Mental Health Bill [HL]

Report stage
Wednesday 2nd April 2025 Lords Chamber

Report (2nd Day)

Relevant documents: 10th and 18th Reports from the Delegated Powers Committee. Welsh legislative consent sought.

19:14

Amendment 47

Moved by

[Baroness Tyler of Enfield]

47: After Clause 51, insert the following new Clause—
“Mental Health CommissionerAfter section 142C of the Mental Health Act 1983, insert—“Mental Health Commissioner
142D Independent Mental Health Commissioner: establishment(1) There is to be an office known as the Office of the Mental Health Commissioner.(2) The Office in subsection (1) must be established by the Secretary of State three months after the day on which the Mental Health Act 2025 is passed.(3) The Office of the Mental Health Commissioner will be led by an individual appointed by the Secretary of State titled the “Independent Mental Health Commissioner”.(4) The role in subsection (3) is referred to as the “Mental Health Commissioner”.(5) The Mental Health Commissioner may appoint staff to the Office of the Mental Health Commissioner they consider necessary for assisting in the exercise of their functions in section 142E. 142E Functions of the Commissioner(1) The Mental Health Commissioner is responsible for overseeing the implementation and operability of functions discharged by relevant bodies and persons under the provisions of this Act, the Mental Health Act 1983, and the Mental Capacity Act 2025 particularly regarding the provision of treatment, care, and detention of people with a mental disorder.(2) The Mental Health Commissioner must publish an annual report on the use of functions discharged under this Act, which must assess—(a) the quality of mental health care treatment provided by relevant services;(b) the accessibility of mental health care treatment services;(c) the relationship between mental health and the criminal justice system;(d) inequalities of mental health care provision regarding protected characteristics under the Equality Act 2010;(e) the use and effectiveness of detention measures under this Act, including but not limited to Community Treatment Orders, for the purposes of therapeutic benefit outlined in section 1(2B);(f) challenges surrounding stigma of mental health conditions;(g) the accessibility of advice and support to mental health service users, their families and carers on their legal rights;(h) other issues deemed appropriate by the Mental Health Commissioner.(3) In fulfilling their duties under subsection (1), the Mental Health Commissioner may review, and monitor the operation of, arrangements falling within subsection (1), (2) and (3) for the purpose of ascertaining whether, and to what extent, the arrangements are effective in promoting the principles in section 118(2B) of this Act.(4) Subject to any directions from the Secretary of State, the Commissioner may take action necessary or expedient in connection for the purposes of their functions.(5) This may include—(a) collaborating with health services, public authorities, charitable organisations, and other relevant entities, including NHS bodies, the Care Quality Commission, and the Parliamentary and Health Service Ombudsman;(b) ensuring enforcement authorities and public bodies under the Mental Health Act 1983 have the necessary capacity and resources to adequately discharge duties under the Mental Health Act 1983 and this Act.142F Appointment, Tenure, and Remuneration of the Mental Health Commissioner(1) The Secretary of State may by regulation make provision for the appointment, tenure, removal, and general terms of appointment of the Mental Health Commissioner.(2) The Secretary of State may also by regulation determine the Commissioner’s remuneration, allowances, and pension entitlements.142G Examination of cases(1) The Secretary of State may, by regulations, make provision for the examination by the Mental Health Commissioner of the cases of those who are detained under this Act receiving treatment by authorised mental health care providers.(2) The Secretary of State may, by regulations, provide for the Office of the Mental Health Commissioner to access and examine relevant data on mental health treatment provision held by NHS England and any other authorities the Secretary of State considers appropriate.142H Regulations(1) Regulations under sections 142F and 142G are to be made by statutory instrument.””Member’s explanatory statement
This amendment establishes the office of the Mental Health Commissioner and makes provisions for relevant duties and responsibilities.

[Baroness Tyler of Enfield (LD)]

My Lords, Amendment 47 would establish a mental health commissioner for England. The role would fill a major gap in the operation of the Mental Health Act and the rights of people with mental health difficulties. I believe this role is essential in ensuring oversight and advocacy for people affected by the Mental Health Act.

Unlike existing bodies, the commissioner would have a strategic, cross-government focus working to promote mental health, tackle inequalities and be a powerful advocate for the rights and well-being of those living with mental health problems, who would finally have a voice at the top table. The commissioner would also play a vital role in the public sphere, tackling stigma and discrimination and championing policies that support good mental health across society. The commissioner would have the independence to comment on the implementation of the reformed Mental Health Act and any subsequent changes or issues that arise. International evidence highlights the impact such a role can play in improving outcomes.

I know concerns were raised in Committee that the commissioner would duplicate the CQC’s Mental Health Act responsibilities. I simply do not believe this is so. The CQC is an arm’s-length body that has a statutory responsibility to inspect and regulate health and care services and intervene in cases of abuse of people’s rights, and it has powers to tackle poor practice in providers. Its work is essential, but its ability to oversee implementation is limited and it absolutely does not have a policy advisory function. I welcome the announcement of a new chief inspector for mental health at the CQC, who will lead the inspection of mental health providers. It is long overdue. However, like the CQC, the new chief inspector will have no role to work across government to take a view on public health policies or their implementation and to speak publicly on them, so the roles of the new chief inspector and the commissioner in my amendment are separate and distinct.

The commissioner would complement the CQC in the same way as the Children’s Commissioner complements Ofsted. I was very pleased to hear that the Minister recently had a productive meeting with the Children’s Commissioner, including, as I understand it, a discussion on children and young people’s mental health. I look forward to hearing more about that. I am sure that the Minister understands the distinct role that the Children’s Commissioner has in championing the rights of children with mental illness and that it is separate from the role of Ofsted.

Finally, I know that some concerns have been raised about resources. I emphasise again, as I did in Committee, that I envisage the commissioner having a very small secretariat, similar perhaps to the Domestic Abuse Commissioner or the Victims’ Commissioner. I believe the latter has around 10 staff. Of course, the commissioner would prioritise their work sharply. For a small investment, I believe that the commissioner could transform the way government and public services support our mental health, bringing a deep understanding of mental health into the heart of government, with statutory authority and independence that will enable them to inform policy, support delivery and oversee progress. They can bring government departments together to make the best use of resources and advocate for mental health in the public sphere. I beg to move.

[Lord Bradley (Lab)]

My Lords, I will speak briefly to Amendment 47, so eloquently moved by the noble Baroness, Lady Tyler. As the House will know, the establishment of a mental health commissioner was a recommendation of the joint scrutiny committee on the Bill, of which I was a member, but, disappointingly, it was not included in the Bill. As I have said on a number of occasions, I believe that a commissioner could be a voice at a national level, promoting the interests of those who are detained or are likely to be detained under the Mental Health Act, together with the interests of their families and carers.

There will be a need for rigorous, robust and consistent oversight of the implementation of the Act, wider mental health policy issues and service development, particularly workforce capacity, over the next decade and beyond. The establishment of a mental health commissioner could ensure public confidence, transparency and accountability during that period.

However, since Committee, the landscape has shifted somewhat. First, throughout the passage of the Bill, as we have heard, the Minister has made the case that the CQC, as the regulator, already has responsibility for the range of activities proposed for a mental health commissioner. This view was recognised by the Official Opposition. I still have considerable doubts about it but, as we have heard, the CQC has now created the role of Chief Inspector of Mental Health, because it at last recognises the crucial importance of mental health services in supporting people to lead fuller, healthier lives, and the need for specialist expertise in regulating those services. The eminent doctor, Arun Chopra, has been appointed. I hope to meet him as soon as possible, to be clear about his role and the range of activities that he sees it as his role as regulator to undertake. I hope that may go some way towards allaying my concerns.

Secondly, and importantly, the Secretary of State, Wes Streeting, has stated that, in future, he is determined to be directly accountable to Parliament for the performance of the health service—obviously, including mental health. To achieve that, he wishes to reduce arm’s-length bodies. As we all know, he has already announced the abolition of NHS England. Clearly, that will lead to significant uncertainty during the reform process, and the establishment of a mental health commissioner at this time would be unlikely to land favourably. It is clear to me that primary legislation might be required, yet again, to implement the NHS reforms that the Secretary of State is advocating, so Parliament may have a further opportunity to consider the new architecture of the NHS and then determine whether to bring forward plans for, among other things, enhanced advocacy and oversight of the implementation of the Act, and to support the policy development that a mental health commissioner, as we have heard, could bring to the table.

In the meantime, I will continue to take every opportunity to hold the Government to account, as the Secretary of State has assured us he will welcome. The Secretary of State should be looking particularly at the implementation of this Act and the capacity of the service to deliver it in a timely way. I will be looking at further developments of mental health policy, particularly the interface between health and the criminal justice system in the future.

[Lord Meston (CB)]

My Lords, I support the introduction of a commissioner. There seem to be three basic arguments that suggest it would be a good measure to take at this stage.

The first is the proven value and quality of work done by other independent commissioners, particularly the Children’s Commissioner, the Domestic Abuse Commissioner and the Victims’ Commissioner, as already mentioned. The second is the need for a commissioner to oversee the prolonged implementation of this Bill when it is enacted and the wide-ranging scope of work to be covered by the new legislation. Thirdly, a commissioner will enable standards of good practice to be maintained and raised. The existence of a dedicated commissioner should in fact remove, or at least reduce, the need for periodic statutory reviews of specific areas of work and functions in the field of mental health.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I have attached my name to Amendment 47, in the name of the noble Baroness, Lady Tyler, and I raised this issue at Second Reading.

A powerful case has already been made for a mental health commissioner, so I am just going to make one comparison here. At the same time as this Bill has been going forward, in the other Chamber I have been dealing with the Armed Forces Commissioner Bill. An Armed Forces ombudsman was created, which in some ways has parallels with the Chief Inspector of Mental Health and the CQC. It was found that that was not effective or strong enough, and now the Government themselves are going for the Armed Forces commissioner model.

There is another parallel. One of the reasons why it is felt so strongly that there needs to be an Armed Forces commissioner model is that members of our Armed Forces do not have the same rights. They have certain responsibilities laid on them and are treated differently from other members of society, which is why they need a special advocate. The parallel with people who are potentially subject to the Mental Health Bill is obvious.

In the health space, I have been heavily involved over the years with the Patient Safety Commissioner, which was initially resisted by the Conservative Government of the time. Eventually the fight was won, and it is now seen to be a huge success. This is a model that we can see working and that is seen to be necessary.

The Government have expressed a desire to get rid of arm’s-length bodies and make decisions themselves. The Government devolve decision-making to those so-called quangos—the arm’s-length bodies—but that is not the case with the Patient Safety Commissioner; there is no parallel here. They are a person who is there as an advocate and to have oversight; they are not making decisions. I do not think the Government can shelter under that umbrella.

[Lord Kamall (Con)]

My Lords, I thank the noble Baroness, Lady Tyler, for, as others have said, the eloquent way in which she introduced her amendment.

I know this is a topic that noble Lords across the House feel strongly about, and I appreciate the arguments in favour of the creation of a commissioner. Indeed, as other noble Lords have said, it was a recommendation of the pre-legislative Joint Committee.

Having listened keenly to what the noble Baroness has said, and having discussed this issue with her and her noble friends, I have to say that I agree with the noble Lord, Lord Bradley, when he says that the landscape has changed. We are now at a time when the Government are looking to reduce duplication and arm’s-length bodies—something that I believe a responsible Opposition should support. We believe it should not be necessary to have a new, separate, independent mental health commissioner.

We were going to group this amendment with the ideas about strengthening the CQC, but that has been ungrouped and we will talk more to it in the next group. When I had some conversations with those who supported the independent mental health commissioner, they said I should look to Children’s Commissioner as an example. I looked at the Children’s Commissioner; it does a great job, but it has a staff of 25, a temporary staff of 31, and expenditure of £3 million. That may not sound a lot of money but I wonder whether that amount of money could be better invested in strengthening the CQC. One of the things about any bureaucracy is that they grow and have more non-essential roles as other bits of legislation bring them in. I worry about the cost and duplication of functions.

I completely understand the argument from those who say that the CQC has not been doing its job and those who have criticised it for being ill-equipped. That is why we tabled our amendment, which will be discussed in the next group, about strengthening CQC functions. However, rather than saying all that now and repeat it in the next group, I do not wish to detain the House any longer. I believe there should be a comprehensive review of the CQC and proper accountability, and I hope we can achieve that without an independent commissioner.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, I thank all noble Lords for their contributions on this fiercely and keenly debated proposal. Amendment 47, in the name of the noble Baroness, Lady Tyler, leads me to say that we continue to be of the strong view that the functions of the proposed commissioner, as set out in the amendment, would clearly overlap with the existing responsibilities of other organisations, most notably the CQC. I must respectfully disagree with the noble Baroness: the CQC has a statutory role in monitoring the Mental Health Act. It publishes an annual report that serves to drive policy improvements in this area.

19:30

It remains our position that inserting yet another body into an already cluttered and fragmented patient quality and oversight landscape is seriously unlikely to provide the clear and strategic leadership or the effective voice for mental health patients that the noble Baroness and all of us seek.

As my noble friend Lord Bradley, supported by the noble Lord, Lord Kamall, referred to, in the six weeks since we last debated this issue in Committee, there have indeed been key shifts to the wider context in which we are working. First, as has been acknowledged, there has been the appointment of the first Chief Inspector of Mental Health, Dr Chopra. I am very glad to hear the welcome in the Chamber for the establishment of a new post and the appointment. This is a very significant milestone that will improve the voice of mental health in-patients and help to see that their rights are better upheld.

Supporting implementation of the Mental Health Act reforms will be a key priority of the chief inspector and I am confident that this and the wider reforms that the CQC is making progress with under the new leadership will significantly improve its effectiveness as a regulator of mental health services. Like the noble Lord, Lord Kamall, I will speak more to this point when we consider the amendment in his name in the next group.

[Lord Scriven (LD)]

Can I just ask the noble Baroness a very quick question? Will the newly appointed person have a statutory right to call for papers and witnesses from other departments to deal with mental health issues, as a commissioner would?

[Baroness Merron (Lab)]

I cannot draw a comparison with a commissioner but I will be very pleased to answer the noble Lord definitively in writing.

Secondly, as announced by the Secretary of State, we are abolishing NHS England as part of the radical reforms we are making to the national health system to rid it of duplication, inefficiency and waste, so that vital resources can be redirected to the front line. On this, we very much look forward to the much-anticipated report from Dr Penny Dash on the wider patient safety and oversight landscape. Of course, as noble Lords will be aware, the 10-year plan for the NHS is being co-developed with staff, patients and the public. I believe these changes only confirm that creating a new mental health commissioner would be not only duplicative but completely at odds with the important and very live reforms that the Government and the CQC are making.

During the course of the Bill, including today, I have heard noble Lords speak passionately about introducing a mental health commissioner role akin to that of the Children’s Commissioner. I very much value the work of the Children’s Commissioner and, as I have said before, I do not accept that it is a valid comparison. More pressingly, following a constructive meeting last week with the Children’s Commissioner, which the noble Baroness, Lady Tyler, referred to, I can report that she is concerned about the establishment of a mental health commissioner. In her view, covering all aspects of children and childhood is a critical part of her role. This is because children see their mental health as indistinguishable from their wider health and experience of childhood. We discussed this at some length. The Children’s Commissioner’s view is that the proposed establishment of a mental health commissioner risks taking a siloed approach to the barriers and challenges that children face, and I feel it is incumbent on us to listen to that view.

I also reiterate that I am deeply concerned about the level of resource needed to take this forward, as required in the amendment, as was understood by the noble Lord, Lord Kamall. This would be on top of the resources needed to remodel the healthcare quality and regulatory landscape to avoid the risk of duplication and waste. I can honestly say that I do not feel that this can be justified, particularly in the current climate.

The noble Baroness, Lady Bennett, made comparisons with the Government’s plan to introduce an Armed Forces commissioner. This is a manifesto commitment that we are certain addresses an important and specific gap: the strengthening of support for Armed Forces communities to improve service life. Furthermore, we are talking about an entirely different set of responsibilities, aimed at different set of needs in an entirely different environment. So I have to say once again that I do not believe that it is a useful comparison with respect to Amendment 47. For these reasons, I ask the noble Baroness to withdraw the amendment.

[Baroness Tyler of Enfield (LD)]

My Lords, I thank the Minister for her response and particularly thank other noble Lords who have contributed. I apologise to the noble Baroness, Lady Bennett, for forgetting to thank her for adding her name.

The short answer is that we disagree quite fundamentally on this. I do not accept the argument that the Minister has just put forward that the comparisons that I and the noble Baroness, Lady Bennett, have drawn are not good; I think they are very good. Of course, I understand that the landscape has changed. I understand that arm’s-length bodies, particularly large ones, have gone out of fashion and I understand the reason for that. I am talking about a very small body that acts as an advocate. I think that is different. I do not think it is something that the CQC can or will do.

I am pondering on what the Children’s Commissioner has said. I understand the point about children and their mental health being part of their wider experience, but we have to remember that a lot of the work of the mental health commissioner would be about adults who are being detained and whatever. We are not going to agree, so I suspect the best thing to do is to test the opinion of the House.

19:37

Division 6

Ayes: 49

Noes: 129

19:47

Amendment 48

Moved by

[Baroness Tyler of Enfield]

48: After Clause 51, insert the following new Clause—
“Review and reporting on inequalities in Mental Health Act Measures(1) As soon as reasonably practicable after the end of each calendar year, the Secretary of State or appropriate national authority must conduct a review, in consultation with relevant bodies with commissioning functions, on the use of treatment and detention provisions contained in the Mental Health Act 1983, broken down by race and other demographic information.(2) Having conducted a review under subsection (1), the Secretary of State or appropriate national authority must publish a report on the progress made in reducing inequalities in treatment outcomes and the use of detention under the Mental Health Act 1983 on people who have protected characteristics under the Equality Act 2010.(3) In this section “the appropriate national authority” means—(a) in relation to services or unit whose area is in England, the Secretary of State;(b) in relation to units or services whose area is in Wales, the Welsh Ministers.”Member’s explanatory statement
This amendment requires the Secretary of State or Welsh Ministers to review and report annually on the use of treatment and detention measures under the Mental Health Act 1983, analysing data by race and other demographics to assess progress in reducing inequalities for those with protected characteristics under the Equality Act 2010.

[Baroness Tyler of Enfield (LD)]

My Lords, Amendments 48 and 49 are in my name. I thank the noble Baroness, Lady Bennett, for adding her name to Amendment 49.

As debated throughout the passage of the Bill, a primary driver of the review into the Mental Health Act was the shocking racial injustices in the use of that Act. The figures are well known to us: black people are disproportionately more likely to be detained and put on a CTO, and experiences and outcomes for people from racialised communities are, on average, worse. One of the main policy objectives set out in the Bill’s impact assessment is to

“reduce racial disparities under the MHA and promote equality”.

That is great but, given that, I have found it surprising from the outset that race and racial disparity were not mentioned anywhere in the Bill or the Explanatory Notes.

Instead, there has been an expectation that non-legislative programmes—in particular, the patient and carer race equality framework, which is a contractual arrangement—and some of the Bill’s broader reforms will reduce racial disparities without specific legislative requirements. I was grateful to the Minister for organising a helpful recent round table on reducing racial disparities. I learned a lot about the operation of the PCREF, if I might call it that; I will return to it shortly.

I believe there is currently insufficient collection and reporting of data on the experiences and outcomes of people from racialised communities under the Act. That in turn hinders the ability to scrutinise progress being made in reducing racial disparities. I know from our deliberations on Monday that further thought is being given to this and that new research is being commissioned. I very much welcome that, so what would my amendments do?

In brief, my Amendment 48 would require the Secretary of State and Welsh Ministers

“to review and report annually on the use of treatment and detention measures”,

broken down by detected characteristics. This would enable us to understand whether these reforms are fulfilling their intended purpose of bringing down inequalities and to identify any further action needed. However, I firmly believe that this needs to be accompanied by Amendment 49, which would introduce a new responsible person role at hospital level in mental health units to tackle and report on racial and other inequalities, as recommended by the Joint Committee.

The Minister has expressed concerns that a responsible person role may duplicate existing roles and duties, such as those under the Equality Act. I do not believe that will be the case. Where there are people performing similar roles, they can take this on but, in many places, local PCREF leads do not exist. Where they do, they can take on the responsible persons role and that is absolutely fine. I think this role would actively assist providers in complying with PCREF and their Equality Act duties. It would also help to drive implementation of other measures in the Bill, such as advance choice documents and opt-out advocacy. These important measures are much more likely to succeed if someone is clearly tasked with ensuring that the mental health unit implements them, everyone knows who is in charge and who is accountable.

There is a model for the use of a responsible person at unit level, in the Mental Health Units (Use of Force) Act 2018. Under that legislation, the role is accountable for ensuring that the requirements of the Act are carried out. It is a senior role which may be carried out by an existing member of staff, such as a medical director or director of nursing. That would be a good model to follow. Giving an existing senior clinician with the necessary clout the responsibility to make things happen and creating clear accountability would really help to bring down disparities at local level.

The scope of the PCREF, which is NHS England’s anti-racism framework, is rightly much broader than the Mental Health Act. The responsible person in my amendment would be accountable for ensuring that the voices and interests of detained patients and their carers are properly reflected in the PCREF.

Finally, I was very grateful to the Minister for our recent correspondence following the helpful round table I referred to. I was very struck by the acknowledgement at that event of the big difference that a responsible person could make in enabling the patient and carer race equality framework to reduce both racism and racial inequalities in the way the legislation operates. As the Minister knows, I have made the—hopefully—helpful suggestion that some form of pilot of the responsible person role could considered at an appropriate time when the PCREF has bedded down and with some idea of how effective, or otherwise, it might be. Any assurances the Minister could provide would be much appreciated. I beg to move.

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Tyler. I have attached my name to the noble Baroness’s Amendment 49. As the noble Baroness said, like Amendment 48 it addresses one of the primary reasons for reviewing the Mental Health Act in the first place. Black people are over 3.5 times more likely to be detained under the Mental Health Act than white people, and over seven times more likely to be placed on a community treatment order. Their experiences and outcomes are worse. All of those are facts. As the noble Baroness, Lady Tyler, said, the Bill somehow does not seem to be addressing that. We are taking an overall systemic view but not addressing the issues of a particular population. The reason I chose to sign Amendment 49—we are going to come shortly to the amendment in the name of the noble Lord, Lord Stevens, looking at the resources being put into the Mental Health Act—is that this is another way of putting resources into what everyone agrees is a crucial issue. This is a different way of allocating resources.

The noble Baroness, Lady Tyler, has made the case that PCREF is not the same thing. The Care Quality Commission does not have the same kind of situation. We are talking about people at a local trust level here; that is where the responsible person would be. As the noble Baroness said, if there is already someone, because of local arrangements, fulfilling this role, they can simply adopt this along the way. It does not have to be any kind of duplication. I note that the campaign group Mind very strongly backs this amendment. It delivers where we started from on this whole Bill.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I will speak to Amendment 61, which calls for a review into the causes and consequences of the huge spike of diagnoses of mental disorders. It should also investigate the impact of this on the availability of services that we envisage treating people with a mental disorder that this Bill seeks to help.

If, in our best efforts to provide alternatives to detention for the severely ill, we hope to ensure that adequate care in community settings exists, we must look at the phenomenon that threatens to squeeze out those who most need access to such services. Implicit to this endeavour is to ask if, inadvertently, some aspects of policy set in train a self-fulfilling prophecy. Rebranding any deviation from the norm, troublesome behaviour, anxiety or even, according to the Government’s curriculum review, GCSE exam stress, under the therapeutic language of mental health has consequences. As Tony Blair has noted recently:

“you’ve got to be careful of encouraging people to think they’ve got some sort of condition other than simply confronting the challenges of life”.

Yet the young especially are prone to internalising the narrative of medicalised explanation and adopt an identity of mental fragility and illness. This can create a cohort of citizens demanding official diagnoses, NHS intervention and treatment.

This week, the media has featured the new book by Dr Alastair Santhouse, a neuropsychiatrist from Maudsley Hospital. In the book No More Normal: Mental Health in an Age of Over-Diagnosis, Dr Santhouse argues that it has become crucial to reassess what constitutes mental illness:

“so that we can decide who needs to be treated with the limited resources available, and who can be helped in other ways”.

He worries the NHS has

“buckled under the tsunami of referrals”.

Other state services are straining to the point of dysfunction as well. Despite the fact that the number of children with education, health and care plans has more than doubled in less than 10 years, parents are still desperately complaining about waiting for years for autism and other assessments. In other words, the demand is just galloping.

All of this is leading to at least 18 councils being at risk of insolvency, according to the Guardian on Monday. The present row over PIPs and the welfare system collapsing under the costs of ever greater numbers claiming disability payments for mental disorders is now a major political issue. I have been partly inspired to table this amendment by the Health Secretary Wes Streeting’s concern about overdiagnosis of working-age adults leading them to be “written off”, as he said. It is especially tragic that this is happening overwhelmingly among young people.

My concern, and the point of this amendment, is that this can skew NHS provision. A Savanta poll of 1,001 GPs for the Centre for Social Justice’s report Change the Prescription reported that four in five, 84%, of GPs believe that the ups and downs of normal life are now wrongly being redefined by society as mental disorders. Of those GPs, 83% now believe that anti-depressants are too easily prescribed to patients. But the GPs are under so much pressure from patients demanding treatment that they prescribe them. Similarly, in 2013 and 2014 just 1,800 adults were prescribed drugs for ADHD, but last year 150,000 adults were prescribed with ADHD medication. Waiting lists keep growing and lots of anger continues.

When I last spoke on this topic in the Mental Health Bill debate, the media picked up on it and I was inundated with emails, largely from people furious with me for challenging overdiagnosis; I had a tsunami of hate mail. There was even a formal complaint sent to the standards committee of the House. People said, and I understood it, “How can you say there is an issue with overdiagnosis when I can’t get a referral for myself” or “for my child” and so on. It is true that a GP cannot formally diagnose ADHD as it requires specialist assessments. The average waiting list for an ADHD referral on the NHS is now three years. This lack of formal diagnosis is not necessarily stopping service provision becoming overwhelmed and distorted, and I think this mood will have a very damaging impact on what we want this Bill to do.

I will finish with an apocryphal tale from the University of Oxford’s disability report from 2022-23. It reveals that the university has, under pressure from students, agreed to

“accept a wider range of disability evidence”

as a key to giving 25% more time in exams and the use of computers in exams. The university’s explanation is telling. It talks of

“a wider context of extensive and ever-growing waiting times for ADHD and autism diagnostic assessments”,

so it aims to reduce “administrative burdens and barriers” for disabled students.

20:00

The parallel for us in relation to the Bill is that the hard-fought-for arrangements for the disabled at university are now potentially being corrupted by an overdemand and by demands for diagnosis. Diagnosis itself is now being conflated with supporting documentation, so it is enough for those students to be on a GP’s waiting list for formal assessment to be treated as though they are disabled. I hope noble Lords can see the dangers of such trends off-campus for the Bill here.

My personal worries are about the culture of draining society of resilience and of a dependent citizenry, but for this Mental Health Bill it would seem sensible for the Government to review the confusion about who services are for and what is driving this extraordinary increase in those demanding NHS, mental health and autism services—because it seems to me that it is social rather than medical. Whatever is happening, it could mean that those most in need will be neglected in the scramble for official labels and treatments.

Some reassurance from the Minister at the Dispatch Box that this will be looked at, rather than overlooked, would make me feel that this major social phenomenon is not going to be swept under the carpet—because I think it will negatively impact on the implementation of the Bill.

[Baroness Browning (Con)]

Before the noble Baroness sits down, she mentioned autism several times, but the whole purpose of the Bill is to remove autism and learning disability from mental health, where it previously was. In fact, I served on the Bill Committee, as did others in the Chamber, in 2005-06, when I was really opposed to autism being added to the 1983 Act. But it was added, and now it is being taken out, I am very pleased to say.

I hope that the noble Baroness will accept that there is a piece of legislation about this on the statute book: the Autism Act 2009, which is being reviewed by the House at the moment. Autism is not some fad, something that people just make up, or something temporary; it is a lifelong neurological condition. I raise the failure to provide the right services for people with autism who are in that part of the spectrum where they need support. Not everybody does: it is a spectrum, and I quite agree that there are people on the spectrum who cope quite well with life, knowing that they have autism and not needing that sort of support. We have discussed that support a lot in the course of this particular Bill, and if you do not provide it where it is needed—this is the weakness that we are looking at in the current Autism Act—that leads to quite serious mental health conditions, including suicide. Of all the conditions that the noble Baroness mentioned, among the autistic community the suicide rate is the highest.

[Baroness Fox of Buckley (Non-Afl)]

I genuinely appreciate that intervention. That is what I think too. It is precisely the inappropriate use of terms such as autism in relation to this overdiagnosis that concerns me, because it is too glibly used. That is part of what I am talking about. I absolutely want those people who need the intervention to get it, but my concern is if it becomes widely used socially, in the way that I did not want to go into in great detail, on university campuses or in society in general. I note the TikTok phenomenon of people getting diagnoses and that being used, and so on. My concern is that the label, the labelling process and the demand for diagnosis and treatment squeeze out the very people that the noble Baroness is talking about.

I too have spent many years trying to distinguish between autism and mental illness. It drives me mad that people do not know the difference. My problem is that, in the debate about this issue, they are very often all lumped together in a way that is medically not clarifying, but the demand for a medical label can mean that people are not even that choosy about which one they get. That is where I have tried to raise an issue.

[Baroness Browning (Con)]

I am very grateful for that response. The noble Baroness said that autism is different; it certainly is different, which is why it has its own Act of Parliament.

[Lord Kamall (Con)]

My Lords, as I said on the previous group, I will start by speaking to the amendment in my name and that of my noble friend Lord Howe. It would require the Secretary of State to conduct a review into the ability of the CQC to effectively fulfil its role

“in carrying out its duties under the Mental Health Act 1983, and … in regulating the provision of mental health services”.

We have also included proposed new subsection (3), which would ensure that the review of the CQC’s functions will also include an assessment of whether it will be able to “effectively carry out” its new duties under the Bill.

As the Minister will know, in May 2024, Dr Penny Dash was commissioned to conduct the independent review of the operational effectiveness of the CQC. The full report, published in October, found

“significant failings in the internal workings of CQC which have led to a substantial loss of credibility within the health and social care sectors, a deterioration in the ability of CQC to identify poor performance and support a drive to improved quality—and a direct impact on the capacity and capability of both the social care and the healthcare sectors to deliver much needed improvements in care”.

In addition, my noble friend Lord Howe raised the issues arising from his meetings with the charity Blooming Change on a number of occasions. It has raised serious concerns about the CQC’s monitoring activity. We also know that the Secretary of State himself has claimed that the CQC is not fit for purpose, and that there are some fundamental issues with how the CQC oversees the mental health care system.

As we have heard from other noble Lords, one solution would be to have an independent mental health commissioner. Our solution is to call for a review of the CQC that specifically focuses on its mental health functions, to make sure that it does its job properly. The review conducted by Dr Dash comprehensively assessed the CQC’s ability to regulate primary, secondary and community care, but it did not focus on the sufficiency of mental health care regulation. I thank the Minister for the brief meeting with my noble friend and me earlier this week, in which she indicated that she would be able to give greater assurances on this particular issue. I look forward to what the Minister has to say on it, because this is part of our justification for not supporting the mental health commissioner: we want to see a strengthened CQC. We do not want duplication, but, in avoiding duplication, we want to make sure that the CQC does the job it is supposed to do. I hope I can get that assurance from the Minister when she speaks.

I have some sympathy with Amendment 61, in the name of the noble Baroness, Lady Fox, in line with the comments of the former Prime Minister, Tony Blair, but I also have some sympathy with what the Secretary of State said. We thought about whether we could find an appropriate amendment to table on this. We have to be very careful and sensitive about this issue: we in Parliament or officials in Whitehall cannot hope to pronounce on the issues individuals face in their homes or communities. It is about getting the balance right.

The noble Lord, Lord Alderdice, also spoke about the concerns about overdiagnosis, but we cannot just make a generalisation. We have to make sure that the mental health professionals are doing their job, with the right guidance, to ensure that we understand the needs of each individual. For that reason, I thought it was far too difficult—and it would have been insensitive —for me to lay an amendment on this topic. I did not want to go there for that reason. This is an issue that has to be discussed, but we have to do it in the most appropriate way—in a sensitive way that understands those who suffer seriously from mental health conditions.

Let me turn to the amendments tabled by the noble Baroness, Lady Tyler. She and I have both raised the issue of racial disparities. In Committee, I went in very strongly on it—this is the issue that matters to me personally very much, and I shared some of my own experience of racial discrimination. I am as frustrated as everyone else that we still have not resolved the problem to this day; we still do not understand why, disproportionately, black men in particular are subject to detentions and community treatment orders. I asked questions at the time. What do we know? What do we not know? What are we doing to fill that knowledge gap? Once we have filled that knowledge gap, what are we going to do about it? Once again, I thank the Minister and her officials for the detailed meetings that they had with us when they laid out some of the things that they are doing. Could I tempt her to share with noble Lords some of that discussion and her letter, to assure us all that the Government really are on top of that issue, know what they are doing and are going to address these problems?

I was unsure about how effective the provision in Amendment 49 would be. I know that it is not very fashionable for politicians to say, “I don’t know”; we are supposed to make a firm decision one way or the other and agree or strongly disagree. But I wanted to reflect on whether that amendment would represent an additional burden on the healthcare professional, additional cost or additional bureaucracy. Given that we cannot, at this stage, say for sure how this will turn out, I support the suggestion of the noble Baroness, Lady Tyler, to pilot a scheme of a senior responsible person to address racial disparities. If we could pilot it in some places, it would give us the data to understand whether a responsible person would be effective in addressing those disparities. We all know that more needs to be done. We have had successive Governments of all political colours, and we still have not solved this problem. Let us be determined, as a House, whichever party we are, to tackle this problem of racial disparities, and let us make sure that we do it in the most effective way.

I am grateful for what the Minister said on Monday, but I hope that she will give some consideration to what the noble Baroness, Lady Tyler, said about piloting a responsible person to see whether that works. Maybe it will not work, but at least we would have the data and evidence. I would appreciate the Minister giving a more detailed explanation of some of the research that is being conducted to fill that gap, so we can understand why there are still racial disparities and what Governments of any political colour would have to do to address them.

[Baroness Merron (Lab)]

My Lords, I thank all noble Lords for their contributions on this important and somewhat wide-ranging group of amendments.

I turn first to Amendment 48, tabled by the noble Baroness, Lady Tyler. We very much recognise that there are inequalities in the use of the Act between different demographic groups, and particularly that there are significant racial disparities. The noble Lord, Lord Kamall, has rightly expressed some frustration with the fact that we all find ourselves where we are today.

To those points, I would say that these inequalities are explored in the impact assessment published alongside the Bill. I reiterate how grateful I am to Peers who recently attended our round table to examine research findings and ongoing work to address racial disparities under the Act. I am glad to hear that the noble Baroness, Lady Tyler, found it helpful—as indeed I did.

I offer the assurance that NHS England already publishes the Mental Health Act Statistics annual reports, broken down by ethnicity and other demographic information, including gender, age and index of multiple deprivation decile. We are improving the data through the patient and carer race equality framework, and we will monitor these inequalities as part of the overall monitoring and evaluation of the reforms.

Furthermore, as I announced on day one of Report, I commit to update Parliament annually on our progress with implementation, including racial disparities. I also committed to undertake further investigation into racial inequalities under the Act. As far as possible, we want to better understand where disparities are most significant across the patient journey, what drives those disparities and, most importantly, where we can most effectively intervene to reduce those inequalities. I very much look forward to keeping Peers updated on those findings, as the noble Lord, Lord Kamall, has rightly requested.

20:15

Amendment 49, also in the name of the noble Baroness, Lady Tyler, seeks to create a new role of a responsible person. We agree that there is a need to improve organisational leadership, improve data collection and change culture across the mental health system. This is exactly what the patient and carer race equality framework is designed to achieve; it requires a nominated executive lead at board level, who is accountable for the delivery and oversight of the framework and implementing culturally appropriate care. This is now part of the NHS standard contract and, I am glad to say, applies both to the NHS and independent providers of NHS-commissioned care. It builds on the duties that apply already under the Equality Act 2010.

These existing duties and contractual requirements cover all the key responsibilities of the proposed responsible person role. The added benefit of having many of these requirements set out in the patient and carer race equality framework is that it can be updated more regularly than primary legislation. This allows us to take a more agile and iterative approach throughout the implementation of the Bill, to ensure that we do what noble Lords want the legislation to do: that is, capturing, reporting and acting on the right data and information from front-line services.

I appreciate the suggestion of the noble Baroness, Lady Tyler, for pilots. We believe that the points that I have just raised go further than the suggested pilots and, as the noble Baroness will be aware, that the addition of a responsible person in the legislation is duplicative and unnecessary.

I turn to Amendment 60, tabled by the noble Earl, Lord Howe, and the noble Lord, Lord Kamall. Two major independent reviews into the CQC have reported under this Government in the last few months. One was by Dr Penny Dash, on the CQC’s operational effectiveness as a regulator of all health and social care providers, including mental health, and the other was by Professor Sir Mike Richards, on the CQC’s single assessment framework. These reviews were prompted by very significant concerns that the CQC was no longer fit to spot poor performance, resulting in quality and safety concerns falling under the radar, which is not acceptable. We are most grateful to Dr Dash and Professor Sir Mike Richards for their recommendations, which the CQC has accepted in full.

As I have already mentioned, we particularly welcome the appointment of Dr Chopra, the CQC’s first Chief Inspector of Mental Health. As I have said, this is a very significant milestone, and one which will improve the voice of mental health patients and help to see that their rights are better upheld. To offer further assurance to the noble Lord, Lord Kamall, the Chief Inspector of Mental Health will carefully explore how to strengthen the focus on Mental Health Act compliance in regulatory assessment of providers and how to ensure that the CQC has the capabilities and systems to ensure effective monitoring of providers’ compliance with all aspects of the Mental Health Act, including the reforms. On top of that, the CQC is working to strengthen the expertise in its workforce and improve how it carries out assessment of services. Under the leadership of a new chief executive, Sir Julian Hartley, it is working to build the foundations for good regulation, including looking at the organisation’s purpose and value.

I reiterate the point that I have made to the noble Lord, Lord Kamall, in previous meetings that the department’s director-general of secondary care and integration has been meeting the CQC’s chief executive and his team every two weeks to monitor progress, with regular reports made to the Secretary of State so that he can keep abreast of developments. These changes will see that the CQC is better placed to regulate mental health services.

On the CQC’s specific role in relation to the Mental Health Act, I have listened carefully to the concerns raised by noble Lords and I am pleased to announce that we plan to report on the CQC’s monitoring functions under the Act in the first of the Government’s annual reports on implementation of the Bill. We will also invite the new chief inspector of mental health to provide their reflections on the CQC’s statutory functions and their role as a partner in the delivery of these reforms, which will feature in our report. This will draw on the chief inspector’s valuable professional background in the field, both in the delivery of front-line clinical psychiatric care and as medical director of the Mental Welfare Commission for Scotland. The report will be laid before both Houses of Parliament.

Finally, I turn to Amendment 61. I was interested to hear that the noble Baroness, Lady Fox, was inspired by the Secretary of State’s comments to bring forward this amendment. As she rightly said, the Secretary of State has set out previously that he believes that there is an issue with overdiagnosis of some mental health problems. I thank the noble Baroness, Lady Browning, for her helpful intervention to shine more light on the discussion that was had. There is no doubt that too many people in this country are being written off and not getting the support that they need, which is why the Government’s shift from sickness to prevention is so important. We know that, if support can be provided to people much earlier, the onset of mental illness and deterioration of mental health can be prevented. That is why, as one of a number of measures, we are rolling out mental health support teams to schools in England.

I say to the noble Baroness, Lady Fox, that this is an important area, and we are keen to take a closer look and, as ever, follow the evidence. We are looking into the best way of getting into these questions and addressing these issues. I hope that my words and promised actions have given reassurance—

[Lord Kamall (Con)]

I am sorry to interrupt. Just to go back to my amendment on the CQC, one of the arguments for those who believed in creating an independent mental health commissioner was that they would be a voice for the patients. With that strengthened role for the CQC, where is that voice for the patients? That was one of the justifications for those arguing for creating a mental health commissioner. We decided not to support that because we thought that function should be part of what the CQC does. Could the Minister reassure us on that point?

[Baroness Merron (Lab)]

For me, it is about not just somebody speaking for others but getting those voices heard. I hope that the noble Lord and all noble Lords have heard my acknowledgement of the importance of that. Those with lived experience need to be properly heard and their voice amplified. I have given a number of reassurances on that point.

With that, I hope that the noble Baroness can withdraw her amendment.

[Baroness Tyler of Enfield (LD)]

My Lords, I thank all noble Lords who have contributed to this group and the Minister for her responses. I also thank the noble Lord, Lord Kamall, for supporting my suggestion about a pilot for the responsible person. I have noted that the Minister has said that a pilot is not really necessary because what the Government are doing goes further than that. That is one way of looking at it, but I have to be honest and say that it is not quite how I see it. I completely take the point that we need to see what happens when the PCREF has bedded down. Let us see what it achieves, but if it does not achieve what we all want to see then we will need to think at that point about whether a responsible person would make the sort of difference that was being talked about at that very helpful round table.

I look forward to hearing more about the various actions that the Minister mentioned in relation to the CQC. I of course look forward to meeting the new chief inspector and will be interested to hear how they see their role, particularly the extent to which they think they are an advocate, providing a voice for people with mental health difficulties. This gets to the very heart of this Bill and the very reason why we have it in the first place. It is an incredibly important issue. We could talk about it for a long time, but we cannot. The hour is late and it is incredibly unfortunate that we have had such a truncated second day of debate. I know that these things happen but, given the importance of the topic, it is extremely unfortunate. Having said that, I beg leave to withdraw my amendment.

Amendment 48 withdrawn.

Amendment 49 not moved.

Amendment 50

Moved by

[Baroness Tyler of Enfield]

50: After Clause 51, insert the following new Clause—
“Workforce sufficiency assessment by Integrated Care BoardsAfter section 142C of the Mental Health Act 1983 (inserted by section 51 of this Act), insert—“142D Workforce sufficiency assessment by Integrated Care Boards(1) Each Integrated Care Board must conduct a workforce sufficiency assessment every two years to evaluate whether it has sufficient workforce resources to deliver services under this Act effectively. (2) The assessment may include—(a) an analysis of current workforce levels across all relevant service areas;(b) identification of workforce shortfalls;(c) an evaluation of the impact of staff shortages on patient care and service delivery;(d) proposals to address workforce challenges.(3) Integrated Care Boards may consult any relevant personnel or organisations they deem appropriate when conducting the assessment.(4) Each Integrated Care Board must publish a report outlining its findings upon completing the assessment.(5) The first reports must be published 12 months after the day on which the Mental Health Act 2025 is passed.””Member’s explanatory statement
The amendment requires Integrated Care Boards to produce a biennial report assessing workforce sufficiency, identifying shortages, and proposing measures to address workforce challenges in delivering services.

[Baroness Tyler of Enfield (LD)]

It is funny how these amendment groupings work, is it not? I will speak to my Amendment 50 and say a few comments on Amendment 59 in the name of the noble Lord, Lord Stevens, to which my name is attached.

We have talked a lot throughout the passage of this Bill, and rightly so, about the importance of how it is implemented and in particular about ensuring that sufficient resources are available to allow a much-needed expansion of community mental health services. To be blunt, unless this happens, the Bill just will not be implemented. To put this into context, those waiting the longest for elective community mental health care—both adults and children—have waited two years, which is twice as long as those waiting for elective physical health care. Parity is still a long way off.

I was very grateful to the Minister for sharing the Government’s implementation plan and for arranging a helpful discussion with her and officials.

My Amendment 50 would require integrated care boards to produce a biennial report assessing workforce sufficiency, identifying shortages and producing measures to address workforce challenges in delivering these services. We all understand that it will take time to enact the Bill’s provisions and that systems will take time to build capacity, including training of an expanded work- force—particularly given existing workforce challenges. In Committee, I talked about the workforce impacts of the Bill, drawing on figures and research from the Royal College of Psychiatrists. I will not repeat those figures, save to say that NHS England set a target back in 2016 to have more than 1,040 consultant psychiatrists in post in England by last year. Based on these targets, as of last year, there was still a shortfall of 769, so we still have a long way to go. Of course, the mental health workforce goes considerably wider than consultants.

I turn to Amendment 59 in the name of the noble Lord, Lord Stevens, to which I have added my name and which we very strongly support on these Benches. This amendment would ensure that mental health funding is not cut as a share of overall health service funding until this Bill is fully implemented. Indeed, it is vital, given the pressures on public finances, including on the overall health system and the pressures that they pose to mental health spending. Critically, the amendment would not tie the Government’s hands in whatever decisions they make about the overall level of NHS spending.

One reason why I support this so strongly is because the Written Statement from the Secretary of State on 27 March on the amount and share of spend on mental health was, frankly, not reassuring, with mental health spending expected to go down as a proportion of overall NHS spend this year and a forecast for similar next year. I know that it was small amounts, but this could be part of a trend. It just reinforces the point that mental health spending and parity of esteem are not currently sufficiently protected, which I believe underlines the need for legislative cover. Therefore, if the noble Lord, Lord Stevens, is minded to test the opinion of the House, we will certainly support him.

20:30

I conclude by emphasising that legislative backstops and reporting duties are necessary to ensure that the implementation of the Bill is timely and effective. That is underlined particularly by the delays in the implementation of both the Mental Health Units (Use of Force) Act 2018 and the liberty protection safeguards introduced in the Mental Capacity (Amendment) Act 2019, to replace the deprivation of liberty safeguard systems, neither of which have been taken forward. Both are very relevant to patients affected by the Mental Health Act. I beg to move.

[Lord Stevens of Birmingham (CB)]

My Lords, this Bill has been years in gestation, and we have heard, in Committee and on Report, that it is going to be years in implementation. The Government, not unreasonably, have pointed to two principal rate limiters for that: workforce and funding. As we have just heard in the powerful speech from the noble Baroness, Lady Tyler of Enfield, her Amendment 50 is responsive to the staffing constraints and concerns, and my Amendment 59 tackles the funding question. I am grateful for her support and that of the noble Baroness, Lady Bennett of Manor Castle, and the noble Lord, Lord Scriven.

In a nutshell, as the noble Baroness says, this amendment does not seek to tell the Government, or indeed the House of Commons under its privilege, how much to spend on the NHS. All it says is that there should be a floor on the share of that total going to mental health for a time-limited period while the Act is being implemented; in other words, the Government would continue to decide the size of the NHS pie. The Government, of whichever complexion, could decide to grow or shrink it, but the slice of that pie devoted to mental health would be protected for a time-limited period, not only at the local ICB level but nationally.

We had a debate on this in some detail in Committee, so I will not repeat the arguments in favour, but I will update the House on two developments since then. First, in consultation with the Public Bill Office, this Report amendment is more tightly drawn, focusing specifically on the mental health services that are in scope of this Bill and are required for its implementation. Secondly, as the noble Baroness, Lady Tyler, has just noted, since we debated this point in Committee, new evidence has emerged, sadly, as to precisely why this amendment is needed. Previously, Ministers have argued, in good faith, that the Government are committed to protecting the mental health share anyway, whereas last Thursday, the Written Ministerial Statement disclosed that the Government now intend to shrink the share of NHS funding on mental health services in the year ahead.

The Written Ministerial Statement says:

“This is because of significant investment in other areas of healthcare”.


That is not a justification; it is a mathematical tautology. It reveals a preference entirely antithetical to what will be required over the years to get this Bill implemented.

It may be argued that it is a small percentage reduction, even though it is an important negative new precedent that has been set. However, a small percentage reduction on a large pound note number itself constitutes a large pound note number. Mental health services will be missing out on hundreds of millions of pounds more, not only in the year ahead but over the decade that it will take to implement the Bill. If that is not corrected in subsequent years, over £1 billion of funding has, in effect, been removed from mental health services and the implementation of the Bill as a consequence of that decision.

In summary, there are, sadly, real grounds for concern about whether the implementation of this Act will be properly and expeditiously resourced. If the Government want to argue that this amendment is unnecessary, because they are going to do what it says anyway, it is not clear why they would therefore object to its inclusion in the Bill. But if the Government’s argument is that they do not support the amendment because they would like the flexibility to cut mental health funding shares, then, to my mind, that really points to the necessity of the amendment.

[Baroness Bennett of Manor Castle (GP)]

I rise briefly, having attached my name to Amendment 59 in the name of the noble Lord, Lord Stevens, and backed by the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven. We saw in Committee multiple amendments all trying to address the resource issue. We have focused on this one because it is both an elegant solution, as the noble Lord, Lord Stevens, just outlined, and it is—emanating from the Cross Benches—a moderate solution that can and I think will attract wide support from around the House.

As the noble Lord and the noble Baroness have said, parity of esteem has never been achieved and, on the current figures, is currently going backwards, in the wrong direction. We have to focus on the fact that the waiting lists for community mental health care for adults and young people and children are twice as long as those for physical healthcare. That is the outcome of the inequality of esteem with which mental health is being treated. I note that the Rethink Mental Illness Right Treatment, Right Time report found that most people living with a severe mental illness experienced worsening mental health while waiting for treatment, with 42% requiring urgent care and 26% being hospitalised. We are aiming to shift from hospital care—in-patient care—to community care, but we are actually forcing things in the other direction because people reach such a state of crisis. I have to preface the horror of what I am about to say with a warning. The Right Treatment, Right Time report found that 25% of people whose mental health deteriorated while waiting for treatment attempted suicide, which highlights how the lack of funding for mental health care impacts on that awful statistic.

This is a step to create a framework that heads in the right direction. As noble Lord, Lord Stevens, said, how could you possibly oppose this?

[Baroness Fox of Buckley (Non-Afl)]

My Lords, very briefly, I will say that I absolutely support this amendment. I think it is worth clarifying what I said earlier about overdiagnosis. The danger is that that can be interpreted as meaning that I want cuts; what I actually want is targeted intervention for the right people, rather than saying, “Oh, everybody’s been calling themselves mentally ill, so let’s cut the services”.

I completely agree with the noble Baroness, Lady Tyler of Enfield, that, if we do not sort out the amount of community provision, what we have done over the last few weeks, never mind the years preceding it, will have been a waste of our time, because the Bill will not be worth the paper it is written on—that is the danger. It is very tempting, in a period of intense economic difficulties, to suggest that this might be one of the first things to go—so I do think this is a very good amendment.

I will remind the House of a discussion we had late the other evening on the plight of prisoners. If there is no community resource for people leaving prison—ex-prisoners—they will deteriorate and end up becoming very ill in the community and being incarcerated again. I discussed that in great detail. In other words, this is essential if we are serious about saying that we do not want to lock people up but, instead, want to treat them appropriately.

[Lord Scriven (LD)]

My Lords, I rise very quickly to support the amendment from the noble Lord, Lord Stevens, and have put my name to it.

I will add a couple of extra things to the noble Lord’s very well-argued case. Modest as it may be, I think it is an effective measure—and this is why I think it is and why the House should support the noble Lord’s amendment if he decides to push it to a vote. It is not that the Secretary of State has announced that the percentage will decrease next year; the percentage decrease happened during this financial year, going down from 9% to 8.78%. So we are now on a trend for the percentage of National Health Service spend on mental health.

Furthermore, one has to question the priority of the Government when they look at the national planning guidance and some of the targets that have been dropped from it. There are no plans to target the 2 million long waiters waiting for mental health care. It would be slightly disingenuous of the Minister, in response, to talk just about the mental health investment scheme, because all it refers to is ICB spend. The uniqueness and cleverness of the amendment from the noble Lord, Lord Stevens, is that it talks about all health service spend, including non-ICB spend, specialised commissioning and other elements that need to be there.

Mental health takes up 20% of illness treated by the NHS, which will probably be spending 8.7%. Because of the trend that is happening, the amendment from the noble Lord, Lord Stevens, is absolutely vital to ensure not just that the percentage is maintained but that the community facilities within this will be funded and implemented.

[Earl Howe (Con)]

My Lords, I will not speak at length, but I express my support for the case put forward by the noble Baroness, Lady Tyler, in her Amendment 50. Her concerns around the resourcing of the mental health workforce are well founded and there is no better source of evidence for those concerns than the CQC, which I thank for briefing me, very fully, on this subject at the beginning of last month.

When we look at the issue of workforce sufficiency, a paradox confronts us. Between 2019 and 2024, the mental health workforce grew by nearly 40,000 full-time equivalent staff—an increase of 35%. Yet, when we sit down to read the CQC’s recently published Monitoring the Mental Health Act in 2023/24, we find that staff shortages are a pervasive feature throughout the service. There is a cocktail of reasons for this apparent contradiction: very steeply rising patient demand; patients being admitted to hospital with a greater acuity of mental illness; a struggle in many places to recruit staff with the right skills; and poor retention of skilled staff, with, as a consequence, a high reliance on agency workers. That all impacts the quality of care given to patients, because, with hospital staff suffering burnout and temporary staff coming and going, there is often no opportunity to develop the kinds of therapeutic relationships that make patients feel psychologically safe and secure.

Of course, not all areas of the country are the same. Geographical disparities affect the availability of different skill sets, resulting in different kinds of problems manifesting themselves: for example, in one of the three high secure hospitals, the CQC encountered cases where patients were being kept in their rooms during the day. Elsewhere, on a number of in-patient wards, patients with autism or a learning disability reported that staff lacked the necessary training to look after them properly. In other settings, the lack of training is more basic: agency staff very often do not know how to operate the hospital’s IT system. This mixed picture underlines the fact that the amendment from the noble Baroness, Lady Tyler, is expressed in exactly the right way, since it mandates that biennial staff sufficiency reviews should be done not centrally but by commissioners locally.

That formula is appropriate for another reason. Depending on where you are in the country, there can be different sorts of barriers to accessing care, whether the barriers are for people from ethnic minority groups, for children and young people or simply for people living in areas of high deprivation. The more people find it difficult to access the care that they need, the more seriously they can be at risk. That particularly applies to children. The noble Baroness, Lady Bennett, made that point. We have not heard much from the Government about workforce planning generally, but this is an area where this exercise just cannot wait.

This leads me to Amendment 59, in the name of the noble Lord, Lord Stevens. It will not be much comfort to him if I say that I am right behind the sentiment of the amendment. He knows that, sadly, I cannot ask my colleagues on these Benches to vote for it, simply because I do not think it is appropriate for primary legislation to tie the hands of Government in matters of health spending. Those macro decisions surely have to be for Ministers.

Nevertheless, the flagship principle at the centre of the amendment is parity of esteem—a principle that is enshrined in statute and to which I am totally signed up, alongside, I am sure, all of your Lordships. However, parity of esteem is a broad concept and should, in my view, be measured in a range of ways, not simply by reference to monetary input, important as that is—and it is important.

20:45

The noble Lord is right to focus our minds on the recently published and very troubling announcement on mental health spending. I therefore hope that the Minister will be able to deliver, at the Dispatch Box, some robust assurances on mental health spending, as well as on parity of esteem more generally, which will obviate the need for the noble Lord to press his amendment and will satisfy honour on all sides.

[Baroness Merron (Lab)]

My Lords, I am grateful for all the contributions and considerations this evening, to which I have listened closely.

I first turn to Amendment 50 in the name of the noble Baroness, Lady Tyler. Workforce is absolutely a critical factor in enabling these reforms and we have committed to recruiting 8,500 more mental health staff over the course of this Parliament. The impact assessment sets out our expectations for the additional workforce that is required to deliver the Bill.

However, there are already various mechanisms in place to monitor and address concerns about the mental health workforce. The amendment would be duplicative and unnecessary. Providers registered with the CQC—both NHS and independent services—are required to deploy enough suitably qualified, competent and experienced staff, as outlined in Regulation 18 of the Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. If CQC finds a breach in Regulation 18, it can take action.

The Mental Health Act Code of Practice also states that local authorities should ensure that there are sufficient approved mental health professionals and independent mental health advocates. All staff in CQC-registered providers must receive the appropriate training that is necessary to enable them to carry out their duties under Regulation 18 of the Health and Social Care Act Regulations 2014.

At a national level, CQC reports on workforce sufficiency as part of its monitoring of the Mental Health Act report. We would argue that this is a much better process than requiring integrated care boards to mark themselves on how well they are fulfilling their duties.

Furthermore, as I said on Monday and wish to reiterate, we are committed to laying an annual report on implementation, which will set out progress made and future plans for implementation. This will include information on the expansion of the workforce, including second opinion appointed doctors, Section 12 doctors and approved clinicians. It will also include details of the key statistics and outcomes under the Mental Health Act, including detention rates, community treatment order rates and other key metrics, such as racial disparities and outcomes for children and young people, all of which noble Lords rightly seek. I hope this annual commitment will be welcomed by your Lordships’ House and that this, combined with the existing workforce monitoring I have referred to, will allow the noble Baroness to withdraw her amendment.

On Amendment 59, I also understand —as does the noble Earl, Lord Howe—the intention of the noble Lord, Lord Stevens, which is to ensure that we invest in delivering these reforms. I want to be clear: as I said in Committee, there are already mechanisms in the NHS Act to prioritise mental health spend to deliver these reforms.

To reiterate the point that I made previously, we believe that this amendment is not the right mechanism to ensure that we do that. I will return to the three main reasons for that, but I want first to refer to the point the noble Lord, Lord Stevens, made when he spoke of “shrinking mental health spend”.

[Lord Stevens of Birmingham (CB)]

It was the shrinking share of mental health spend.

[Baroness Merron (Lab)]

I thank the noble Lord for that correction from a sedentary position. Perhaps I could provide some more clarity, which the noble Earl, Lord Howe, also asked for.

The proportion of spend is almost exactly the same as it was last year, with a difference of just 0.07%. We understand concerns that the share of overall NHS funding for mental health will reduce slightly. However, this does not mean that mental health funding is being cut, and I would not want noble Lords to think that to be the case. To be clear, spending on mental health support will increase relative to 2024-25 and is forecast to amount to £15.6 billion—an increase of £680 million in cash terms, and equivalent to £320 million in real terms.

Perhaps it would be helpful for me to return to the three main reasons for not supporting this amendment. The first is—as the noble Earl, Lord Howe, helpfully referred to—what I would call a point of principle. Primary legislation should not be used to constrain spending in this way. Multiyear budgets for government departments will be set by the established spending review process, which considers spending in the round and in the context of the Government’s policy priorities. Additionally, it is Parliament that is responsible for scrutinising government spending and approving spending set by departments for the current financial year as part of the estimates process.

Secondly, the amendment as drafted applies only to spend under the Mental Health Act. The mental health system, as noble Lords will appreciate, does not structure its accounts based on the legal framework under which a patient is held. A single ward, for example, could contain a mix of patients under the Mental Health Act and informal patients who would not usually be considered to be under the Mental Health Act. Likewise, community services will support a mix of people, some on community treatment orders and others who are not. It would be impractical to require services to split costs based on the ever-changing patient mix within their care.

The third reason for not accepting this amendment, and perhaps the most fundamental point, is that the share of spend on the Mental Health Act could reduce over time, which is not undesirable. I will explain why. The genesis of these reforms is the review initiated by the noble Baroness, Lady May, to address the rising rates of detention. We all want to see more people cared for effectively in the community so that the need for the use of the Act is reduced. This would require more investment in preventive community services, which, I put to noble Lords, is surely the preferable model for supporting severe mental illness. In creating a legal requirement for the share of spend specifically under the Mental Health Act not to decrease, this amendment would actually preclude the shift from detention to prevention that I know we all want to see.

So, while I absolutely understand the intention, and I can commit that we will invest to deliver these reforms, we cannot support this amendment, which, for the reasons I have outlined, we believe is fundamentally flawed. For these reasons, I hope that the noble Baroness will withdraw her amendment and the noble Lord will not press his.

[Baroness Tyler of Enfield (LD)]

My Lords, this has been another incredibly important group of amendments. We are very short of time. I thank everyone who has contributed. I welcome that the Minister has committed to an annual report on implementation. I hope that there will be an opportunity for a debate in both Houses when that annual report is received. I was very grateful to the noble Earl, Lord Howe, for his support on my Amendment 50, which I will not be pushing to a vote. I do not consider it to be duplicative and unnecessary. If I did, I would not have tabled it. I thought that it was quite good, but I am not pushing it to a vote.

My final comment is that I was very pleased that there was widespread support for the very important amendment tabled by the noble Lord, Lord Stevens. It was variously described as modest, elegant, clever and other things. It had an awful lot going for it, but I leave it to the noble Lord, Lord Stevens, to say how he wishes to proceed. I beg leave to withdraw my amendment.

Amendment 50 withdrawn.

Amendment 51

Moved by

[Lord Meston]

51: After Clause 51, insert the following new Clause—
“Determination of ability to decide for persons under 16(1) For the purposes of this Act and the Mental Health Act 1983, a person aged under 16 (referred to in this section as a child) is able to make the relevant decision if they can—(a) understand the information relevant to the decision;(b) retain the information; (c) use or weigh that information as part of the process of making the decision;(d) communicate their decisions (whether by talking, using sign language or any other means).(2) Where a child is able to decide in accordance with subsection (1) above, that child will be competent for the purpose of this Act.(3) A child is not to be regarded as unable to understand the information relevant to a decision if he is able to understand an explanation of it given to him in a way that is appropriate to his circumstances (using simple language, visual aids or any other means).(4) A person determining a child’s ability to decide under this section must—(a) have due regard to Article 12 of the United Nations Convention on the Rights of the Child adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989 (“the Convention”), and(b) must be able to show reasonable grounds for their belief that the child is or is not able to make the relevant decision.(5) When considered by any appropriate court or tribunal, any question whether a child is able to make the relevant decision within the meaning of this Act must be decided on the balance of probabilities.”Member’s explanatory statement
This amendment inserts a test for determining a child’s ability to make decisions (competence) under the Mental Health Act.

[Lord Meston (CB)]

My Lords, I explained this amendment on the assessment of competence of under-16 year-olds on Monday, and was grateful for the forceful support that it received. However, I recognise the realities of the Government’s determined objections to it. I record my thanks to the Minister for her explanation in a letter to me and the noble and learned Baroness, Lady Butler-Sloss, this afternoon, indicating the Minister’s wish to make progress on the matters which we raised. I therefore simply ask the Government to consider circulating a preliminary draft of the guidance to be produced, preferably before the Bill leaves Parliament. I also ask them to consider whether a designated task force could be used to formulate that guidance. I will not be moving my amendment.

Amendment 51 not moved.

Amendments 52 and 53 not moved.

Amendment 54

Moved by

[Baroness Keeley]

54: After Clause 51, insert the following new Clause—
“Human Rights Act 1998: provision of treatment for a mental disorder as a public function(1) This section applies where—(a) a patient is receiving aftercare under section 117 of the Mental Health Act 1983,(b) a patient is accommodated in a hospital for the purpose of being given medical treatment for mental disorder, or(c) a person's health or social care arrangements in connection with their mental disorder give rise to a deprivation of their liberty, within the meaning of that term as under Article 5(1) of the European Convention on Human Rights. (2) The provider of treatment or care under subsection (1) is to be taken for the purposes of section 6(3)(b) of the Human Rights Act 1998 (acts of public authorities) to be exercising a function of a public nature, if the treatment or care is arranged by or paid for (directly or indirectly, and in whole or in part) by a local authority in England, Wales or Scotland, or by a NHS Health Board, an NHS Integrated Care Board, or by a Health and Social Care Trust.”Member’s explanatory statement
This amendment ensures the Human Rights Act 1998 applies when people receive outsourced mental health treatment or after-care, or are deprived of their liberty in connection with a mental disorder. It addresses a gap in human rights protection exposed by Sammut & Ors v Next Steps Mental Healthcare Ltd & Anor [2024] EWHC 2265 (KB).

[Baroness Keeley (Lab)]

My Lords, Amendment 54 in my name is the same as the one I tabled in Committee. It aims to ensure that the Human Rights Act 1998 protects individuals whenever the NHS, local authorities or other state bodies outsource mental health treatment or aftercare to private providers. It also seeks to secure human rights protection whenever people are deprived of their liberty by private health or social care providers in connection with mental disorders.

I am grateful to my noble friend the Minister for her comments on this amendment when it was debated in Committee and for all her engagement on the related issues before and since. I am grateful to the noble Baroness, Lady Barker, for her support for this amendment, and to her and other noble Lords who spoke in favour of the amendment in Committee. I am also very grateful to Dr Lucy Series and Professor Luke Clements. They helped with drafting this amendment and provided notes and briefings on the need to close this gap in human rights protection for mental health patients when their care is commissioned from private health and social care providers.

As we noted in Committee, after the 2007 case of YL v Birmingham City Council, Parliament moved to close gaps in human rights protection with Section 145 of the Health and Social Care Act 2008 and, more recently, with Section 73 of the Care Act. The noble Earl, Lord Howe, reminded us in Committee that, as Health Minister, he tabled a government amendment to the Care Bill in 2014 to close the gap in human rights protection.

However, the recent High Court case of Sammut v Next Steps Mental Healthcare Ltd showed that mental health patients and many other users of outsourced health and social care services were still not protected. The judge held that the Human Rights Act did not apply because Mr Sammut’s care was arranged under Section 117 of the Mental Health Act 1983, not under the Care Act. This judgment highlighted the narrow limitations of the Human Rights Act as a remedy for using outsourced public services such as private care provision or mental health treatment. This raises concerns about the human rights protection of thousands of other people who are deprived of their liberty in private health and social care settings in connection with their mental disorders.

Amendment 54 addresses these gaps in human rights protection for three groups of people: patients such as Mr Sammut, who are receiving mental health aftercare from private providers; any patient receiving in-patient mental health services, whether subject to the Mental Health Act or not; and anybody who is deprived of their liberty by a private provider of health or social care in connection with a mental disorder. It would ensure better protection for people with mental disorders in private care settings.

21:00

I add that it would also be possible to expand the scope of the amendment to include non-publicly funded care arrangements where Article 5 of the Human Rights Act is engaged. This would mean including people whose care arrangements were paid for privately from their savings or by family members. Amendment 54 could be adapted so that, anywhere Article 5 safeguards are engaged, a registered health or care provider could be treated as a public body.

I am grateful to my noble friend the Minister for meeting me and the noble Baroness, Lady Barker, before Report and discussing these issues of the gaps in human rights protection after the Sammut case and how those gaps are to be dealt with. As I mentioned in our meetings with the Minister, there are other areas of outsourced health and social care affected by the Sammut ruling, including children’s social care. I have written to my noble friend Lady Smith of Malvern about the possibility of incorporating an amendment similar to Amendment 54 for outsourced social care and education in the Children’s Wellbeing and Schools Bill. There is also a gap for other areas of outsourced health and social care funded from the NHS, including NHS continuing healthcare and any healthcare for physical illnesses commissioned by the NHS. If there is to be—and I think it is likely—an NHS Bill in this Parliament, that could provide a vehicle to close any remaining gaps in human rights protection for outsourced health and social care. For now, I commend what is a simple but important amendment, and I hope it can be supported.

[Baroness Barker (LD)]

My Lords, at this late hour I do not intend to speak at great length, but I do not want anybody to misinterpret that as in any way diminishing the support for the amendment of the noble Baroness, Lady Keeley. I believe that this is very important.

It is important for two main reasons. The first is that we all know that the Human Rights Act is under attack on many different fronts for many different reasons. I happen to be—it is perhaps fair to say or apt to describe as—a human rights absolutist: I do not believe that human rights can be picked or that you can pick and choose whose human rights you support. Human rights are universal. You cannot call yourself a human rights supporter unless you are prepared to stand up for the human rights of people you do not like and you do not care for. I suggest that among the people whose human rights are most at risk are those who are stuck away in care homes without anybody paying any attention to them—perhaps without relatives —and about whom, frankly, nobody cares. They are the people who are at the mercy of, particularly, providers who have a commercial interest in maintaining them in the positions where they are rather than seeking to address their care in more fundamental ways. If nothing else, I want us to acknowledge that.

Secondly, I want to pay tribute to all those health professionals and to people such as solicitors who choose to work in this most unglamorous part of the legal system. There is no great financial reward in putting yourself out to stand up for these people, but they do. It is their dedication that has brought this back to the attention of people in this House.

The noble Baroness, Lady Keeley, and I were to a certain extent, as we all have been throughout the passage of the Bill, assuaged by the noble Baroness, Lady Merron, and the very personable way in which she has listened to all of our concerns, but we were not yet convinced that the Government, who are uniquely placed to stick up for the rights of these people, are doing so to the extent that they should. That is why we have taken the time and troubled your Lordships this evening. I hope that all of the provisions of this amendment are taken up by the Government.

[Baroness Chakrabarti (Lab)]

My Lords, I declare an interest as a member of that persecuted minority of activist human rights lawyers. Crucially, it is a privilege to follow the noble Baroness, Lady Barker, and my noble friend Lady Keeley, who have done so much wonderful work on this. I also commend the brains trust of mental health professionals and lawyers who sat behind them.

On 24 February, we had a lengthy discussion on this in Committee, and it was one of the best debates in which I have had the privilege of participating in your Lordships’ House, and not just because everybody agreed. But they did. I do not remember a single person speaking against my noble friend’s amendment in Committee. We disagree well in your Lordships’ House, but it says something that not a single person disagreed. In particular, I commend the eloquent speeches on that day by the noble and learned Baroness, Lady Butler- Sloss, and by the noble Earl, Lord Howe, on the Opposition Front Bench.

I have been very excited to hear that my noble friend the Minister has been in such constructive meetings with my noble friend Lady Keeley. Whatever debates there are about contracting out vital public services, nobody on any side of this House wants people to be treated less decently and with fewer human rights because of a service being provided directly by the state or a decent contractor. With that, I look forward expectantly, with hope in my heart, to the response of my noble friend, who is very experienced, decent and wily.

[Earl Howe (Con)]

My Lords, having listened to the noble Baroness, Lady Keeley, and her clear and concise explanation of this amendment both today and in Committee, I can do no other than express my full support, yet again, for all she has said. This is indeed an important issue that case law has exposed as needing resolution, and the amendment seems to achieve that aim extremely well. I may have read the runes incorrectly, but I dare to entertain the hope that, if the amendment is not to be accepted as it stands, which of course would be very gratifying, the Government will take the matter forward in the way the noble Baroness has asked.

[Baroness in Waiting/Government Whip (Baroness Blake of Leeds) (Lab)]

My Lords, it gives me enormous pleasure to respond to my noble friend Lady Keeley’s amendment. I had not joined the team during Committee, so I was not present at the meeting that everyone has described, but I have read the verbatim report and I express my thanks for the sincerity and the careful, thoughtful way that the arguments have been put forward by all noble Members who took part and those who have spoken today.

I am, of course, aware of the wider strong support for this issue. I am very grateful for the references to the different organisations that have engaged in this. I am also struck by the comments from the noble Baroness, Lady Barker, about reference to other professionals—all those unsung heroes who do not get the recognition they deserve. I think that we all join together to express our gratitude.

I express my condolences to the family of Paul Sammut. As we have discussed, his case has helped bring this to our attention. We recognise the concern around unequal coverage and rights to redress under the Human Rights Act, and the court judgment has highlighted the need to clarify the position of private mental health and care providers under the Human Rights Act when providing mental health-related care arranged and paid for by the NHS and local authorities.

Tonight, I commit that we will return to this issue when the Bill goes to the other place. There, we can have proper discussion and further consideration of some of the issues raised. My noble friend Lady Keeley has raised the issue of the wider implications of this, and I am particularly conscious of the references to children’s services. It is an issue that we have, of course, been discussing with the DfE, which has responsibilities to look at the ramifications for it.

We need to keep working on this, recognising the gap that my noble friend and others have raised in this place, but committing to taking it forward as part of the legislative process. I know that my noble friend the Minister has put a lot of time into this and is thankful for the input. She has graciously offered further meetings on this point as we move forward in the discussions and we look forward to the outcomes in due course.

[Baroness Keeley (Lab)]

My Lords, I am very pleased to hear that Ministers will pick up this issue and hopefully take action to close this gap in human rights protection during the Bill’s passage in the other place. I thank noble Lords, and noble and learned Lords, for their support for this amendment in Committee and today. It has been important that we have that support, as my noble friend Lady Chakrabarti said. I want to thank the Minister. She has done a huge amount of work with us on this amendment and I thank her and my noble friend Lady Blake for agreeing to take action on this important issue of human rights protection. That said, I beg leave to withdraw the amendment.

Amendment 54 withdrawn.

Amendment 55 not moved.

Amendment 56

Moved by

[Baroness Hollins]

56: After Clause 51, insert the following new Clause—
“Long-term segregation: independent medical review After section 142C of the Mental Health Act 1983, insert—“142D Independent medical review of long-term segregation of patients with learning disabilities or autism(1) Where a patient with a learning disability, autism, or awaiting autism assessment is placed in long-term segregation under section 142D (Notification requirements for long-term segregation for patients with learning disabilities or autism), the Secretary of State or a designated body must arrange for an independent review within 28 days.(2) The responsibilities, procedures, and reporting requirements for such reviews must be specified in the Code of Practice under section 118 of the Mental Health Act 1983.””Member’s explanatory statement
This amendment seeks to introduce an independent review process for patients with learning disabilities or autism placed in long-term segregation under the Mental Health Act 1983.

[Baroness Hollins (CB)]

My Lords, although funding for independent reviews for people detained in long-term segregation will continue until 2026, it is not really enough. Independent reviews have been found to be effective and need to continue until the practice of long-term segregation ends. I am sorry that it is so late, but I should like to test the opinion of the House.

21:12

Division 7

Ayes: 51

Noes: 106

21:23

Amendments 57 and 58 not moved.

Amendment 59

Moved by

[Lord Stevens of Birmingham]

59: After Clause 30, insert the following new Clause—
“Consultation: bus funding formula(1) Within six months of the day on which this Act is passed, the Secretary of State must publish a report detailing a proposed bus funding formula for consultation.(2) The report published under subsection (1) must include—(a) the Secretary of State’s rationale for proposing that formula,(b) an evidence-based assessment of the distributional effect of that formula between various transport authorities in England, and(c) any alternative funding formulas that the Secretary of State has considered but chosen not to pursue.” Member’s explanatory statement
This amendment requires the Secretary of State to publish a proposed bus funding formula for consultation, including their reasoning, an assessment of its impact on different transport authorities, and details of alternative approaches considered but not adopted.

[Lord Stevens of Birmingham (CB)]

My Lords, I am grateful to the Minister for her response to Amendment 59. I accept that there are some philosophical differences of view that she expressed. However, I do not think it was right to say that the scope of Amendment 59 does not include any community and preventive mental health care, since the Bill itself includes provisions that relate to those types of services. In any event, now is not the time for further relitigating. I wish to test the opinion of the House on Amendment 59.

21:24

Division 8

Ayes: 19

Noes: 112

21:34

Amendments 60 to 63 not moved.

Amendment 63A

Moved by

[Baroness Bennett of Manor Castle]

63A: After Clause 51, insert the following new Clause—
“Duty to implement preventative policies for mental disorders(1) The bodies listed in subsection (3) must implement policies which take a preventative approach to the management of mental disorders which are likely to lead to detainment under the Mental Health Act 1983.(2) The policies must be adapted to the needs of the local community that those bodies serve.(3) The bodies in subsection (1) are integrated care boards, local health boards and local authorities.”Member's explanatory statement
This amendment seeks to ensure that ICBs, LHBs and local authorities take a preventative approach to the management of mental disorders which lead to detainment and adapt their approaches to the needs of their local area.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I am acutely aware of the hour so I will be very brief. My Amendment 63A would provide for a duty for ICBs, local health boards and local authorities to implement preventive policies for mental disorders.

I join the noble Baroness, Lady Tyler, in regretting how the debate on this crucial Lords-starter Bill has been squeezed. However, I am in a lovely position because, in responding to the group beginning with Amendment 48, the Minister essentially supported my amendment. She said that if support can be provided much earlier, mental ill-health can be prevented. That is essentially what this amendment seeks to do.

I am obviously not going to divide the House at this stage of the evening, but I have spoken over the years to so many public health professionals, consultants and directors in local authorities, and they continually express the frustration that everyone knows that investment in preventive healthcare is the way to take pressure off the NHS. Understandably, when someone turns up with an acute mental health crisis or a broken leg, we have to treat that, and that is where the resources go.

This amendment is an attempt to write into the Bill—I hope it might be revisited in the other place—the duty of prevention. And it has to be a duty. This aligns very much with the Government’s rhetoric and their approach to public health. I will not press the amendment to a vote, but I hope this can be the start of a discussion.

[Lord Scriven (LD)]

My Lords, because of the lateness of the hour I will be very brief. These Benches support the aim of the amendment in the name of the noble Baroness, Lady Bennett of Manor Castle. It is important that, throughout all this, there is an element not just of treating the acute phase of mental ill-health but trying to ensure that prevention is there within the health service and across the whole of government, national and local. We believe on these Benches that a mental health commissioner would have been really helpful for that, as they could highlight elements that could help with prevention—but the House has made its decision on that.

I have only one question for the Minister. One of the three shifts of the Government is towards prevention. How do the Government see prevention of mental ill-health fitting into that shift, not just in NHS services but, as I said, across the whole of government, including local government, to determine how they can use their resources and levers to bring about what the noble Baroness, Lady Bennett of Manor Castle, is trying to achieve?

[Lord Kamall (Con)]

My Lords, this will probably be the last time I speak on Report—and I am sure many people are grateful for that. Before I make my last remarks, I want to put on record my gratitude to the Minister, her officials and the Whips for the amount of time they have given us in discussing a lot of these amendments. It is certainly appreciated by our side and, I am sure, by other noble Lords.

Given the time, I will not take another hour. The sentiment behind this amendment is unquestionable. During my time as Minister, I was repeatedly reminded of the need to focus on prevention, and of course I agreed to that. As we know, the noble Lord, Lord Darzi, in his report on the state of the NHS, repeated his emphasis on the shift to prevention. If we believe in parity of esteem, where possible, this should be applied to mental health.

If we can shift from a situation where we are treating patients and repeatedly detaining them, such that they are detained for longer, to a scenario where we can treat and prevent those conditions worsening, our mental health system will be better for it. I am sure that all noble Lords can agree with this. So we strongly agree with the intent here, which is in line with one of the Government’s other intentions: a shift from hospital to community.

However, when I have discussed this amendment with others, I have heard one concern that I am still reflecting on. This amendment states that ICBs, local health boards and local authorities must implement preventive policies. It has been suggested to me that this might be too prescriptive or may place a duty on smaller bodies that may not necessarily have the resources to implement such policies. Those who suggest this tell me that it may appear more reasonable to place that duty on the Secretary of State or the Department of Health and Social Care, which have the capabilities and resources to implement preventive measures. Such a policy could work if the department had to work with ICBs and local authorities, as well as local community non-state civil society organisations, to move towards preventive care. As I said, I am still reflecting on this, but I do not wish to detain the House while I make up my mind. So, with that, I look forward to the response from the Minister.

[Baroness Merron (Lab)]

My Lords, I thank all noble Lords for their contributions on Amendment 63A in the name of the noble Baroness, Lady Bennett. I am grateful for the appreciation of the noble Lord, Lord Kamall —and the appreciation shown throughout Report—for the whole team. Similarly, I reciprocate thanks to all noble Lords and their offices for their assistance in improving the Mental Health Bill.

As the noble Baroness observed, we agree with the intention of the amendment: there must be a focus on prevention and the commissioning of services must reflect the needs of the local community. However, we do not feel that it is necessary to place this requirement in statute. As the noble Baroness knows, the Government are currently co-developing the 10-year health plan with the public, staff and patients. As part of this, we are exploring ways to stimulate the shift from sickness to prevention so that we can deliver an NHS fit for the future.

I turn to the points raised by the noble Lord, Lord Scriven. First, progress is already being made to transform community mental health services. In the last 12 months, more than 400,000 adults have received help through new models of care that aim to give people with severe mental illness greater choice and control over their care. We are going further by piloting the 24/7 neighbourhood mental health centre model in England, building on learning from international exemplars such as those in Trieste, which I know the noble Baroness, Lady Bennett, has taken a great interest in. Six early implementers are bringing together their community, crisis and in-patient functions into one open-access neighbourhood team that is available 24 hours a day, seven days a week. This means that people with mental health needs can walk in or self-refer, as can their loved ones.

ICBs are already required to have policies that reflect their communities under the National Health Service Act 2006, as amended by the Health and Care Act 2022. Section 3(1)(i) of the NHS Act 2006 also specifies the duty of an ICB to commission certain health services, including

“such other services or facilities for the prevention of illness”.

An integrated care board must arrange for the provision of services

“to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.

ICBs and their partner NHS trusts and foundation trusts, including their mental health trusts, are also required to prepare a joint forward plan, which describes how the ICB will arrange for NHS services to meet their population’s physical and mental health needs.

Given that these duties already exist, given the Government’s commitment to a shift from sickness to prevention, and given the progress being made on community transformation and expansion of crisis services, we do not consider that it is necessary to create any additional duties within the Mental Health Act and I hope the noble Baroness will feel able to withdraw her amendment.

21:45

[Baroness Bennett of Manor Castle (GP)]

I thank the Minister for her detailed response and the positive mention of Trieste. I echo the noble Lord, Lord Kamall, in thanking the Minister for her genuine engagement in the debates on this Bill. On this final point, it is worth noting that a very small number of noble Lords put in an enormous amount of work into the Bill. It would be nice to see a wider engagement across the House rather than the weight being carried by such a small number of people.

On the amendment, I thank the noble Lord, Lord Scriven, for his expressions of support for the general intention at least. On the point made by the noble Lord, Lord Kamall, on whether the duty should potentially rest with the Secretary of State rather than locally, we come back to some of the debate that we had in the earlier group when we were talking about a responsible officer. It is about laying duties down at the level where services are delivered, which is why I took this approach.

None the less, given the hour, I shall stop there. The Bill is now going to the other place, and I hope that we see a real level of attention and focus there as well, as there has been in your Lordships’ House. I beg leave to withdraw the amendment.

Amendment 63A withdrawn.

Clause 52: Power of Secretary of State to make consequential provision

Amendments 64 and 65

Moved by

[Baroness Merron]

64: Clause 52, page 64, line 23, at end insert—
“(3A) A statutory instrument containing (alone or with other provision) regulations under this section that amend or repeal provision made by primary legislation may not be made unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.(3B) Any other statutory instrument containing regulations under this section is subject to annulment in pursuance of a resolution of either House of Parliament.”Member’s explanatory statement
This amendment and my other amendments to clauses 52 and 53 would ensure that regulations made under the consequential amendment powers in the Bill that amend or repeal primary legislation are subject to the affirmative resolution procedure.

65: Clause 52, page 64, line 24, leave out subsection (4)
Member’s explanatory statement
See the explanatory statement for amendment 64.

Amendments 64 and 65 agreed.

Clause 53: Power of Welsh Ministers to make consequential provision

Amendments 66 and 67

Moved by

[Baroness Merron]

66: Clause 53, page 65, line 1, at end insert—
“(4A) A statutory instrument containing (alone or with other provision) regulations under this section that amend or repeal provision made by primary legislation may not be made unless a draft of the instrument has been laid before, and approved by a resolution of, Senedd Cymru.(4B) Any other statutory instrument containing regulations under this section is subject to annulment in pursuance of a resolution of Senedd Cymru.”Member’s explanatory statement
See the explanatory statement for amendment 64.

67: Clause 53, page 65, line 2, leave out subsection (5)
Member’s explanatory statement
See the explanatory statement for amendment 64.

Amendments 66 and 67 agreed.

Clause 55: Commencement

Amendment 68 not moved.