Mental Health Bill [HL]

Debate between Baroness Merron and Lord Stevens of Birmingham

Wednesday 2nd April 2025 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am grateful for all the contributions and considerations this evening, to which I have listened closely.

I first turn to Amendment 50 in the name of the noble Baroness, Lady Tyler. Workforce is absolutely a critical factor in enabling these reforms and we have committed to recruiting 8,500 more mental health staff over the course of this Parliament. The impact assessment sets out our expectations for the additional workforce that is required to deliver the Bill.

However, there are already various mechanisms in place to monitor and address concerns about the mental health workforce. The amendment would be duplicative and unnecessary. Providers registered with the CQC—both NHS and independent services—are required to deploy enough suitably qualified, competent and experienced staff, as outlined in Regulation 18 of the Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. If CQC finds a breach in Regulation 18, it can take action.

The Mental Health Act Code of Practice also states that local authorities should ensure that there are sufficient approved mental health professionals and independent mental health advocates. All staff in CQC-registered providers must receive the appropriate training that is necessary to enable them to carry out their duties under Regulation 18 of the Health and Social Care Act Regulations 2014.

At a national level, CQC reports on workforce sufficiency as part of its monitoring of the Mental Health Act report. We would argue that this is a much better process than requiring integrated care boards to mark themselves on how well they are fulfilling their duties.

Furthermore, as I said on Monday and wish to reiterate, we are committed to laying an annual report on implementation, which will set out progress made and future plans for implementation. This will include information on the expansion of the workforce, including second opinion appointed doctors, Section 12 doctors and approved clinicians. It will also include details of the key statistics and outcomes under the Mental Health Act, including detention rates, community treatment order rates and other key metrics, such as racial disparities and outcomes for children and young people, all of which noble Lords rightly seek. I hope this annual commitment will be welcomed by your Lordships’ House and that this, combined with the existing workforce monitoring I have referred to, will allow the noble Baroness to withdraw her amendment.

On Amendment 59, I also understand —as does the noble Earl, Lord Howe—the intention of the noble Lord, Lord Stevens, which is to ensure that we invest in delivering these reforms. I want to be clear: as I said in Committee, there are already mechanisms in the NHS Act to prioritise mental health spend to deliver these reforms.

To reiterate the point that I made previously, we believe that this amendment is not the right mechanism to ensure that we do that. I will return to the three main reasons for that, but I want first to refer to the point the noble Lord, Lord Stevens, made when he spoke of “shrinking mental health spend”.

[Lord Stevens of Birmingham (CB)]

It was the shrinking share of mental health spend.

[Baroness Merron (Lab)]

I thank the noble Lord for that correction from a sedentary position. Perhaps I could provide some more clarity, which the noble Earl, Lord Howe, also asked for.

The proportion of spend is almost exactly the same as it was last year, with a difference of just 0.07%. We understand concerns that the share of overall NHS funding for mental health will reduce slightly. However, this does not mean that mental health funding is being cut, and I would not want noble Lords to think that to be the case. To be clear, spending on mental health support will increase relative to 2024-25 and is forecast to amount to £15.6 billion—an increase of £680 million in cash terms, and equivalent to £320 million in real terms.

Perhaps it would be helpful for me to return to the three main reasons for not supporting this amendment. The first is—as the noble Earl, Lord Howe, helpfully referred to—what I would call a point of principle. Primary legislation should not be used to constrain spending in this way. Multiyear budgets for government departments will be set by the established spending review process, which considers spending in the round and in the context of the Government’s policy priorities. Additionally, it is Parliament that is responsible for scrutinising government spending and approving spending set by departments for the current financial year as part of the estimates process.

Secondly, the amendment as drafted applies only to spend under the Mental Health Act. The mental health system, as noble Lords will appreciate, does not structure its accounts based on the legal framework under which a patient is held. A single ward, for example, could contain a mix of patients under the Mental Health Act and informal patients who would not usually be considered to be under the Mental Health Act. Likewise, community services will support a mix of people, some on community treatment orders and others who are not. It would be impractical to require services to split costs based on the ever-changing patient mix within their care.

The third reason for not accepting this amendment, and perhaps the most fundamental point, is that the share of spend on the Mental Health Act could reduce over time, which is not undesirable. I will explain why. The genesis of these reforms is the review initiated by the noble Baroness, Lady May, to address the rising rates of detention. We all want to see more people cared for effectively in the community so that the need for the use of the Act is reduced. This would require more investment in preventive community services, which, I put to noble Lords, is surely the preferable model for supporting severe mental illness. In creating a legal requirement for the share of spend specifically under the Mental Health Act not to decrease, this amendment would actually preclude the shift from detention to prevention that I know we all want to see.

So, while I absolutely understand the intention, and I can commit that we will invest to deliver these reforms, we cannot support this amendment, which, for the reasons I have outlined, we believe is fundamentally flawed. For these reasons, I hope that the noble Baroness will withdraw her amendment and the noble Lord will not press his.

Mental Health Bill [HL]

Debate between Baroness Merron and Lord Stevens of Birmingham

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Lord Stevens of Birmingham (CB)]

Very briefly on the question that the noble Baroness, Lady Fox, raised, the notion of supply-induced demand is a well-known phenomenon across health services. However, I have to say to her that I think that we are a long way off that being the problem that is principally confronting children and young people’s mental health services. We have a massive gap between the need for effective therapies for children and young people and their availability.

When the process of trying to expand children and young people’s mental health services kicked off several years ago, the goal was that we would get to a situation where one in three children and young people with a diagnosable mental health condition would get some form of specialist mental health support. That number has now been exceeded. I was just looking at the stats published last week and, although I do not see the most up-to-date number for it, I would be surprised if more than one in two are currently getting specialist mental health support for a diagnosable mental health disorder, not just distress. So, we are a long way off confronting this problem of supply-induced demand, whatever broader cultural or therapeutic labelling questions that she rightly points to may be in the ether. Fundamentally, we are going to need more services to benefit the children and young people who need them, not pretend that this is somehow all vapourware, imaginary or a cultural deformity, unlike our predecessors in the Victorian era.

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

I thank noble Lords for their contributions on this important set of amendments. I say at the outset that I note the various observations that are outside the Bill, as the noble Baroness, Lady Barker, pointed out, but I have noted them and I am sure we will discuss them on a number of occasions.

First, I turn to Amendments 46 and 47, tabled by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe. I have heard how many noble Lords are in support not just of those two amendments but all the amendments in the group. I am sure noble Lords will not be surprised to know that I understand where people are coming from and I will be pleased to go through the response to them.

The noble Earl, Lord Howe, spoke about “troubling and sensitive matters” and about being inspired by testimonies that came through the charity Blooming Change—I express my thanks to that organisation for the work it does. Officials in the department have met the group and it made a very helpful contribution. Hearing from those with lived experience is crucial to making sure that this is the best Bill, and I know that many noble Lords have done that, so I thank the noble Earl for bringing that into these amendments.

Amendments 46 and 47 would change the definition of appropriate medical treatment to include treatment which

“seeks to minimise the patient’s distress and promote psychological wellbeing and recovery from any childhood trauma”.

Childhood trauma can of course have a devastating impact on psychological well-being. Effective and compassionate in-patient care must be informed, as I have said, in co-production with people with lived experience and be trauma informed. NHS England’s Culture of Care Standards for Mental Health Inpatient Services certainly underlines this.

The noble Earl, Lord Howe, and other noble Lords raised concerns around in-patient settings and how appropriate they are, which I understand. I hope it will be helpful to say in answer that the new definition of “appropriate medical treatment” introduces the requirement that treatment has to have a reasonable prospect of benefiting the patient. We would expect the setting in which someone is going to be detained to be considered as part of this. Of course, I am more than aware—without wanting to go into the generics in this group or any other group—that the place in which we start, in terms of the suitability and availability of the right settings, is not where I am sure any of us would want to be.

We also know that the sensory environments in settings can cause difficulties for people with sensory sensitivities. To support NHS services to address sensory aspects of the environment, which the noble Baroness, Lady Bennett, referred to, NHS England has published a sensory-friendly resource pack, which outlines 10 principles to improve the sensory environment and signposts other resources.

The clause in the Bill that defines “appropriate medical treatment” already requires decision-makers to take into account the nature and degree of the disorder and all other circumstances, which could include childhood trauma, when considering whether medical treatment has a reasonable prospect of therapeutic benefit. The definition of medical treatment is unchanged and is indeed broad, including nursing care, psychological therapy and medication. All these interventions could include an overall aim to minimise distress and promote psychological well-being.

Amendments 50 and 51, tabled by the noble Baronesses, Lady Tyler and Lady Bennett, aim to ensure that the clinician considers non-drug-based interventions as part of the new “clinical checklist”. The checklist requires clinicians to identify and evaluate alternative forms of medical treatment when deciding whether to give a particular medical treatment to a patient. As I have already mentioned, the definition of medical treatment under the Act is broad. As well as non-drug-based interventions, it includes specialist mental health rehabilitation and care. On the point raised by the noble Baroness, Lady Bennett, which is an important one, it does include the therapeutic environment or setting. This requirement, as outlined, would apply to all patients falling under Part IV of the Act. It includes patients with a learning disability and autistic patients who are detained for assessment under Section 2 and patients detained for treatment under Part III.

With specific regard to those with a learning disability and autistic people, I recognise the concern that they are more likely to be prescribed an antipsychotic than the general population. I emphasise that psychotropic medication should only be given for the right reasons, in the lowest dose, for the shortest time. NHS England has a national programme of work to stop overmedication and the inappropriate prescribing of these medications, which is aimed in particular at people with a learning disability and autistic people. Noble Lords will be aware of the STOMP programme. Alongside it is a national supporting treatment and appropriate medication in paediatrics programme called STAMP—the two are not to be confused. These programmes work particularly closely with those with lived experience, families and carers organisations, and a wide range of health and social care professional bodies.

Amendment 53, in the names of the noble Earl, Lord Howe, and the noble Lord, Lord Kamall, would require the approved clinician to offer a patient any treatment that is appropriate, having applied the new clinical checklist. The reference to medical treatment in that checklist should already be read in accordance with Clause 8, which inserts a new definition of appropriate medical treatment to enact the principle of therapeutic benefit.

The clinician must also support the patient to participate in decision-making to make sure that they do not simply offer their preferred treatment to the patient, with no discussion or consideration of alternatives. The Bill also requires clinicians and, where relevant, the second opinion appointed doctor to provide a written record that the treatment being administered meets the definition of appropriate medical treatment. Therefore, it is felt that the Bill already meets the intention of this amendment. Furthermore, if the intention is to ensure that a range of treatments is being considered by the responsible clinician, I can reassure noble Lords that this is already the case, because, as I have said, the definition of medical treatment is broad.