. My sister lived her last years, until she died in 2018, in a real house near our family home with three ladies she had been with previously, and we could visit whenever we wanted. My brother died 30 years ago, so he did not live to see this. My other sister and I had moved to London, but my mother was delighted, as were we, that Patricia lived in a proper house with its own kitchen with home-cooked meals and we could visit whenever we liked.
When the noble Lord, Lord Stevens of Birmingham, in his previous role as chief executive of NHS England, asked me to establish and chair the steering group in support of transforming the care of children and young people with autism and learning disabilities, your Lordships can see why I jumped at the opportunity. As the chair of the steering group, my task was to help bring together all those organisations which had important roles in reducing the number of children and young people with autism, learning disabilities, mental health conditions and behaviours that challenged, but with no criminal backgrounds, being detained.
The steering group included representatives from the Department of Health and Social Care, the Department for Education and local government, as well as charities advocating for these children and young people. What became crystal clear was that detention happens when local education, health and children’s social care services either do not or cannot meet their complex needs appropriately. Although the world has clearly moved on a long way from the days of my sister’s incarceration, I am afraid that I heard some very distressing accounts from families and hospital staff about the reality of detention, as eloquently described by my noble friend Lady Keeley, and not so short of enforced solitary confinement, as described so eloquently in the important work of the noble Baroness, Lady Hollins.
At the same time, I saw inspiring examples of what is possible when local community services come together around the needs of children and young people, including on a visit to a special school in north London where I saw pupils who in other circumstances would have been locked away in secure hospitals. The head teacher worked with a multidisciplinary team, including social workers, speech and language therapists, psychologists and others, who liaised closely with the pupils’ families.
One key issue was raised repeatedly by families and those youngsters who could speak for themselves in the stakeholder engagement meetings we held. Although NHS guidance states that each child or young person in such a situation should receive a care (education) and treatment review—CETR—and DfE guidance requires that they should also receive an education, health and care plan, or EHCP, this was all too often either not happening in a timely manner, or it was happening but not being acted upon. This was partly a matter of resources, partly a matter of priorities, and partly a lack of joined-up work between health, education and local government.
This important Bill includes proposals to strengthen current arrangements, and this is to be greatly welcomed. In particular, the assumption that children and young people with autism and learning disabilities should not be detained if at all possible—and, if this is not possible, for only the minimum of time and with a proper review and plan for treatment in place—is a huge step forward. I am delighted that it has received wide support across the political parties, beginning with the noble Baroness, Lady May, when she was Prime Minister and subsequently under more recent Governments. It shows families such as mine that society is beginning to make real progress towards greater understanding and humanity in its attitude towards people with learning disabilities and autism—albeit sometimes more slowly than we would wish for.
However, legislation on its own can take us only so far. Genuinely sustained improvement will require multiagency work—including at government level, as my noble friend Lady Keeley said—with high levels of co-operation in the community to provide effective support for children and young people at risk of being detained. Stronger multiagency community services, combined with the Bill’s provisions, would ensure a very different life for those children and young people and their families from the one my sister had.
Lord Stevens of Birmingham (CB)
I am very pleased to follow that very powerful speech from the noble Baroness, Lady Ramsey, which reminded us all of the personal stakes that we are debating, as did many other such speeches today. I started my NHS career 30-odd years ago running a large psychiatric hospital outside Newcastle, where in some respects the quality of care was high but in others, frankly, far too many people with long-term mental health problems had been warehoused, in effect, for decades. That was a point in time when there was a big shift to re-provide services in less restrictive community settings.
I mention that simply to remind us that it was not the Mental Health Act 1983 per se that triggered all that; it was a combination of better therapies, alternative services and, frankly, greater power and influence for the voice of users of mental health services that together constituted that initial shift in services. So, as we think about the Bill before us, of course we must attend principally to the content of the legislation but we must also think about how quickly it will be implemented and the context in which it will land.
As we have heard, this is a very well-vetted piece of legislation. We will want to pay attention to the unintended consequences that various noble Lords have raised and I agree with others that some components are seriously underpowered. The advance choice documents provision, I am afraid, will not cut it as currently described. We heard that from the noble Baronesses, Lady Buscombe and Lady Barker, the noble Earl, Lord Howe, and many others. Unlike the clinician checklists set out as a requirement in Clause 11, the care and treatment plans that are a statutory requirement in Clause 20, or the new rights for voluntary in-patients to access independent advocacy set out in Clause 38, when it comes to the advance choice documents all we have is a fairly vague, subjective responsibility on the NHS and integrated care boards to give it their best shot. I am paraphrasing, but only slightly. In effect, they are asked to provide information and help to the extent that they consider appropriate. Frankly, a notice on a noticeboard with a phone number to call would constitute progress as far as the Bill is concerned. We need to address this fundamentally. Based on the comments this evening, it sounds as if there may be a latent majority for an amendment when we get to Report, depending on how our debate in Committee has gone.
That is just one example of the Bill’s content. The related question is the one the noble Lord, Lord Scriven, very powerfully raised: however good this is, when will it actually see the light of day? When will it be implemented? Actually, the most salient piece of this legislation is lurking right at the end, at Clause 53(3), which says that most of this stuff will spring into life only through the fiat of the Secretary of State at a date yet TBD. As the impact assessment—which, again, as the noble Lord said, is a very important and revealing document—says, a lot of these measures are seriously back-loaded. Even the ones that are supposedly front-loaded are highly dependent on a set of resourcing which may or may not occur.
For example, the new detention criteria for people with learning disabilities and autistic people may start in 2026-27, but next to a little asterisk is written:
“This timeline is highly indicative as an illustration for modelling purposes. This reform will commence once systems are able to demonstrate sufficient levels of community support for people with a learning disability and autistic people as an alternative to hospital-based care”.
As we have heard from the noble Baroness, Lady Keeley, and others, we have been waiting for that for some long years. My concern is that we run the same risk here as we saw with, say, the implementation of the Dilnot reforms: something sits on the statute book but never actually comes to life because it is always, “Mañana, mañana”, given the chicken and egg problem of resourcing and alternative services to allow the thing to come about. There is an implementation timescale question that I am sure we will want to pay attention to.
Related to that is the extent to which the Bill interacts with the real-world state of mental health services, social care, housing, the criminal justice system and so forth. Two of the four principles in Clause 1—“Choice and autonomy” and “Least restriction” of care—are intrinsically tied to the availability of alternative services. Therefore, you cannot divorce the Bill from decisions that this Government and future Governments will make on its resourcing.
If we want a moment of legislative humility, let us cast our minds back to the Health and Social Care Act 2012, where parity of esteem was legislated from the rooftops. Frankly, we did not see parity of esteem begin to kick in on the back of that declaration. In fact, between 2010 and 2016—a time of rising mental health need—the mental health workforce was cut by 9.4%. I took the decision—with the support of the now noble Baroness, Lady May, as Prime Minister—that, from 2016 onwards, we would introduce the mental health investment standard. This required that, each year, the share of NHS funding going on mental health could not fall—it had to be at least constant and should be rising—to stop the squeeze that was otherwise taking place. As a result, in contrast to that 9.4% reduction, we have seen a 26.5% increase since then. In his review for the new Government, the noble Lord, Lord Darzi, said:
“This important intervention has … enabled much of the mental health capacity that was cut in the first part of the 2010s to be rebuilt”.
That is why this House was good enough to support my amendment to the 2022 health Act, which was then adopted by the Government. This ensured that, prospectively, before the start of each financial year, the Government of the day have to set out their stall and declare whether they intend that mental health spending will grow as a share of the overall pie in the year ahead. The reason that is so important is not just history: at a time when, understandably, there will be great political focus on waiting times for physical health and routine operations, the most likely outcome, absent that mental health investment standard, would be that mental health services would get screwed at a time when other things are prioritised.
We will want a renewed commitment by the new Government to that mental health investment standard, perhaps as early as the planning guidance for the coming year, 2025-26. We will be able to take stock of that before Committee to make a judgment about whether we should recommend a strengthening of that mental health investment standard in the statute, because it is inconceivable that the good measures laid out in the Bill can actually be implemented while mental health services are squeezed as a share of the growing NHS budget.
In the western movie “The Magnificent Seven”, Steve McQueen said that, as gunslingers, “We deal in lead”. Clearly, here in Parliament, we deal in law, but my underlying point is that law gets you only so far. The question is not just the content of the law but how it is implemented, how fast and in what context. We need to keep our eyes on all those as the Bill proceeds.
Baroness Bennett of Manor Castle (GP)
My Lords, as the last Back-Bench speaker in this rich and informed debate, I note that we in the Green group start our meeting each week by asking ourselves what original things we have to say, specifically as Greens, about a Bill or a debate—so it is useful to come at this particular point in the circle. As Greens, we very much agree with the need for the Bill, which virtually every noble Lord noted. We also very much agree with the need to strengthen it.
I respectfully disagree, however, with a number of noble Lords who have suggested that we are seeing an overmedicalisation of life events. Perhaps this is not quite what they meant to suggest, but it sounded like they were saying that we do not have a mental health crisis in our society. I would very much say that we do. I agree with the noble Lord, Lord Crisp, that there is a great need for more talking therapies and that, for want of those, medical professionals are very often forced to resort to pharma solutions.
We need the talking therapies, but we also need treatments because we have a mental health crisis. Behind that is not any characteristic of individuals but a deeply unhealthy society and, when we are thinking about this Bill, we have to think about it in that context. We have to think that when we compare ourselves to the societies we generally consider comparable, we have much greater health problems than them. We must ask ourselves why. This is true of mental and physical health, in so far as it makes any sense to make a division between those two. I do not think anyone this evening has yet used the phrase “the gut-brain axis”, but in the last decade there has been an explosion of understanding of the link between the microbiome and mental health. We have, particularly in the UK, a broken food system. This is of course a long way from legislation but, if we are to think systemically, it is the context in which we have to think about the Bill.
As some noble Lords have made reference to, there are also the social issues to consider, whether the levels of poverty, the insecurity of income and housing, or the pressurised jobs that treat workers like robots and make them ill. We have a loneliness epidemic, which I do not think anyone has mentioned yet, but that is very much related to our mental health epidemic. We have a huge problem with domestic violence, which is also related to mental ill-health, particularly among the victims. We need to take a public health approach to mental health. While that is not directly part of the Bill, we cannot talk about mental health without talking about all those issues.
On other areas on the Greens’ unique approach to mental health issues, we do not believe that the coercive power of the state—which is what the Bill is talking about—should ever be put into private hands; nor do we believe that healthcare should ever be run on a for-profit basis. Here, I remind us of the points made by the noble Baroness, Lady Keeley, about when the private provision of mental health care has gone horribly wrong.
A number of noble Lords have focused on the problem of stigma; perhaps we have made progress over recent decades, but we still have a long way to go. We have to think very carefully about using the rhetoric of “strivers versus skivers”, and the suggestion that all we have to do is get these people into a job and then they will be fine, because that is the underlying message we are hearing from certain very senior quarters in our society. I must mention that there has been talk of combining support for people seeking jobs and mental health care. I would not necessarily say not to do that, but it has to be done with extreme caution to ensure that it is not something that puts more pressure and stress on people, interfering with them becoming well.
More positively, I commend the Government on bringing the Bill forward so early in their term and on making it a Bill that starts in the House of Lords. I compare it to the Domestic Abuse Act, during the passage of which many noble Lords who have taken part in today’s debate also took part. There was a genuine effort from all sides of the House to make that Act better, and it has been very clear this evening that there is the same desire in this Chamber today.
Many noble Lords have made the point about the need to resource what is in the Bill—we also said that about the Domestic Abuse Bill—including, to single out a few, the noble Lords, Lord Alderdice and Lord Adebowale, and many others. There have also been some really good ideas in this debate, and here I particularly single out the noble Baroness, Lady Watkins. The idea of a safe staffing level for community services strikes me as a potentially transformative idea that is really essential. Far too often, care in the community has simply meant being abandoned in the community, being left in the hands of horribly overworked staff, who are then subject to abuse and questioning when things go wrong because they simply have not been able to handle the workload, through no fault of their own. It is really crucial that we tackle those issues.
I will quickly whizz through some specific points of the Bill, particularly focusing on things that other people have not said. I have not heard a great deal of discussion of the idea, as recommended by the Joint Committee on the Draft Mental Health Bill, that we have a mental health commissioner. The briefing from the Centre for Mental Health draws a parallel with the powerful impact of the Children’s Commissioner; I would also add the impact of the Patient Safety Commissioner, on which I worked with the noble Baroness, Lady Cumberlege, over many years. Again, that was a case in which your Lordships’ House was very powerful in pushing to create that position. Having the Patient Safety Commissioner has made a real difference, and having a new statutory role to champion mental health across government and speak up for people with mental illness is something we really should be including in the Bill.
Very briefly, I agree with the noble Baroness, Lady Fox, on community treatment orders. The Bill still allows these to be continued indefinitely rather than placing a time limit on them with an option for a new one if needed. These should not be renewed without proof of necessity and proportionality.
I will use my remaining time to focus particularly on the importance of children and young people. Many other noble Lords have addressed and given us statistics on how our mental health services are failing young people. I want to draw another parallel with another element of what the Government are doing and which I have praised. A couple of nights ago, rather late in your Lordships’ House—about this sort of time, actually—we were discussing the Government’s plan for a new youth strategy and their plan to make sure that there is really strong consultation on it with young people. The one direct question I will put to the Minister is: I am sure the noble Baroness is aware of the phrase “Nothing about us without us”. What is being done to ensure that there is a real say for young people, particularly young people with experience of the mental health system, to ensure they actually have the chance to be involved in the Bill?
I will rush into one final, technical point. The Bill introduces the new statutory care and treatment plans for all patients. That is welcome, but many under-18s are admitted on an informal basis, so they will not be covered by this. How will that be dealt with?
One final rushed point is that the noble Lord, Lord Alderdice, and others, have talked about how we can learn from other parts of the UK. The mental health Act in Wales includes a measure to give people the right to have a mental health assessment if they request help. That is surely something we could learn from and include in the Bill.
Baroness Tyler of Enfield (LD)
My Lords, I apologise for my croaky voice. It has been an excellent and very well-informed debate. Like all other noble Lords today, I welcome the early introduction of this Bill, after so many years of delay, to modernise the woefully out-of-date 1983 legislative framework. Indeed, it has been one of the longest and most tortuous gestation periods of any piece of legislation I can remember.
I thank so many organisations for the excellent briefings I have received, as well as those who have worked so hard to get us to this stage, including the independent review chaired by Sir Simon Wessely and the cross-party Joint Committee chaired by the noble Baroness, Lady Buscombe.
Those people directly affected by this piece of amending legislation deserve better. From these Benches, we welcome the introduction of the Mental Health Bill as an important step towards modernising the mental health care system and enhancing patient rights. We are encouraged by the Bill’s emphasis on empowering patients and giving them greater control over their treatment decisions, and we want firmly to establish the principle that detention is an opportunity for treatment and a path to recovery, rather than being seen solely in terms of containment.
Like so many others, I particularly welcome the fact that the Bill seeks to limit detention for people with learning disabilities and autistic people who do not have a co-occurring mental health condition and removes prisons and police cells as suitable places of safety. As my noble friends Lord Scriven and Lord Alderdice said, this reform package moves incrementally in the right direction, seeking to balance the rights of individuals with the imperative of public safety.
But there is much more to do to strengthen and improve the Bill and to look at the wider context, particularly at the adequacy of existing mental health services outside of the Act and broader social inequalities. Ensuring we have the necessary funding, the workforce with the right skills and training in the right place will all fundamentally affect the implementation of this Bill.
However, I am disappointed that quite a number of the recommendations by the Joint Committee have not been picked up, in particular those on a mental health commissioner, on the interface between the Mental Capacity Act and this Bill and on strengthening duties on integrated care boards and local authorities to ensure an adequate supply of community services for people with learning disabilities and autism—points to which I shall return. Will the Government provide a detailed response to the Joint Committee report setting out the rationale for the recommendations that have been accepted and those that have not?
There are a number of themes that we will want to explore in Committee, and the first is prevention. We all know that, in healthcare, prevention is better than cure, and the noble Lord, Lord Darzi, Wes Streeting and the Prime Minister have all said it is one of the big three transformational shifts that are needed. We need to apply that same principle to this Bill and live up to that mantra. Put simply, we need to focus on preventing people from reaching the point where they risk being sectioned in the first place. That means deeper and wider preventive mental health in our communities. Currently, as a country, we focus on treatment rather than prevention. We spend around £230 billion on healthcare but only £3.5 billion on public health and only about 3% of that on preventive public mental health work. There is so much more we could do in schools, with walk-in hubs in the community and regular mental health check-ups et cetera.
A key Liberal Democrat objective in this Bill will be promoting good mental health. I believe we need a power included in the Bill that enables the relevant health and local authorities to undertake the promotion of mental health with realistic resources attached. That is also why I want to see a new right to both assessment and treatment for mental health introduced, similar to the Care Act rights that we introduced back in 2014, for people to get the help they need at earlier stages, directly preventing unnecessary admissions.
On racial disparities, given that two of the key drivers of the 2018 review were to reduce detention rates and the stark disparities in the application of the Act on some racial groups—as the noble Baronesses, Lady May and Lady Berridge, said so powerfully—we must explore what other opportunities exist to strengthen legislation in this regard. Specific examples would be putting the Patient and Carer Race Equalities Framework on a statutory footing and including an equity principle—in addition to the four existing guiding principles—which, like the noble Lord, Lord Bradley, and my noble friend Lord Scriven, I would like to see in the Bill to underline that these principles sit at the heart of all decision-making covered by it. I also support a new responsible person role at hospital level to oversee and monitor race equality in the day-to-day operation of the Act, with a corresponding duty on the Secretary of State to report annually on progress against reducing inequalities. Such a package could have real teeth.
Like the noble Lord, Lord Bradley, and others, I also strongly support the establishment of a mental health commissioner, as recommended by the Joint Committee. Such a commissioner would both promote access to treatment across the spectrum of mental health services, including things like beds for eating disorders, and oversee implementation of the Act, including ensuring that racial disparities are fully addressed and monitoring the use of community treatment orders.
On seeing detention as an opportunity for treatment and recovery, I would like to see the definition of appropriate medical treatment strengthened to take account of the settings in which treatment is delivered, including community settings, and the importance of non-drug-based intervention—either in tandem with medication or on its own—where it is clinically effective.
As many noble Lords have said, the Bill makes some important changes to better regulate the use of CTOs. These were originally meant to be a route out of disproportionate sectioning but, in reality, they have exacerbated the number of black people who are subject to compulsion under the Act. However, the revisions in the Bill currently stop well short of adopting all the independent review’s recommendations. For example, they allow CTOs to continue indefinitely, rather than placing a time limit on each CTO, with the option to make a new one if it is still needed. As my noble friend Lady Parminter made clear, we should explore this in Committee.
As many others have said, we need to view equal treatment between Part II and Part III patients as paramount. Ensuring that all patients detained under the Mental Health Act, including those involved in the criminal justice system, have equal access to advocacy, mental health tribunals, appeals and other rights—no matter which part of the Act they are detained under—is a key principle. Given, as I have said, that one of the key drivers for reform was addressing racial inequalities, and that black people are significantly more likely than white people to be detained under Part III, we currently risk further entrenching these disparities.
Much has rightly been said about people with learning disabilities and autism. The changes to Section 3 are an important step in ending the human rights scandal of inappropriate detentions of autistic people and people with a learning disability. As the noble Lord, Lord Touhig, and the noble Baroness, Lady Hollins, said, legislative change must be accompanied by investment in the right community support. Without this, autistic people and people with learning disabilities will continue to reach crisis point with their mental health. There is a real risk of these groups falling into the criminal justice system, simply due to lack of community provision. This has been the New Zealand experience, as the noble Baroness, Lady Watkins, highlighted. They are then unable to access Section 117 aftercare support. We are told that this change will be enacted only once sufficient provision is in place. Can the Minister provide more details on how this decision will be taken and what the Government will do to ensure that capacity is being built up in the community?
My noble friend Lady Barker, the noble Lord, Lord Bradley, and others expressed concerns about the interface between this legislation and the Mental Capacity Act. I share these concerns. I feel that it is currently fuzzy and unclear, leading to inconsistency in practice and confusion as to which legal framework applies. We must explore this further in Committee, including understanding what has happened to the liberty protection safeguards that were introduced under the Mental Capacity (Amendment) Act but have not yet been implemented.
I am also aware of concern within the sector that there has not been adequate or meaningful engagement with people with learning disabilities or autism, or sufficient time for them to be properly involved in decisions that directly affect their lives. How do the Government intend to remedy this? Do they have a plan of stakeholder engagement, particularly with groups led by people with learning disabilities and autism?
One area which particularly concerns me and about which we have heard a lot today is the position of children and young people who are too often receiving poor-quality care in unsuitable conditions. There are many things we can do in Committee to strengthen the position for children. I was profoundly moved by the family experience that the noble Baroness, Lady Ramsey, recounted. I thank her for that.
There is much else that I would like to say about implementation, but I have probably run out of time. I welcome the collaborative style adopted by the Minister towards improving the Bill. I look forward to working with other noble Lords on this vital and long-overdue piece of legislation.
Lord Kamall (Con)
My Lords, this has been a fascinating debate. Having read the various reports sent by many organisations, including the excellent briefing from the House of Lords Library, I felt pretty well briefed but, having listened to today’s contributions —including the moving contributions from my noble friend Lady Browning and the noble Baronesses, Lady Parminter, Lady Keeley and Lady Ramsey—I realised that there is so much more for us to learn.
These Benches welcome the Bill. In particular, I pay tribute to my noble friend Lady May, who, as Prime Minister, commissioned the Wessely review to consider a number of issues: why, as we heard from many noble Lords, were detention rates increasing and, in particular, what could be done to reduce inappropriate detention? I understand very well the point made by the noble Baroness, Lady Parminter, about when detention may be appropriate or inappropriate. The review also considered how to improve the way that different agencies respond to people in crisis to ensure that they are treated with dignity and respect. It looked at the disproportionate number of people from certain ethnic backgrounds, specifically Afro-Caribbean men, being detained under the Act and what should be done about it.
I am also grateful to noble Lords who served as members of the pre-legislative Joint Committee on the 2022 draft mental health Bill, which was based on the recommendations of Sir Simon Wessely’s review. Some of them have spoken in this debate: in particular, my noble friend Lady Buscombe, who chaired the Joint Committee; my noble friend Lady Berridge; the noble Baroness, Lady Hollins, who has a long history in this area from personal and professional experience; the noble Baroness, Lady Barker, who has many times said, “I told you so”; and the noble Lord, Lord Bradley, who was a champion for mental health during the passage of the Health and Care Bill. Quite often I was urged to resist some of his amendments but, with hindsight, I am glad that he prevailed to ensure that we continue to discuss the parity between mental and physical health. As many noble Lords have said, the challenge is how we turn those words into action throughout the system. I also thank the noble Baroness, Lady Neuberger, who sat on the Wessely review and who, when we looked at and discussed this when I was the Minister, gave me quite a bit of time—partly, I think, because she chairs the trust of the hospital where I was born.
They all had very incisive insights so, in approaching this debate with my noble friend Lord Howe, we considered the report from the Joint Committee and this generated many of our questions. We wish to probe the Government on the recommendations from the report, especially those with which the Bill seems to disagree. We will not, at this stage, tell the Government where we agree or disagree; it is more to understand the Government’s reasoning for not including specific recommendations from the Joint Committee.
We also ask the question: if and when the Bill is passed, what next? How and when will the Government implement the main changes in the Bill, as was alluded to by the noble Baroness, Lady Murphy, and the noble Lord, Lord Scriven? Last week during Oral Questions, one of the ministerial colleagues of the noble Baroness, Lady Merron, made what sounded like a government commitment. But when questioned by one of my noble friends, that Minister admitted that it was not a commitment but an aspiration.
Similarly, the briefing notes accompanying this year’s King’s Speech stated that the Bill would take
“a number of years to implement”
and that the Government would introduce these reforms
“in phases as resources allow”.
At this stage, therefore, we would like to understand which changes the Government plan to introduce immediately and which reforms they are aspiring to, rather than actively planning. This is to make sure that we avoid some of the problems that the noble Lord, Lord Alderdice, alluded to in his contribution.
I move now to the main areas that have been raised in today’s debate on which we would like to learn more about the Government’s intentions. The noble Lord, Lord Touhig, reminded the House that autism is not a mental health condition. My noble friend Lady Browning highlighted the lack of understanding of people with autism. The Joint Committee recognised the risk that people with autism or a learning disability could be given additional and unnecessary medical mental health diagnoses in an attempt to justify detention, when they can no longer be detained under Part II of the Mental Health Act. What firm plans do the Government have, in this Bill or otherwise, to try to manage and mitigate this risk?
The Joint Committee recommended a full statutory review of the use of community treatment orders within three years but, as my noble friend Lord Howe pointed out, there is no commitment to such a review in the Bill. Can the Minister explain the Government’s reasoning for not committing to a review within three years?
On children, both the independent review and the Joint Committee made recommendations—some of which are not in the Bill—about the treatment of children, such as the inappropriate placement of under-18s into adult wards or into facilities that may be miles away from their home. Can the Minister clarify the Government’s position on these two specific issues?
On advanced care documents, which the noble Baroness, Lady Barker, has championed for many years, the Joint Committee recommended that these be made a statutory right for all patients detained under the Mental Health Act. As my noble friend Lady Buscombe has said, this could be done in the form of an app if we make sure to push through the digitalisation of the NHS and the whole care system. The Bill as it stands does not follow up on this recommendation, preferring to place a duty—one noble Lord alluded to it being “vague”—on NHS England and ICBs to inform patients about advance care documents. Many noble Lords, including the noble Lord, Lord Stevens, have raised this issue, so I think the House would find it helpful if the Minister could explain the Government’s reasoning behind not introducing these documents as a statutory right in the Bill.
We welcome the Bill removing police stations and prisons as places of safety for patients not in the criminal justice system. However, as my noble friend Lord Howe said, one unintended consequence raised by several bodies was that this could lead to a rise in the number of people admitted to A&E departments, sometimes escorted by police and having to wait in crowded spaces with a lack of specialised facilities until they can be assessed by clinicians. When do the Government envisage that NHS trusts will be able to deal with the potential increase in the number of mental health patients admitted to hospitals as places of safety?
The president of the Royal College of Psychiatrists, who contributed to the independent review, raised concerns about the proposed changes to the treatment of those with learning disabilities or autism, as there may be times when community services cannot manage the level of risk that such patients present, and when it might take some time to decide whether this is related to co-occurring mental illness. In such cases, patients may be brought into A&E, but what happens if their behaviour is perceived as affecting the safety of others in the A&E department? This could lead to the police being called, and suddenly they are in the criminal justice system. I wonder how the Minister sees the Bill dealing with such a situation.
I now turn to the issue of early intervention, which the British Association of Social Workers raised during pre-legislative scrutiny and which the noble Baroness, Lady Watkins, raised today. The BASW stressed the importance of early intervention to prevent the admission of mental health patients into hospitals in the first place, which they described as being at
“the interface of mental health and mental capacity legislation”.
A number of noble Lords have talked about whether we could have gone back to first principles and started with fusion legislation. We note that Sir Simon Wessely suggested that this was not practical or would take too much time; I do not wish to misquote him. My noble friend Lady Berridge also mentioned the interface with the Children Act. This all asks how we can do this in a holistic way, but by taking a step back are we just waiting even longer for something to be done to fix the problems with the existing legislation? We have obviously decided on this route but I ask the Minister what thought is being given to future fusion legislation or rethinking the interface between the various Acts affected here?
The pre-legislative scrutiny committee also recommended
“the creation of a Mental Health Commissioner … to oversee the direction of travel … and implementation, monitoring outcomes and supporting cultural change … be an advocate for patients, their families and carers and speak up about the stigma still attached to severe mental illness”.
Yet the Government have decided not to accept this recommendation. I note that a number of noble Lords across the House have spoken on this missing part of the legislation. Can the Minister explain why the creation of a mental health commissioner has not found its way into the Bill?
One of the main reasons for commissioning the independent review was to examine why so many people of Afro-Caribbean heritage are detained under the Mental Health Act. Indeed, Sir Simon Wessely wrote in his report that one of his earliest academic papers, in 1989, was on the subject of the overrepresentation of those of black, African and Caribbean heritage among those diagnosed with schizophrenia. Are the Government, the NHS and the department any closer to understanding the key factors behind this overrepresentation? What do they believe can be done to reduce this disparity, or does it need further research?
The Minister might find this odd coming from me, given that when I was Minister I quite often tried to shield the Government from this—now that the roles are reversed, there might be a certain irony—but I will ask about a workforce plan. In all honesty, when we were in government we were pressured by the Treasury not to accept this, and it quite often pushed back when we tried to make the case for this, so I understand that it is a real challenge for the Government. We completely understand, and it would be unfair of me now to take advantage of the fact that I am in opposition. Our Government belatedly published a workforce plan. What is the thinking on publishing a workforce plan, given that many noble Lords across the House have asked about this, particularly once the Bill becomes an Act? How long would it take to actually implement this? We need to understand more about the resources—otherwise, it could make things worse.
I realise that I and other noble Lords have asked many questions, and I certainly do not envy the Minister. We look forward to her responses, either now or in writing, and we welcome her engagement with noble Lords across the House.
Baroness Merron (Lab)
My Lords, I put on record my gratitude to all Members of your Lordships’ House for contributing to what was widely agreed, I am sure, to have been an excellent debate—excellent not just because of the level of engagement but because of the detail. I really feel that spirit of wanting to improve the legislation and the support for the Bill thus far. I will endeavour to respond to as many themes as possible; I am very grateful to the noble Lord, Lord Kamall, for his sympathy, which I accept, but I regard that as a good thing. I regard it as admirable that I will not be able to answer all the questions, because that is the purpose of being here. It sets us up for Committee. It is obviously going to be a very rich Committee, and I very much look forward to it.
I hope noble Lords will understand that I look forward to following up on the many points that I will not get a chance to address in the time I have and doing a proper review of the debate today, picking up points as needed. I pay tribute to the dedication and the detailed attention to the Bill that noble Lords have already given. I am very glad to see my right honourable friend the Secretary of State gazing on. The reason I say that now is that the Secretary of State knows only too well—and not just from me—the contribution that your Lordships’ House makes and will continue to make. I for one certainly appreciate it, as I know he does.
I also thank the noble Baroness, Lady Parminter, for her bravery in sharing her and her family’s experience and anguish of eating disorder. I say the same to my noble friend who shared her experience about her sibling. It is not always easy to do that, but it really brings a lived experience of those around the person we are often thinking about, and it is so important that we do that. This debate has confirmed to me what I knew already—but it is always worth doing it again. It is the product of persistence and of a number of investigations and recommendations. It is also inspired and underwritten by the tireless campaigning that many have undertaken to improve the rights and experiences of people with mental health conditions and learning disabilities and autistic people.
It also reflects the input of those with lived experience, which was first raised as necessary in the debate by the noble Baroness, Lady May. It is about striking the right balance between getting the details of a framework of legislation right, along with the urgent need for reform, and the point that noble Lords have raised about how that is going to be done.
Attitudes and knowledge, as many noble Lords have acknowledged, have changed radically. Mental health is increasingly out of the shadows, and through the Bill we can make sure that legislation does a much better job of keeping up with a shift in societal attitudes and expectations and the development of treatment.
Regarding the role of your Lordships’ House, like the noble Baronesses, Lady May and Lady Barker, I recognise the relevance of this House. I too welcome that the Bill has started its passage through Parliament here because I believe your Lordships’ House will do the job that it is here to do, which is to improve legislation, and this debate today has certainly confirmed that.
In looking at what we are trying to achieve, I am reminded of the words of Professor Sir Simon Wessely in his foreword to the independent review’s final report, where he said that
“we want the Mental Health Act to work better for patients, the public and professionals. We hope that the result will be to reduce the use of coercion across the system, whilst giving service users more choice, more control and better care, even in the event that detention is still required. And we particularly hope that the end result will be to reduce the inequalities and discrimination that still remain”.
Almost six years after the former Prime Minister, the noble Baroness, Lady May, commissioned that independent review, the draft legislation before us speaks to those aspirations as well as delivering our manifesto commitment to modernise the 1983 Act.
On the reduction of detentions, I certainly agree with the noble Baroness, Lady Murphy, and other noble Lords that reducing detentions cannot be achieved by legislation alone. It will depend on having the right services in the community.
New models of care in the NHS are already giving over 400,000 adults greater choice and control over their care. We are also trialling new models of care through six early implementers, bringing together community crisis and in-patient functions into one neighbourhood team that will be available 24 hours a day, seven days a week, to increase access and improve continuity of care in the community. I know from the debate today that many noble Lords are looking for that sort of development and good practice.
As we know, the Bill makes a number of improvements in respect of patient experiences and care, and of the increase of choice and autonomy. It seeks to tackle racial discrimination and provide safety for public, staff and patients, and to provide better support for those with autism and learning disabilities.
I turn to some of the main themes that have been raised. I say to the noble Baroness, Lady Tyler, that we continue to be committed to engaging with those with lived experience. Part of the point of the Bill is that, where those with lived experience have not had their voices heard, I believe our continued engagement will allow that.
On racial inequalities, many have spoken passionately about this matter, including the noble Baronesses, Lady Watkins and Lady Buscombe, and the noble Lord, Lord Adebowale. The racial disparities associated with the operation of the current Act were one of the many drivers of reform, and rightly so. The changes in this Bill will give patients greater say in their treatment and encourage more collaboration and less coercion in care and treatment planning, which are all crucial to reducing inequalities. This will include increasing oversight and scrutiny of community treatment orders, where racial inequalities are at their most acute. It will also be about encouraging the uptake of advance choice documents, where those with lived experience, as I said in my opening remarks, have been very generous in their reference to their use in reducing inequalities. Legislating so that people can choose their own nominated person will also protect rights.
Inequalities in outcomes are not just a result of how the Act has been applied but also due to wider social and economic factors. We will therefore be working across government to ensure that the Bill’s provisions are effectively implemented, aiming to reduce those racial disparities in decision-making under the Act, starting with using the code of practice to make clear which actions can be taken in the application of the Act. We are also taking forward non-legislative reforms recommended by the independent review, including the Patient and Carer Race Equality Framework and also piloting culturally appropriate advocacy models to support those from minority ethnic backgrounds to understand their rights under the Mental Health Act and to give voice to their individual needs.
On the mental health commissioner, I have heard many comments, including those expressed by the noble Baronesses, Lady Murphy, Lady Barker, Lady Buscombe and Lady Berridge, and the noble Lord, Lord Bradley, and others. That is quite a group to address, but I will have a go. It is true that we have not taken forward the pre-legislative scrutiny committee’s recommendation to establish a statutory mental health commissioner. We recognise that improvements need to be made to the quality of care and the patient safety landscape. However, the concerns are that the proposed mental health commissioner’s function would be potentially largely duplicative of existing bodies and functions, and nobody wants to risk diluting accountability or causing confusion. As noble Lords will know, Dr Penny Dash has been asked by the Secretary of State to assess if the current range and combination of organisations within the healthcare regulation landscape is effective and to make recommendations of what might be needed, and I think it is important that we await her recommendations.
Learning disability and autism were raised by a number of noble Lords, in particular by the noble Baronesses, Lady Hollins, Lady Buscombe and Lady Browning, my noble friends Lady Keeley, Lady Ramsey and Lord Touhig, and the noble Lords, Lord Scriven and Lord Adebowale. This is a very important point and I recognise that we want to improve care and support for the over 2,000 people who are currently detained, as well as anybody who may need support in the future. We know from the NHS’s safe and wellbeing reviews that four in 10 people who are detained in this group have needs which could have been met in the community with appropriate support. That is why we are going to be focusing on developing community services and improving the quality of care, which will happen alongside the Bill’s reforms.
Through the Bill, we will be taking forward a package of measures for those with a learning disability and autistic people, so there will be a significant programme of work, alongside investment. I will be pleased to engage with expert stakeholders and those with lived experience, including parliamentarians, and to update your Lordships’ House as we progress.
With regard to the recommendations of the pre-legislative scrutiny committee, there is no doubt in my mind that the Bill has benefited greatly from undergoing scrutiny in 2022. It is a better Bill for that and we have tried to incorporate more of the Joint Committee’s recommendations within it. Many of those recommendations relate to the statutory code of practice and we will consider how we take these forward following Royal Assent.
On the important point of implementation, raised by many noble Lords, including the noble Lords, Lord Adebowale and Lord Bradley, the truth is that we estimate that the full implementation of these reforms will take around 10 years. The speed at which we can implement will be limited by the time that we need to expand and train the workforce. This goes to the point raised by the noble Lord, Lord Kamall, and I am grateful for his honesty in the way that he described previous work on the workforce. I thank him and his ministerial colleagues—predecessors of mine—who have worked on this.
The reality is that while some reforms can commence much sooner than others, we will need to commence powers under the new Bill in phases. Implementation will depend on what happens during the passage of the Bill and the reality of future funding settlements—to the point raised by the noble Lord, Lord Stevens—as well as other developments, such as the 10-year plan, but I can briefly give an indicative timeline.
A small number of reforms relating to the criminal justice elements of the Bill will commence within two months of Royal Assent. In the first year after Royal Assent, there will be a focus on updating the code of practice and creating the necessary secondary legislation to enable implementation. We will need a further year to train existing staff on the reforms and ensure that processes are in place. We would therefore hope to commence the first phase of significant reform in 2027, and to commence further reforms as and when there is sufficient resource in place to do so. In the spirit of honesty, the truth is that for what I would call the most burdensome reforms—for example, the increased frequency of mental health tribunals—those would not be likely to commence before 2031-32.
Alongside the passage of the Bill itself, we are looking closely at implementation in relation to learning disability and autism. Again, the exact timing of implementation of the reforms will depend on future funding. I know that noble Lords will understand that I am limited in what I can say on that, but we have already demonstrated our direction of travel by: treating and resourcing mental health seriously, including having a mental health professional in every school; introducing open-access Youth Futures hubs; recruiting 8,500 mental health workers; and having £26 million in capital investment. Indeed, there is the priority that many noble Lords, including the noble Lord, Lord Crisp, have acknowledged of bringing this Bill forward as a matter of urgency.
The noble Lord, Lord Meston, and the noble Baroness, Lady Berridge, raised the disparity of treatment between children and adults. It is true that there are a small number of reforms which do not apply to children and young people, as was also raised by the noble Baroness, Lady Watkins. It is the case that there is a difference; nevertheless, we are committed to improving children and young people’s autonomy over their care and treatment. We still believe that these reforms will go some way to achieving this. Like adults, under-18s should be supported to share their wishes and feelings by the clinician when it comes to care and treatment decisions.
On the issue of prison transfers, which was raised by the noble Baroness, Lady Watkins, and the noble Lords, Lord Scriven, Lord Bradley and Lord Adebowale, we recognise that operational improvements are needed to ensure the safe and effective implementation of the statutory 28-day limit. NHS England is indeed taking steps to address some of the barriers to timely transfer of patients. The wording in the Bill, which refers to the need to “seek to ensure” a transfer within 28 days, should be sufficiently robust to provide accountability for a breach of that time limit, while recognising that there are multiple agencies involved.
As we know, while this legislation—
Baroness Berridge (Con)
I hate to interrupt, given the lateness of the day and the lateness of the hour, but the point that a number of noble Lords were making in relation to children is that this Bill potentially does not sit with the principles under the Children Act. If the Government intend impliedly to repeal parts of the Children Act, then it would be good to have that clarification from the Dispatch Box.
Baroness Merron (Lab)
I look forward to coming to that point in Committee. The marrying up of legislation will be important, as is making progress on the Bill. That applies to the point of the noble Lord, Lord Alderdice, and others about fusion. We do not want to hold up this Bill while we make progress, but we will be mindful of the interface with other legislation.
In this Bill we are starting with the most overdue reforms to make the law fit for the 21st century. I very much look forward to working through the Bill in much greater detail in Committee. I am most grateful to all noble Lords who have not just spoken this evening but worked to get us to this point.
Baroness Merron
That the Bill be committed to a Committee of the Whole House, and that it be an instruction to the Committee that they consider the Bill in the following order: Clauses 1 to 3, Schedule 1, Clauses 4 to 23, Schedule 2, Clauses 24 to 38, Schedule 3, Clause 39 to 54, Title.