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Lords today, I welcome the early introduction of this Bill, after so many years of delay, to modernise the woefully out-of-date 1983 legislative framework.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

Integration of Primary and Community Care (Committee Report)

Baroness Tyler of Enfield Excerpts

Thursday 9th May 2024 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, this debate is very timely as it picks up neatly from our recent debate on the long-term sustainability of the NHS. One of the key takeaways from that debate was the urgent need to move to a more preventive model of care, with investment moved upstream. It will be critical if we are to lower waiting times, improve access and reduce health inequalities.

It is indisputable that funding growth in the health and care system is skewed towards the acute sector. Despite the fact that the majority of daily NHS activity happens in general practice in the community, a large proportion of expenditure on health and social care goes towards acute hospital trusts. Community sector funding has grown at only half the rate of hospital trusts in recent years. The answer to overcrowded hospitals is not simply more hospitals; the health and care system must be radically refocused to put primary and community care at its core.

As we have already heard, a more radical shift to a preventive model of health was one of the key findings of our Select Committee, which was so superbly chaired by the noble Baroness, Lady Pitkeathley—whom I always think of as my noble friend. In short, our committee found that a lack of co-ordination between the everyday primary and community services relied on by people using the NHS was leading to substandard care, missed opportunities for home or community-based treatments, and an undue strain on already overstretched hospitals. Our report argued for a healthcare sector where patients were given the type of care they needed, when, where and how they needed it. That might be access to a GP, a pharmacist, a district nurse or a mental health nurse, along with greater focus on more joined-up preventive care. The evidence is quite clear that investing in primary and community care—which includes mental health—results in lower demand in hospital and emergency care. It really is not rocket science.

A wholesale shift in thinking and culture is required, and it goes a lot wider than funding, as our report said. As the King’s Fund has argued, it involves national measures and targets for the health and care system shifting towards longer-term goals to integrate care and ensure that services can focus on population health rather than being focused on short-term acute measures. This approach is very much backed up by the World Health Organization, which has argued that a primary and community care-focused approach is the most effective and sustainable way of improving the health and well-being of our population.

We have already heard about integrated care systems, which have an important role to play in delivering this change, particularly if they focus on population health, as was the original intention. From the evidence we received, it was clear that local leaders know the challenges for their local communities and the local landscape of primary and community care, and they know it best. Leaders of integrated care systems, place-based partnerships, including health and well-being boards, and primary care networks are best placed to design and deliver joined-up primary and community care.

ICBs should be held to account for their achievements in growing primary and community care services rather than for the performance management of hospital systems, and a stronger primary care voice on ICBs and representation from the voluntary sector would undoubtedly help.

It was clear, as we all know, that the workforce is crucial, not just in primary and community health but in adult social care and the voluntary sector. We need a skilled and well-valued workforce to support people to live independent and healthy lives. Surely the Government should now commit to fully funding and delivering the NHS long-term workforce plan, alongside developing an equivalent plan for social care, where workforce shortages are leading the sector to struggle to support those who need social care, in turn placing additional pressures on primary and community care. Can the Minister say when the Government will heed the calls of so many in this Chamber and in the wider sector to produce a workforce strategy for social care?

Other speakers will no doubt focus on the importance of data sharing for successful joined-up services. We must ensure that patient records can be easily accessed across the health and social care system, including in primary and community care. I found the government response to our recommendations on this issue vague and technocratic. Will the Minister please say exactly what the Government are doing to ensure this happens?

I will pick up on a couple of other specific points from the government response. Recommendation 2 of our report said that elected local government officials should be given the right to chair ICBs where that was the will of the board, underlining the truly joint and equal role of NHS bodies and local authorities in producing a holistic health and social care system. The government response did not make clear whether they were prepared to let this happen. Can the Minister please answer this specific point?

Recommendation 5 was for the Secretary of State to instruct the CQC to develop a specific integration index to compare how well ICSs co-ordinated different services in their areas. The government response does not commit to implementing this. Will the Minster say what the Government’s intentions are in this area?

Finally, recommendations 14 and 16 contained important proposals on training and job rotation. We saw a clear tension between our hospital-centric system of health and care, with increased specialism, and people having increasingly complex health and care needs, which need an integrated, holistic response, hence the need for a different approach to training and job rotation. I would like to see clinical and managerial health leaders strongly encouraged to work in community settings and develop experience across a range of sectors. I found the government response on this unsatisfactory—indeed, there was no response to the point about job rotations. I strongly urge the Government to think again.

NHS: Long-term Sustainability

Baroness Tyler of Enfield Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I, too, thank the noble Lord, Lord Patel, for the debate and I congratulate the noble Baroness, Lady Ramsey, on her outstanding and moving maiden speech. As we have already heard today, public satisfaction with the NHS has fallen to an all-time low but, despite this, there is still strong support for its three founding principles: free at the point of delivery, primarily funded through taxation and available to everyone.

Last year, the King’s Fund published a report on the performance of the NHS compared with the health systems of 17 other OECD countries. Essentially, it was a scorecard which showed that, on the plus side, the NHS performs well in protecting people from some of the “catastrophic costs” of falling ill, and a relatively low share of the UK’s health budget is spent on administration—some might be surprised at that. On the minus side, the report concluded that the NHS has fewer key resources than its peers, below-average health spending per person, fewer doctors and nurses, less equipment such as CT and MRI scanners, and fewer hospital beds. In addition, the report said the NHS performs noticeably less well on outcomes such as survivable cancers, treatable mortality and life expectancy.

Various independent commentators have concluded that changing the funding model is not the primary answer. Nor, of course, is it either desirable or feasible to always just pour more money in. The important thing, as the Health Foundation has argued, and I concur, is to get the current NHS model to work better—that is, to reform the way it works. The key, surely, is to increase capacity in the right places. That is so simple to say but so hard to do. It is indisputable that funding growth is skewed towards the acute sector. Despite the majority of daily NHS activity happening in general practice and the community, a large proportion of expenditure on health and social care goes towards acute hospital trusts.

In my view, the answer to overcrowded hospitals is not simply more hospitals. As the noble Lord, Lord Patel, and others have said, the health and care system must be radically refocused to put primary and community care at its core if it is to be effective and sustainable and so that people can get access to their GP, a pharmacist and a district or mental health nurse.

That was one of the key findings of the Select Committee on Integration of Primary and Community Care, on which I had the privilege to sit, which was so expertly chaired by the noble Baroness, Lady Pitkeathley. The committee found a lack of co-ordination between the everyday primary and community services relied on by people using the NHS, which was leading to substandard care, missed opportunities for home or community-based treatments and overstretched hospitals being put under even further strain.

I turn now to productivity. Respected health commentators have been looking at what is called the productivity conundrum. A recent Institute for Government report found that, despite increased spending, much of which has gone on increasing staff numbers, there has been no resultant rise in productivity, if measured against metrics such as the number of patients treated. We really need to understand why this is. The report drew particular attention to the fact that most hospitals are running at above full capacity. They do not have enough beds and it is estimated that each day around 13,000 beds are occupied by people who do not need to be there but cannot be discharged because of lack of community and social care. We all know that, after years of neglect and underfunding, our social care system is in crisis.

Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees and they are being replaced with junior staff who are naturally less experienced and need more support. Staff burnout, low morale and pay concerns are cited as the principal reasons for this. A recent IFS report also concluded that, while

“It is difficult to measure productivity … the NHS is less productive now than pre-pandemic”,


particularly in hospitals. The report was at pains to say that was not about staff not working hard but pointed the finger at Victorian estates, too few diagnostic machines and outdated IT systems causing communications problems within and between hospitals.

I believe that there should be far greater focus on retention and making the NHS an attractive place to work. That should be central to the NHS workforce plan, and we need a plan for social care, too. If not, we shall never clear the backlog or reduce waiting lists. We also know that valuable NHS equipment and operating theatres too often stand idle in the evenings and at weekends. Can the Minister say what plans the Government have to address this and whether they might include bringing in independent clinical teams from outside the NHS—a point raised by the noble Lord, Lord Reid.

Finally, are we going to see a productivity plan to set out how the productivity increases announced in the spring Budget, alongside the £3.4 billion additional capital investment will be achieved? In my view, Parliament needs to be scrutinising these plans.

National Health Service: 75th Anniversary

Baroness Tyler of Enfield Excerpts

Thursday 30th November 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords I start by expressing my heartfelt thanks to all NHS staff for the tremendously difficult and important job they do. I particularly pay tribute to the memory of close to 1,000 NHS and care workers who died while working to save others during the terrible Covid pandemic. We owe them a debt of immense gratitude. Like other noble Lords who have spoken today, I know that I and other family members owe our lives to the NHS, and that is why it holds such a central place in our country’s social fabric and in our hearts.

It is against that backdrop that I want to talk about the need for reform. As we mark the NHS’s 75th anniversary, it is right that we should reflect on its performance and what could and should be done to improve and renew it. We have already heard a lot of statistics about waiting times and numbers treated; I want to concentrate on the wider context for health and then look specifically at the thorny question of productivity.

It has been estimated that some 80% of the health needs of people across the country are not within the direct control of the NHS. We also see large inequalities in health outcomes between different groups and communities. The terms “NHS policy” and “health policy” are too often used interchangeably, but they are not interchangeable. Most policy which impacts the health of the nation—housing, transport, employment and so on—is made outside the NHS, which is why we need to focus on the wider determinants of health and devise cross-government strategies to improve health and well-being. It is also why it is so important to ensure that more money goes into prevention and public health rather than just into the NHS, a point just made so compellingly by the noble Baroness, Lady Taylor of Stevenage. Looking at health and well-being in the round, rather than simply at how we prop up the NHS in its current form, must be at the forefront of our thinking. We have already heard, and it is very concerning, that public satisfaction with the running of the NHS is at its lowest level in 25 years.

What is going on? In July this year, the chief executives of three health think tanks, the Health Foundation, the Nuffield Trust and the King’s Fund, wrote a letter to the three party leaders calling for an end to “short-termism in NHS policy-making”, warning that promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis is a strategy “doomed to failure”. We would do well to heed that. The letter outlined four key areas to focus on: investing in physical resources; reforming adult social care; committing to a long-term workforce plan; and cross-government working on the underlying economic and social conditions affecting health.

Specifically, the letter pointed out three things. First, due to a decade of underinvestment compared to the historic average, and capital spending well below comparable countries, the health service has fewer hospital beds than almost all similar countries, outdated equipment, dilapidated buildings and failing IT. Secondly, despite long-term objectives to reduce reliance on acute hospitals and move care closer to the community, which I very much support, spending continues to flow in the opposite direction. Thirdly, while the NHS long-term workforce plan is to be welcomed, ambitious steps to increase the number of staff, through training, apprenticeships and international recruitment, et cetera, risk being frittered away if trainees continue to drop out and poor morale and sickness continue to drive staff to leave and retire early. In short, sustained action is needed to make the NHS a better place to work.

Finally, as we have said so many times in this Chamber, we cannot reduce pressures and improve the performance of the NHS without addressing the challenges faced by adult social care. I join the noble Lord, Lord Prentis, and ask, once again, what plans the Government have to provide a social care workforce plan to complement the NHS plan?

It is also worth comparing the NHS to the healthcare systems of other countries. The King’s Fund did this recently and concluded that, first, the NHS is neither a leader nor a laggard when compared to the health systems of 18 similar countries. Secondly, the UK has below-average health spending per person compared to those countries. Thirdly, the UK lags behind other countries in its capital investment and has substantially fewer key physical resources than many of its peers, including CT and MRI scanners and hospital beds. Finally, the UK has strikingly low levels of clinical staff, including doctors and nurses, and is heavily reliant on foreign-trained staff. All that is critical to productivity, which I want to turn to finally.

Respected commentators such as the IFS, the Institute for Government and the Health Foundation have been looking at what has been called the productivity conundrum. The Institute for Government report The NHS Productivity Puzzle found that despite increased spending, particularly since 2019, much of which has gone on increasing staff numbers, there has not been a resultant rise in productivity if measured against metrics such as the number of patients treated. It draws three conclusions. First and foremost, hospitals are running at above full capacity, they do not have enough beds, and too many of the beds they do have are full of people who should not be there. There is a lack of capital investment, low diagnostic equipment stocks, et cetera. Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees, and they are being replaced with more junior people who are naturally less experienced and who need more support. Staff burnout, low morale and pay concerns are cited as key reasons. Thirdly, it says, the NHS is badly managed and all the changes over the last decade have made managers’ jobs a lot harder.

Finally, a recent IFS report came to similar conclusions about the reasons for the low productivity. It acknowledged it was difficult to measure productivity, and that point came out clearly when Amanda Pritchard was before the Health and Social Care Committee recently. She argued that it is hard to measure productivity, but what plans do the Minister and NHS England have to publish their own analysis of NHS productivity and ways to improve it?

There is much that we could and should be doing. My points and the IFS statement should not be interpreted as NHS staff working less hard. It is the other points that are most important. I expect they are many reasons, but the need to make the NHS an attractive place to work is critical and should be central to the NHS workforce plan.

Mental Health: Children and Young People

Baroness Tyler of Enfield Excerpts

Thursday 23rd November 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, it is always a great pleasure to follow on from the wise words of the noble Lord, Lord Laming. I congratulate my noble friend Lord Russell on securing and introducing this debate in such a moving and comprehensive way. It is such an important issue and is very dear to my heart. I also congratulate the noble and learned Baroness, Lady Hale, on her excellent and highly entertaining maiden speech. I was a bit perplexed when I saw that it was her maiden speech, but now I understand. I also thank the many charities and others in the sector who have sent me excellent briefings.

It has been an excellent and very well-informed debate. I will pick up on some of the main themes covered. Quite rightly, we have heard a lot about the state of children’s mental health in this country, and many of the statistics are indeed bleak. To summarise a complex picture, an increasing number of young people are experiencing mental health problems for a wide range of reasons, which have been highlighted compellingly today. Yet far too many are unable to access the help that they desperately need, either through school or NHS services.

Without doubt, young people’s mental health services are struggling to meet demand. As a result, thresholds for treatment are very high, with many young people turned away because they are “not well enough”. Those who do get accepted into CAMHS are often left waiting many months, if not years, for treatment, during which time their mental health often deteriorates.

I will say a few more things about demand for, and access to, services. Mental health providers are concerned that they are seeing an increase in both the severity and complexity of the mental health needs of children and young people—exacerbated by both Covid and the cost of living crisis, which we have heard about today. The NHS Confederation estimates that demand has increased by 89% and that mental health services are treating double the number of children and young people with eating disorders who need urgent care than before the pandemic—which we just heard about. That is the equivalent of six children in a class of 30. The number of referrals to CAMHS reached a record number in May of this year and the number of urgent referrals of children to crisis teams has also reached a record high. Particularly worryingly, suicide rates among young females have been steadily increasing.

Looking ahead, it is pretty daunting. It has been estimated that 1.5 million children and teenagers will need new or additional support for their mental health over the next three to five years. That is going to take a very different approach. The unpalatable fact is that only around a third of children with a probable mental health problem are, at the moment, able to access treatment. I think that shows how far away from parity of esteem with physical health we really are.

I am particularly concerned about the huge regional inequalities and the lottery of what support is available depending on where you live. My noble friend Earl Russell referred to an FoI investigation by the journalist Justine Smith, published in the House magazine in April. It revealed a postcode lottery in child mental health care, with some desperate young people waiting up to four years for help. Results from the 58 trusts and boards that responded to the request showed that the position in England was considerably worse than in Scotland and particularly Wales. Almost three-quarters of the English trusts said that they currently had at least one young person who had been waiting at least a year, and two-fifths had someone waiting at least two years. Funding ranged from £35 per child under the former Doncaster clinical commissioning group—0.5% of its total budget—to £135 per child in Salford, or 2.2% of its budget. That is a huge difference. I think variations of this scale are simply unacceptable. This data needs to be tracked and published regularly to throw a spotlight on what is going on locally.

On funding, years of underfunding and neglect of children's mental health services have taken their toll, as we have heard loud and clear. They have been subject to what I call the “double Cinderella syndrome”, or indeed the “double-8 syndrome”—by which I mean that only 8% of mental health services spending was spent on children and young people's mental health in 2021-22, and in 2022-23 just over 8% of the NHS budget was spent on mental health generally. To meet increasing demand, it has been estimated that funding for mental health services would have to rise to as much as £27 billion by 2033-34. That is the backdrop against which the very welcome but, frankly, relatively modest increases in government funding since 2017 should be viewed.

The NHS Long Term Plan, published in January 2019, included a welcome commitment that funding for children and young people’s mental health services should grow faster than both overall NHS funding and total mental health spending. But it has become harder to track whether this has happened in the switch from CCGs to integrated care boards, and with the changes to how the mental health investment standard and the dashboard operate. So could the Minister say when the NHS mental health dashboard is next due to be updated and whether, and by how much, the commitment in the NHS Long Term Plan has been met? If he does not have those figures to hand, could he please write to me.

A point not covered so far in our debate relates to the fact that mental health is now part of a new major conditions strategy, rather than having its own stand-alone strategy. I know that many consider that a regressive step. This occurred following the cancellation of the previous long-term mental health and well-being plan that had been proposed by the Government. With the new major conditions strategy focusing on a range of conditions such as cancer, heart disease, musculoskeletal disorders, dementia and respiratory diseases, there is a clear risk that it will focus mainly on middle-aged and older people and that the mental health of infants, children and young people will be neglected.

So, what is needed? A lot of it has been covered in today’s debate and I support others who have been calling for a comprehensive cross-government strategy, looking at all aspects of mental health support. There are a number of things that need to be included.

I will start with prevention; any good strategy should start with prevention. The Royal College of Psychiatrists has recently published a report calling on the Government to prioritise the mental health of babies and children. It set out evidence showing that intervening very early on may help stop conditions arising or worsening, and prevent babies and young children developing mental health problems in later life. This might include support for mothers in pregnancy, working with parents to promote attachment to their children and recommending parenting programmes in the early stages—many of the things that the noble Baroness, Lady Hollins, talked about. I very much hope that family hubs will develop such services so that they are available wherever people live. Could the Minister say whether this is the case? I fully endorse the calls today for the family to be supported as the primary source of emotional support and well-being.

I turn next to early intervention services. Again, we have heard today how crucial early intervention is to stop problems escalating. In other words, the earlier a young person can get support for their mental health, the more effective it is likely to be. That is why I have been a strong backer of the early drop-in support hubs for 11 to 25 year-olds. They are on a self-referral basis, which I think is exactly what is needed, and are embedded in the community. They have been championed by YoungMinds and many others. I very much welcome the £5 million announced by the Government last month for 10 existing hubs and I strongly support the call for a national network of hubs to support young people who do not meet the threshold for CAMHS support.

I move on to schools, which have an absolutely vital role to play, as my noble friend Lord Storey set out so eloquently. I have always supported the creation of mental health support teams in schools. I was struck by research evidence earlier this year from Barnardo’s, which delivers 12 such teams. The research found that the teams are effective at supporting children and young people with mild to moderate mental health problems. They improve their outcomes and, critically, are cost effective; they say that they save the Government £1.90 for every £1 invested. But, as we all know, the problem has been the frankly glacial rollout of this programme.

The high demand and long waiting lists for CAMHS that I talked about earlier place real pressure on these mental health support teams, which were not really set up to deal with the more severe issues. The Barnardo’s research identified a gap in the current model to address the needs of children with moderate or more complex needs, children with special educational needs and younger children. It recommended that the rollout should include school counsellors to fill this gap. I support this recommendation and am delighted that next Monday I will be introducing my Private Member’s Bill, which is designed to ensure that every school has access to a qualified mental health professional or school counsellor—a key Lib Dem policy, as we heard earlier. I hope that this will provide a much-needed boost to ensure that all schools are able to provide their pupils with the mental health support they need.

I turn briefly to CAMHS services. As the Children’s Commissioner pointed out in her annual report, the stark reality is that too many children still face high access thresholds, rejected referrals and long waiting times. Children’s mental health was looked at by the Lords Select Committee examining the implementation of the Children and Families Act 2014, which I had the honour to chair. We were shocked by the results of a survey we commissioned, which showed that in many places CAMHS had reached crisis point. I vividly remember one mother, who told us:

“Having had a seven-year-old son who was so dysregulated he was trying to throw himself out of windows and grabbing knives, there was no support for him (or us). The GP, after two failed CAMHS referrals as he ‘didn't meet the threshold’ told us, if we could at all afford it, even if it means borrowing money, to find support privately. That CAMHS will not accept a child unless they have made two viable attempts on their own life”.


I join my noble friend Lord Russell in asking the Minister what plans the Government have to implement the four-week clinical access standards for children and young people’s community health services, which have already been piloted? What have those pilots found? Will a fully funded plan be introduced to reach those standards?

In-patient care is another key area of concern that has come up today. It is estimated that some 3,500 children under the age of 18 are admitted to mental health in-patient facilities. As my noble friend Lord Allan said, despite the commitment to eliminate out-of-area placements, too often children are still being admitted to places far from home without a clear understanding of their rights and subject to restrictive interventions and inappropriate care. The right reverend Prelate the Bishop of St Albans made that point compellingly.

The transition to adult mental health services is just not working for too many young people. The NHS long-term plan set out an ambition to move to a nought to 25 model for young people. I supported that, but it is not clear what progress has been made towards it. Is the Minister able to say more about this? There is significant variation across the country in the age at which young people are expected to move to adult services. This transition is often abrupt and based on a person’s age rather than their readiness. Differences in threshold also mean that young people getting support from CAMHS may not meet the threshold for support for adult services, so yet again they fall through gaps.

I finish with a number of questions for the Minister. I ask him to write to me if he is unable to answer them now. What plans do the Government have to expand access to mental health support teams to children and young people across all schools and colleges in the country as quickly as possible? How do the Government intend to tackle the major regional inequalities in spending and wait times for CAMHS? Given the Government’s regrettable decision to roll back on previous plans to publish a stand-alone 10-year mental health plan, can the Minister say how the Government will ensure that the inclusion of mental health in the forthcoming major conditions strategy will properly tackle the huge challenges in children and young people’s mental health? Given the recent funding for the 10 innovative early support hubs, can the Minister clarify when this programme will report, what the evaluation will entail, and whether Ministers will commit to a rollout if findings are favourable? Given the postponement, yet again, of the long overdue reforms to the Mental Health Act, what immediate action are the Government taking to improve the plight of under-18s admitted to in-patient care units to ensure they and their families are aware of their rights and receiving appropriate care?

Today’s debate has shown that there is a lot of consensus on what we need to do. I hope the policymakers will listen to us so that we can make real progress.

King’s Speech

Baroness Tyler of Enfield Excerpts

Thursday 9th November 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, the central theme of the gracious Speech was long-term decisions to change this country for the better, but so very much was missing. I particularly liked the description we heard of it as thin gruel.

As other noble Lords have said, in appropriately trenchant terms, and my key point today, where was the long-awaited mental health Bill? It is beyond disappointing that a new mental health Bill to reform the 1983 Act was not part of the King’s Speech. Coupled with the abandonment of the 10-year mental health plan earlier this year, many in the sector and beyond are now understandably concerned that mental health is no longer a political priority.

I will just give a quick reminder of the facts. A new mental health Bill was a manifesto commitment from this Government in both 2017 and 2019. As we have already heard from the noble Baroness, Lady Watkins, and my noble friend Lady Barker, there is a totally unacceptable disparity between the white population and black and other racial groups when it comes to detention under the Act. This cannot go on. The 2018 independent review of the Mental Health Act, chaired by Sir Simon Wessely, set out very clear recommendations for modernisation, including greater legal recognition of detained people’s treatment choices. The Act simply does not work for children and young people, with many having bad experiences when detained in hospitals. Much time and effort has already taken place to reform the Act, including a White Paper, and a draft mental health Bill introduced last year, which underwent pre-legislative scrutiny, as we have heard, in a Joint Committee chaired by the noble Baroness, Lady Buscombe, earlier this year.

Given all of this, is it any wonder that Sir Simon Wessely expressed his deep disappointment in the summer at the prospect of the Bill being delayed yet again, when, to use his own words,

“we’re so close to the finishing line”?

He added:

“Lots of people have put a lot of work into this. It’s not controversial. Nobody seems to disagree with what we’re trying to do”.


I cannot help wondering whether that is at the heart of its non-appearance.

Can the Minister say when the Government will issue their response to the Joint Committee report and explain what they intend to do in the absence of this much-needed reform? Will the Minister explain precisely why the Government have reneged on their commitment?

The gracious Speech mentions that “record levels of investment” are expanding mental health services. This is of course to be welcomed, but that is only part of the picture. Simply put, the current levels of investment do not in any way match the level of increasing need. Mental health has not received any of the additional funding committed to bring down elective waiting lists. As a result, over 1.2 million are stuck waiting for mental health support and targets contained in the NHS Long Term Plan are slipping backwards on perinatal mental health, children and young people’s services, NHS talking therapies and mental health crisis care. On top of this, there are chronic shortages in the mental health workforce, with 20% of mental health nursing posts currently vacant.

It is welcome that the Government are restating their commitment to deliver on the NHS Long Term Workforce Plan. However, the plan is much weaker on retention measures and fails to address many issues that contribute to high attrition rates across the whole NHS workforce. As others have said, implementation of the long-term workforce plan simply will not work without an accompanying social care workforce strategy. We urgently need a national workforce strategy that raises the status of the social care workforce and ensures that career progression, pay and rewards attract and retain the right people in the right numbers. Can the Minister say if and when the Government will commit to such a plan?

The CQC State of Care annual report, published only last month, received surprisingly scant attention in this Chamber, despite drawing attention to how the combination of the cost of living crisis and workforce pressures has led to what it termed “unfair care”, with longer waits, reduced access and poorer outcomes for some people in accessing health and care services. Most worryingly, it reported that “unfair care” really means that those who can afford to pay for treatment do so and those who cannot face longer waits and reduced access. Research by YouGov shows that eight in 10 of those who used private healthcare last year would previously have used the NHS, with separate research showing that 56% of people had tried to use the NHS before using private healthcare.

As we have heard, smoking is a big contributory factor in health inequalities, particularly for people with mental illnesses. That is why I welcome legislation to create a smoke-free generation by restricting the sale of tobacco and e-cigarettes to children. But other than that, sadly, there was little of real substance to address the difficult and persistent issues facing many babies, children and young people. Although the Speech contained a pledge to

“ease the cost of living for families”,

there was no specific commitment to support the 4.2 million children living below the poverty line. According to ONS polls, the cost of living remains the most pressing issue facing the country, with 89% of respondents reporting it as an important issue. What plans do the Government have to tackle child poverty?

On financial inclusion, we have heard so much about people’s problems and concerns about the cost of living and about their lack of financial resilience. We urgently need clear leadership from the Government, with a national financial inclusion strategy joining up the work of government and industry, and building the long-term financial resilience of the country.

In conclusion, there is simply so much more to do to change this country for the better for all our fellow citizens. This requires a radically new approach.