The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
I thank the noble Baronesses for their very detailed questions. I will write if I do not cover all the questions.
We want pre-legislative scrutiny to commence at the earliest opportunity, and I understand that this is being discussed by the usual channels. The hope is to appoint the committee if possible before the summer; we want to do this as soon as possible. Our ambition is that once pre-legislative scrutiny has been completed and understood, we can introduce the Bill in the new year, to allow noble Lords the scrutiny that the Bill deserves. That is the indicative timeframe at the moment. As long as things go smoothly, pre-legislative scrutiny will start as soon as possible and we will then, I hope, be in a position to have a better-informed Bill, the new draft of the Bill having been through pre-legislative scrutiny.
We hope to see a lot of potential amendments to the Bill following pre-legislative scrutiny. Having had a baptism of fire in this House, in coming straight into this position and taking up the Heath and Care Bill, I know that there will be many valid points that will no doubt be taken on board as we debate the mental health Bill. As we saw with the debate on the Health and Care Bill, noble Lords across the House were able to improve it. Even though as government Minister I sadly had to disappoint on some of the amendments, I think we made a better job of it.
I am pleased that the important issue that black people are four times more likely to be detained under the Act, and 10 times more likely to be subject to a community treatment order, was raised. Central to addressing this is the patient and carer race equality framework, which is being rolled out by NHS England and NHS Improvement. We hope that this will support NHS mental healthcare providers to work with their local communities to improve the ways in which patients access and experience treatment.
We have already commenced culturally appropriate advocacy pilots, providing improved culturally appropriate services so that people from different backgrounds and their needs can be understood. One thing I would caution is that it is very easy to group people with the same skin colour as having the same needs. There is incredible diversity—I know this myself, coming from one of the immigrant communities—within these communities and in the pressures that arise from one community to another. Overall, it is important that we address those. We are working with Health Education England to undertake programmes on the diversity of the workforce, and to make sure that patients’ voices are represented.
Both noble Baronesses talked about the principles. We felt that the principles informed every decision we have made in developing the draft mental health Bill. Although it has not been possible to create clear overarching principles in primary legislation as recommended by the independent review, the reforms break down the review’s principles into specific duties that appear in the draft Bill—for example, ensuring that people are detained only when absolutely necessary; ensuring that if people are detained this must be for the purpose of, and have a reasonable prospect of, providing them with therapeutic benefit; introducing new patient safeguards to make it harder to override someone’s refusal of a particular treatment; and the creation of a new clinical checklist which will put greater emphasis on tailoring treatment to the individual patient. We believe that, together, these more specific duties deliver much of the intended impact of the review’s principles, but in a better way.
The overall picture of the sector is a mixture of private and state providers, but for us, it matters that the Care Quality Commission has the role of making sure that all providers are regulated properly and that they meet requirements. All providers in receipt of NHS contracts must meet requirements, including those in the NHS provider licence and the NHS standard contract. Contracts to private providers can be and are terminated when these are not met.
We have consulted on the independent review’s recommendations, and less than half the consultees supported the approach of giving patients the ability to appeal treatment at the MHT, the power sitting with a single judge acting alone. I am sure that this will come up in pre-legislative scrutiny and as we debate the Bill itself.
On the workforce, once again, there has been growth, but we all understand that demand is outstripping supply. We are looking at that as part of the long-term plan and the Health Education England review. I do not have an exact date; every time I ask for one, I am always told that it will be soon. I do not think that means it is being kicked down the road—I just think that there is not a proper date yet, given that all the consultations and responses have to be addressed. Work is ongoing to confirm plans to 2024 for integrated care systems.
We are providing more than £90 million of additional funding in 2022-23—£70 million as part of the NHS long-term plan and £21 million through the community discharge grant—to make sure that we reduce in-patient numbers and ensure that people with learning disabilities and autistic people can live in the community.
I am very aware of the issue of children and young people’s mental health. There are a number of different factors, and it is not easy to narrow them down to one. There could be environmental factors; it could be pressure; it could be that some of them are child carers, who feel large amounts of pressure at too young an age. In 2021-22, we provided an additional £79 million in response to the pandemic to expand children’s mental health services in that financial year, but we are very aware of how much more demand there is for mental health services, particularly for children. For us, two years is a relatively small proportion of our life, but for children it is a massive proportion, and they want to get that time back. That has created huge mental health issues for children, so we are tackling that.
As I said, I will write to the noble Baronesses on all the questions I have not answered.
Baroness Chisholm of Owlpen (Con)
My Lords, the noble Baroness, Lady Merron, talked about patients being detained for too long, particularly those who have been sectioned. My right honourable friend Jeremy Hunt MP, down the other end, talked yesterday about how it would be good to put something in the Bill to say that those who had been sectioned had to be re-evaluated fortnightly, or at least monthly. This is a very good idea, because we know that there are problems with people, particularly those in the autistic community, who are detained for far longer than need be. Could my noble friend the Minister make sure that this is brought up in Bill meetings? I hope that it could go in the Bill.
Lord Kamall (Con)
I thank my noble friend for the question and for raising this issue. I am aware that my right honourable friend the Secretary of State intends to meet Jeremy Hunt to discuss this in more detail. In my first week, or first fortnight, as Minister, one of the debates I took part in was led by the noble Baroness, Lady Hollins, about detention. That brought home to me at a very early stage in my ministerial career how shocking some of these events are and the way that young people, particularly those who are autistic or have other conditions, are being treated. My right honourable friend the Secretary of State will meet Jeremy Hunt to discuss this, and I hope that it will also be approached in the pre-legislative stage. If not, I am sure that it will be debated in this Chamber.
Lord Judge (CB)
My Lords, I admire the enthusiasm for speed that the Minister expressed earlier from the Dispatch Box. Can he say whether that rules out having detailed pre-legislative scrutiny? This Bill should have no political elements to it at all, except possibly the cost, but all the other issues should be capable of sensible evaluation between intelligent people trying to achieve the same objective, which is improvement in our mental health services. Can the Minister’s enthusiasm for speed please not lead us to the problem identified in this House on the Procurement Bill this afternoon, where, after Report, there are 322 government amendments? That is not the way to legislate.
Lord Kamall (Con)
The noble and learned Lord makes an important point. I am very much aware of today’s earlier discussion, when I was smiling, perhaps over-smugly, thinking, “At least we’ve got pre-legislative scrutiny.” However, I accept the noble and learned Lord’s point that it has to be proper pre-legislative scrutiny. I hope he will forgive my lack of experience on this. I am not yet aware of the difference between good and thorough pre-legislative scrutiny and brief pre-legislative scrutiny, so I will have to take this back to the department and will write to him and others.
Lord Davies of Brixton (Lab)
We thank the Minister for the draft Bill. Although it is on the law of mental health, it has clear financial implications and so a specific commitment to provide the resources to implement the changes in the law would be valued. In addition, however, given the agreement that there is about what will be in the Bill, what steps are the Government taking to get it implemented straightaway? There are so many proposals in Sir Simon Wessely’s report that could be implemented immediately, so I hope the department is pursuing that proactively.
It is important to understand a bit of the context here. We are heading into financially difficult times. We know that there is a close connection between people’s personal financial problems and mental health and that there will be an increasing level of indebtedness, which automatically means greater need for services. Maybe the Minister can reassure us that the resources will be there to carry out what is in the proposals.
Lord Kamall (Con)
The noble Lord makes an incredibly important point. We have seen the impact that the pandemic has had on mental health across all age groups. During the Health and Care Bill, the noble Lord and many others raised the issue of parity between mental health and physical health, and I thank him for that. That brought home that the current legislation is out of date, which is why we really need to update it. I also thank noble Lords who have spoken so far for agreeing that this is not a party-political issue at all. We all want to address this issue, and maybe the issue of funding will come up. The Government remain committed to achieving parity between mental and physical health services to reduce inequalities. We are making good progress; investment in NHS mental health services continues to increase each year, from almost £11 billion in 2015-16 to £14.3 billion in 2020-21. We expect all current CCGs—and ICBs once operational —to continue to meet the mental health standard, and we have made a number of amendments. We are investing more than £400 million over the next four years to eradicate mental health dormitories. Clearly, as we go through the Bill, there will be financial implications, which will be considered as we debate it. I cannot give a clear pledge on which measures will be implemented until we have seen the Bill. Clearly, however, we understand that a lot of this is long overdue, so the quicker we can get this done and come to an agreement satisfactory to all sides of the House, the sooner we can get on with implementing it.
Baroness Tyler of Enfield (LD)
My Lords, I welcome many of the proposals contained in the draft Bill, particularly those that give people affected by the Bill more say over their treatment and care. However, as others have said, the Bill is currently worryingly silent on workforce issues, and I think we all agree that they will be critical to the successful implementation of any reforms. My specific question to the Minister is: what assurances can he give that children and young people aged 18 and under will benefit from the reforms at least as much as adults and, specifically, will they be able to access the same treatment safeguards as adults?
Lord Kamall (Con)
When I was having initial discussions on the various parts of the Bill, children and young people’s mental health clearly came up. The statistics are staggering. Some 420,000 children and young people were treated through NHS-commissioned mental health services in 2021. That is an increase of 95,000 in just a few years. That is still without us being aware of everyone who needs access to the system, or young people and their parents and families being aware of what support is available.
We are continuing to increase investment into mental health services by at least £2.3 billion a year by 2023-24, as set out in the NHS Long Term Plan. There is also the extra money in response to the pandemic, which saw extra demand. We have 287 mental health support teams in place in around 4,700 schools and colleges across the country but, once again, more needs to be done. It is one of those issues where demand outstrips supply.
We now have mental health support teams covering 26% of the country a year earlier than planned, but we hope to increase this progressively over the years so that as many schools as possible are covered. We have delivered 7 million well-being for education recovery programmes. We understand the tensions and workforce issues that will inevitably arise. The Health Education England review and the Government’s strategic review are considering all the changes in healthcare overall; all the technologies and ways of delivering services; and the change from secondary to primary and down to the community. We are working out in the response what workforce we need for each of those changes.
Baroness Hollins (CB)
My Lords, the average stay for people with learning disabilities and autistic people detained under the Act is five and a half years and, shockingly, many people are criminalised during their admission, making their discharge even more difficult. Although removing learning disability and autism from the Act is clearly the right thing to do, does the Minister agree that, unless there is some improvement in the care and support provided in the community to avoid those admissions in the first place, this could put people at risk? That is a concern in the wider community at the moment. We should take them out, but how do we look after people better?
Lord Kamall (Con)
I start by paying tribute to all the work the noble Baroness has done in this area, and for educating me more on this issue when I was a relatively new Minister. All I can say at this stage is that patients who have a co-occurring mental illness as well as a learning disability or autism may well be detained under the Act, but we want to make sure that there is support in the community. This is one of the big debates we have seen on a number of issues—for example, on social care. How much of social care will be in homes and how much will be in the community? Does technology improve that? Does constant online communications technology, sensors and the ability to speak to somebody online almost immediately change that equation? A lot of that will be discussed as we debate the Bill and by the experts who, we hope, will be on the pre-legislative scrutiny committee.
Baroness Armstrong of Hill Top (Lab)
My Lords, I chair the Public Services Committee and we are currently concluding a report on workforce in the public sector. I hope the Minister will be able to read it and think about it over the recess to make sure that he takes account of it. In my work with women with complex needs, particularly those who have been groomed, it is absolutely clear that their sexual exploitation has led to significant trauma. The NHS will never be able to be the first body they interact with, or able to train enough people in the next 10 years to look after the wide range of people who we know now need mental health care. That means the Bill must link to the work of the voluntary sector and how we address trauma in people first approaching a public service, or any service. I am concerned that the Government think they can do it just by training more people, which will take a long time. They need to be working in a pathway that starts at a very different level.
Lord Kamall (Con)
I could not agree more with the noble Baroness. One thing we must be well aware of is that, although there are pressures and we are asked for more funding, the Government alone cannot do all this. Sometimes officials, be they from local or national government or from another state organisation, are mistrusted by vulnerable people. Local civil society groups, voluntary organisations and, often, those who have suffered the same problems themselves and then been inspired to set up their own organisation to support others—who can empathise with the situation many of these poor women are in—are sometimes the best first point of contact. As the Government spend more on this, we must make sure that we are not squeezing out the voluntary sector or local civil society, but working in partnership with them.
Lord Mawson (CB)
My Lords, my colleagues and I have been involved in this space for many years. I was in conversation with my colleagues just last week. I agree with the noble Baroness, but one of the challenges we face is the financing when organisations try to create this more integrated environment. The money and the streams coming out of the Treasury are endlessly pulling apart the very services that need to be connected. I encourage the Minister and his colleagues to look at some of that. In Bromley-by-Bow we are still dealing with 62 different funding sources from government, with all the attendant bureaucracy that is trying to deal with this problem.
Lord Kamall (Con)
The noble Lord makes a very important point from his own experience. I thank him for all his engagement and for educating me on what happens in the community. We must be careful because often, these issues are not simple or binary but are multi-faceted, and we then have different initiatives from the Government, which overlap. There is probably an incredibly complex Venn diagram of who is responsible, where the funding pots are and at what level you get the funding—is it local government, national government or philanthropy networks, for example? I would love to make it easy—but will I be able to?
Also, whenever you have change there are often winners and losers. Often, those who lose out because of change are very concentrated and make their voices heard, while the winners are dispersed and we do not hear them saying, “This is a great change.” Therefore, we must be very careful with any change in funding. However, the noble Lord makes an incredibly important point. We must ensure that we are not squeezing out civil society and pulling people in many directions, and that it is much easier to access finance. The noble Lord, Lord Glasman, made the point that as a Labour Peer, he is incredibly proud of 1945 and the welfare state, but that he worries that in doing such things, sometimes the state squeezes out local community groups and breaks the bonds in local communities. We must ensure that we get the right balance.
Lord Stevens of Birmingham (CB)
My Lords, I welcome the draft mental health Bill. Prime Minister Theresa May was right to ask Sir Simon Wessely to develop these proposals, which command wide support across the sector. It was pleasing to hear the Minister commit to the Bill’s passage through Parliament before, and hopefully well before, the next election. However, as a number of noble Lords have pointed out, to will the end is to will the means. The Minister will know that the Royal College of Psychiatrists and others, in the impact assessment for this draft legislation, have shown that to make this work in practice will require more people working in mental health.
To that end, if the Minister does not mind me banging a familiar drum, it is surely paradoxical that UCAS is reporting that only 16% of applicants for undergraduate medicine and dentistry got an offer this year. We are turning bright and brilliant young people away at precisely the time when the NHS, and indeed our mental health services in the future, will need their services. Deans of medical schools report that this year is the hardest in living memory to enter undergraduate medicine. Can the Minister give us a date by which the Government will declare their hand on the needed expansion of undergraduate medicine?
Lord Kamall (Con)
I am sure the noble Lord is aware that one of the things we found when looking at the shortage of doctors—even though we have more doctors than ever before—was that some people are likely to stay close to where they were trained. That is why, for example, we have opened the new medical schools, and we are bringing more doctors into the system. Clearly, that will not happen overnight, since training to be a doctor takes a very long time.
We are also looking at what else needs to be done at that level. There are other pathways, such as nurses becoming doctors after a certain amount of time. Clearly, international recruitment plays an important role there. Our aim is to have an additional 27,000 mental health professionals in the NHS workforce by 2023-24. We are investing money to achieve that, but again, it is a question of how long it takes for the money to get through. At the same time, we must ensure that by having this additional workforce in the NHS, we are not squeezing out the voluntary sector but ensuring that we are working in partnership with it.
Baroness McIntosh of Hudnall (Lab)
My Lords, I am sure the Minister will agree that if we get to point of having to apply the Mental Health Act to a particular individual, the system has failed because that person is, by definition, in crisis. I entirely accept that this Bill is necessary because the current legislation is no longer fit for purpose—Simon Wessely’s review is a very salutary read in that respect—but it is none the less the case that what we really need is to better equip our preventive services to deal with incipient mental health problems as they emerge, trying to prevent them becoming critical. That has been alluded to, in various ways, during this discussion.
Can the Minister tell the House where the £900 million —I think that is what he said—that is being committed immediately to the improvement of mental health services is to be spent? The real crisis is in the availability of human resource to deliver the service. There simply is not enough of it, as many people in this House, and certainly beyond, know from personal experience.
Lord Kamall (Con)
As noble Lords discussed during the Health and Care Bill, prevention is crucial. One thing I became aware of when I became a Minister was, when talking to the NHS and others, how they want to move away from purely curing to prevention. In response to the noble Baroness’s specific question, I commit to write to her on the exact allocation of that, but there is one area that plays an incredibly important role. We know, for example, looking back on the crisis, that when we did not know how long it would last, that created a lot of uncertainty. Uncertainty is very unbalancing for people, and it is a huge factor in them having mental health issues. Clearly, one of the issues that came up during the Bill was the use of civil society organisations, social prescribing, music and art therapy, but also conversations—people being able to talk to someone about the issue they are facing and feeling they are not alone. Clearly, that is something we have looked at, in terms of prevention, but in response to the specific question I commit to write to the noble Baroness.
Baroness Royall of Blaisdon (Lab)
My Lords, I am sure that prevention will be part of the new 10-year mental health strategy—or I hope that it will be—and also part of the 10-year suicide strategy. My noble friend asked when we might expect to receive a copy of that strategy, because of the exponential need, which the Minister has recognised, especially in relation to young people. I remind noble Lords of my interests in the register. I urge the Government to produce that strategy as soon as possible.
Lord Kamall (Con)
Clearly, there are a number of different facets to mental health and what we are looking at, but suicide is one of those areas. In fact, my right honourable friend the Secretary of State met a very well-known anti-suicide charity, or support group, the other day, to talk about this specific issue. It is a tragedy; we must do all we can and treat it with the same urgency that we would any other major killer. We know about the high percentage of male suicides and what proportion that is of young men’s deaths. We are looking at the drivers linked to suicide, including those that were not necessarily reflected in our previous strategy, such as gambling, domestic abuse and online safety.
We are engaging widely to shape our plan. We have announced a number of commitments for that plan, including a best practice guide, safety plans, et cetera, by early next year. I do not have the exact date yet, but I keep being told it is soon. That is not very helpful, I know, but I will try to get more information for the noble Baroness.