Mental Health Bill [HL]

Baroness Keeley Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I will speak to Amendment 62 in this group, which is in my name, and I will try to be as brief as possible. This group is all about the statutory care and treatment plans, and I very much welcome them. They are a very positive part of this legislation and should help patients achieve recovery and hopefully discharge from mental health in-patient units as quickly as possible.

My amendment seeks to ensure that individuals who are turning 18 during a care and treatment plan have their plans reviewed to ensure that there is continuity of care when transitioning from child to adult services. I spoke earlier about the tricky issue of transitioning from child to adult services. It is important for three reasons. Young people aged 16 to 25 experience high rates of mental health problems but are less likely to access the support they need; young people often experience tricky transitions, meaning that too often they fall through the gaps—we have heard so many stories about in this Chamber in the past; and, again as we have said earlier today, young people really should have a say in their care and treatment.

We know that there is a high level of mental health need among young people in the 16 to 25 age group and that it is going up. I have no wish to return to the earlier debate about whether that rise is real, but the numbers according to NHS Digital are very much on the increase. So, while 16 to 25 year-olds are experiencing high levels of need, they are often having real difficulties accessing support. It is sometimes talked about as the treatment gap, which is what the noble Lord, Lord Stevens, talked about earlier on, and it is far wider here than for other age groups.

These poor transitions between CAMHS and adult services are generally the problem because, after someone reaches their 18th birthday—which is the upper limit for CAMHS—young people too often face a real cliff edge when trying to access mental health support. They are no longer in the age range for CAMHS and simultaneously may not reach the threshold for adult services. Effectively, it leaves young people in limbo, with no access to the mental health support they require.

There is a range of reasons for these challenges, including poor information and, very importantly, a difference in treatment models. While children’s services are generally seen as more nurturing, with a focus on treating developmental and emotional disorders, adult services in contrast focus on treating severe and enduring mental illness, meaning that young people with these diagnoses are less likely to be accepted. Just as I have mentioned, the high thresholds for support often result in young people being told that they are not ill enough for the services they need, so unfortunately things get worse and they end up being detained. Without that support during transition, young people can experience all sorts of worsening symptoms and other life outcomes. That is the rationale behind my Amendment 62.

I will mention another couple of amendments in this group that have my strong support. Amendment 64, in the name of the noble Baroness, Lady Keeley, from whom we have still to hear, really emphasises the critical importance of ensuring that, where young carers are involved in a family situation, they are identified, particularly by adult mental health practitioners, who may not have them in mind first and foremost, that people proactively look for them, and then that the young carers—who are often hidden, with their needs only identified when there is a crisis—are supported. That amendment has my full support.

Lastly, I support Amendment 59, in the name of the noble Lord, Lord Davies. At this point—because I have not done it yet—I refer to my interests in the register, both as a member of the Financial Inclusion Commission and president of the Money Advice Trust. I absolutely support what the noble Lord said about the importance of these plans, including matters to do with finance. The links between money problems and mental health are now well proven and this legislation should reflect them. The Bill provides a once-in-a-generation opportunity to ensure that people’s holistic needs, including finances, are considered as a key part of supporting recovery from a mental health crisis.

[Baroness Keeley (Lab)]

My Lords, I rise to explain the significance of Amendment 64 in my name, which aims to cover the situation of both young carers and young children in a family where a care and treatment plan is being prepared for their parent. I thank the Carers Trust for suggesting this amendment and providing a briefing on this issue. I also thank the noble Lord, Lord Young of Cookham, for his support for the amendment and, of course, the noble Baroness, Lady Tyler, who has just spoken of her support for it.

Briefly, the amendment adds the requirement that a practitioner preparing or reviewing a care and treatment plan must ask whether there are children in the family and take actions to respond if the children need help or protection from harm. This amendment would, as I said, cover young carers, but it would also cover young children where there may be safeguarding concerns—a topic which the Child Safeguarding Practice Review Panel highlighted as a theme in its latest annual report.

As the noble Baroness, Lady Tyler, just touched on, young carers are so often hidden, and often their needs are identified only when there is a crisis. Even then, the extent of their caring role and the impact it has on the child’s development may not be recognised quickly or fully assessed. This amendment would help to ensure earlier identification of children who might be in need of information, support or protection from potential harm. It would mean staff asking the right questions early on to ensure that the right information is recorded and actions taken. It would help with adequate signposting of information and a chance to offer appropriate support to avoid a crisis or manage it appropriately.

The amendment also mirrors the new wording in the Working Together to Safeguard Children statutory guidance, which covers adult social practitioners:

“When staff are providing services to adults, they should ask whether there are children in the family and take actions to respond if the children need help or protection from harm. Additional parenting support could be particularly needed where the adults have mental health problems”.


There is evidence that having a parent with a mental health problem is one of the biggest risk factors for a first episode of major depressive disorder in children and adolescents.

This is not inevitable. Research suggests that intervention can enhance parenting skills in households affected by parental depression, and it can change the way that children cope. In turn, this can reduce the risk of children internalising problems that may threaten their life chances. The amendment is designed to enhance the ability of agencies working individually and together to identify and respond to the safeguarding needs of families. It is about supporting the challenging work of finding out what is happening to children and anticipating risks and harm, of knowing when action is needed. In most cases, children receive the support, help and protection they need, but sometimes children are seriously harmed or, worse, they can die because of neglect.

Policy initiatives in recent years have called for a wider family focus on safeguarding children so that all staff recognise that meeting the needs of family members who may put children at risk benefits the child, the adult and the family as a whole. This amendment would support those efforts. The amendment is in keeping with guidance from the Social Care Institute for Excellence to “Think child, think parent, think family”, to ensure that the child is heard and their needs are met.

The Carers Trust believes that the amendment would unlock additional support from mental health professionals to work with parents and children to enable the child to have age-appropriate understanding of what is happening to their parent and information about what services are available for them in their situation and how they can access them.

To illustrate the need for the amendment, I have two short case studies. Aidan was four when his mother was first sectioned under the Mental Health Act. Throughout his childhood, Aidan’s mother was regularly sectioned and would sometimes be in hospital for a number of months. There were many occasions when the police were involved because his mother had disappeared, which was particularly scary for Aidan. In his words:

“To me, you only ever saw the police if you’d done something wrong, so I remember when they turned up at our house, I thought mum was in trouble”.


Seeing his mother being taken into hospital on a regular basis meant that Aidan had lots of questions and worries. In his words again:

“There were so many times where I wondered whether mum would ever come home. I knew she’d been sectioned but I had no idea what that actually meant or if she would ever get better”.


Staff at the hospital who were treating Aidan’s mother would regularly see him visiting. Despite this, none of the staff there told Aidan or his father about support that might be available or asked whether Aidan might need any help. It was only when Aidan was 12 and his attendance dropped at school that he was identified as a young carer.

The second case is Vamp’s story. This is a pseudonym chosen by her family. The case study is taken from a recently published child safeguarding practice review which found that a 13 year-old girl died as a result of taking drugs sold to her in a park. It was identified that her mother had had a period of serious mental illness, and that illness was identified as the catalyst for things deteriorating for the young person. Tragically, two years on, the young person had died. This is taken from the relevant extract from the child safeguarding practice review:

“Vamp’s mother did not feel that her daughter had been a young carer … as the mental illness was short term. However, Vamp’s sister described the situation as being so difficult for both. When their mother was discharged home from hospital, it was only Vamp and her mother at home. Vamp’s sister was only a young adult, and with her own baby to care for. She … said she felt that no one checked in on their mother. Vamp’s sister … said that professionals expected her mother to manage to parent Vamp, which she was not able to do alone, she needed professional help”.


This is a simple but important amendment to protect young carers. I urge my noble friend the Minister to consider it, and I commend the amendment to the House.

[Lord Young of Cookham (Con)]

My Lords, I have added my name to Amendment 64, in the name of the noble Baroness, Lady Keeley, and shall speak briefly in support. I have not contributed to this Bill before, but I have sat through many of the debates. Without sounding pompous, it struck me that this was our House at its best, dealing with a complicated Bill in a sensitive and non-partisan way and drawing on the unique expertise we have in our House.

As I listened to the earlier debates on detention and community treatment orders, I asked myself how the children in the families concerned would be informed and what the impact on them would be. We have just heard from the noble Baroness, Lady Keeley, the impact on Aidan when his mother was sectioned. By definition, the people covered by the Bill are vulnerable people; many of them will have carers, and many of those carers will be young carers. As the noble Baroness has just said, this amendment simply helps improve the earlier identification of children of parents being detained under the Act and to ensure that they have access to support, if they need it, and are safeguarded where necessary.

The 2021 census showed that there are 50,000 young carers caring for over 50 hours a week. An astonishing number—3,000 of them—are aged between five and nine. The Carers Trust has shown that those young carers at school are at risk of a poorer attendance record, lower academic achievement and more liable to social isolation and, sadly, bullying, if they are not identified early. As the noble Baroness, Lady Keeley, just said, having a parent with a mental health problem is actually one of the biggest risk factors for depression in children and adolescents. But it is not inevitable: research suggests that intervention can reduce that risk and change the way that children cope.

As a vice-chairman of the APPG on Young Carers, I know that we took evidence last year from young carers, and we heard that on average it takes three years for a young carer to be identified, with some of them taking over 10 years before being identified. Improving early identification is one of the top priorities of the all-party group, so that they can access support and not be negatively affected by their caring situation.

This amendment will help to tackle the issue, which is reported by young carer services, that many potential young carers are not identified by adult mental health services. For example, one young carers service, the Young Carers Alliance, reported that 20% of the young carers it supports are supporting a parent with a mental illness, yet they did not receive a single referral from the adult mental health services in the space of an entire year.

In our inquiry, we also heard from the charity Our Time how, when it comes to identifying young carers by mental health professionals, we are way behind countries such as the Netherlands and Norway. Both those countries have introduced requirements for health professionals to consider whether adults with mental health problems have children. This referral may not be a one-way process; if the child is a carer, he or she may have an insight into the events that trigger an episode in the parent and may actually help the professionals to identify an appropriate treatment pathway.

A final benefit of this amendment is that it would help adult mental health in-patient units ensure that they are complying with the duty under Section 91 of the Health and Care Act 2022 to consult with any carers, including young carers, before discharging an adult from hospital. Again, last year, we heard of patients being discharged without the young carer being informed, often where they were the principal carer. For these reasons, I hope that the Government can support this amendment. I look forward to the Minister’s reply.

--- Later in debate ---

[Baroness Merron (Lab)]

The noble Baroness is right to raise that point. This is the difference between legislation and practice, and we have to bridge that gap. We are very alive to the point she makes, but the important point about this amendment is that we are trying to include all those whom the patient wants to be involved, not just restricting it to parents. I take the point she has made and will, of course, ensure that we attend to that. I would say that that is, as I say, more a case of how things are implemented.

On Amendment 62, in the name of the noble Baroness, Lady Tyler, and the noble Lord, Lord Scriven, it is important that the transition of a young person to adult services is planned and managed with the utmost care by the clinical team. This is reflected in existing care standards and guidelines, which set out what should be met, what relevant teams should meet and how to provide specific support where a young person’s care is being transferred to adult services. This should take place six months prior to the patient turning 18 years of age. On reviewing the patient’s statutory care and treatment plan when they reach adulthood, in Clause 20, subsection (5)(d) of new Section 130ZA already sets out that that plan must be reviewed following any change in circumstances or conditions. We think that turning 18 and transitioning from children and young people’s services to adult is a significant change and absolutely requires review of the plan. We will make this explicit in the code of practice.

Finally, I turn to Amendment 64. I thank my noble friend Lady Keeley for sharing the reality of how this manifests itself by sharing with us individual circumstances. I also thank the noble Lord, Lord Young, whose work on young carers is well known and respected. We support the intention to ensure that children are properly safeguarded. If a person is known to services, immediate safeguarding needs to form part of the planning by approved mental health professionals on behalf of the local authority and others involved in the Mental Health Act assessment before bringing a person into hospital. If a person is not known to known to services, the professionals should work with the relevant agencies to make sure the necessary steps are taken. The statutory guidance Working Together to Safeguard Children sets out how all practitioners working with children and families need to understand their role in this regard.

[Baroness Keeley (Lab)]

I just want to reflect that the noble Lord, Lord Young, said in his speech that young carers services almost never receive any referrals from adult mental health services, despite the provision that already exists and has done for a number of years in codes of practice. This is a difficult thing—I tried to bring in legislation for that in the other place on a number of occasions. I just thought that was worth pointing out.

[Baroness Merron (Lab)]

I thank my noble friend for pointing that out. On the points raised about protections for young carers, the code highlights that children who are caring for parents with severe mental illness are entitled to request a young carer’s needs assessment under the Children Act. It goes on to cover the information that young carers should be offered to help navigate such a challenging time.

Returning to the guidance about which I was speaking, as has been identified, it already outlines the responsibility of multiagency safeguarding partners. Protecting children at risk of abuse and stopping vulnerable children falling through the cracks is very much at the heart of the Children’s Wellbeing and Schools Bill, which was introduced to Parliament last month.

NHS: Patients with Allergies

Baroness Keeley Excerpts

Thursday 12th December 2024 Grand Committee

[Baroness Keeley (Lab)]

My Lords, it is a pleasure to speak in this short debate on this important subject. I congratulate my noble friend Lady Ramsey of Wall Heath on obtaining the debate and on her excellent opening speech, and I am very pleased to follow my noble friend Lord Mendelsohn.

It is a surprising fact that one in three people in the UK live with allergies—perhaps it will not surprise any of us in the Room now, having heard the opening speeches. I am one of those 21 million people, as I have a number of food allergies or intolerances, which have increased over the last 30 years. My allergies are not as serious as the ones that cause an anaphylactic reaction, but they do affect day-to-day living, as I have to avoid wheat gluten, rich dairy products and—at this time of year perhaps the most difficult exclusion—chocolate.

Avoiding allergens in products at home has become a little easier. Thirty years ago. it was very hard to avoid wheat, which is often in many products with ingredients labelled as starch but which is often wheat starch. I learned to cook with different flours, as I am sure every parent with a child with allergy learns to do, but they often had to be bought at health food shops. Now, large supermarkets have a section for “free from” or “made without” products and stock a range of gluten-free flours. At this point, it is worth explaining to those who are not in this world that these products are very expensive indeed. Small loaves cost more than £3, and many of the flour products are very expensive, so the point made about low-income families is very pertinent.

However, the most difficult aspect of day-to-day living with allergies is avoiding allergens in food when eating out, including at work and at school, buying food when travelling or on holiday and buying food from takeaways, because in that situation you have to rely on a shop selling food knowing which ingredients are in the products. It relies on chefs, kitchen staff, waiters and baristas playing their part in faithfully recording requests to avoid allergens and passing that information on to the staff preparing food or drinks, but that does not always happen.

An article in the Times highlighted that more than 50 young people, including a child of nine, have died in less than a decade as a result of severe allergic reactions to food or drinks bought in restaurants, cafés, shops or schools. We have heard in a number of colleagues’ speeches about Natasha Ednan-Laperouse, who died aged 15 after eating a Pret a Manger sandwich which contained sesame. As we have heard, her parents have campaigned on the issues in her case and been told of many deaths of other young people—almost all of which, it seems, were avoidable. They were shocked to hear of so many avoidable deaths. Her father Nadim said:

“When Natasha was growing up we didn’t know any other parents whose children were food-allergic and she was the only one in her primary and secondary school … Then we received thousands of letters when it became public from people who said, ‘We fear every day what happened to your child will happen to ours’”.


He also said that the common themes in the stories they were told by parents included a lack of understanding among catering staff about allergies and how serious they can be, or a human error meaning that they were given the wrong food product.

As we have heard, Natasha’s parents’ campaigns have been focused on two areas: Natasha’s law, an important measure that came into force in 2021, tightening legislation to force outlets that package their own food products on-site to provide a full list of ingredients on the labels, with any of the top 14 allergens, including milk, nuts, eggs and sesame, highlighted; and, as we have heard, the Natasha Allergy Research Foundation is funding a £2.7 million immunotherapy trial across six hospitals that aims to gradually desensitise patients to their allergens through everyday foods. On the number of cases, it is worth saying that, as an MP, I had two local cases within one year of young people who tragically died after eating food containing allergens, despite in both cases the young person or their parents describing their allergies and being assured by waiters and serving staff that the food they were eating was safe for them.

Allergy UK tells us in its excellent briefing that 62% of people with allergies say it affects all aspects of their lives, and I am sure all of us who are contributing here can appreciate that, but among adults with anaphylaxis 40% experience post-traumatic stress disorder because, as my noble friend Lady Ramsey said earlier, it strikes terror in parents’ hearts. Allergy UK also tells us that, despite hospital admissions for people with allergies being 615% up in the last 20 years and rising sharply among children, we have only 40 specialist allergists in this country. As we have heard, specialist services are not well spread across the country; the pattern is distorted. The NHS underutilises preventive strategies such as early allergen introduction; and treatments like immunotherapy have been rejected due to perceptions of the high short-term cost, despite the fact that immunotherapy drastically reduces the high cost of future emergency admissions and hospitalisations.

I join Allergy UK in hoping that the Labour Government may be more receptive to preventive strategies, and I would be grateful if the Minister could give us an update on any possible new preventive strategies for allergies. I also ask my noble friend to look at the call from Allergy UK for the Government to introduce a specialist allergy nurse and dietician at primary care level within every integrated system. With 21 million people living with allergies and so many avoidable deaths of young people and hospitalisations due to allergens, I hope the Government can agree to look at the gaps in allergy management within primary care.

Physician and Anaesthetist Associate Roles: Review

Baroness Keeley Excerpts

Thursday 5th December 2024 Lords Chamber

[Baroness Keeley (Lab)]

My Lords, I welcome the opportunity to speak in this short debate on the review of the physician associate and anaesthetist associate roles and what actions the Government plan. I congratulate the noble Baroness, Lady Bennett of Manor Castle, on the debate and her opening speech. I will start by focusing on the way in which physician associates are used in the NHS and some of the consequences this has had.

In July 2023 I led an Adjournment debate in the Commons on the use of physician associates in the NHS. I did so to raise issues in the case of Emily Chesterton, the daughter of my former constituents Marion and Brendan Chesterton. Emily tragically died of a pulmonary embolism, aged 30, after seeing the same physician associate twice at her GP practice and being misdiagnosed.

The circumstances of Emily’s death were investigated by a coroner in March 2023. Messages from Emily examined at the inquest evidence Emily’s belief that she was seeing a doctor, that the appointments with the physician associate were short and that Emily was not examined fully. The conclusion of the coroner was:

“Emily Chesterton … attended her general practitioner surgery … with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived”.


Crucially, the physician associate did not seek medical advice after seeing a patient who had presented twice in one week with significant risk factors for pulmonary embolism, and she sent Emily home without consulting a doctor about her symptoms.

I said in that Commons debate that Emily’s case raises serious questions about the wider use of physician associates in the NHS. In particular, it raises questions about allowing physician associates to carry out unsupervised one-to-one consultations with undifferentiated patients in general practice. PAs are a dependent role; they are meant to be under the supervision of a designated medical practitioner, but that does not appear to have been the case with the lack of supervision that occurred in the case of Emily Chesterton.

The GP practice later raised concerns about the physician associate’s knowledge and understanding of what investigations she should perform on a patient presenting with those symptoms, about her ability to recognise an unwell patient and escalate those concerns to a doctor, and about her overconfidence and lack of insight into the limitations of her own clinical knowledge and practice.

Since I raised Emily Chesterton’s case, my fears about these roles have increased. There have been other deaths involving PAs. Susan Pollitt died after a drain was mistakenly left in her abdomen for 21 hours by a PA. The inquest concluded that her death in Royal Oldham Hospital in July 2023 had been caused by an

“unnecessary medical procedure contributed to by neglect”.

The Northern Care Alliance NHS Foundation Trust, which runs the Royal Oldham, found that Mrs Pollitt would have survived had the drain been removed earlier.

As we have heard, there are also examples of PAs taking on roles that are far too complex for their experience and knowledge. Alder Hey Children’s Hospital has now admitted that, from 2019 to 2023, a PA worked in a role that involved child sexual abuse medicals. Alder Hey had originally denied that PAs were being used in its paediatric sexual referral centre, which is for children under 16 who have experienced sexual abuse.

Dr Matt Kneale, former chair of the Doctors’ Association, said

“This is flagrantly unsafe. I have no confidence that those cases have been assessed to the same competence of a senior paediatric doctor. Children deserve better”.


Alder Hey later admitted that it stopped deploying a PA within its safeguarding team after concerns were raised by the Crown Prosecution Service and the police about relying on the evidence of a PA in court cases.

The Royal College of Paediatrics and Child Health has just published a survey of the experience of paediatricians working with PAs, with 2,200 responses. The survey reported the following safety issues in the work of PAs: misdiagnosis, 63%; miscommunication, 58%; failure to escalate deterioration, 48%; undetected deterioration, 23%; and ordering ionising radiation—which PAs are not allowed to do—9%. The RCPCH survey also reported that 72% of paediatricians with experience of working with a PA believe that their recruitment should be halted.

There are many more examples where patient safety is seen to be endangered by the way in which PAs and AAs are being used in the NHS. This is not helped by seeing a number of posts on social media with PAs videoing themselves, their patients and their clinical settings just to make posts on TikTok or other social media. Concerned consultants who highlighted these inappropriate videos to the press have said that PAs are coming very close to the line of professional misconduct by making these videos.

The new Government have inherited what is effectively a Wild West in medical care, because a new medical role was brought in without regulation, with only voluntary registration and no national scope of practice for PAs and AAs. GP members of the BMA have voted in favour of stopping hiring PAs in general practice and phasing out the PA role. They also stated that the role of PA is inadequately trained to manage undifferentiated patients and that there should be an immediate moratorium on such consultations. The medical royal colleges, as we have heard in this debate, are making their strength of feeling heard on these safety issues. This was recently summarised by Professor Martin McKee in an article in the BMJ.

As I mentioned, the Royal College of Paediatrics and Child Health found substantial safety concerns with PAs working in paediatric settings. The Royal College of GPs has agreed to oppose the role of PAs working in general practice, following a consultation of its members.

The Royal College of Physicians of London is now advocating for a limit to the rollout of the PA role, following a survey of its members. Its sister royal college in Edinburgh has called for a delay in implementation

“until clear nationally agreed scope and ceiling of practice protocols are in place and clear plans regarding post-registration training and assessment of PAs are defined”.

The Royal College of Surgeons has also expressed concerns, including the risk that the expansion of these roles could undermine the roles of surgical care practitioners, surgical first assistants and advanced nurse practitioners. As we have heard, the Royal College of Anaesthetists, after noting concerns about the current use of AAs, has called for a pause in their recruitment.

The Royal College of Radiologists says it has

“no plans to bring PAs into the College and we do not anticipate a significant expansion of the role within our specialties”.

The Royal College of Emergency Medicine also

“does not currently support the expansion of the Physician Associate workforce in Emergency Medicine”,

again supported by a member survey expressing widespread concern. Now, as we have heard, the Universities of Chester and Portsmouth have halted recruitment to their PA courses for 2025, and the University of Leeds no longer lists the course on its website.

On announcing the Leng review, Secretary of State Wes Streeting said that

“there are legitimate concerns over transparency for patients, scope of practice and the substituting of doctors”.

I agree.

I believe the issues that need to be tackled are these. We need to focus on the unsafe substitution of physician associates in what should be doctor-only roles and rotas, and we should put a stop to that substitution while the Leng review is in progress. We need to accept that it is time to pause the recruitment of PA and AA roles and to halt the expansion of their numbers, particularly until after the Leng review reports, and we should take action, as we have heard, so that PAs and AAs in existing roles are now given the opportunity to retrain into other roles.

In the interim, I hope we can accept that there must be proper regulation of PAs and AAs. They must work within a national scope of practice agreed with the royal colleges. As a first step, as we have heard, the BMA’s safe scope of practice could be adopted.

After the tragic deaths, such as those of Emily Chesterton and Susan Pollitt, we must also hear the voices of patients and the public. Do people want these roles, or would they rather see a doctor?

I end with a quote that Emily’s mother, Marion Chesterton, sent to me. She said:

“We hope that, for all our sakes, precise, thorough and true regulation of PAs will end the chaos, confusion, vagueness and potential danger to patients. We pray for clarity, honesty and co-operation. If our daughter’s life means anything, please, sort out this sorry mess. No more Emilys”.

Mental Health Bill [HL]

Baroness Keeley Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Baroness Keeley (Lab)]

My Lords, I am glad to take part in this debate in your Lordships’ House, after four years as a shadow Minister for Mental Health and six years on the Health Select Committee in the Commons.

In welcoming this Second Reading, I will speak about dealing with the inappropriate detention of autistic people and people with learning disabilities in mental health hospitals. Noble Lords, including those who served on the Joint Committee on the draft Mental Health Bill, understand that too many autistic people and people with learning disabilities have been detained in inappropriate facilities and for far too long. But we, as politicians and legislators, have not made the changes needed to stop this.

The Winterbourne View scandal and a series of other scandals since 2010 have shown abusive treatment meted out to autistic people and people with learning disabilities detained in inappropriate units. In 2011, following the shocking revelations made by journalists of the abuse to residents detained in Winterbourne View, which was rightly described as “torture”, the then Prime Minister pledged to close all inappropriate in-patient units by 2014. That did not happen. Since then, successive Governments have also committed to targets to reduce the number of autistic people and people with learning disabilities in in-patient settings and to prioritise housing and support in the community for those individuals. These targets have all been missed.

In 2021, the Commons Health and Social Care Select Committee, of which I was a member, completed an inquiry into this treatment. Commenting on the missed and delayed policy targets, the inquiry report suggested that “a more radical approach” was needed to unlock community provision for this group of people. Now there is a chance for reform but there are widespread concerns to raise with my noble friend the Minister that the measures in the Mental Health Bill will not be enough in themselves. While it is welcome that the Bill makes it harder to detain a person under the Mental Health Act on the grounds of autism or learning disability, there are widespread concerns, as we heard in this debate, that this could lead to people being held under alternative routes, including the Mental Capacity Act 2005 deprivation of liberty safeguards. We must guard against that happening.

In many cases, autistic people and people with learning disabilities are not being detained just because of the legal framework they are under. They get stuck for years in mental health hospitals because of the lack of support for them in the community. In too many cases, discharge planning is repeatedly delayed because those responsible see the needs involved as too complex or feel that there are no suitable care providers. I will mention two cases to illustrate this: a young autistic woman called Bethany, and Tony Hickmott.

When I first raised Bethany’s case in the Commons, she was a 17 year-old autistic woman with extreme anxiety, kept in seclusion in St Andrew’s hospital, Northamptonshire. In a cell-like room, she was fed through a hatch in a metal door. When her father Jeremy visited, he had to kneel at the hatch in the door to speak to her. Bethany was detained and held in seclusion despite an assessment that the hospital setting that she was in could not meet her needs and a recommendation that she should be moved to a community residential setting with high support.

The lack of funding for support in the community was clearly a factor. The Walsall Council officer responsible for her placement told Bethany’s father that her care had already cost the council £1.2 million. “To be frank,” the officer said to him, “Walsall could do with a breather”. Moving Bethany to a community setting would involve her local council paying £100,000 to £200,000 a year from the adult social care budget, instead of leaving the NHS to pay the much higher bill, which was £676,000 a year. It seems that Bethany was being held in isolation so that the local council responsible did not have to pay her costs, but the very high costs of her detention were then borne by NHS England.

I raised Bethany’s case numerous times in the Commons and she was at last discharged to live in the community. Fast forward seven years and her father talks about what a happy life his daughter now has, in her own property, with good support from a wonderful care team.

The outcome has not been as positive for Tony Hickmott, an autistic man with learning disabilities. In 2022, Tony had spent 21 years in a secure assessment and treatment unit and it looked as if he could finally move back to his hometown of Brighton, close to his parents Pam and Roy.

Tony had stopped meeting the criteria for being detained in a psychiatric hospital in 2013, but it was ruled that he could not be discharged from there because a suitable community placement could not be found for him. His parents applied to the Court of Protection in 2019 and, after a number of hearings, the judge ruled that Tony should be discharged from hospital to live in a specially renovated house with care from a brought-in provider.

This should have been a happy ending too, but it was not. Reports describe that Tony is now effectively barricaded into the bedroom, with the care staff in his home operating the house like a seclusion room. Tony’s parents, now in their 80s, are prohibited from taking him out into the community. He is held under the deprivation of liberty safeguards. I hope that Tony Hickmott’s care provision can be improved.

Much could have been done by Governments over the last 12 years to tackle this issue of inappropriate detention. The new Government now have the chance to change this. First, we must act to prevent new inappropriate admissions of autistic people and people with learning disabilities. Secondly, we must act to enable the discharge of the 2,000 autistic people and people with learning disabilities detained inappropriately in mental health units.

As we have heard in this debate, the average length of detention for this group is 5.4 years, with 355 people detained for more than 10 years. Mencap has estimated the cost of this care in inappropriate units for this group as £534 million a year. Detentions are often, as we have heard, far away from family and friends, with alarming reports of people from this group being overmedicalised, subject to physical restraint and shut away in isolation. All this is as traumatic for those detained as it is devastating for their families. As Mencap has said, its findings on the staggering cost of institutional care show that this is

“an appalling waste of public money on the wrong type of care”.

I hope that there is now a will to change this.

As I mentioned, there is first the issue of ensuring no new placements of autistic people and people with learning disabilities in those inappropriate mental health units. The Commons Select Committee inquiry report made recommendations on how this could be achieved.

Secondly, the issue of who is paying for care and community support must be tackled. I support the plea made by the noble Baroness, Lady Hollins, for an action plan to succeed the Building the Right Support Action Plan. The Commons Select Committee inquiry recommended that the Department of Health and Social Care should

“redesign the financial incentives … so that local authorities”

and local NHS bodies

“do not seek to ‘offload’”

the care of

“autistic people and people with learning disabilities onto the NHS or place these individuals in inpatient facilities”.

Tackling these issues of funding flows now needs strong cross-governmental action.

There are some further actions that could be taken to improve the mechanisms around this area of work. I thank the human rights lawyer Dr Oliver Lewis for his input. Currently, mental health tribunals are not considered useful in dealing with people stuck in hospital in-patient units. Tribunals dealing with cases for this group should be required to have a medical member with expertise in autism and learning disabilities. Working through the practical issues of achieving a discharge destination for people currently detained could be improved if mental health tribunals are given the power to compel a local authority or NHS body to find a discharge destination in the community or if the Court of Protection was used more to rule on discharge arrangements.

The Bill presents an opportunity to correct an oversight under Section 73 of the Care Act 2014 affecting human rights, which the noble Baroness, Lady Barker, raised earlier. I too thank Dr Lucy Series and Professor Luke Clements for information about the issues raised in the Sammut judgment. As we have heard, that is a ruling that means the Human Rights Act does not apply where mental health patients get Section 117 aftercare in private settings. There is a real concern about the broader implications of this for patients receiving continuing healthcare through private services, children in private social care, and even patients detained in private hospitals under the deprivation of liberty safeguards. This latter group could expand to include the numbers of learning disabled and autistic people who are detained in hospital under the deprivation of liberty safeguards because they are no longer eligible for detention under Section 3 of the Mental Health Act. I am sure it was Parliament’s intention to protect the human rights of vulnerable adults and children for whom the state arranges health and care services. I hope that my noble friend the Minister will agree to the suggested meeting with Lucy Series and Luke Clements to discuss that.

I hope that we can bring forward amendments as necessary to correct this oversight as well as to address the other issues I have raised.

Carers and Poverty: Carers UK Report

Baroness Keeley Excerpts

Thursday 21st November 2024 Lords Chamber

[Baroness Merron (Lab)]

One of the key things in all this is the identification of carers. As has been discussed in your Lordships’ House on a number of occasions, a lot of people do not identify as carers. Therefore, we are encouraging GPs and, in the case of young carers, schools, to identify carers, so that they can get the support they deserve. The noble Lord, Lord Darzi, identified that making sure that unpaid carers receive recognition and support is key, and it will be in the 10-year plan as we go forward.

[Baroness Keeley (Lab)]

My Lords, I want to raise the issue of the 21-hour study rule whereby an unpaid carer is not allowed to claim carer’s allowance and be in full-time education of more than 21 hours a week. I cannot see a good reason for that rule. It would be very welcome if the Labour Government changed the rule to allow unpaid carers to study without losing their carer’s allowance.

[Baroness Merron (Lab)]

I thank my noble friend for that and can assure her that I will be discussing that very point with ministerial colleagues and am happy to return to her on it.

National Carers Strategy

Baroness Keeley Excerpts

Tuesday 19th November 2024 Lords Chamber

Asked by

[Baroness Keeley]

To ask His Majesty’s Government what plans they have to develop a National Carers Strategy.

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

My Lords, we are committed to supporting unpaid carers through our renewed vision for adult social care and the 10-year plan for the National Health Service. We have already taken action to increase the carer’s allowance earning limit, meaning that carers can earn around £2,000 a year more without affecting their entitlement. We have heard the calls for a national carers strategy and will continue to work collaboratively across government to ensure that unpaid carers are visible, valued and supported.

[Baroness Keeley (Lab)]

I thank my noble friend the Minister for that reply, particularly on cross-governmental working, because I think that is one of the most important aspects. The Labour Government’s first national carers strategy was launched in 1999 by the Prime Minister, Tony Blair. The second strategy in 2008 had the support of Gordon Brown and seven Secretaries of State, because evidence from unpaid carers had shown that support for carers could not be solved by one government department but needed work across several. Sadly, Conservative Governments after 2015 did not continue with the national strategy, preferring a much less effective carers action plan. Carers are partners in care, so will my noble friend the Minister consider the strength of feeling among carers and their support organisations that they need and deserve a high-level strategy across government departments to support them?

[Baroness Merron (Lab)]

I certainly agree with the emphasis that my noble friend is putting on the need for cross-government working. I know she has been a champion of that for many years in the other place and that she will continue in your Lordships’ House to ensure that unpaid carers are properly supported and recognised. I can tell my noble friend that Minister Kinnock, as the lead Minister for unpaid carers, regularly engages with those with lived experience, the organisations that represent them and—importantly to the point my noble friend is making—with Ministers from other government departments, most recently the Department for Work and Pensions. We will be formalising our cross-government working with relevant departments and NHS England.

NHS Dentistry: Recovery and Reform

Baroness Keeley Excerpts

Wednesday 7th February 2024 Commons Chamber

[Victoria Atkins]

My right hon. Friend raises an interesting point. Indeed, that is exactly the sort of discussion I am having with my right hon. Friend the Levelling Up Secretary, because I am really interested in having that connected and joined-up approach between planning and health. I think it could bring dividends for us all.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I do not believe that what the Secretary of State has described will deal with the complexity of dental problems out there. I have a constituent who was referred to the Manchester Dental Hospital for a possible abscess and was told that even an urgent referral would take a month. In fact, the dental hospital did not get back to her for five months after the referral; it offered her a telephone consultation. The amount of pain and infection meant that she had to seek private treatment at a cost of £4,000, but many cannot afford that, including the young man wheeled into Royal Bolton Hospital in great pain, leaking blood on the floor after trying to remove a painful tooth with pliers. What does the Health Secretary say to patients who have long-standing and complex dental problems and are paying the price by waiting in pain, paying for private treatment or trying to remove their own teeth?

[Victoria Atkins]

I take that constituency case very seriously. I am really keen to urge the hon. Lady that if a constituent contacts her in future with that level of discomfort and pain, she should advise that constituent to contact 111 and, if necessary, go to accident and emergency—[Interruption.] Labour Members are shaking their heads, but what she has just described is a serious situation. That constituent needs medical attention, and the NHS is there, ready and willing to help. That is the advice that she should be giving her constituents, and I hope that she takes it as seriously as I do. [Interruption.]

Oral Answers to Questions

Baroness Keeley Excerpts

Tuesday 23rd January 2024 Commons Chamber

[Victoria Atkins]

I thank my hon. Friend for her interest and, of course, her many years working as a clinical psychologist. She brings that experience to the Chamber. National commissioning guidance to integrated care boards was published in November. It sets out that a mental health in-patient stay for a person with a learning disability

“should be for the minimum time possible, for assessment and/or treatment which can only be provided in hospital”.

In overseeing implementation of the action plan going forwards, the “Building the right support” delivery board will maintain focus on quality of care and on reducing long stays.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

It is vital for the Government to do more to move autistic people and people with learning disabilities out of in-patient units and back to their communities. Recently, in the trial of staff at Whorlton Hall, we saw staff who were cruel and uncaring. Delivering sentences, the judge said that Whorlton Hall was an

“unpredictable and…frightening place to live”.

Is it not time for the Government to close down those units and move the majority of people into the community?

Draft Anaesthesia Associates and Physician Associates Order 2024

Baroness Keeley Excerpts

Wednesday 17th January 2024 General Committees

[Barbara Keeley (Worsley and Eccles South) (Lab)]

It is a pleasure to serve on this Committee with you in the Chair, Dame Caroline. I am pleased to be able to speak in our discussion of this very important area of legislation, as the right hon. Member for Suffolk Coastal just called it. In my view, this issue is so important that we should be debating it in the Chamber; perhaps we could have found a way to do that.

Schedule 1(3)(a) to the order states that the regulator

“has the objective of promoting and maintaining—

(i) public confidence in, and

(ii) proper professional standards and conduct for members of, the anaesthesia associate and physician associate professions”.

I hope that the regulator takes those duties very seriously, because public trust in physician associates has already been damaged by the very sad death of Emily Chesterton, who died after being seen twice and diagnosed by a physician associate at a local GP practice. Emily was the daughter of my constituents, Marion and Brendan Chesterton, and I raised her case at an Adjournment debate on 6 July 2023. I would like to give details of Emily’s case, because it illustrates the need for the greatest clarity in the distinction between doctors and staff in the medical associate professions.

Emily Chesterton died in November 2022 after suffering a pulmonary embolism, after being seen twice by a physician associate, rather than a GP. She was just 30 years old when she died. Emily was a budding actor in musical theatre. She and her partner had moved to London from Boothstown, in my constituency, to pursue their careers in the arts. They registered with their local GP surgery, the Vale Practice in Crouch End, north London. Emily had been diagnosed with polycystic ovary syndrome and had also contracted covid-19 in late summer 2022. Marion Chesterton, her mother and my constituent, said that Emily had been feeling unwell for a few weeks before she made an appointment at the Vale Practice on 31 October 2022, as she had calf pain and was breathless. Emily believed that this appointment was to see a GP, but the person she was booked to see at the practice was a physician associate.

Physician associates and doctors have a very different depth of expertise. Physician associates have to complete just two years of clinical training, following a biosciences undergraduate degree. Doctors, on the other hand, must complete a five-year medical degree, as well as several years of foundation training and specialism training, interspersed with national exams. As both the Minister and my hon. Friend the Member for Bristol South on the Opposition Front Bench have said, physician associates are intended to support and assist more medically qualified staff, not replace them.

In Emily’s case, after a short appointment, the physician associate diagnosed Emily with a sprain and possibly long covid. Emily was told to rest and take paracetamol. At no point during the appointment at the GP surgery was Emily made aware that the person who had diagnosed her was not a doctor.

A week later, on 7 November, Emily began to feel very unwell. Her leg was swollen and hot, and she struggled to walk a few steps without becoming out of breath. She made another appointment at the Vale Practice and saw the same physician associate. It appears that this was a short appointment, and that Emily’s legs were not examined. The physician associate suggested that Emily’s breathlessness was due to anxiety and long covid. She prescribed propranolol. In messages that Emily sent to her family on that day, it appears that she described seeing “the doctor”, and that she was never told that the person she was consulting for medical assistance was not a fully qualified GP.

In its serious incident report after Emily’s death, the Vale Practice stated that patients should not see a physician associate twice for the same condition. The guidelines make it clear that physician associates cannot prescribe; any prescriptions need to be signed off by a supervising GP. It appears that the oversight of prescribing medication was missing, and the system failed in Emily’s case.

Later in the evening of that same day, 7 November, Emily’s health deteriorated, so she took a propranolol tablet, as advised by the physician associate. She then became drowsy, and then very ill. Her partner Keoni recalled to the inquest that she lost her pulse, and he had to perform CPR on her, which recovered the pulse. He then called an ambulance.

Emily suffered a cardiac arrest on the way to the hospital. Her family had to say their goodbyes to her while she was still on the machine that was pumping her heart for her. Keoni recalled that staff at the A&E department at Whittington Hospital, where Emily died, told him that the propranolol tablet “definitely would not have helped” Emily’s condition, and staff had to give her an antidote to the drug.

The circumstances that led to Emily Chesterton’s death were investigated by a coroner, and there was a hearing at St Pancras coroner’s court on 20 March 2023. Messages from Emily to her partner and family at the time of her appointments were shared at the inquest. These messages provide evidence that Emily believed that she was seeing a doctor. They also provide evidence that the appointments with the physician associate were short, and that Emily was not examined fully.

The coroner’s conclusion was as follows:

“Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”

That heartbreaking statement lays out clearly the failings in the health system, which should have supported Emily with appropriate care.

Sadly, further failings were evidenced in the incident report that the Vale Practice provided to the coroner. In particular, it was noted that the physician associate who saw Emily did not introduce herself and her role to Emily during the appointment. The practice said that the physician associate had failed to explore the causes of Emily’s symptoms, failed to refer Emily for clinical investigations, and failed to consult a doctor after seeing a patient who had presented twice in one week with significant risk factors for pulmonary embolism. The practice also raised concerns about the physician associate’s overconfidence and lack of insight into the limitations of her clinical knowledge and practice. Although the physician associate’s contract at that practice was later terminated, Mrs Chesterton was upset to learn that she was still practising in the NHS in London, but I understand that that changed after I raised concerns in the Adjournment debate.

I must add that Emily’s is not the only case like this. Sadly, Ben Peters, a previously healthy 25-year-old, died from a heart haemorrhage after being diagnosed with a panic attack by a physician associate. A freedom of information request sent to Scottish health boards found that there have been at least 12 “never events” linked to physician associates in Scottish health authority areas.

These cases demonstrate the urgent need for this profession to be regulated in a way that avoids further confusion among patients, their families and medical staff. To patients, associates and doctors may look the same—they appear to be doing a similar job—but the fact is that the associates do not have the same qualifications or expertise as doctors. I understand that it was originally envisaged that physician assistants would be vital members of multidisciplinary teams, assisting with the workload and contributing to a high quality of care, but the regulator must ensure that there are now clear guidelines for associates to make their role clear to patients when they introduce themselves. As I have described, that did not happen in the case of Emily Chesterton.

There is a bigger question around the titles of associate. At the time of my Adjournment debate, Marion Chesterton raised with me the point that the title sounds

“extremely grand, even grander than a General Practitioner”.

Some have suggested changing the title back to the original title of physician assistants and anaesthesia assistants to avoid that confusion. There may be other solutions that the Minister could consider.

Getting the approach to associates right will become even more urgent as the profession grows in line with the proposals set out in the NHS long-term workforce plan. There is certainly a need to tackle workforce shortages in the NHS, as my hon. Friend the Member for Bristol South said. A lack of qualified professionals is the root cause of many of the challenges that our health service faces. We must be careful that any adaptations to the workforce to fix those issues do not push existing professionals out.

I had many GPs write to me after my Adjournment debate about Emily’s case. One told me,

“There is much talk amongst GP locums of work drying up, possibly due to the increasing use of Additional Roles Reimbursement Scheme staff (including the associate roles) to fill vacancies (and these are much cheaper than employing locum GPs), and last week there was considerable disquiet about the Surrey practice that made its salaried GPs redundant due to ‘new ways of working’.”

He wrote on,

“For GPs—salarieds, locums, and trainees—who have been working in an over-stretched, high-stress system, and [who have] been told that there is a national shortage of GPs—this leaves many wondering about the security of their career and exploring other options. I am seriously concerned that the many intelligent, enthusiastic and valuable people in training and working as GPs are looking at options outside the NHS, outside medicine, and outside the country.”

I am sure the Minister would agree that this is deeply concerning when the UK already faces intense competition from other countries to retain our doctors. While multidisciplinary teams with a diversity of roles are vital, doctors must still be valued. Most importantly, patients and clinicians must have a clear understanding of the skills, qualifications and limitations of those providing care.

I want to acknowledge that there have been many tragic cases leading to avoidable deaths of patients that have involved other roles. We could look at the case of Connor Sparrowhawk, an epileptic teenager who had a seizure and drowned in a bath at a hospital unit run by Southern Health. Connor was just 18. Dame Caroline, you will know well the case of Oliver McGowan, who died in Southmead Hospital at the age of 18. Oliver was prescribed the anti-psychotic medication olanzapine by a consultant in the hospital, despite his notes saying that he had reacted badly to it previously. Oliver died as a result of the brain injury caused by the medication.

Those are tragic cases, but in neither of them was it the role and the limitations of an NHS professional that caused the problem. The issues I have raised are about the safety of patients and the accepted standards of knowledge, training and experience that we should expect from our medical professionals in order for them to provide a high quality of care. I hope that the Minister notes the points raised in this debate, and takes steps to ensure that the NHS workforce delivers for patient safety.

--- Later in debate ---

[Andrew Stephenson]

I thank my right hon. Friend the Member for Suffolk Coastal and the hon. Members for Bristol South, for Leicester East, for Worsley and Eccles South, for York Central, and for Wirral West for their contributions to today’s debate.

I would like to turn first to the contribution by the hon. Member for Worsley and Eccles South, who spoke movingly on behalf of her constituents Marion and Brendan Chesterton about the death of their daughter, Emily. I know that the hon. Lady also did so in a very moving fashion during an Adjournment debate, which was responded to by my predecessor, my hon. Friend the Member for Colchester (Will Quince). Ahead of today’s debate, I was very keen to listen to that debate, so I watched it back and I am keen to see what more we can do to learn lessons.

No family should ever have to endure the loss of a child, and no words from me will assuage the family’s grief. However, I hope that by passing this order we are helping to ensure that some lessons have been learned and that we can deliver improved patient safety through better regulation of these roles. I recognise that there have been delays to the previously published timescale for the regulation of AAs and PAs. Although that is in part due to the pandemic, it is important to reiterate that this work is being taken forward as part of a broader package of reforms of regulators, governing a whole range of medical professions. That work is significant and complex. On that basis, a huge amount of work and input from all the regulators and a range of stakeholders has contributed to the draft legislation for AAs and PAs, which will be used as a template for reforms to other regulatory bodies.

Throughout this process, officials from my Department have met the BMA and other stakeholders to develop the policy behind this legislation. On the basis of feedback received through public consultation and additional targeted engagement, officials have made a number of amendments to the draft order to ensure that the legislation is fit for purpose and delivers the flexibility and autonomy required to empower regulators to be able to introduce new regulatory processes that would better serve patients and their registrants. That engagement has been crucial in shaping both our policy intention and the resultant legislation to ensure that it remains a practical piece of legislation that can be used by regulators.

The forthcoming GMC rules consultation, which will follow the passage of this order, represents a further opportunity for the BMA and others to have input into the regulation of these roles. When I met the GMC, I was assured that they were confident that they could bring forward this consultation quickly so that there are no further delays to the timetable of implementing these regulations.

Turning to the AA and PA titles, which quite a few Members have raised today, the physician associate title has been well established in the UK since 2014, and the Government have no plans to change the titles of PAs or AAs. As set out in the National Institute for Health and Care Excellence guidelines, all healthcare professionals directly involved in patient care should introduce themselves and explain their role to the patient. AAs and PAs are not and should never be referred to as medical practitioners, doctors or consultants.

The GMC has published interim standards for AAs and PAs in advance of regulation that make it clear that professionals should always introduce their role to patients and set out their responsibilities in the team. Ahead of regulation by the GMC, the Faculty of Physician Associates has issued guidance for PAs, supervisors, employers and organisations that helps to provide a structured and standardised way of using the title. In addition, NHS England has produced patient-facing materials that have been shared widely with GP practices to support patient awareness and understanding of the PA role.

[Barbara Keeley]

I thank the Minister for his words of sympathy; I will pass them on to Mr and Mrs Chesterton. On patient-facing advertising, I think a couple of months ago, I raised with the previous Secretary of State for Health, the right hon. Member for North East Cambridgeshire (Steve Barclay), a post from Norfolk and Waveney integrated care system that read, “Got abdominal pain that isn’t going away? A Physician Associate based in your GP practice can help…They are highly skilled at diagnosing conditions”. That was marketing material related to the role, which does not help. We have had tragic cases like Emily’s, and it does not help to have over-egged advertising like that. Can the Minister can say anything about that?

[Andrew Stephenson]

I completely agree. Things like that do not help, and that is why bringing forward these regulations will help. The GMC is obviously very keen to start its consultation and have the regulations introduced. As soon as this is set out in statute, it will be very helpful, not just for PAs but everybody, particularly employers and others, in ensuring that they never oversell the abilities of a PA and are clear about the role of a PA or AA in an integrated health team.

Turning to the shadow Minister, the hon. Member for Bristol South, I thank her for her contribution and join her in paying tribute to the PAs and AAs already working in our NHS. She asked about the impact on training opportunities for junior doctors, which leads me on to addressing quite a few of the points about why we have decided to go with the GMC as the regulator. The assessment of the most appropriate regulatory body for AAs and PAs was completed in 2019 following a public consultation. The majority of respondents were in favour of the GMC taking on regulation, including the professional bodies representing the two roles and the medical royal colleges. For the record, from a total of over 3,000 responses, 59% of respondents felt that the GMC was the most appropriate, while 20% thought it should be the HCPC.

Regulation of the associate roles by the GMC will allow it to take a holistic approach to the education, training and standards of associate and doctor roles. That will enable a more coherent and co-ordinated approach to regulation, hopefully ensuring that concerns around training places for junior doctors, for example, are addressed appropriately. I am happy to reassure the shadow Minister that I will continue to work with all stakeholders to ensure that we get the regulations right.

I thank the hon. Member for York Central, who spoke knowledgeably about these roles. We would all agree that it has been long recognised that we need to reform the legislative framework for the regulation of healthcare professionals to make things faster and more flexible. The current UK model needs to change to better protect patients, support our health service and help the workforce to meet future challenges.

Successive Governments have considered such reforms, but they have never come to fruition until now. While it is our intention to work as swiftly as possible to deliver reform for each regulator and profession, we will prioritise delivery based on criteria including the size of the registrant base, the need for reform, and our assessment of regulators’ readiness to implement the changes. Based on those criteria, we intend to start working with the regulators to develop reform legislation for their professions over the next couple of years.

The hon. Lady asked about fee levels. I believe the GMC’s current plan is to charge AAs and PAs a fee of £221 per annum, adjusted for inflation. That is what PAs are currently paying the FPA—of course, AAs do not currently pay a fee. The GMC, like the NMC and other regulators, works on the basis of their activities being funded by the fees from registrants, which is an important way of keeping them independent from Government.

This draft order represents a vital step forward to improve patient safety by ensuring that PAs and AAs meet the standards that we expect of all regulated professionals and that they can be held to account if serious concerns are raised. I hope that I have addressed as many of the points raised by the Committee as I can, but I am more than happy to continue dialogue with the Opposition Front-Bench team and others to ensure we get the changes right. I commend the draft order to the Committee.

Building an NHS Fit for the Future

Baroness Keeley Excerpts

Monday 13th November 2023 Commons Chamber

[Wes Streeting (Ilford North) (Lab)]

I congratulate the Minister on being the great survivor of the Department of Health and Social Care. She must surely be due a carriage clock or the long service medal by now. The only long-term decision for a brighter future seems to be that she is still in her place, although she did not offer much of a brighter future.

More positively, I see far more than one nervous face on the Government Benches—I see lots of nervous faces among those contemplating the next general election—but one is undoubtedly that of the hon. Member for Uxbridge and South Ruislip (Steve Tuckwell). I congratulate him on his election and wish him well for his maiden speech, which I can confidently say will be the best speech we hear from those on the Conservative Benches all day.

At a time when patients cannot get a doctor’s appointment, families are struggling to pay the mortgage and major conflicts are having an impact on our economy and security, the Prime Minister has spent the past five days deciding whether to sack his Home Secretary for publicly disobeying him, undermining the police and inflaming tensions on our streets. Finally, having had the sheer poor judgment to have appointed someone to such high office when she had already been forced to resign for a serious national security leak, he has summoned up the guts to sack the worst Home Secretary in history. Yet, as we see, the merry-go-round of the Conservative clown show continues. After 13 years, the Conservatives have run out of names at the bottom of the barrel, so they are starting all over again. May I offer my sympathies to the Conservative Members who did not get the call from No. 10 today? What kind of message does it send to their constituents that their own party leader cannot find a suitable candidate for Foreign Secretary among the 350 Conservative MPs who sit in this House?

The arsonist has today returned to the fire, because when it comes to the national health service, Lord Cameron has quite a lot to answer for as the architect of austerity and the biggest top-down reorganisation in the history of the NHS—a £3 billion disaster that has led straight to the biggest crisis in the history of the NHS. That is before we even begin to take into account his record of ushering in the “golden” age between Britain and China; taking 20,000 police officers off our streets; and having food bank Britain leave more than 1 million people dependent on charity to feed themselves and their families. That is Lord Cameron’s legacy and as the current Prime Minister admits, “some mistakes were made”. Who is he trying to kid when he tells us that this recycled Conservative Government offer the change our country needs?

I would welcome the Secretary of State for Health and Social Care, the hon. Member for Louth and Horncastle (Victoria Atkins) to her position, but of course she is not here this afternoon, having just been appointed earlier today. She is the fifth Secretary of State for Health and Social Care that I have faced in this job in less than two years, although, to be fair, two of those appointments were the right hon. Member for North East Cambridgeshire (Steve Barclay). The Government said they would make

“Long-term decisions for a brighter future”,

but they cannot even deliver a long-term Secretary of State for Health.

We know where the Secretary of State is—she will be in the Department being briefed about the challenges of the job and being brought up to speed. No doubt she and new Ministers will want to review the decisions she is inheriting and to start to think afresh about whether she wants to proceed with those decisions as they have been working through the machine. That is why it is so grossly irresponsible to change Ministers every five minutes and constantly churn from one face to another, when it is clear to everyone but the Prime Minister that it is not just a change of faces around the Cabinet table that we need, but a change of Government.

As the Secretary of State sits in the Department being briefed by her civil servants, I will help them out with the induction by offering her a primer on what she inherits: millions of patients a month unable to get a GP appointment when they need one; 24 hours in A&E—not just a television programme, but a reality for far too many; ambulances not arriving on time, if they arrive at all; the 12th month of the worst strikes in the history of the National Health Service; NHS dentistry in managed decline, to the point where people are forced to pull out their own teeth—DIY dentistry in 21st century Britain; a generation of young people who have paid the price for lockdowns with their mental health, forced to wait years for the support they need; the longest waiting lists and the lowest patient satisfaction in history. That is the record of the Secretary of State’s seven predecessors: failure, upon failure, upon failure, upon failure, upon failure, upon failure, upon failure.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

My hon. Friend is absolutely right about that list of failures—it is shocking. I would like to add to the list that over 2,000 autistic people or people with learning disabilities are detained in inappropriate units, when this Government promised over 10 years ago to close them all down.

[Wes Streeting]

I thank my hon. Friend for her intervention. As I make progress through my speech I will come back to the breath-taking complacency about mental health we heard from the Minister a moment ago.

Given the scale of the crisis and given that the Prime Minister has made fixing waiting lists one his five priorities, hon. Members might have expected something in the King’s Speech to deal with it. Instead, we got nothing on the NHS as it heads into its most challenging winter yet and we got nothing on social care, just kicking the can down the road and delaying reforms until after the election. There was nothing on dentistry, despite even Conservative Back Benchers crying out for a rescue plan, and nothing on mental health, despite the Conservative party committing to reform, not just in its last manifesto but in its last two manifestos.

It was the longest King’s Speech in almost a decade, with the fewest Bills. Does that not just sum up the modern Conservative party? Plenty of slogans, but no solutions. What we got was a Bill that will not come into effect until after the general election and a sack-the-nurses Bill. On the tobacco and vapes Bill, the question is not whether Labour will support it, but whether the Conservative party will support it. Government Members will remember that I first proposed that smoking ban back in January. I say they will remember, because they made their feelings known in newspapers at the time. They called it “nanny state” and

“an attack on ordinary people and their culture”.

They accused me of “health fascism”. Well, they can now make their considered and nuanced views known to the new Secretary of State—I am sure she is looking forward to receiving them. It just demonstrates that where Labour leads, the Government follow.

The Prime Minister may be too weak to whip his Back Benchers to vote that crucial measure through, but on the Opposition Benches we will put country first and party second. Labour MPs will go through the voting Lobby and make sure that the legislation is passed, so that young people today are even less likely to smoke than they are to vote Conservative.

I am afraid to disappoint the Government, but we will not be supporting the other Bill in the King’s Speech that relates to health. Most people look at the crisis in the NHS and think it needs more doctors and nurses. The Conservative party looks at the health service and concludes that we need to sack more doctors and nurses. The Government are saying that public servants should be sacked for failing to provide minimum standards on strike days, but the Government have not met the four-hour A&E standard since 2015; they have not met the standard for treatment within 18 weeks since 2016; and they were doing so badly on meeting cancer waiting time standards that they have simply got rid of the standards altogether. If the Conservatives are proposing to sack doctors and nurses for failing to provide minimum service levels, can we now sack Ministers for failing to meet minimum standards on non-strike days?

The new Health and Social Care Secretary has an opportunity to break with the past year. Strikes are crippling the NHS and they are putting patients in harm’s way. Her predecessor may have thought that they were a useful excuse for his failure, but they were, and are, a misery for patients and staff alike. The Government must stop the scapegoating of NHS staff, go into these negotiations with good faith, work at finding a solution, and, finally, bring these strikes to an end. There will be no progress on turning around our national health service until the Government make some progress.

When summing up I hope the Minister will explain why action was not taken on the Mental Health Act 2007, because, I am afraid, the Minister’s opening remarks were entirely unsatisfactory. The Bill has gone through Committee. It has cross-party support. It is ready to go, so where is it? The treatment of people with learning disabilities and autism under the current Act shames our society. The disproportionate impact on black people, who are four times more likely to be sectioned than white people, is appalling. Prisons and police cells are no place for people with mental ill-health. Surely that is not controversial in 2023. It is, as the former Prime Minister, the right hon. Member for Maidenhead (Mrs May), said, “a burning injustice”. I cannot understand why the Government have broken their promise to address that matter finally.

It is long past time that mental health was treated with the same seriousness as physical health. Labour will not only reform the Mental Health Act in our first King’s Speech, but recruit thousands more mental health professionals, provide hubs in every community, and set up mental health support in every school, so that young people can get the help they need when they need it. [Interruption.] The Minister says that they have done that. What planet is she living on? This is the problem with these Ministers. Even when the faces change, the lines remain the same. The Minister has not changed, but she is still reading from the same failed script. This is the problem with the Conservative party. Its message to the country is simple: “You have never had it so good. Everything is going really well. The reason we are churning all the Ministers in our Cabinet is that they are doing such a good job. It is job done and time to give someone else a chance.” I am afraid that that is why these Conservatives are so out of touch and will struggle at the next general election if their message to the country is that it has never had it so good.

Furthermore, unlike this Government, who crashed the economy in the most reckless way, we will pay for our policies, making sure that they are fully costed and fully funded—in this case, by ending tax breaks for private schools and private equity fund managers. Politics is about choices: Labour chooses the wellbeing of the many, not the interests of the few, and we will fight the election on those lines any time. I say call the election tomorrow, because we are ready.

When it comes to dentistry, I should also say farewell to two former Ministers, the hon. Members for Colchester (Will Quince) and for Harborough (Neil O’Brien). As the hon. Member for Harborough departs Government, I hope that he does not take with him his pledge to bring forward a recovery plan for NHS dental services. It has been seven months since he announced that such a plan would be forthcoming, yet it is now nowhere to be seen. Indeed, last week, integrated care systems were given permission to raid their dentistry budget underspends and to remove the ringfence. That follows a pilot in Cornwall, trialling making NHS dentistry available only to children and the most vulnerable. It is the managed decline of NHS dentistry before our eyes. If people want to know what the future of the NHS would look like with five more years of the Conservative Government, they need only look at the ghost of Christmas past in NHS dentistry. The Conservatives blame the previous Labour Government, but they have been in power for 13 years. In 2010, we stood on a manifesto committed to reforming the NHS dental contract. They have had 13 years to do it, and they have failed again and again, leaving us in the situation that we are in today, with Dickensian stories of desperate people performing DIY dentistry and tooth decay being the most common cause of children aged six to 10 being admitted to hospital. It did not need to be this way.

I say to the new Secretary of State and her team that she may not have a plan, but Labour does, and she is more than welcome to nick it. We will deliver 700,000 more urgent appointments a year, recruit dentists to the areas most in need, introduce supervised toothbrushing in schools to prevent children’s teeth from rotting, and reform the NHS dental contract so that everyone who needs an NHS dentist can get one—

--- Later in debate ---

[Barbara Keeley (Worsley and Eccles South) (Lab)]

The shadow Health Secretary, my hon. Friend the Member for Ilford North (Wes Streeting), raised the fact that there have been five Health Secretaries in two years. The Conservatives have also had 12 Culture Secretaries since 2010, so perhaps it should not surprise us that, among the many glaring omissions in the Gracious Speech, there was an absence of any measures to support those who work in Britain’s cultural sector, and particularly musicians. I want to focus on that.

Music industry leaders tell me that their sector feels left behind. Freelancers feel left out in the cold without the financial stability they deserve. In too many communities, cultural provision is now dependent on the good will of talented individuals who are prepared to manage on shoestring budgets with low income levels. We can do so much better in this country. As a music leader recently told me:

“The warning bell has been ringing for years, and this Government seems to have taken for granted the drive, passion and sacrifice which has somehow kept the industry alive.”

I have been told repeatedly that the problems faced by creatives come back to this: a decline in arts education, which is leading to skills shortages; falling funding levels; and the challenges to touring caused by the Government’s failure to get a visa waiver for touring in the Brexit deal. The Government choose to ignore those problems and pretend that they are supporting the sector adequately—even today they are setting ambitious growth targets for the creative sector. I want to begin by looking at the squeeze on arts education, and in particular the decline in music education.

We know that state-funded schools are increasingly unable to provide strong music education—or in some cases any music education. Policies such as the English baccalaureate, combined with the crisis in music teacher recruitment and squeezed school budgets, have led to a reduced provision of music education for young people in state schools. On average, music provision in state-funded schools is only 47 minutes a week. That is significantly below the Government’s target of one hour, which is a bare minimum. Compare that paltry target with parts of Germany, where secondary school students study music for at least two hours a week, or Finland, where music is studied for eight hours a week. Meanwhile, the uptake of music at A-level has fallen by a catastrophic 45% since 2010. There is a similarly worrying picture when it comes to studying music at GCSE.

In this difficult environment for schools and teachers, the role of music education hubs is all the more important, yet those hubs have had their funding reduced by 17% in real terms since 2011, and Government plans to reduce the number of hubs risk a further deterioration of the music offer. The Government’s failed education policies mean that the opportunities to gain the skills necessary to be a musician are becoming increasingly the preserve of those young people whose families who can afford to pay privately, either through attending independent schools or through private music tuition. As a result of those Conservative policies, less than a quarter of the music and performing arts workforce now come from a working-class background.

As well as fewer opportunities in schools, there are now barriers to both budding and established musicians touring beyond the UK’s borders. The failure of the former Culture Secretary to obtain a touring agreement with the European Union for cultural workers resulted in an appalling mess of red tape and extortionate fees for bands and orchestras looking to perform in EU countries. Agents, promoters, record labels and musicians have all told me that this is proving devastating for artists, particularly those trying to break into the industry. The freelance opera singer Paul Carey Jones said:

“As ever, it’s those at the start of their careers, without the backing of an established reputation, who will suffer the most…the consequent long-term damage to the UK’s position as a global force in the performing arts is incalculable.”

In a recent interview on LBC, the Culture Secretary implied that sorting out the mess of visas for touring musicians is not under the control of her Government, but it is up to the Government to renegotiate it and to find a solution for touring musicians.

Then there are the financial challenges that many musicians face. A recent survey by the Musicians’ Union found that musicians earn, on average, just £20,700 a year from music. Nearly a quarter of musicians reported that they did not earn enough to support themselves or their families, even after their lengthy training. There is a direct link between the working conditions of musicians and decisions to cut arts and culture budgets. Local authorities are the biggest funders of culture in the UK, but, as we know, they have suffered a 40% real-terms reduction in central Government spending since 2010. That has meant a £1.4 billion shortfall in spending on culture, heritage and libraries. Meanwhile, Arts Council England had its per capita budget reduced by 13% between 2009-10 and 2021-22. It is therefore no surprise that the number of filled jobs in music is falling.

In the last year alone, the number of filled jobs in music performing and visual arts fell by a tenth—a drop of 35,000 roles. That reduction is even greater in roles relating to instrument manufacture, sound recording and the operating of music venues. How can we expect children and young people to aspire to work in the music industry if there are no jobs for them to go into?

Funding shortfalls may also sadly have an impact on the important work undertaken by music organisations in health and care. For example, the Liverpool philharmonic has just celebrated 15 years of its music and health programme, which works with the NHS to help people access music to support their recovery and their wellbeing. Another brilliant health initiative is the English National Opera’s “Breathe” programme, where ENO chorus members have used singing techniques to aid recovery from covid-19 or long covid. There is also a great deal of work involving musicians bringing joy to people with dementia and those living in care homes.

The failure to support musicians and other creatives is not a peripheral issue, because expression in all its forms is central to the task of recreating a sense of community, identity, pride and hope, and our creative workers are at the heart of that potential. We will never achieve the diversity needed for the arts sector to thrive under the Tory policies I have discussed. The systemic failure to protect creative workers under this Conservative Government has led to working-class representation in the creative industries halving since the 1970s.

Today, the Culture Secretary is in Manchester, praising the creative industries as a driver of economic growth. At the same time, she is presiding over the cutting of the funding streams that feed them, and expects them to run on empty, doing more with less, year after year. It is time for this Government finally to accept that their policies have failed, and that Britain’s culture sector would be better off under a Labour Government.