Mental Health Bill [HL]

(Limited Text - Ministerial Extracts only)

Report stage
Wednesday 2nd April 2025 Lords Chamber

[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.

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[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.

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19:37

Division 6

Ayes: 49

Noes: 129

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[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.

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[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.

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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.

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21:12

Division 7

Ayes: 51

Noes: 106

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21:24

Division 8

Ayes: 19

Noes: 112

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[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.

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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.

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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.