Mental Health Bill [HL]

Debate between Baroness Bennett of Manor Castle and Baroness Tyler of Enfield

Committee stage
Monday 24th February 2025 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I rise to speak to Amendment 130 in the name of my noble friend Lord Scriven, who is unable to be in his place today. On these Benches, our view is that this amendment is essential to the success of reforms proposed in this Bill. It would ensure not only accountability but the continuous assessment of costs and implementation timelines related to the vital provisions of the Bill. In short, it is a costed plan. It is grouped with various other important amendments, some of which I strongly support.

The issue we have repeatedly encountered in both mental health policy and community care is that we end up with community but very little actual care within it. This gap leads to preventable health crises, placing individuals and services under immense strain. Therefore, we must do everything to avoid this outcome. Yet so far in Committee we have not heard the necessary reassurances that adequate provisions will be in place nor that they have been properly costed and strategically planned for community care.

At its core, this amendment champions the need for transparency in the investment and execution of mental health care, specifically within community settings, where the demand will be greatest when the changes in legislation are brought forward. We cannot afford to enact these mental health reforms without a clear understanding of their financial and structural impact on the health and social care system, the justice system, local authorities and, most importantly, the lives of those who rely on these services.

In short, the amendment would require the Secretary of State to lay a report before Parliament within four months of the passage of the Bill and annually thereafter. The report would provide a detailed assessment of both the monetised and non-monetised costs associated with the provisions of the Bill. Specifically, it would outline the financial commitments necessary for the training of NHS staff and approved mental health professionals, the expansion of community care services and the provision of adequate housing and care for individuals with autism or learning disabilities. Furthermore, the amendment would ensure that the Care Quality Commission was adequately resourced to uphold the highest standards of mental health provision. These are fundamental requirements, because without a clear cost framework and implementation plan, we risk leaving individuals in crisis without the support they need.

However, it is important to say that the amendment is not simply about numbers; it is about real lives. The monitoring and evaluation strategy included within this proposal would ensure that reforms were not just theoretical but delivered tangible improvements in patient care. It would require the Secretary of State to assess patient outcomes, collect user feedback and measure the effectiveness of new safeguards and support mechanisms.

If we fail to scrutinise and report on the costs and impact of this legislation, we risk underfunding critical services, delaying implementation, and ultimately failing those who are most vulnerable. Mental health services, particularly those delivered in the community, are a necessity and not a luxury. They prevent hospitalisations, support recovery and uphold the dignity of those living with mental health conditions. This amendment would ensure that these services were not only established but were adequately funded, effectively implemented and continuously improved.

I turn briefly to Amendments 163 and 164 from the noble Lord, Lord Stevens, which I see as complementary and mutually reinforcing to Amendment 130. In particular, Amendment 164 would ensure that mental health funding was not cut as a share of overall health service funding until this Act was fully implemented. The amendment supports the principle of parity of esteem by putting a floor under the aggregate mental health service funding share in England; in essence, enshrining the mental health investment standard in law, something that we very much support. I beg to move.

[Baroness Bennett of Manor Castle (GP)]

My Lords, in speaking chiefly to my Amendment 153, I shall say briefly that I very much agree with what the noble Baroness, Lady Tyler, just said and support, as does she, the related amendments that come after this. They interrelate with an amendment of mine that was discussed earlier in Committee about the funding of community services. Funding is the great issue right across the board, and it is essential that there is something in the Bill that addresses that. My amendment, although it looks somewhat different from the others in this group, is closely related to them, because, as the noble Baroness said, we have to be concerned about the implementation of the Bill and not just its nature.

My amendment says that for-profit companies should not deliver under the Bill. It does that in two ways. It says:

“Any new facilities or organisations created to deliver the provisions of this Act must not be operated by for-profit companies”.


It then says that within five years of the day on which this Act is passed, the Secretary of State must ensure that what is now for-profit in this space is transferred to not-for-profit. Why is that essential to implementation? I shall put it into three categories.

The first is the cost of paying profits from what should be money for the provision of services. The second is quality issues associated with for-profit companies; after all, their directors and management have a duty to maximise the return to shareholders. That is the way that for-profit companies are set up in this country. The third is that there are issues of stability.

--- Later in debate ---

[Baroness Tyler of Enfield (LD)]

My Lords, yes, I am afraid it is me again. I thank my noble friend Lord Scriven and the noble Baroness, Lady Bennett, for adding their names to Amendment 134. Of course, we have already acknowledged in many of our debates that the provisions in the Bill rely heavily on strong and effective community provision being in place, but there are real concerns within the sector that community provision is not currently sufficient to support the changes set out in the Bill. In my view, the new duties placed on local authorities and integrated care boards to ensure an “adequate supply” of community support lack teeth, and no real accountability measures have been put in place as yet to ensure that this duty is fulfilled. My Amendment 134 would place a general duty on integrated care boards to ensure that services in the community had the necessary level of resource to meet demand for services.

This amendment is closely related to the amendments in group 1, already debated—indeed, I am not quite sure why this one was not included in that group; groups remain a bit of a mystery to me. It is worth noting that the Equality and Human Rights Commission recommended in its response to the Joint Committee that the Government should, in line with the recommendation of the independent review, ensure that there was

“sufficient, high-quality, appropriate, community-based mental health services and pathways to meet the needs of all adults, children and young people”.

It stressed:

“These should include therapeutic alternatives to detention, preventative support to minimise the risk of crisis, and wider community services that enable good mental health and recovery”—


something I will be returning to in a later amendment. Is the Minister able to say what consideration the Government have given to that specific recommendation?

The EHRC also felt that the Bill needed strengthening

“to ensure sufficient community-based services in practice in order to end inappropriate detentions. This was highlighted in the most recent annual review of the Mental Health Act by the CQC, which stated: ‘While we support the government’s objective to reduce hospital admissions for people with a learning disability and autistic people under the MHA, this can only be achieved by an increase in community support, including trained staff, and high-quality alternatives to admission’”.

I want to finish by focusing on the workforce aspect. Following the previous Government’s 2021 White Paper, the Royal College of Psychiatrists commissioned an independent assessment of the impact of the proposed changes on the psychiatric workforce to better understand how many additional psychiatrists would be required to deliver the reforms in the proposed year of implementation and, indeed, 10 years later. Based on that White Paper, the research found that by 2023-24, an additional 333 full-time equivalent psychiatrists would be needed in England, costing £40 million per year, and that by 2033-34, a further 161 full-time equivalent psychiatrists would be needed. While these figures may not necessarily accurately reflect the exact number of psychiatrists needed to deliver the reforms we are talking about in the Bill, or the current timelines for the legislation, they demonstrate clearly the impact on a workforce which is already understaffed and carrying high vacancy levels.

Back in March 2016, NHS England set a target to have an additional 1,040 consultant psychiatrists in post in England by March 2024. Based on these targets, as of July last year there was a shortfall of some 770 psychiatrists across England. That is a big shortfall. The impact assessment, while absolutely voluminous, is—as far as I can see—silent on where these people are going to come from. However, it estimates costs of around £99 million for alternative mental health care for people no longer admitted to hospital. It also estimates some £5.5 billion of savings from fewer overall admissions and fewer detentions for people with a learning disability or autism. It goes on to say that the benefits

“should not be understood as cashable”.

Can the Minister say what specific mechanism will be used for diverting more money into community services?

Psychiatrists are absolutely critical but are only one part of the wider mental health workforce, which also includes mental health nurses, clinical psychologists, mental health social workers, occupational therapists and others. Can the Minister say whether detailed plans to grow the overall mental health workforce will be contained in the 10-year plan and the upcoming spending review?

I am conscious that I have asked quite a lot of detailed questions, so if the Minister would prefer to write to me with her response, that is fine. I add that I am sympathetic to the aims of Amendment 157 in the name of the noble Lord, Lord Davies. I beg to move.

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to again follow the noble Baroness, Lady Tyler of Enfield, and offer support to her. I will be very brief because there has already been a comprehensive introduction.

It is useful to draw a comparison to see how we might look at some kind of composite as we get towards Report. This amendment places a general duty on integrated care boards to ensure that services in the community have the adequate levels of resource, which is why I signed it, but who gives the resources to the integrated care boards? Ultimately, it is the Government.

My earlier amendment sought a regular process of reports and parliamentary oversight, and I suggest that we need both. This is a good, strong amendment to give the duty to the ICBs. But we also need to see that there is the oversight and that ICBs have the capacity to support the duty they are being given.

Mental Health Bill [HL]

Debate between Baroness Bennett of Manor Castle and Baroness Tyler of Enfield

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, Amendments 65 and 133, in my name and that of my noble friend Lord Scriven, are both about tackling racial injustices in the operation of the Act. I am sympathetic to the amendments that we have just heard about from the noble Baroness, Lady Whitaker, who set them out eloquently. I also strongly support Amendment 138, in the name of the noble Lord, Lord Kamall.

As I have said in previous debates, a primary driver of the review of the Mental Health Act was the shocking racial injustices in the use of the Act, and we need to have that front and centre in our minds as we work our way through the Bill. Addressing racial inequalities is one of the key issues identified in the 2018 review, and there remain concerns that the Bill still does not go far enough to address that deeply entrenched inequity. As I set out on the first day of Committee when introducing my amendment on including equity as an additional principle in the Bill, black people are more than three and a half times more likely to be detained under the Mental Health Act than white people and over seven times more likely to be placed on a community treatment order. I make no apology for repeating those figures because I think they are scandalous.

Evidence shows that, on average, people from racialised communities experience greater difficulty accessing mental health services and have poorer experiences and outcomes, and we have heard examples of that. For example, black or black British people are more likely to be detained for longer and to experience repeated admission. They are also more likely to be subject to police powers under the Act and experience higher levels of restraint. It is worth noting that the noble Lord, Lord Darzi, in his recent report on the NHS, said the use of restrictive interventions in in-patient mental health settings had continued to rise, and the most recent data shows that people from a black or black British background are still significantly more likely to be subject to restrictive intervention.

I readily acknowledge that there are some measures in the Bill that should have a positive impact for people from racialised communities—for example, the introduction of the advance choice documents that we were talking about earlier, which I very much welcome—but, in my view, the Bill in its current form still only scratches the surface, really. It does not take on many of the recommendations in this area from both the independent review of the Act and the pre-legislative scrutiny committee. Can the Minister explain why those recommendations were not taken on board?

I turn to my amendments. Amendment 65—and I thank the noble Baroness, Lady Bennett, for adding her name—is a probing amendment designed to understand better the Government’s thinking on how they intend to address racial disparities in the use of community treatment orders, which we debated at length on Monday. I do not want to repeat that, save to say that community treatment orders have been used more widely than anticipated and disproportionately on individuals from particular ethnic backgrounds. It is vital that this is closely monitored to ensure that the disproportionality in use is tackled head on. We must not focus just on reductions in the overall numbers of CTOs. Does the Minister agree that that should include collecting evidence on the effectiveness of NHS England’s patient and carer race equality framework and its approach to reducing the overrepresentation of people from black and minority ethnic communities?

Just to show that, rather like my noble friend Lord Scriven, I do not get out enough, I noticed that page 88 of the lengthy impact assessment talks about 13 pilots—trusts that have already started to make changes as a result of this anti-racism framework. Can the Minister update the House on their progress? If she cannot do so now, perhaps she could write to me.

We know that people from these racial backgrounds may also be reluctant to seek help from formal services, based either on previous negative experiences or in some cases because of social stigma attached to mental health issues within their own community. Amendment 133 would require mental health units to appoint a responsible person to address and report on racial disparities and other inequalities relating to the use of the Act. This is really important and it is vital that a new responsible person role is introduced at hospital level to oversee race equality and address inequalities in the operation of the Act.

The responsible person would be responsible for publishing a policy on how that unit plans to reduce racial and other disparities which are based on protected characteristics in that unit or community mental health service. They would have responsibility for monitoring data on equalities as well as overseeing workforce training and policies and drawing up policies to address bias and discrimination. In my view, the creation of a responsible person role at local level would materially help us to move forward to a more transparent and accountable mental health system, and this accountability would be reinforced and amplified by the responsibility this amendment also places on the Secretary of State to report on progress made on reducing inequalities at national level. That is set out in proposed new Section 120H.

I really believe that such a dual-pronged approach to clear and transparent accountability could make a tangible difference in this critical area of public policy, and I look forward to the Minister’s response.

[Baroness Bennett of Manor Castle (GP)]

My Lords, as has already been acknowledged, I have put my name to Amendment 63, tabled by the noble Baroness, Lady Whitaker, and Amendment 65, tabled by the noble Baroness, Lady Tyler. Both of them have done a comprehensive job of introducing the amendments so I will be extremely brief.

The noble Baroness, Lady Whitaker, is well known in your Lordships’ House for championing the many issues affecting Gypsy, Roma and Traveller people. I particularly wanted to sign Amendment 63 because it is a very broad-ranging amendment—it is crucial that everybody gets culturally appropriate forms of explanation. It struck me as we were debating that we are focused now on mental health, but I think this probably would also apply right across the NHS to physical health because there are, of course, cultural differences in understanding our bodies, et cetera.

If we imagine the case, perhaps, of a refugee who suffers mental health difficulties, having fled their home country, where they were subject to abuse by the authorities. It is important to make sure, if they are to be sectioned, that that is carefully explained to and understood by both the patient and potentially the patient’s family. There needs to be an extra level and a sensitivity to that person’s circumstances. We will all have different circumstances, but it is important to look at it in that broad frame.

On Amendment 65, we have already canvassed quite extensively the way in which minoritised communities are currently seeing significant disparities in the way they are treated under the law in the area of mental health, particularly in community treatment orders. The noble Baroness, Lady Tyler, described this as a probing amendment. Whether this is the exact means or not, it is clear that we have to have much better data and to make sure that as soon as trends and patterns emerge in that data, they are acted on. It is encouraging to hear that this is being piloted and work is being done but it is crucial that this becomes standard and that is why it is tempting to feel that it really has to be in the Bill.

Mental Health Bill [HL]

Debate between Baroness Bennett of Manor Castle and Baroness Tyler of Enfield

Committee stage
Tuesday 14th January 2025 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, I shall speak very briefly, having attached my name to Amendments 19 and 20. I support all of the previous amendments, which are in essence about people knowing about care and treatment review plans. I particularly wanted to sign these two amendments because of the clause identified by the noble Lord, Lord Scriven, and the noble Baroness, Lady Hollins. It states that integrated care boards and local authorities “must have regard to” the plan—as the noble Lord outlined, that is a very weak, weaselly form of words—rather than having a duty to deliver the plan that has been established for the well-being and health of a person. The phrase in the Bill now really is not adequate.

I want to share something with noble Lords. On Friday night, I was in Chorley, in Greater Manchester, at a meeting with the local Green Party and NHS campaigners. One of the things I heard there was a huge amount of distrust and concern about integrated care boards and the restructuring arrangements that have happened with the NHS. I am not going to get into those issues now but, with the words “must have regard to”, we are leaving an open door and a door to distrust. Surely the right thing is for this Bill to say that the ICB has a duty to deliver a care plan.

On Amendment 20, we will undoubtedly talk endlessly about resources, but that there must be a compelling reason is the right terminology to have in the Bill; it really has to be justified. I believe that both of these amendments should be in the Bill.

[Baroness Tyler of Enfield (LD)]

My Lords, I will speak to Amendment 13 in my name in this group, but wish to add my support to the amendments that have already been talked about: those in the names of my noble friends Lady Barker and Lord Scriven, and the very important amendment in the name of the noble and learned Baroness, Lady Butler-Sloss. I have experience in my wider family of someone with autism, so I know full well the importance of having the parents and the wider family involved in review meetings. Frankly, it would be very difficult indeed if they were not there for those review meetings to express the wishes and preferences of the individual concerned.

I guess that that is quite a helpful link to my amendment, which is about communication needs. I know that we explored this issue pretty thoroughly in our debate on the first group—you could argue that my amendment could have been in either the first grouping or this grouping, but it is in this grouping. I will keep it short, because we have talked about this quite a lot. In essence, the amendment is designed to ensure that communication needs being met is included on the list of the subject matter that must be considered and on which recommendations must be made during the care (education) and treatment review meetings.

It is clearly vital, as we have all acknowledged, that every effort is made to ensure that autistic people and people with learning disabilities are involved in their own care and treatment decisions and are able—this is the critical point—to express their preferences and needs. To ensure that this is the case, their communication needs must be understood, considered and met; the noble Lord, Lord Kamall, made that point powerfully in our debate on the first group. Often, this needs to include understanding a person’s communications preferences; having the right sort of environment; making sure that the environment is supportive; or, sometimes, using very specific communication tools, which do exist. This can also include—this refers to the amendments from the noble and learned Baroness, Lady Butler-Sloss—the involvement of a person who knows and understands the patient well, quite often a family member or advocate. That can be key to meeting someone’s communications needs.

I am sure we all agree that care and treatment reviews need to be designed to ensure that the person affected is central to the decisions being made about their care and treatment. It is therefore absolutely self-evident that communications needs should be considered and discussed at the beginning of those meeting to ensure that the person concerned is able to express their thoughts, wishes, feelings and preferences, so that everyone involved in the care and treatment of individuals is equipped to meet those moving forward.

I am very supportive of the amendment tabled by my noble friend Lord Scriven which would lengthen the time between reviews from 12 months to six months. I think 12 months is just too long. An awful lot can happen in that period and circumstances can change. I know that we have a subsequent group on care and treatment plans, but on the point made by my noble friend Lady Barker, it is important to think of the individual in a fully joined-up way, looking at housing needs as well. I know that we are going to return to it in a subsequent group, but it vitally needs to include things such as money matters, debt advice, ensuring that the individual does not fall into financial exclusion and all of that. I have put my name to an amendment on that in a later group.