Health and Care Bill

Debate between Baroness Hollins and Baroness Barker

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness Hollins (CB)]

I love this debate—it is brilliant—but it makes the point that this is an ideal opportunity to pre-empt a later Bill and get on with the job now where it belongs. Given the strength of feeling in the Committee, if we cannot reach a solution to this, I will bring it back on Report.

[Baroness Barker (LD)]

My Lords, I feel for the Minister in his position. He is right: people observing our proceedings will see us laughing, but in practice this is really serious. I talk to colleagues in local government who receive endless requests from the NHS to turn up to meetings and they do not go, and why? It is not because they do not think that it is important, but because local government has been hollowed out over the last 10 years to the point where it has very senior management and front-line staff, and does not have large numbers of people in the middle doing middle-management planning jobs that exist in the NHS. That was the reality before Covid and is the reality now. Each of those building blocks that the Minister is putting in may be some great stepping-stone to a nirvana for the NHS, but they are just another obstacle for local government. It is so important that we in this House are not tied to constituencies or particular areas of importance. Speak truth to power—to the Government. We are building something unsustainable that will not work.

Mental Capacity (Amendment) Bill [HL]

Debate between Baroness Hollins and Baroness Barker

Committee: 2nd sitting (Hansard - continued): House of Lords
Monday 15th October 2018 Lords Chamber

[Baroness Hollins]

My Lords, my Amendments 38, 39, 40, 41 and 43 would add in families, friends and carers. They build on and support Amendments 15 and 16, which were debated earlier and tabled by the noble Baroness, Lady Jolly. They would require that every cared-for person has access to an approved mental capacity professional, regardless of whether the assessor considers that the cared-for person might object to the care and treatment proposed.

Not everyone will be able or willing to risk expressing an objection to those currently providing their care. It can be very hard for a person to object to care given by a staff member on whom they may be totally dependent, and may feel obliged to agree with, when they view them, correctly, as somebody who has power over them. I suggest that for some people this will not be an easy judgment even if they are trying to object, particularly if they have difficulty communicating. It is often the case that family members are the most skilled at communicating with their loved ones, as I suggested earlier, and are therefore most likely to understand their feelings and wishes—feelings which may be communicated with subtlety or nuance, and which are unlikely to be confided to unfamiliar people or people perceived to have power over them.

In those situations where someone is not able to communicate their objections, it is vital that their family and others with an interest in their welfare are able to object for them and to trigger a referral to an AMCP—someone whom they can be confident has the right expertise. Otherwise someone with profound communication impairments might not be able to object while those close to them have serious concerns about the arrangements, yet are not able to request an AMCP. Those with the most profound impairments must not miss out on the involvement of an AMCP in this situation. In the 2014 report from the House of Lords post-legislative scrutiny committee, Nicola Mackintosh spoke about the compliant nature of many incapacitated adults. She said that,

“if you have a vulnerable person detained in a care home who is physically or verbally expressing a wish to leave, those cases are more likely to be raised before the court than cases involving a compliant, incapacitated person. That was the case in the Bournewood case. I do not think the DoLS scheme has cured the illegality”.

I do not think that the Bill, as amended, will fill the Bournewood gap. My Amendment 44B has identified a similar issue to that in Amendment 44A, proposed by the noble Baroness, Lady Thornton. It has been tabled to protect the rights of people detained for treatment in assessment and treatment units, and other hospital settings, for treatment for mental disorder. It would include NHS and independent hospitals. These are often the most restrictive settings where the liberty protection arrangements will apply and there are serious concerns about the rights of patients with learning disabilities who are placed in these settings.

However, due to the rules governing the interface between the Mental Capacity Act 2005 and the Mental Health Act, which this Bill leaves largely untouched, these patients will not receive any independent assessment by an AMCP. The reason for this, as I understand it and put as simply as possible, is that the Mental Capacity Act cannot be used to authorise a detention if the person is viewed as objecting to their detention; the Mental Health Act must then be used. This means that patients detained in hospital under DoLS or its successor, the LPS, will by definition be regarded as not objecting by those responsible for their detention. This would include people such as HL in the Bournewood case, who may not be capable of expressing an objection or whose behaviour is hard to interpret by those who do not know them well.

Under the Bill, a person will qualify for an assessment by an AMCP only if there is reason to believe that they are objecting, so for this group a specific trigger is needed to ensure that their detention is scrutinised by an independent, specially trained professional to ensure that it is justified, having regard to the alternatives. Last year there were 4,670 DoLS applications for patients in this category. I hope the Minister will agree that it is important for people in these settings to have access to an AMCP automatically.

I have also had some communication with Professor Sir Simon Wessely today, but I did not achieve the same certainty as my noble friend, who is not in her place. I hope that the Wessely review will remove the learning disability exemption in the Mental Health Act, which allows people with a learning disability to be detained if their behaviour is abnormally aggressive and so on, and that instead their detention will be on the same grounds as for any other person. I beg to move.

[Baroness Barker]

There are two amendments in my name in this group. Amendment 44 is designed to probe an issue that is clearly worrying lots of noble Lords: that the condition that triggers an AMCP is that the person is objecting to their care in a particular place. The noble Baroness, Lady Hollins, is always very good at helping us to understand legislation from the point of view of people with learning disabilities. My background and my chief concern is with older people with dementia who are probably disproportionately likely to be overlooked by this provision because they will not necessarily be vocal.

I return to the questions raised by the noble Baroness, Lady Thornton: why would you object if you do not know what you are objecting to? What will happen if you do object? Will you receive any help? Currently, best interests assessments are required for DoLS detentions but, as I understand this, where a person does not object they do not get to see an AMCP. If they are in a care home, it is the care home staff, but in hospital and community settings the responsible body can use evidence from other assessments to make a determination for somebody. What is the evidence base for this? Do we know how many people currently object to their care and treatment? Why is that considered a sufficiently robust basis on which to make this a criterion in law? There is something deeply flawed and deeply wrong about this.

Amendment 59 may seem a bit strange on the face of it. It inserts a requirement to keep a record of refusals of authorisations. One of the things that the Select Committee of your Lordships’ House found was that the evidence base for DoLS is very sketchy. I have to make it clear that the Select Committee’s report was put together and came out just around the time of the Cheshire West ruling. In the light of that ruling, the number of applications shot up. We have never had a robust evidence base for the way DoLS work. I agree with the noble Baroness, Lady Hollins, that this is not going to close the Bournewood gap, but we should at least try to cover up some of the deficiencies there have been in the past. Therefore, trying to get together some basic stats and information, including how many times things like DoLS have been refused, is important.

I know, as will other noble Lords, that among professionals, or rather among stakeholders, there was a big discussion prior to Cheshire West about whether having lots of DoLS applications was an indication that in fact you were a good provider or whether that would somehow be indicated by the fact that you had none. That is not the right calculation; you can argue it either way.

We still need to get to the bottom of the transparency of the decision-making around this. That was my reason for tabling what might seem to be a rather strange amendment.

Mental Capacity (Amendment) Bill [HL]

Debate between Baroness Hollins and Baroness Barker

Committee: 1st sitting (Hansard - continued): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Baroness Hollins]

This needs emphasis because of the culture of care that we have in this country. There is still such a paternalistic attitude towards the person, that not to emphasise it is to miss the point.

[Baroness Barker]

I thank noble Lords for their support. We will need to return to this and I am glad that the Minister has taken that point.

Another reason for tabling the other amendments to ensure that arrangements are the least intrusive and least restrictive option is that, as we will debate on later amendments, the Bill is somewhat deficient in the extent to which it requires that people should be given information on which to base the consultation.

I make no apologies for raising this again at this time. It is something that I hope we will discuss between now and later stages of the Bill. I hope that the Minister can understand the reasons for the concerns that lay behind the amendment. Having said that, at this point, I beg leave to withdraw the amendment.

Care Bill [HL]

Debate between Baroness Hollins and Baroness Barker

Wednesday 16th October 2013 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I commend the amendment of the noble Lord, Lord Patel of Bradford. I shall not say much more than that other than that he commented on the risk that the current situation could lead to more likelihood of a more medical approach to aftercare. Noble Lords might think that as a retired psychiatrist I would support that, but I do not; it is incredibly important that people who have a history of mental illness and need aftercare services receive the broadest possible support so that admission to hospital is not simply because there is inadequate support for them in the community. I commend his proposal.

[Baroness Barker (LD)]

My Lords, I wish to indicate my support for the continuance of Section 117, as I have done on many occasions before, not least during the passage of the most recent Mental Health Act—when various people, whom I shall not embarrass now by saying who they were, did indeed stand up to defend some of it—because it works.

When the Law Commission first made this proposal in its report, I had occasion to talk to that body. The noble Lord, Lord Patel, is right; the commission relies very heavily on the Mwanza case, and there is a great deal of dispute about the advisability of doing that. The question that I had when I first met the Law Commission still remains: when everything else in the legislation is geared towards enabling health and social care to work together to enable the transfer of people from acute health settings back into the community, why rip up the one piece of legislation that has been there doing that for 30 years? It is not just that some of us see Section 117 as being important with regard to the individuals whom we might know or come across; rather, we see it as an important means of bringing about the transfer that some of us have long hoped would happen in mental health services whereby, instead of having patients who revolve between acute and the community, we could have proper care planning in which people’s mental health needs were addressed by some of the same people, whichever setting they were in. It is not just about trying to preserve a pot of money; it is about trying to keep open a pathway to good and better practice. That is why the noble Lord, Lord Patel, as he always does in this area, has presented the House with a very persuasive argument. I have not yet fully understood why the department feels the need to make the changes that it is making.

Care Bill [HL]

Debate between Baroness Hollins and Baroness Barker

Monday 22nd July 2013 Lords Chamber

[Baroness Barker]

My Lords, I support the amendments of the noble Baroness, Lady Greengross. They go straight to a gap that exists for older people who have capacity but are physically dependent upon people who may be abusing them. With all respect to the noble Lord, Lord Patel—whose arguments I listened to very carefully because they were very thoughtful, and I would not want to disregard what Mind has found in its consultation with its members—I point out to him that members of Mind are likely to have protection under either the Mental Health Act or the Mental Capacity Act. The people to whom the amendment tabled by the noble Baroness, Lady Greengross, is addressed do not have that protection. For me, that swings the argument.

Elder abuse has a rather odd standing in the general consciousness. It does not have the same profile as the abuse of children. It goes up and down the public agenda depending upon whether there has been some scandal or an awful case in the papers. People’s reactions to it vary enormously. When people are polled on their views about this, the phrasing of the questions in any consultation can have a profound impact. Were we faced with a question that said: “Would you like social workers to have the power to intrude into your house?”, most of us would say no, but if we were asked, “Do you think that somebody ought to be able to look out for people who are extremely vulnerable and may not be able to get out and tell anybody?”, we would say yes. That goes straight to the consultation that the Government have already held, and the reason for some of its findings. Professionals who have had experience of dealing with people and operating under the law have said that they think there needs to be a greater degree of protection, albeit with brakes and conditions, such as the necessity of getting the agreement of a JP—not just social workers barging in because they feel like it.

Taken together, the amendments tabled by the noble Baroness, Lady Greengross, get the right balance. They are not about empowering bossy professionals to wade in regardless of what people want but they are quite important, not least because of something the noble Baroness, Lady Greengross, said, which was of tremendous importance: the largest percentage of people who abuse vulnerable elderly adults are family members. The consequence of that is that very often people who are being abused are highly reluctant to do anything about it because they fear that there will be repercussions against their family members. That is why it is necessary to have a bit more legal force behind some of this than we would otherwise think we should, and I think that, on balance, the noble Baroness’s amendments are right and proportionate.

Finally, there is a very good case for the Government to accept the amendments or something like them within this legislation. They should do it now when we are not making decisions in the shadow of a scandal and when we can talk about best practice in neutral terms.

[Baroness Hollins]

My Lords, I shall speak briefly in support of my noble friend’s Amendment 92ZFC because it applies to people with learning disabilities—particularly people with mild or moderate learning disabilities who may not meet the eligibility criteria for care and support in a situation where someone has befriended a person with a learning disability, moved in with them and concerns have been raised by neighbours that the person may be being abused. This is not about family carers; it is a mate crime. It is the sort of crime of which Steven Hoskin was a victim. He was subsequently murdered. Somebody moves in, and the local authority is unable to speak to the adult with a learning disability to check whether they are okay because the other person always answers the door and will not let anybody in. This power of access would change that, and I support my noble friend.

Health and Social Care Bill

Debate between Baroness Hollins and Baroness Barker

Wednesday 16th November 2011 Lords Chamber

[Baroness Hollins]

My Lords, I shall speak to Amendments 203C and 215A. Although the Bill places a duty on each clinical commissioning group to,

“obtain advice appropriate for enabling it effectively to discharge its functions from persons who (taken together) have a broad range of professional expertise in … the protection or improvement of public health”,

it places no duty on clinical commissioning groups to act at all times with a view to the improvement of public health. Such an omission will render the delivery of public health outcomes significantly less likely, with clinical commissioning groups free to act without regard to the wider public health needs of the populations they serve.

The Government’s intention to leave public health—and therefore public mental health—entirely to local authorities could mean that the opportunity will be lost for clinical commissioning groups, local authorities and national agencies to work in consort to achieve better outcomes. There is a fundamental relationship between mental health and well-being and almost all other aspects of individual and public health. Handing responsibility for public mental health solely to local authorities could have deleterious consequences for achieving good outcomes in public health more generally unless precautions are taken.

The purpose of these two amendments is to try to mitigate the consequences of this decision. They would ensure that clinical commissioning groups are required to act in such a way that they contribute to the improvement of public health—and public mental health—and are required to demonstrate in what ways their actions fulfil such an obligation.

I should also like to add my support to the amendment of the noble Baroness, Lady Tyler. I was unable to participate in the discussion about the previous group— where perhaps the comments I am going to make might have been more relevant—because of a commitment to speak at the same time to an amendment in Grand Committee to the Welfare Reform Bill, due to the rather unfortunate timetabling of that Bill.

The point that is relevant here as well is that public health relies on the relationship between so many different agencies, and I am thinking here particularly about the contribution made by education. The example I want to give is about the health of the next generation, which relies so much on the way in which children are parented. Education and support for future parents seems such a worthwhile investment. I want to give just as an example the work of the charity Teens and Toddlers. It does not work by telling teenagers to change their behaviour, because that does not work; it offers them a holistic and transformative experience which has a much greater effect. It really is a health intervention as well as an educational one. The programme allows teenagers to spend two hours a week for 15 weeks looking after a toddler in a nursery. They also spend time talking through what that experience has taught them. What is so extraordinary is the effect of the programme, which is now available in 12 London boroughs and 13 other areas of the UK. Some 97 per cent of those who graduated from the programme have not become pregnant before the age of 20, and 92 per cent have continued in employment, further education or training. I am sure that the Minister will agree that public health is so much more than the responsibility of only the local authority and the NHS.

[Baroness Barker]

My Lords, I want to address briefly the question that Clause 15 should stand part of the Bill raised by the noble Baroness, Lady Thornton, and her colleague on the Front Bench. At this stage I do not intend to go over the points which have already been made so expertly. I simply want to ask a simple question. Clause 15 sets out the functions and the shared duties of local authorities and the Secretary of State to improve public health. What is not clear is which duty falls to the Secretary of State and which to local authorities at any one time. What would be the trigger for an intervention by the Secretary of State? It is quite important that noble Lords should understand this as we go ahead. Would I be right or wrong to assume that it would be exceptional, rather than the norm, for the Secretary of State to intervene? Is that what the department thinks? If it were exceptional, can the Minister set out under what circumstances it is envisaged that the Secretary of State would intervene?

For example, if a local authority unilaterally decided to cut its entire funding of sexual health services, would that be regarded as something which would cause the Secretary of State to intervene? If a local authority came up with a good argument for why it should not fund such services, or there was a major outbreak of an environmental nature, would the Secretary of State intervene under additional powers? I can understand the logic of this in that both the Secretary of State and local authorities need to have powers, and those powers should be shared, but I would welcome further clarification on how these powers will be exercised both jointly and separately.