Mental Health Bill [HL]

Baroness Tyler of Enfield Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I rise to speak to Amendments 102, 105 and 106 in my name. These amendments all deal with extending the provision of advocacy services to informal patients below the age of 18. When I read the other amendments in this group, I thought, “Goodness me, this is going to be a bit tricky, isn’t it?”. It felt at one point as if we were diametrically opposed, and that is not a comfortable position to be in against someone with years of expertise who is as distinguished as the noble Baroness, Lady Murphy. However, I have listened carefully to what she has to say and the nub of it is her concern about resources. On that point, I fully get it, about the workforce generally and advocates in particular. I am going to press on with my amendments none the less, because I am trying to deal with the principle as opposed to the resources.

Both the Independent Review of the Mental Health Act and the Joint Committee on the draft Bill recommended that advocacy should be extended to informal patients. Currently, only those detained under the Mental Health Act 1983 have a legal right to advocacy services. The Mental Health Bill introduces a new opt-out scheme, meaning that all detained patients will get an automatic referral to advocacy services. The Bill also extends advocacy to informal patients, but they will not be captured by the new opt-out scheme, meaning that informal patients will still be required to ask for support via an advocate. This is at the very nub of the problem with which I am concerned.

It is crucial that children and young people aged under 18 admitted to mental health in-patient care informally should have an automatic referral to advocacy services, in line with those who are detained under the Act. There may not be very large numbers—that is relevant to the resource concerns—but it is worth remembering that a higher proportion of children and young people are admitted to mental health hospitals informally. Indeed, it is estimated that around 31% of under-18s are admitted to in-patient care this way—namely, on the basis of their own or parental consent. Having access to an advocate automatically will help young informal patients understand and exercise their rights and ensure they have a say in the decisions made about their care and treatment. This could also lead to improved outcomes and prevent young people being kept in hospital for any longer than they need to be—something I am sure we all agree on.

It is worth adding that the lack of access to advocacy for informal patients has been a long-standing concern. There is a real concern that children and young people admitted informally will continue to experience problems accessing an advocate under the new system proposed as part of the Bill. It has been noted that, often, young informal patients do not understand their rights and feel an underlying threat that, if they break the rules in some way, they will be sectioned. We have to take that into account. Despite the concerns about resources, which I fully understand, access to an advocate is crucial in helping children and young people who are informal patients navigate what is a very complex system.

[Baroness Berridge (Con)]

My Lords, I will speak briefly to support the amendment tabled by the noble Baroness, Lady Tyler. The extension of advocacy services to children and young people is important, because, as she outlined, there is a disproportionate number of children who are voluntary—I think there are just under 1,000 a year—in mental health institutions.

It is also important to recognise that there are other additional rights that children have when they are detained, or when they have agreed and consented to go into hospital. They need to continue their education while they are in there. It is important to advocate for what their entitlement is while they are in hospital—I think we are all used to walking past the hospital school that is within a normal physical illness hospital—thereby enabling them to continue their education and considering what their rights are in that regard. That is obviously so important for them and their recovery, so I support the amendment from the noble Baroness, Lady Tyler.

Mental Health Bill [HL]

Baroness Tyler of Enfield Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Murphy (CB)]

My Lords, as the noble Earl, Lord Howe, has mentioned, we will be talking about risk factors in the next group but one, and I will not go into the statistics and predictions at this point.

As has been pointed out, Clause 4 implies that specific risk factors for detention under Part II are readily identifiable and assessed, but as we will see, predicting episodes of violent behaviour or self-harm is peculiarly difficult to do. The clause suggests that it is not clinicians who will be doing these risk assessments but that the Secretary of State will somehow have some expertise from ICBs in how to do this. Apart from the rather obvious wisdom that the best predictor of future behaviour is past behaviour, I am not sure how these regulations can be drawn up.

I am anxious about the common prejudices around, for example, black patients of African Caribbean descent living in London, who have a higher risk of being detained under Part II than white patients, or Asians of an Indian subcontinent background. Who will draw up this list to say which of these items is going to lead to the risk of detention under Part II?

There have always been opportunities for the Secretary of State to intervene in the detention of patients under Part III of the Act, and some Secretaries of State have been more risk averse than others. I suspect that under this clause we will find some Secretaries of State taking a more hard-line view about who should and should not be detained. That gives cause for enormous anxiety, so I would like to know how the Government intend to devise these regulations to document specific risk factors.

[Baroness Tyler of Enfield (LD)]

My Lords, this is an important set of amendments, and, as the noble Earl, Lord Howe, said, they are central to decisions about whether to detain people under the Act.

I agree that the definition of “serious harm” is important, and it would be helpful to hear from the Minister what the Government are thinking there, how it will be applied, and how any thresholds will be established.

I endorse what the noble Earl had to say about children and young people, what a huge decision it is to detain someone under 18 in hospital against their will, and how hard we need to work to avoid that, whenever that is safe for themselves and other people.

Finally, and very much linked to that, I strongly support Amendment 139 on the availability of community-based services, which we have already talked about and which we will turn to in subsequent groupings. It is a very good amendment, particularly the provision which states:

“The Secretary of State must publish a report to assess whether there should be more community-based services for community patients in order to prevent”—


I see this as a key preventive measure—

“detention under the Mental Health Act 1983”.

My one point is that the amendment talks about publishing that within two years of the day on which this Act is passed. I personally think that in an ideal world we might see a report a bit earlier than that. However, as I say, Amendment 139 certainly has my full support.

[Baroness Parminter (LD)]

I am sorry that I did not jump up in time before my Front Bench spoke.

I just wanted to add my voice to support Amendment 139 in the name of the noble Earl, Lord Howe, and the report on community-based services. It is really timely and we need it. The case was made very carefully and well by others, so I will not expand much other than to say that an extensive report was done in November by the leading charity, Beat, which looked at the case for more intensive community care and daycare for people with eating disorders in order to avoid—the very point that the noble Earl, Lord Howe, made—ending up getting to such a point of severity that they need to go into mental health facilities and be detained, which indeed happened to my daughter, as I made clear at Second Reading.

The case has been well made that a report should be made. I agree with my noble friend Lady Tyler that two years seems quite a long time off, particularly as recent work has been done, particularly in the field of eating disorders, to show that you can both reduce the number of patients and reduce the cost if you make the investment up front in community services.

--- Later in debate ---

This amendment aims to ensure that, given that we have brilliant researchers making real progress, Parliament knows about that, it is incorporated into treatment, and we are really keeping up. As we heard earlier in the debate on this group, we are not at the moment.

[Baroness Tyler of Enfield (LD)]

My Lords, I want briefly to make a couple of comments on this important group. As everyone has acknowledged, an absolutely vital change to the Bill is that, in the future, people with learning disabilities and autism will not be detained by the Bill and their needs are to be met in the community. I am sure we can all agree on and gather around that.

The noble Lord, Lord Beamish, made the point that, far too often in the past, people with learning disabilities and autism have been overlooked. I see the Bill as a real opportunity to do something substantive about that. That is why I note some of the amendments we have heard about in this group—certainly those in the names of my noble friends Lord Scriven and Lady Barker, and others—about the importance of having properly trained staff with up-to-date knowledge and expertise, as the noble Baroness, Lady Bennett, has just mentioned.

For any of this to happen, it is important that there is a proper plan, that is costed; the resources need to be available, and properly trained staff with up-to-date expertise need to be available in the community. To ensure that there is some sort of accountability around all this, I reiterate the question that my noble friend Lord Scriven asked the Minister: when will we see new targets—we have not got any at the moment—to reduce the number of detentions of people with learning disabilities and autism? It would be helpful to know that those targets will be put in place and that there is some way of monitoring the progress on all the important things we have been talking about in this group.

[Lord Patel (CB)]

I agree with what has been said: we need a definitive plan for how things will work out. We cannot rely on it being in five or 10 years because, as the noble Baroness, Lady Murphy, said, it then just becomes an ambition rather than a target to achieve.

I support the amendment of the noble Baroness, Lady Browning, which strongly asks that the people who look after children with autism and learning disabilities are properly assessed by properly trained and accredited people. We know that, currently, children are ending up in detention inappropriately because they are assessed to have a psychiatric condition such as schizophrenia—as the noble Baroness, Lady Browning, said—when, although they might have some psychiatric sub-condition, they fundamentally have autism or learning disability problems.

I am sorry that the noble Lord, Lord Adebowale, is not here to speak to his Amendment 150, which asks quite powerfully for a clear plan to be laid out, with resources tied to it, to achieve the ambitions there are in the Bill. I would have supported his amendment probing the Minister as to how resources will be allocated to achieve the ambitions for those targets to be met.

--- Later in debate ---

[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.

[Baroness Tyler of Enfield (LD)]

My Lords, I think that I am speaking in the right group. Amendments 45 and 48 are in my name, and although they are in this group, they are of a rather different nature. They are about the framework and definition of “appropriate medical treatment”.

I will briefly outline the overall context and why I thought it important to bring these two amendments forward. I am particularly concerned that many in-patients in mental health hospitals, particularly autistic people and people with a learning difficulty, continue to face detention in hospital settings which can provide little or no therapeutic benefit. The environment of these hospital settings can be incredibly overstimulating and distressing. We continue to hear stories of restrictive practices, including physical, mechanical and even chemical constraint, as well as the use of solitary confinement.

--- Later in debate ---

[Baroness Tyler of Enfield (LD)]

I shall make a few points in response to the amendments that we have been discussing in this group. The noble Baroness, Lady May, made, very powerfully, an incredibly compelling case. The point she made about police officers sitting in A&E for many hours is so important. Not only is that a waste of police resources, it is often completely inappropriate for the person suffering from acute mental health problems. It can also be incredibly alarming for others in A&E. We all know that, sadly, far too many people are waiting for far too long in A&E, in the sort of environment that is in no way conducive to their overall health, physical or mental. That is my first point.

My second point relates to something that the noble Lord, Lord Davies, said. There will still sometimes be a role for police officers. I know from personal experience how much a police presence can be required when a person suffering a very acute mental health crisis is likely to harm both themselves and others. Those others can often be family members who are trying to support the person suffering from the crisis but are also pretty scared for their own safety. It is important that we are talking about widening the range of people who can be that primary responder, but we are not saying that it should never be the police.

I agree that if we have a wider primary responder, that individual must be prepared to do it, happy to do it and appropriately trained. We heard a lot in earlier groups about the importance of good training. I was particularly taken with the statistic that the noble Baroness, Lady May, raised about the views of paramedics and how many of them support this, because they are the people right at the sharp end. I cannot quite remember the number who support it, but it was very large, and so I think it is something that we should take seriously.

Finally, I want to lend my support to Amendment 49A in the name of my noble friend Lady Barker. Speeding up access to appropriate services is important, as is making the best use of the workforce that we have. For those two reasons, the amendment that my noble friend put forward is important.

[Lord Meston (CB)]

My Lords, I hesitate to interrupt, but I want to make much the same point that the noble Baroness has made based on my experience of a trip to A&E last year. I mentioned it anecdotally at Second Reading. There was a very disturbed person in A&E when I was having to wait there for some three hours. The hospital staff were struggling to contain the person in one room, as he kept leaving. He was not violent, but he was obviously distracting the hospital staff and worrying the other people present, who included children. As soon as anybody asked the staff what they were going to do, they said that they had to wait for the police. I have no doubt that the whole episode that I witnessed was prolonged by the need to wait for the police. Clearly, if this amendment or something like it is approved, it will widen the range of those who could be called upon to deal with such a crisis.

Mental Health Bill [HL]

Baroness Tyler of Enfield Excerpts

Tuesday 14th January 2025 Lords Chamber

Moved by

[Baroness Tyler of Enfield]

21: Clause 4, page 8, line 21, at end insert—
“(ba) the person is under 18 years old and satisfies the conditions in (b)(i) and (b)(ii),”Member’s explanatory statement
The amendment inserts a new subsection that extends the duty on integrated care boards to establish and maintain a register for those at risk of detention to all children and young people under the age of 18.

[Baroness Tyler of Enfield (LD)]

My Lords, I will also speak to Amendments 27 and 32 in my name. My amendments all relate to children and young people, but this group also includes important amendments in the name of my noble friend Lord Scriven, which I support, on the duties on commissioners, integrated care boards and local authorities regarding care provisions for people with a learning disability or autism. Also important are the amendments from the noble Baronesses, Lady Browning and Lady Hollins. I add my condolences to the noble Baroness, Lady Hollins. I am sure we are all thinking of her today.

By way of context, the Bill introduces a new duty on integrated care boards and local authorities to commission community services for those with a learning disability and autism. The Bill also places dynamic support registers on a statutory footing. These are welcome and much-needed duties, and the Bill presents a crucial opportunity to strengthen the support provided to those with learning disabilities and autism. However, I want to go further. I recognise that there is some piggybacking on my part, but I am passionate about the mental health support that is available to children and young people, so I believe that the duties to provide community services should be extended to include everyone aged under 18, to ensure that children and young people can have their needs met without them having to be admitted as in-patients. That is where is my Amendments 21, 27 and 32 come in—they are all interrelated.

Amendment 21 seeks to extend the duties placed on integrated care boards to maintain a register of those at risk of detention to all under-18s. Amendments 27 and 32 would extend the new commissioning duties on integrated care boards and local authorities to include under-18s. In essence, the duties are both to identify and to commission services in the community that meet the needs of all under-18s.

As I think we all know, the Bill has been introduced at a point when waiting times and thresholds for mental health support for children and young people across early intervention services, targeted support services, CAMHS, et cetera are worryingly high. Consequently, too many children and young people are left to reach crisis point. Evidence shows that the number of children referred to emergency mental health care in England has increased by more than 50% in three years. These amendments will not only help to achieve improved outcomes for children and young people but have wider benefits for the mental health systems through intervening at an earlier stage, providing improved care for children and young people in the most appropriate settings, and reducing costs. This is all in line with the Government’s key drive to move to a more community-based, preventive model of healthcare—and, frankly, that should apply to mental health as well as to physical health, and to children and young people as well as to adults.

We all know, as we have discussed so many times in this Chamber, that children’s mental health support has historically been woefully underfunded. There is a lack of clear accountability to ensure that effective community provision is in place. I therefore consider that adding all children and young people to the new commissioning duty placed on local authorities and ICBs in the Bill is crucial to ensuring that their needs can be met at an early stage, preventing crisis and later admission to mental health in-patient care. We should worry about the whole system and try to prevent people getting to in-patient care, as well as worrying about those who do. In short, my argument is that their needs should be met without the need to detain children and young people, wherever that is possible.

Research has demonstrated that children’s and young people’s experience of in-patient care is consistently poor, too often further harming their mental health. A survey conducted by Mind on children’s and young people’s experience of care in mental health hospitals found that 69% of the young people surveyed said that their experience as in-patients had not been positive. In my view, a shift to such community-based provision would not only reduce the number of children and young people requiring in-patient beds but would in turn reduce demand for in-patient care and the risks of children and young people being cared for in what can often be highly unsuitable environments. It would also ensure that those with the most complex needs who do need in-patient care receive high-quality care in a setting that is right for them.

In case people are sceptical as to whether this sort of care can be provided in the community, I am aware of case studies of types of support in the community, such as hubs and the like, that can be used to manage high levels of risk. Where that care is provided in the community, in a relaxed, warm and calm environment, it can often be an alternative to young people having to visit A&E, where they may not get specialist mental health support and waiting times can be so long. I beg to move.

--- Later in debate ---

With those remarks, I ask that the noble Baroness will be good enough to withdraw her amendment.

[Baroness Tyler of Enfield (LD)]

My Lords, I thank the Minister for her response. I also thank other noble Lords who have participated in this debate.

For me, the nub of this grouping has been the whole issue of prevention—I think “getting upstream” was the phrase my noble friend Lord Scriven used—and having in place within the community better and more responsive services, with the aim of reducing admissions to in-patient care but, at the same time, improving the in-patient care that is available, because the only people there are those for whom nothing else will work. It is very welcome that the Bill puts the dynamic support register on a statutory footing. On the two amendments from the noble Baroness, Lady Hollins, beefing that up still further, I think I heard a slightly encouraging response from the Minister. I will look carefully at Hansard tomorrow, as I am sure will the noble Lord, Lord Crisp, to see what was said.

I can see that while some people may think that prevention is very important, they would ask what it has to do with this Bill. I do not see it like that. You have to take a system-wide approach. To get the whole mental health service working, even when you are looking at what I call the hard end—the crisis end—you have to look at what is happening at the preventive end and try to reduce the number of people who might need to be admitted. That would send an important message that there are clear legislative requirements for what services should be available within the community. This Bill, frankly, is the obvious place to do it—hence the amendments around children and young people that I raised.

I was pleased to hear the Minister say that the transformation and the 10-year plan will apply at least as much to mental health as to physical health. That is very encouraging and I am glad that we have got it on record. I was not altogether surprised that the Minister thought that my amendments were unnecessary. I do not agree. I was not just talking about children and young people with learning disabilities and autism. They are obviously a very important group, but my rationale for trying to broaden it out to all children and young people was, in essence, to make sure that only those with the most complex needs would receive that higher-quality care in an in-patient setting—everyone would benefit from that approach. The Minister talked about a new approach to children’s and young people’s services, and I look forward to hearing more details. I do not know whether the Minister can tell us when we might expect to see that.

Finally, my view is that the 1983 Act was never really designed with children and young people in mind; I think everyone agrees with that. This Bill is an opportunity for us to put children and young people centre stage—hence my amendment. This is such an important topic that I think we shall be returning to it on Report. On that basis, I beg leave to withdraw my amendment.

Amendment 21 withdrawn.

Mental Health Bill [HL]

Baroness Tyler of Enfield Excerpts

Tuesday 14th January 2025 Lords Chamber

Moved by

[Baroness Tyler of Enfield]

1: Clause 1, page 1, line 11, at end insert—

“Equity

addressing inequalities in treatment, particularly racial inequalities, outcomes, and related provisions regarding protected characteristics”

Member’s explanatory statement
The purpose of this amendment is to include a fifth guiding principle to ensure that there is equity in treatment and outcomes addressing inequalities related to protected characteristics, particularly racial inequalities, in the operation of the Code of Practice and the Mental Health Act 1983 more generally.

[Baroness Tyler of Enfield (LD)]

My Lords, in moving Amendment 1 standing in my name, I will also speak to Amendment 3 in my name. There are other important amendments in the name of the noble Baroness, Lady Whitaker, in this group.

Before I turn to my two amendments, I would like to make one general point. On these Benches we very much welcome this long-overdue Bill and will work with others to strengthen it further. The 1983 Act, which we are amending, is more than 40 years old and no longer reflects current understanding, attitudes or best practice in relation to severe mental illness or learning disability and autism. We need to ensure that the final law is truly fit to serve people’s needs for years to come, and our proposed amendments reflect a comprehensive effort to strengthen mental health services by promoting equity, tackling racial disparity, supporting the well-being of children and young people and ensuring that adequate resources are in place to deliver the Bill’s provisions.

A brief look back at the history shows that significant changes to mental health legislation happen on average every 15 to 20 years. That is understandable because it takes time for legislative reforms to take shape and be implemented. This Bill is likely to be the legislation that impacts on the health and well-being of people with mental health conditions for the next two decades. During our debate, we will be raising issues. It may not be possible to deal with them all in the legislation but they are important to mental health services overall, so I hope the Government will view them as part of a wider package of reform, be they issues around resources in the community or the interface between this Bill and the Mental Capacity Act. It is all part of our wider scrutiny, and I hope that the Government welcome that.

Amendment 1 would add a fifth principle to the existing four set out, which of course I fully support, and provide additional momentum towards the goal of addressing the racial disparities in the Mental Health Act. I believe that making equity one of the guiding principles, as in my amendment, would give it far greater clarity, weight and focus. If we look back at the underlying rationale for this legislation, addressing inequalities, particularly racial inequalities, is one of the key issues identified in Sir Simon Wessely’s review of the Act and is one of the key drivers behind this Bill. However, concerns remain in the sector and beyond that the Bill as drafted does not go far enough to address this deeply entrenched inequity. Adding such a principle would also reflect existing duties under the Equality Act and the requirements of the patient and carer race equality framework, a point made by many noble Lords at Second Reading. This would go some way to recognising one of the key drivers behind reforming the Act: to address racial disparities.

I will give a quick reminder of the key facts. Black people are more than four times as likely to be detained under the Act than white people. Black people are over seven times more likely to be placed on a community treatment order, a CTO. On average, people from racialised communities have a worse experience of care and worse outcomes, and black and 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 to experience higher levels of restraint than white people. These are gaping disparities in the use of the current Act, and we must ensure that the Bill does something about them.

My Amendment 3 is intended to probe whether the principles in subsection (2B) will be statutorily binding. Given that the code can only reflect law and act as guidance, placing the guiding principles in the code leaves a loophole in which they can be deviated from. That is the purpose of this amendment. The Bill provides an updating of the principles to be contained in the statutory code of practice, and that is welcome, but it does not include the statutory principles appearing in the legislation in the way that principles appear in Section 1 of the Mental Capacity Act 2005. I am not clear about the reason for this distinction between the two pieces of legislation, hence this probing amendment. I would welcome an explanation from the Minister of the thinking behind this distinction.

I am aware of strong views held by those working in the sector that it is hard to understand how the principles will be binding unless they are included in the Bill itself. Many feel that this would have much greater force than simply being referenced as “things the Secretary of State must consider” when writing the code. There is also case law. Back in 2005, R (Munjaz) v Ashworth Hospital Authority made it explicitly clear that the Mental Health Act code is guidance rather than instruction.

--- Later in debate ---

With that final comment, and for the reasons I have outlined in my response, I am grateful to noble Lords for their consideration of these amendments and for tabling them. I hope they will feel able not to press them.

[Baroness Tyler of Enfield (LD)]

I thank the noble Baroness for her extremely comprehensive but very helpful response to all the amendments, and I am happy to withdraw.

Amendment 1 withdrawn.

--- Later in debate ---

[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.

Health and Adult Social Care Reform

Baroness Tyler of Enfield Excerpts

Tuesday 7th January 2025 Lords Chamber

[Baroness Merron (Lab)]

The right reverend Prelate is correct to mention—I have raised it myself—not just the digital exclusion of individuals but connectivity. It is one of the reasons that we will approach this in a cross-government fashion. However, on our move from analogue to digital—the noble Lord, Lord Kamall, rightly mentioned the capacity of the NHS—our view is that it can do so much more than it is doing currently. The Secretary of State said in the other place that restaurants, for example, have been texting customers for many years, have they not? They remind customers about their booking and give them a chance to cancel or change it. That is the kind of connectivity and service that we need from the NHS. I assure the right reverend Prelate that, where people are unable to use whatever the digital solution might be, they will be able to deal with it person-to-person or on paper. We will be flexible enough and actively seek out those who are not, as he described, immediately connected.

[Baroness Tyler of Enfield (LD)]

My Lords, the Darzi review estimated the impact of delayed discharges at some 13% of total hospital beds. Given this, can the Minister say how confident she is that the immediate steps to improve the rate of discharge from hospital into social care, which she has already outlined, will happen? How quickly will that happen and over what timescale, and what accountability measures will be established at both national and local levels to ensure that those delayed discharges start to come down, and quickly?

[Baroness Merron (Lab)]

The independent review by the noble Baroness, Lady Casey—in addition, as I mentioned, to producing recommendations that can be implemented straight away next year—is focusing on completing its final report later in this Parliament, so we are looking at the longer term. I cannot give an exact timetable, although I am hopeful that we will be able to update your Lordships’ House with further information, as the noble Baroness quite rightly asked. The matter of discharge requires there being suitable facilities in the community, but we are not in that place, so this will take some time. But I am very hopeful that all of the measures here, and the measures we have taken already, take us further to that point. We will continue to strive on the matter of discharge, because it is a problem not only for the NHS but for patients and their carers and for social care. We are carrying, as we know, a lot of vacancies and a social care system that is creaking at the seams: we must be honest about that.

Mental Health Bill [HL]

Baroness Tyler of Enfield Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I apologise for my croaky voice. It has been an excellent and very well-informed debate. Like all other noble Lords today, I welcome the early introduction of this Bill, after so many years of delay, to modernise the woefully out-of-date 1983 legislative framework. Indeed, it has been one of the longest and most tortuous gestation periods of any piece of legislation I can remember.

I thank so many organisations for the excellent briefings I have received, as well as those who have worked so hard to get us to this stage, including the independent review chaired by Sir Simon Wessely and the cross-party Joint Committee chaired by the noble Baroness, Lady Buscombe.

Those people directly affected by this piece of amending legislation deserve better. From these Benches, we welcome the introduction of the Mental Health Bill as an important step towards modernising the mental health care system and enhancing patient rights. We are encouraged by the Bill’s emphasis on empowering patients and giving them greater control over their treatment decisions, and we want firmly to establish the principle that detention is an opportunity for treatment and a path to recovery, rather than being seen solely in terms of containment.

Like so many others, I particularly welcome the fact that the Bill seeks to limit detention for people with learning disabilities and autistic people who do not have a co-occurring mental health condition and removes prisons and police cells as suitable places of safety. As my noble friends Lord Scriven and Lord Alderdice said, this reform package moves incrementally in the right direction, seeking to balance the rights of individuals with the imperative of public safety.

But there is much more to do to strengthen and improve the Bill and to look at the wider context, particularly at the adequacy of existing mental health services outside of the Act and broader social inequalities. Ensuring we have the necessary funding, the workforce with the right skills and training in the right place will all fundamentally affect the implementation of this Bill.

However, I am disappointed that quite a number of the recommendations by the Joint Committee have not been picked up, in particular those on a mental health commissioner, on the interface between the Mental Capacity Act and this Bill and on strengthening duties on integrated care boards and local authorities to ensure an adequate supply of community services for people with learning disabilities and autism—points to which I shall return. Will the Government provide a detailed response to the Joint Committee report setting out the rationale for the recommendations that have been accepted and those that have not?

There are a number of themes that we will want to explore in Committee, and the first is prevention. We all know that, in healthcare, prevention is better than cure, and the noble Lord, Lord Darzi, Wes Streeting and the Prime Minister have all said it is one of the big three transformational shifts that are needed. We need to apply that same principle to this Bill and live up to that mantra. Put simply, we need to focus on preventing people from reaching the point where they risk being sectioned in the first place. That means deeper and wider preventive mental health in our communities. Currently, as a country, we focus on treatment rather than prevention. We spend around £230 billion on healthcare but only £3.5 billion on public health and only about 3% of that on preventive public mental health work. There is so much more we could do in schools, with walk-in hubs in the community and regular mental health check-ups et cetera.

A key Liberal Democrat objective in this Bill will be promoting good mental health. I believe we need a power included in the Bill that enables the relevant health and local authorities to undertake the promotion of mental health with realistic resources attached. That is also why I want to see a new right to both assessment and treatment for mental health introduced, similar to the Care Act rights that we introduced back in 2014, for people to get the help they need at earlier stages, directly preventing unnecessary admissions.

On racial disparities, given that two of the key drivers of the 2018 review were to reduce detention rates and the stark disparities in the application of the Act on some racial groups—as the noble Baronesses, Lady May and Lady Berridge, said so powerfully—we must explore what other opportunities exist to strengthen legislation in this regard. Specific examples would be putting the Patient and Carer Race Equalities Framework on a statutory footing and including an equity principle—in addition to the four existing guiding principles—which, like the noble Lord, Lord Bradley, and my noble friend Lord Scriven, I would like to see in the Bill to underline that these principles sit at the heart of all decision-making covered by it. I also support a new responsible person role at hospital level to oversee and monitor race equality in the day-to-day operation of the Act, with a corresponding duty on the Secretary of State to report annually on progress against reducing inequalities. Such a package could have real teeth.

Like the noble Lord, Lord Bradley, and others, I also strongly support the establishment of a mental health commissioner, as recommended by the Joint Committee. Such a commissioner would both promote access to treatment across the spectrum of mental health services, including things like beds for eating disorders, and oversee implementation of the Act, including ensuring that racial disparities are fully addressed and monitoring the use of community treatment orders.

On seeing detention as an opportunity for treatment and recovery, I would like to see the definition of appropriate medical treatment strengthened to take account of the settings in which treatment is delivered, including community settings, and the importance of non-drug-based intervention—either in tandem with medication or on its own—where it is clinically effective.

As many noble Lords have said, the Bill makes some important changes to better regulate the use of CTOs. These were originally meant to be a route out of disproportionate sectioning but, in reality, they have exacerbated the number of black people who are subject to compulsion under the Act. However, the revisions in the Bill currently stop well short of adopting all the independent review’s recommendations. For example, they allow CTOs to continue indefinitely, rather than placing a time limit on each CTO, with the option to make a new one if it is still needed. As my noble friend Lady Parminter made clear, we should explore this in Committee.

As many others have said, we need to view equal treatment between Part II and Part III patients as paramount. Ensuring that all patients detained under the Mental Health Act, including those involved in the criminal justice system, have equal access to advocacy, mental health tribunals, appeals and other rights—no matter which part of the Act they are detained under—is a key principle. Given, as I have said, that one of the key drivers for reform was addressing racial inequalities, and that black people are significantly more likely than white people to be detained under Part III, we currently risk further entrenching these disparities.

Much has rightly been said about people with learning disabilities and autism. The changes to Section 3 are an important step in ending the human rights scandal of inappropriate detentions of autistic people and people with a learning disability. As the noble Lord, Lord Touhig, and the noble Baroness, Lady Hollins, said, legislative change must be accompanied by investment in the right community support. Without this, autistic people and people with learning disabilities will continue to reach crisis point with their mental health. There is a real risk of these groups falling into the criminal justice system, simply due to lack of community provision. This has been the New Zealand experience, as the noble Baroness, Lady Watkins, highlighted. They are then unable to access Section 117 aftercare support. We are told that this change will be enacted only once sufficient provision is in place. Can the Minister provide more details on how this decision will be taken and what the Government will do to ensure that capacity is being built up in the community?

My noble friend Lady Barker, the noble Lord, Lord Bradley, and others expressed concerns about the interface between this legislation and the Mental Capacity Act. I share these concerns. I feel that it is currently fuzzy and unclear, leading to inconsistency in practice and confusion as to which legal framework applies. We must explore this further in Committee, including understanding what has happened to the liberty protection safeguards that were introduced under the Mental Capacity (Amendment) Act but have not yet been implemented.

I am also aware of concern within the sector that there has not been adequate or meaningful engagement with people with learning disabilities or autism, or sufficient time for them to be properly involved in decisions that directly affect their lives. How do the Government intend to remedy this? Do they have a plan of stakeholder engagement, particularly with groups led by people with learning disabilities and autism?

One area which particularly concerns me and about which we have heard a lot today is the position of children and young people who are too often receiving poor-quality care in unsuitable conditions. There are many things we can do in Committee to strengthen the position for children. I was profoundly moved by the family experience that the noble Baroness, Lady Ramsey, recounted. I thank her for that.

There is much else that I would like to say about implementation, but I have probably run out of time. I welcome the collaborative style adopted by the Minister towards improving the Bill. I look forward to working with other noble Lords on this vital and long-overdue piece of legislation.

Carers and Poverty: Carers UK Report

Baroness Tyler of Enfield Excerpts

Thursday 21st November 2024 Lords Chamber

[Baroness Merron (Lab)]

I understand the point the noble Baroness is making. I was pleased that my ministerial colleagues Stephen Kinnock, the Minister for Care, and DWP Minister Stephen Timms recently attended a Carers UK-hosted round table to discuss all these points, including poverty and finances. I hope your Lordships’ House will acknowledge and welcome the steps we have already taken and be assured that we know there is much more to do. We will continue to work cross-government on this.

[Baroness Tyler of Enfield (LD)]

My Lords, I welcome the recent announcement about the earnings limit on the carer’s allowance, but that helps only carers who are able to combine paid work with unpaid care. It is estimated that over 1.5 million carers are now providing over 50 hours of care per week, making it impossible for them to do paid work. What are the Government doing to support those carers? Will they look at increasing the carer’s allowance, which is currently £81.90 a week—the lowest benefit of its kind, I believe—and expanding the care-related premium to universal credit and pension credit?

[Baroness Merron (Lab)]

There is to be an increase in the carer’s allowance from April of next year. The change we have made in the earnings limit will, over the next four to six years, bring in an additional 60,000 people who were previously not eligible. The DWP is very conscious of a number of the pressures on unpaid and other carers and will continue to look at that. Further developments will be reported.

NHS: Independent Investigation

Baroness Tyler of Enfield Excerpts

Tuesday 8th October 2024 Lords Chamber

[Baroness Merron (Lab)]

This will take us towards the 10-year plan. There will shortly—really shortly—be an announcement as to how the consultation will take place. It will be available to everybody with an interest in and a commitment to the National Health Service, and to those with lived experience, which is extremely important. It will be the biggest consultation that there has ever been on the National Health Service. I believe that is the way to achieve consensus, but you have to start by asking what the diagnosis is. Although I hear differing opinions in some areas of your Lordships’ House about the contribution of the report of the noble Lord, Lord Darzi, for me it makes a major contribution. If one does not know where one starts, one cannot end up in the right place. However, I absolutely agree with the noble Lord that consensus is key. We do not have the luxury of time for arguing the case, so this widespread consultation will get us to the right place.

[Baroness Tyler of Enfield (LD)]

My Lords, the forensic report of the noble Lord, Lord Darzi, shone a much-needed spotlight on the deteriorating state of children’s health services and worsening health outcomes for children, particularly the long waiting lists of over a year that some were facing before getting hospital treatment. What plans do the Government have to focus investment on children’s health services, which seem to have fallen behind adult health services, and to develop a children’s health workforce strategy as part of the overall NHS long-term workforce plan?

[Baroness Merron (Lab)]

I agree with the noble Baroness that that is unacceptable. There are just too many children and young people who are not receiving the care that they deserve. We know that waits for services are far too long and our determination is to change that—not least, as I am sure the noble Baroness has seen, given that children are at the heart of our opportunity and health missions, and rightly so. To ensure that every child has a happy and healthy start to life, among other measures we will train more health visitors and digitise the red book of children’s health records, so that parents and children can access the right support. We will be restricting vapes and junk food from being advertised to children, which will assist in the prevention of ill health, and we will ban the sale of high caffeine and energy drinks to under-16s. There will also be specialist mental health support in every school and walk-in mental health hubs in every community. I hope all of those will make a difference.

Covid-19 Inquiry

Baroness Tyler of Enfield Excerpts

Tuesday 3rd September 2024 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, the first report of the Covid inquiry, chaired by the noble and learned Baroness, Lady Hallett, shines a harsh spotlight on the country’s state of preparedness for the Covid-19 pandemic. I too pay tribute to the noble and learned Baroness and her team for the extremely thorough and forensic way in which the inquiry has conducted its work and for the clarity of its recommendations. The report indeed makes for very sombre reading.

Before turning to the report’s findings and recommendations, I first remember and pay my heartfelt respects to the hundreds of thousands of people who died as a result of the pandemic. My thoughts are with the families and friends who lost loved ones in the most harrowing of circumstances. I also think of the more than 1,000 front-line health and care workers who died after contracting Covid as a direct result of their work responsibilities. They made the ultimate sacrifice in the service of others and must never be forgotten.

I will never forget the day that we found out—via a Zoom meeting, as it had been impossible to visit—that just under 30 people had died in my late mother’s care home in the first few months of the pandemic. This was a direct result of the policy of rapidly discharging untested patients from nearby hospitals into care homes without adequate PPE being available or proper infection control being in place in those homes. In the first wave of the pandemic alone, there were almost 27,000 of what are called excess deaths in care homes in England and Wales compared with the previous five years—so much for the so-called protective ring cast around care homes. It is very hard not to feel that these people somehow or other were regarded as expendable.

I will not forget saying goodbye to a lifelong friend over an iPad a few days before she passed away, or my friend who had been in hospital for over six months with a very serious and complex condition—made immeasurably worse by her family not being able to visit—who, then, two days before she was due to go home for Christmas, contracted Covid and died. The suffering has been incalculable.

In summary, the report concludes that the UK Government and the devolved Administrations’ systems and emergency planning preparedness, resilience and response failed because of overly complex institutions, systems and structures and a failure to learn from the past. It also found that there was too little involvement in the planning process of local bodies and officials, particularly directors of public health. It is telling that the report concluded:

“Had the UK been better prepared for and more resilient to the pandemic, some of that financial and human cost may have been avoided. Many of the very difficult decisions policy-makers had to take would have been made in a very different context”.


I completely share the sentiments expressed on the day of the report’s publication by the chief executive of the Health Foundation, Dame Jennifer Dixon. She pointed to

“the country’s shocking lack of preparedness for the COVID-19 pandemic”

and went on to say:

“The failure of strategic planning for a major health emergency was compounded by the lack of resilience within public services. The NHS went into the pandemic struggling to keep up with growing waiting lists, following a decade of low spending growth and chronic staff shortages … Lack of capacity limited the NHS’s ability to deal with a surge in demand, which led to too many people going without the care they needed and many died as a result. In England, support for the social care sector, which was already thread-bare, was too slow and limited, resulting in inadequate support for people using and providing care. The consequences of this were devastating”.


It is a damning indictment.

As we have heard, the inquiry’s report throws into stark relief how inequalities put certain communities at disproportionate risk during the pandemic and fuelled the spread of Covid-19. It showed how low-income people, disabled people and people from black and minority ethnic communities were far more likely to get infected and die from the virus. The noble and learned Baroness, Lady Hallett, has warned that inequality is a huge risk to the whole of the UK, and she quoted the views of Professors Bambra and Marmot:

“In short, the UK entered the pandemic with its public services depleted, health improvement stalled, health inequalities increased and health among the poorest people in a state of decline”.


In the light of this assessment, which I consider to be damning, what update can the Minister give me on progress against the NHS long-term plan? Can the Minister say whether the Government will be committing to a social care workforce plan to complement the NHS workforce plan?

Much has been made, rightly, of the impact of years of disinvestment—and, frankly, disinterest at times—in public health by the Government, and how directors of public health were largely sidelined in key decision-making. The stark reality is that, entering the pandemic, the UK public health system had faced severe cuts to its local authority grant of around £1 billion worth of lost funding. This meant that the UK lacked public health capacity in 2020 to respond to Covid with a co-ordinated and effective response. This was particularly problematic in terms of out-of-date PPE, a lack of testing capacity compared with other countries, and a test and trace system that failed to partner effectively with local authorities and all the local knowledge they would have brought.

I am pleased that the report recognises the importance of public health expertise in its recommendations for the creation of a UK-wide independent statutory body for civil emergency preparedness. I hope this will ensure that directors of public health are properly consulted before independent strategic advice is given to the Government.

In future pandemic planning, much more must be done to ensure that mental health is not considered an afterthought. I was struck by the briefing I received from the Royal College of Psychiatrists, which said that, to its knowledge, it was not included in pandemic preparedness exercises, including those relating specifically to flu. Thus, it did not know the extent to which mental health was considered in preparation exercises. That seems extraordinary.

The pandemic made it difficult for people with existing mental health illnesses to access the treatment they needed—meaning that more people were presenting to services at crisis point—and many others experienced mental health problems as a direct result of Covid and lockdowns. By June 2021 some 1.5 million people were in contact with mental health services—the highest figure since records began—and, as we know, the numbers remain alarmingly high.

It has become clear that school closures during the pandemic had a profound impact on many children. For future pandemics or similar events, surely planning and guidance must be prepared for keeping schools, other educational settings, and specialist facilities such as children and adolescent mental health services open for as long as it is safe to do.

In preparing for this debate, I was reminded of the first report of the House of Lords Public Services Committee, published in November 2020, which examined the state of public services in response to the pandemic. I was lucky enough to serve on that Select Committee and it identified a number of “fundamental weaknesses” that

“must be addressed in order to make public services resilient enough to withstand future crises”.

It also identified

“the vital role of preventative services in reducing the deep … inequalities that have been exacerbated by COVID-19”.

One of the report’s key recommendations was:

“An approach to public health that focused on preventing health inequalities over the long term would pay dividends by increasing the resilience of communities and reducing pressures on the NHS when a crisis occurs”.


Indeed, the committee heard that many deaths from Covid could have been avoided if preventive public health services had been better funded.

The evidence we received suggested that the failure in adult social care resulted from insufficient planning coupled with years of underfunding. The Nuffield Trust pointed out that although the Government’s 2016 pandemic-planning exercise, Exercise Cygnus, had

“showed that care homes and domiciliary care would be in need of significant support in a pandemic scenario, no advance arrangements were put in place to meet those needs”,

resulting in, as we have heard, people being discharged from hospital into care settings during the first lockdown without testing and adequate PPE, which led to the tragic loss of thousands of older people. All of this from the Public Services Select Committee remains highly relevant to today’s debate.

Finally, I turn to the thorny issue of Brexit. I recognise that this will always be a contested issue. I note that the inquiry heard evidence that the UK had been made more vulnerable by Brexit; 16 separate pandemic preparation projects were “stopped” or reduced as a result of officials being diverted to brace for a no-deal Brexit. Although we heard a very different story from the Ministers involved, I was struck by the evidence given by the director of emergency preparedness and health protection at the Department of Health and Social Care—an impartial civil servant—who said that pandemic planning had been deprioritised in favour of no-deal Brexit preparations. I restrict myself to saying that the coincidence of timing between Covid and Brexit could not have been worse.

So what next? The noble and learned Baroness, Lady Hallett, made it extremely clear that she expects all the recommendations to be acted on within an agreed timescale and that she will be monitoring progress closely. I noted the statement by the Chancellor of the Duchy of Lancaster after the report was published. A commitment was given to respond within six months. Is the Minister able to give me an assurance that we will get that government report before the end of this year?

The best way we can collectively honour the memories of all of those who died, including those working on the front line and those still living with the impact of Covid, is to ensure that next time we are far better prepared—for without any doubt there will be a next time.

Social Care Reform

Baroness Tyler of Enfield Excerpts

Monday 2nd September 2024 Lords Chamber

[Baroness Merron (Lab)]

I thank the right reverend Prelate for his kind words of welcome. I take the point about invisibility in this area, but it would be fair to say that this Government will want to make this extremely visible. It is an issue that will not go away, and also one that is absolutely crucial, not just for those who rely on social care but for the good functioning and provision of the National Health Service. The two are inextricably linked, and we cannot sort out one without the other.

[Baroness Tyler of Enfield (LD)]

Since 2015, the number of working-age adults requesting care has increased significantly faster than those aged 65, and very few of them are self-funders, so while I welcome the Government’s commitment to establish a fair pay agreement for the workforce, it will work only if it is matched by commensurate local government funding increases; otherwise, it will just squeeze already overstretched care provider and local council budgets. What plans do the Government have to ensure that local authorities have sufficient funding to meet this commitment?