Mental Health Bill [HL]

Debate between Baroness Murphy and Baroness Bennett of Manor Castle

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Murphy (CB)]

My Lords, I give my strong support to the noble Lord, Lord Scriven, asking for a road map, which I think is the political phrase we use now, to get to where we want to be. I remind him that, back when the then Government came in in 1987, we had a documented timetable for closing the learning disabilities hospitals but that never happened; it went too slowly. So, we have left people stranded in various independent sector and NHS facilities, partly, to be honest, because the Department of Health took its eye off the ball as to what was happening to people in long-stay care and just stopped looking. So I agree that we need some kind of timetable; otherwise, the Bill becomes simple aspirations, as we have already said.

Unfortunately, it is not just autism and learning disabilities that require special training. In a lot of areas of mental disorder, people get inadequate training in subspecialties when they are studying the general psychiatric stuff. Psychiatric nurses do not get enough, either. I agree that there are issues here that require a special target, but at the moment they do not get it, so I support that as well.

On the experience of the noble Baroness, Lady Browning, of course it is true that there are an awful lot of bad psychiatrists around. There are bad physicians and bad surgeons—not the noble Lord, Lord Kakkar, before he punches me on the chin. We should not say “bad”; I would say “not the best”. A friend of mine was visited by a community psychiatrist in old age psychiatry about a month ago. I asked his partner how it went, and he said, “Well, he was in and out in 15 minutes. He’d got 10 assessments he was going to do in people’s homes around south Norfolk in that time”. That was a totally inadequate amount of time to get a history from relatives, to get an understanding of what was going on in the home situation and to understand the problems this person was experiencing. I was shocked, but I was told not to be because it happens all the time that there is an inadequate length of time for people’s assessment.

It is hardly surprising that diagnoses are wrong and that people end up with the wrong prescriptions. It is deeply regrettable, but this will happen for as long as community services are underresourced. As we have heard from all around the Chamber, you can put as much in place as you like, but if it is underfunded, has the wrong facilities or is too far away from where people live, it just will not happen. We need a road map, and we need to know when these facilities will be made available, because the rest of it cannot happen until they are.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I will speak to my Amendment 152. We have already had a rich debate, concentrated on certain areas. This amendment deals with a somewhat different area, which is why I wanted to include it at the end. We have talked quite a bit about training and research and the link between the two. The noble Lord, Lord Scriven, said in introducing this group that it was all about autism and learning difficulties, but this amendment also covers mental health, for the interests of clarity.

This is a probing amendment, but there is an argument for doing what it calls for, which is having a report to Parliament, two years after the Bill is passed and then every three years thereafter, about the provision for and progress in research, and the transfer of research findings, in mental health and autism and learning difficulties. This would enable Parliament to keep a check on how much resource is being put into this area and, crucially, how much knowledge is transferred into practice. It would also be a really useful tool for informing Parliament about what is an extremely fast-changing area.

It is worth noting that mental health and disabilities are areas in which research is not just redefining our understanding but often entirely demolishing old models and forcing a restart from the basics. We are also seeing a change in approach, in which I am very pleased to say that there is an increased focus on ensuring that experts by experience can guide and have input into research directions in a way that certainly was not true in the 20th century.

I note, for example, an interesting study from the University of Stirling last year, which spoke to people in Scotland—though I have no doubt this applies more broadly. It looked at how research in autism currently tends to be directed towards biological studies and a search for treatments and cures, but autistic people said that they would prefer a focus on a good quality of life, and that they should have a real say in the research directions. They were concerned that continuing even now are ableism, objectification, and other othering approaches in research directions. I spoke on the previous day in Committee about the failure to apply the social model of disability to learning difficulties and autism. That is very much the case. I hope that that will change, which would change what we should be researching and how we should be training people.

Moving to perhaps more comfortable ground for many people, I note that there is a replication crisis across many areas of research. That is particularly true in the mental health space, where, unsurprisingly, there has been a recent dawning that conducting a great deal of research on US college students does not necessarily produce findings that can be replicated all around the world in all sorts of different research conditions. For example, with Alzheimer’s disease, are amyloid plaques a cause, a symptom or simply correlated? I have no idea, and I doubt that anyone can say, with their hand on their heart, that they know either. This an area in which the continuous failure of medical trials has shown our lack of knowledge.

--- Later in debate ---

[Baroness Murphy (CB)]

My Lords, in this group, we return to the issue of serious harm and risk. Clause 5, on the grounds for detention, implies that the risk factors for detention under Part 2 are identifiable and that risks are readily assessed. A number of clauses in the Bill are all about the same thing, which is why there are so many amendments in this group. They imply, again, that risks are quantifiable and predictable—if only.

Academic research has often stressed how difficult it is to predict episodes of violent behaviour in individuals, because they are rare. Risk assessments given as likelihoods are of limited use when the base rate for violence in a population, particularly serious violence, is low. The same is true, by the way, for suicide and suicidal thoughts.

It has been calculated, using the average of all the current tests and rating scales that have been carefully assessed in research studies, that if 5% of the patient population were in a high-risk category, the tests would correctly identify eight in 100 people who would go on to commit acts of violence, but misidentify as violent another 92 people. In fact, less than 1% of community patients will commit serious violence over the period of a year, which means the tests would correctly identify only three patients out of 100.

Homicides occur at a rate of one in 10,000 patients suffering from a psychosis per annum, which makes prediction more or less impossible. A number of factors are statistically associated with later violence at a group level. Even the most effective predictive combinations of variables constructed by statisticians perform poorly, except at group level. So making statements about individual risk based on the use of these tools is complex, and some would say unsafe and unethical.

Structured risk-assessment systems can be useful in routine clinical practice; indeed, most people use them in day-to-day team thinking about what these risks are. When employed by staff properly trained in their use, they are useful pointers. They perform better than unaided clinical judgment in predicting future violence, but again, at a group level. On an individual level, these checklists need to be part of a detailed understanding of a patient’s mental state, life circumstances and thinking, which is a major contributor to the prevention of harm. This is best achieved, as always, by well-trained professionals operating in a well-resourced environment where staff know well the patient’s history, response to treatment and life circumstances.

The wording of the Bill encourages pseudo exact probabilities and predictions of individual behaviour, which are not possible. This exerts pressure on psychiatrists, particularly at tribunals, to make predictions that may be seriously wrong. Unreasonable expectations of what can be predicted lead to defensive practice—to detaining people where it is not justified by the unreliable evidence. There are several places in the Bill where the impression is given that risks are reliable and predictable, but it is not so. As I say, the same problem arises with suicide and suicidal behaviours.

I ask the Government to look at whether the wording of these clauses is reasonable, given the evidence, and to substitute these certainties with something more flexible, indicating that a more rounded, holistic and comprehensive assessment is necessary. I beg to move.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise to speak to Amendments 86 and 67, in my name, in this group. I put them in that order as Amendment 86 more naturally follows on from—

[Baroness Bennett of Manor Castle (GP)]

Apologies.

[Baroness Murphy (CB)]

I am awfully sorry, but I should have mentioned that I also have almost all the other amendments in this group. They cover the same question—it is just about the wording of these two phrases. Amendment 45, along with one other, is not mine, but most of the amendments are covered by those brief words.