Mental Capacity (Amendment) Bill [HL]

Debate between Baroness Meacher and Lord O'Shaughnessy

3rd reading (Hansard): House of Lords
Tuesday 11th December 2018 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, throughout the progress of this Bill both the Government and noble Lords have been keen to improve the protections and safeguards contained within the reformed deprivation of liberty safeguards system so that the welfare of the cared-for person is always of paramount importance. It is that principle which lies behind the amendment I have laid for debate today.

The amendment makes it clear that any relevant person who identifies that a cared-for person is objecting to arrangements is empowered to raise the matter with the responsible body and can trigger a review by an independent AMCP. Furthermore, the amendment specifies that the responsible body must consider the views of anyone engaged in caring for the person or a person who is interested in their welfare. Importantly, this amendment is explicit that staff of all kinds can raise concerns, as well as others with an interest in the person’s welfare, and it will support staff and others, such as families or carers, in their ability to do so. I take this opportunity to thank the noble Baronesses, Lady Finlay, Lady Thornton and Lady Barker, and the right reverend Prelate the Bishop of Oxford for highlighting this very important issue on Report, and for working with and meeting me to agree a way forward.

The amendment that the Government are proposing makes it easier for inadequacies in care provision to be addressed more swiftly. Recent issues with Gosport, Winterbourne View, Mendip House and, sadly, many other cases have highlighted how important it is that family, friends and staff feel empowered to raise concerns, and for action to be taken as a result. The amendment means that if a member of staff or a family member thinks that the person is objecting and that that is not being properly considered, they can raise it with the responsible body. That body, which of course is legally responsible for authorising a deprivation of liberty, will be able to use that to judge whether an AMCP should therefore complete a pre-authorisation review. Being able to raise such concerns directly with the responsible body is particularly important as it means that staff and others can raise concerns without having to go through those who may be directly involved in the care or treatment of the person. That will enable people to feel supported and more confident to take such action.

The Bill already requires that an AMCP completes the pre-authorisation review if it is reasonable to believe that the cared-for person does not want to reside or receive care or treatment at a place. However, I agreed with noble Lords on Report that we should have something in the Bill which is explicit about the sorts of things the responsible body must consider when making this determination so that staff and families feel supported in speaking up. That is what this amendment achieves. I should add that the Government are committed to ensuring that the measure created by the amendment forms part of the necessary training and support ahead of the implementation of the new system.

Noble Lords will note that this amendment relates to the pre-authorisation review process. We understand that it will also be necessary to make sure that the ability to trigger an AMCP review is in place as part of the ongoing review process. Due to time constraints, we have not been able to table an amendment on this subject now, but I commit that the Government will return to this issue at the Commons stages of the Bill.

I again thank noble Lords for raising this issue and for working with the Government to produce this amendment. I hope the amendment satisfies the demands that noble Lords rightly made to give family and staff a higher profile in raising issues and to include that in the Bill. I beg to move.

[Baroness Meacher (CB)]

My Lords, I hope the House will indulge me for one or two minutes. I welcome the amendment and have no objections to it at all. However, I note that the Government have not come forward with amendments in relation to three other issues. The first is the risk to others and the interface with the mental health review. It would be helpful if the Minister could give us an assurance that the Government will not seek in the Commons to clarify the interface between this legislation and the mental health review. There is talk of using “objection” as the key criterion, but in my view we also need to consider the risk to others as a possible principle to be considered. Can we have an assurance that the Government will not seek to resolve this issue during the progress of this Bill in the Commons?

The second issue concerns independent hospitals, which we have debated. Although I certainly do not wish to reopen that debate, can the Minister give us an assurance that work will be done in preparation for the Commons stages on the very serious situation in which many people find themselves in independent hospitals? These hospitals are often remote and—if I may say so—not well run. People are incredibly vulnerable in them, often far more so than in homes. An assurance that that will be addressed in the Commons stages would be helpful.

The third issue regards domestic situations. Whatever the Government decide to do in the Commons, can they bear in mind the importance of trying to limit the levels of bureaucracy and, ideally, of not continuing to use the Court of Protection? Again, many very vulnerable carers caring for very vulnerable people do not have the resources to deal with a lot more bureaucracy—they already have a hell of a lot to deal with. Can the Minister respond on that point?

NHS: Specialist Services in Remote Areas

Debate between Baroness Meacher and Lord O'Shaughnessy

Tuesday 11th December 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend makes an excellent point. The number of CCGs is reducing over time, as they tend to merge. Of course, they are increasingly coming together into integrated care systems, which cover a larger geographic community. Every one of those makes sure that people have not only community care but specialist care available.

[Baroness Meacher (CB)]

My Lords, how many of the 3 million people who face the closure of their general practice in the coming year are in remote areas where they have a long way to travel to a hospital? What do the Government plan to do to ensure that some form of health service is available to those people? Telehealth can help, but people often need an examination.

[Lord O'Shaughnessy]

The noble Baroness is quite right. There is an urgent need to recruit more GPs. We continue to be committed to that. I am sure she will be pleased to hear there are more GPs in training than there ever have been. We are also providing a £20,000 salary supplement to GPs who go and practise in rural areas.

Mental Capacity (Amendment) Bill [HL]

Debate between Baroness Meacher and Lord O'Shaughnessy

Report: 1st sitting: House of Lords
Wednesday 21st November 2018 Lords Chamber

[Lord O’Shaughnessy]

The reason is that although the deprivation of liberty would take place in that institution, every single case would be examined by an AMCP. The pre-authorisation review and scrutiny would be carried out by the AMCP. They would have the ability to examine the case, to speak to the person and all other relevant interested persons, and to challenge, if necessary, the circumstances of the deprivation of liberty or the care that had been put in place.

To take the hierarchy of decision-making in a care home, for example, the arrangements are made by, but not carried out by, the care home manager. They are referred to the responsible body for preauthorisation review, and if there are concerns of a problem at the level of the responsible body—an objection on behalf of the person or on behalf of somebody who cares for or is connected to them—it would go immediately to the AMCP. In a sense, this vaults the decision-making process beyond the responsible body and, as the noble Baroness, Lady Finlay, pointed out, there are particular issues over which body ought to take responsibility and go straight to, effectively, the last port of call before the Court of Protection. It provides that degree of oversight and challenge in these cases.

[Baroness Meacher]

A concern is that a lot of these people lose touch with their communities and families—they are often a long way from them. Is the assumption here that if somebody objects, then the AMCP would get involved, but that otherwise the hospital management might remain responsible?

[Lord O’Shaughnessy]

That is a perfectly reasonable question, but the AMCP would absolutely look at every case. There would not need to be an objection raised. I was just explaining the hierarchy for non-independent hospital cases. It would be, in a sense, going to the second-highest port of call for scrutiny that we are considering in other cases to highlight the seriousness of it. There would not be that gatekeeper point which the noble Baroness is worried about.

Cannabis: Medicinal Uses

Debate between Baroness Meacher and Lord O'Shaughnessy

Thursday 1st November 2018 Lords Chamber

[Lord O’Shaughnessy]

It is important to state that GPs will not be able to prescribe it; that is part of the new regime. On the specific issue of pain management, the interim guidance from the Royal College of Physicians says there is no evidence to support its use for treating chronic pain. In the meantime, NICE will be providing clinical guidance in about a year’s time, which will take a broader view. So it should not be the case that specialists are providing it in this area—the evidence does not exist and therefore the costs will not occur.

[Baroness Meacher (CB)]

My Lords, I applaud the Home Secretary for finally recognising the therapeutic value of medical cannabis. We know that about 1 million patients up and down the country will be queueing up for these medicines. I very much understand the Government’s narrow approach, but can the noble Lord assure me that Ministers will make available to doctors the comprehensive review of medical cannabis research from the National Academies of Science, Engineering, and Medicine in America? This showed conclusively that there is substantial evidence that medicinal cannabis is valuable for the alleviation of pain—in particular neuropathic pain—and that it does not cause psychotic illness.

[Lord O’Shaughnessy]

We are, thankfully, now taking an evidence-based approach. The Chief Medical Officer said in her statement that there is evidence of therapeutic benefit from cannabis-based products, and that is why they have been rescheduled. However, we need to move cautiously. We know that the active ingredient, THC, is linked to psychotic illness and other things, so we need to make sure that, as we move ahead, its use is properly controlled and that the benefits always outweigh the risks for any patient who takes it.

Health and Social Care Act 2012

Debate between Baroness Meacher and Lord O'Shaughnessy

Thursday 5th July 2018 Lords Chamber

[Lord O'Shaughnessy]

I join the noble Lord in congratulating Trafford General Hospital. I think that one of my colleagues is there today, unveiling a plaque. I am grateful to him also for raising the devo deal for Greater Manchester. It is a very important deal that goes further than any other in the area of health and social care. If it is the case that it is impeded by the Act—and I do not think that that is necessarily a given—I would say that the changes that need to be made ought to be promoted and proposed by Greater Manchester and by the clinicians themselves. That is exactly the sort of thing that the Prime Minister has asked for.

[Baroness Meacher (CB)]

My Lords, perhaps I may pursue the question asked by the noble Baroness, Lady Blackstone, to which the Minister responded, “Yes, we need to look at regulation”. The Minister knows that GPs are leaving the service at an unprecedented rate, and a large part of the reason for that is the regulatory burden. Will he make a commitment to undertake a full investigation of the regulatory burden on NHS staff, with the terms of reference being to reduce that burden?

[Lord O'Shaughnessy]

I agree with the noble Baroness about the importance of bolstering our GP workforce—that is one thing we are absolutely focused on. It is part of the five-year forward view and clearly of the long-term plan as well. I will identify one area where we are trying to make a big difference, which is indemnity insurance. We know that this has been a financial burden on GPs and we are looking at creating a state-funded scheme to provide reassurance. This is just one way in which GPs are looking for support from government.

Cannabis-based Medicines

Debate between Baroness Meacher and Lord O'Shaughnessy

Thursday 21st June 2018 Lords Chamber

[Baroness Meacher]

To ask Her Majesty’s Government what the terms of reference will be for the expert panel of clinicians to advise ministers on applications to prescribe cannabis-based medicines.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, the commission from the Home Secretary is clear: he has asked Professor Dame Sally Davies to set up an expert clinical panel to provide advice to Ministers on licence applications made by a patient’s medical team for the use of cannabis-based products. Professor Dame Sally Davies is currently establishing a clinical panel that will agree the terms of reference.

[Baroness Meacher (CB)]

My Lords, I applaud the Home Secretary for his decisive action on medical cannabis. My Question relates to the second part of Professor Dame Sally Davies’s review. Bedrocan cannabis medicines have been used very safely and successfully in Holland for more than 20 years and are used increasingly across Europe. These medicines are currently subject to 23 random controlled trials and are also approved by European manufacturing standards. Can the Minister assure the House that the terms of reference for the wider review—I am not referring to the initial piece of work—will include the need for the MHRA, which regulates medicines, to consider defining a special category for whole-plant cannabis medicines? This idea came from within the MHRA, so I do not think it is unreasonable. If the review fails to make these medicines available in this country, is the Minister aware that 200,000 people in the UK with uncontrolled epileptic seizures will continue to be further brain-damaged every single day? This is a matter of urgency.

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for her question. Like her, I applaud the speed with which the Home Secretary and the Health Secretary have acted in this matter. It is incredibly important to think about the various stages and actions that have been taken. First, there is an urgent need for the panel which Professor Dame Sally Davies is setting to consider specific licence applications. The second part is to review whether there are therapeutic benefits of cannabis and cannabis-derived products. Then there is the evidence-gathering process, and all the relevant evidence, including the major piece of work done by the US National Academy of Sciences and the paper to be published by the WHO, will be collected as part of that. As the Home Secretary set out on Tuesday, it will make recommendations to the Advisory Council on the Misuse of Drugs subsequent to proposals for rescheduling. That will happen this autumn, if those proposals come forward.

If I may just take the time to say this, the noble Baroness raises a third issue, which is long-term horizon scanning for Schedule 1 drugs for which a therapeutic benefit has not yet been demonstrated but which may be demonstrated in future. We clearly need to set up a device to do that, and the MHRA may be the right vehicle. That is something we are considering.

Gosport Independent Panel: Publication of Report

Debate between Baroness Meacher and Lord O'Shaughnessy

Wednesday 20th June 2018 Lords Chamber

[Lord O'Shaughnessy]

I completely agree with the noble Baroness. Clearly, improvements have been made—freedom to speak up guardians came out of the Francis review into the Mid Staffs tragedy—but I reiterate the point that I made earlier: we cannot be complacent and just assume that what exists now is up to the task, as the noble Lord, Lord Hunt, said, of guaranteeing that this will not happen again. Looking at complaints procedures, protections for whistleblowing and so on will be part of the investigations that we make.

[Baroness Meacher (CB)]

My Lords, the events at the Gosport War Memorial Hospital all those years ago are indeed shocking, but will the Minister consider that they are perhaps a symptom of the fact that we do not have an assumption in end-of-life care that patients’ wishes must be respected? One aspect of this, perhaps slightly removed from Gosport but nevertheless relevant, is that, if people are terminally ill and enduring unbearable suffering but are mentally competent, they have no way of ensuring that they, the patients, can take control and decide when they have suffered enough. In this culture of paternalism—and this really does apply to Gosport—doctors take matters into their own hands and, in a situation such as that in Gosport, paternalistic decision-making by doctors can become extremely dangerous. Does the Minister agree that we need to bring to an end paternalistic decision-making by doctors without reference to patients’ wishes, particularly in end-of-life care?

[Lord O'Shaughnessy]

Giving patients and of course their families much more control over the circumstances in which their lives end is clearly the right thing to do. Some very good practice has been going on—for example, Coordinate My Care across London makes sure that somewhere between 70% and 80% of people who would prefer to die at home are able to do so, as opposed to in hospital. However, it is important to emphasise that in this case by and large we are not talking about palliative care; only a small number of the people concerned whose lives were shortened were in a position where they were, in an objective sense, near end of life. Many were in after a fall, a hip replacement or something else from which they could easily have recovered and lived for many more years. That is the tragic fact. So, while I agree with the noble Baroness, it is important that we do not view the tragedy just in those terms; unfortunately, it is much broader.

Children and Young People: Mental Health

Debate between Baroness Meacher and Lord O'Shaughnessy

Wednesday 28th March 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord hits on an important point. Not only is mental illness unfortunately rising in prevalence, but it is everybody’s responsibility to try to help young people who suffer from it. That is what lies behind the proposals in the Green Paper, which contains a number of elements. He is quite right: there is additional training that will be applicable for all teachers, in mental health first aid, for example. It will also make sure that pupils understand it, changing the PHSE curriculum for more focus on mental health and well-being. That is why the designated leads are so important, because they bring that together at school level. So I agree with the noble Lord that schools have a critical role to play in dealing with this problem of mental health.

[Baroness Meacher (CB)]

My Lords, the Minister will be aware that young people with severe mental health problems can wait up to four and half months for treatment when a young person with severe physical health problems can expect to be seen within the day. Of course we all want equal treatment of these two groups. I very much welcome the Government’s plan to spend £1.25 billion extra in this area. However, does the Minister have an estimated average waiting time for young people with severe mental health problems once the £1.25 billion is in place?

[Lord O'Shaughnessy]

I do not have a specific time, but I point to two things. First, there are now waiting time standards for early intervention in psychosis and eating disorders. Those waiting time standards will become more exacting over time, but they are being met at the moment. The Green Paper also proposes a pilot of four-week waiting times for access to specialist services in the NHS. We have a long way to go—average waits are 12 weeks—so we are inevitably starting incrementally, but the ambition is that over time, we will roll that out as a nationwide ambition. However, I am afraid that I cannot give the noble Baroness a deadline.

Prescription Drugs: Dependence

Debate between Baroness Meacher and Lord O'Shaughnessy

Monday 19th March 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend has just given a much better and more incisive answer than I could have given. There is a distinction; the point here is that these are drugs that people have started to take because they have needed them. I should point out one area that is not included in the review; it is not looking at cancer and terminal pain, because we need to make sure that there is appropriate pain relief for people who are in the last stages of their life.

[Baroness Meacher (CB)]

My Lords, is the Minister aware of the very powerful evidence from the United States that one of the most effective ways of reducing dependency on opioids is to legalise cannabis for the relief of pain? Cannabis is far less addictive and far less dangerous, yet it is incredibly effective for large numbers of patients.

[Lord O'Shaughnessy]

I would definitely be straying into Home Office territory by commenting on that. I would point out that cannabis remains illegal in this country and that the PHE review’s scope is to work within the drug strategy set out by the Home Office.

Health: Flu

Debate between Baroness Meacher and Lord O'Shaughnessy

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree with the noble Baroness about the role of community pharmacy. It is worth bearing in mind that some 88% of people are within a 20-minute walk of a community pharmacy, which is accessible for the vast majority. There are also 20% more pharmacies than there were 12 or 13 years ago. Pharmacies have a critical role to play and are there in the community, but companies come in and out all the time.

[Baroness Meacher (CB)]

My Lords, I talked to a very senior NHS consultant this morning. To my absolute amazement, he said that the latest research showed that compulsory flu jabs for NHS staff provide no significant improvement at all in patient health. This is rather striking and a bit unexpected. Does the Minister have any different research evidence?

[Lord O'Shaughnessy]

That is unexpected and would be worrying if it is true. That is not the information on which we have based our policy. Our information is that, for most people—though not all—flu jabs are effective in mitigating the risk of flu in care settings.

Mental Health Services: Children and Adolescents

Debate between Baroness Meacher and Lord O'Shaughnessy

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Baroness for highlighting this very important issue. She will know that ring-fencing funding for mental health comes up a lot. There has been increased funding for mental health, but there is more than one reason why ring-fencing is not used for clinical commissioning groups, including honouring the principle of clinical autonomy, and we do not ring-fence around particular disease areas. I should point out that CCGs are being monitored now to ensure that they are increasing spending on mental health, year on year, in line with the increases in funding they are receiving, which is £1.4 billion over the coming years. The noble Baroness is of course quite right in what she said about the specific issue of children under the age of 18. That is why, among other things, we have committed to introducing mental health first aid in all secondary schools.

[Baroness Meacher (CB)]

The Minister will be aware that the threshold for children and adolescents who have severe mental health problems is extraordinarily high and that they may have to wait months before getting any treatment, whereas children with similar levels of physical ill health will be treated within perhaps a day or days. Does he accept that we are still an incredibly long way from equality between mental and physical healthcare, and what does he plan to do about it?

[Lord O'Shaughnessy]

I accept the point that the noble Baroness makes. Unfortunately, we are starting from a low base, over many years, in mental health provision, and that is what we are trying to rectify. She will know that the Prime Minister is deeply committed to this agenda. Let me point to a couple of issues. First, there is the introduction of the first waiting time standards—and indeed there are positive early data on meeting those stretching standards—as well as an increase in the number of beds available for those suffering from the most severe episodes of mental illness.

NHS: Working Conditions

Debate between Baroness Meacher and Lord O'Shaughnessy

Wednesday 5th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I can only reiterate that I recognise the pressures on the workforce. That is why we are recruiting more GPs and nurses. There are more than 50,000 in training, and we are aiming to get 5,000 more GPs into the NHS over the next few years. On the noble Baroness’s point about moving treatment out of hospitals and into the community, that is one of the core drivers of the STP process, which is about reorganising care so that it happens sooner and, ideally, in a preventive way rather than after the fact.

[Baroness Meacher (CB)]

My Lords, I think the Minister will be aware that GPs are routinely required to see, diagnose and treat 80-plus patients in a day. What plans do the Government have to ease that situation when it is still getting worse month by month and it is proving impossible to recruit GPs? In the meantime, until things improve, will the Minister have discussions with the CQC and the ombudsman about how best they should undertake their jobs, taking account of the horrendous pressures on NHS staff and on GPs in particular?

[Lord O'Shaughnessy]

The noble Baroness is quite right to talk about the importance of having more general practitioners. I have talked about the increases in recent years—there have been net increases of 5,000 over the last 10 years—and the fact that we are recruiting another 5,000 over the next few years. I do not pretend that it is easy to recruit them, but the numbers are increasing. One of the keys to solving this problem is through the new models of care. In its General Practice Forward View, which was published last year, NHS England demonstrated a renewed emphasis on general practice and reforming it. That is one way of ensuring that GPs can cope with what is of course an increasing workload.