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Lords today, I welcome the early introduction of this Bill, after so many years of delay, to modernise the woefully out-of-date 1983 legislative framework.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?