Mental Capacity (Amendment) Bill [HL]

Baroness Tyler of Enfield Excerpts

Committee: 1st sitting (Hansard - continued): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I have listened to the debate and have ended up feeling slightly puzzled. If we are looking at how we improve the quality of life of “P”, what they experience day to day in how they are looked after is what influences that quality of life—in other words, how well the care plan is planned and executed. It cannot be just about the planning phase but about how well it is executed and how that execution of the care plan is monitored, day to day and week by week. In a care home, the person ultimately responsible for care plans has to be the manager because you must have a vertical structure, even though the plans may well be written by staff at a different level. If a person is in supported living, someone will be responsible for overseeing the care and provision in that supported living arrangement by dint of it being supported. Therefore, that must also be planned for and it will not be a care home manager but somebody else overseeing their care.

I can see that there is enormous concern over care homes. We all know that there are some excellent care homes and we have all, sadly, encountered care homes that are not excellent, where one would have concerns about their ability. If we are trying to drive up a person’s experience and quality of life, and make sure that what is done is necessary—because there is no other way of managing them—there need to be restrictions proportionate to the problems that they pose. I add here that we must consult and make every effort to listen to the person. We have that in another set of amendments later.

It may be that our grouping of amendments at this stage is not right because there is so much that interweaves between them. The worry is that if we then say that the people on the ground and the care plan are not the main part of the assessment, we go back to somebody basically helicoptering in, doing an assessment, seeing how they are and going again and leaving approval—that may be for a year—without any pressure to constantly review. Later amendments seek to put pressure on to review whenever the situation changes—to make it a more dynamic situation that really reflects that people deteriorate. Fortunately, some sometimes improve but most of the time you are faced with deterioration.

The other problem is that local authorities are, we know, incredibly short of finance. We know that they already cannot cope with the burden of assessments that they are being asked to carry out. I cannot see how asking them to take back the role and possibly do three assessments rather than six will tackle the problem of the number of people needing to be assessed and thought about being far greater and not matching—I think it never will match—the resources available.

It is easy to say that we need more people to do this but realistically the number of trained and experienced people is just not there. We have to find another way forward. There is a tension because whoever does the assessment may have a conflict of interest, whether about funding the care or receiving the income from the care. Somehow we need a system that improves the quality of life of the person and is subject to scrutiny more often than just on the occasions that the assessment is done initially or when it is reviewed after a fixed time.

I wonder whether a group of us needs to go away, sit down and really try to work this through with worked examples. I should declare that at one of the meetings I had in Wales we used worked examples in different settings. When we started to work through it for supported living arrangements—that was the table I was on—it became easier to see how it could work and how the triggers could work. I am not saying it was a perfect solution. I think the intention of these amendments is superb but I worry that they might not solve the problem.

[Baroness Tyler of Enfield (LD)]

My Lords, I was not going to intervene on this group of amendments but I have listened carefully to all the points that have been put and they have all been absolutely excellent. There is a tension here, as the noble Baroness, Lady Finlay, just said. My main reaction, particularly when I read the letter from ADASS—I shall not read it out again; I have it in front of me—was of real concern. As the noble Lord, Lord Hunt, said, they are not the sort of people who say these things lightly. They do not scaremonger. They do not exaggerate. They make very carefully calculated judgments, as you would expect of people at that level. I read the letter with great concern.

I was equally concerned when I read the briefing, as mentioned earlier, from the Relatives & Residents Association. One phrase really resonated with me, about the association’s great concern that too often we were asking care managers to be judge and jury about decisions in which they were involved. That is how it was expressed. The noble Baroness, Lady Finlay, made some excellent points. We have to find a way through. It would be genuinely helpful if, as in her proposition, there was time to think about those who will be most involved, as they must be, in care planning for these very vulnerable people, and a sufficiently independent element in arrangements so that people feel that care home managers are no longer judge and jury. I do not think we are there yet. I cannot articulate it at the moment but we must work together to secure a slightly different way forward.

[Baroness Barran (Con)]

I echo the appreciation of the noble Baroness, Lady Tyler, of the explanation of the noble Baroness, Lady Finlay, of the choices we face between the care home manager, who in the best cases will know “P” well, and the local authority assessor, who, as was said, might be parachuted in. It underlines the need for the now-familiar new paragraph 17(2) to be well thought-through and implemented. It is clear that the Bill’s intention is for this to be one of the critical safeguards of how this all works in practice, along with the scrutiny role of the responsible authority, which we will no doubt cover in detail.

Amendment 11 in the name of the noble Baroness, Lady Hollins, raises an important point about supported housing and care homes. It raised in my mind a slightly different question, which may have occurred to other noble Lords: do we need more clarity in the Bill on how it applies in domestic settings? For example, when someone who is normally cared for at home is in a care home for a short stay, perhaps because their carer is in hospital, what is the position in the home once the protection of liberty safeguards have been authorised? I wonder whether my noble friend could consider whether there is a need to clarify exactly the role of the safeguards in domestic settings and how they interface with the Care Act and other bits of legislation that would apply in such cases.

Mental Capacity (Amendment) Bill [HL]

Baroness Tyler of Enfield Excerpts

2nd reading (Hansard): House of Lords
Monday 16th July 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I am pleased to be speaking in this debate, conscious that I am a novice in this area of mental health legislation but very grateful that there are so many other noble Lords across the House with deep expertise in it. To start on a positive note, I welcome the intent behind the Bill and believe that it goes some way towards ensuring that the current high levels of bureaucracy, workforce hours and cost that have been a part of mental capacity assessments since the Supreme Court ruling in the Cheshire West case are offset by a more balanced ability to plan and deliver timely care while still safeguarding patients.

However, I have real concerns about its timing and its interaction with the Mental Health Act, and because it is silent on some of the key recommendations of the Law Commission report. I hope that at the end of this debate, the Minister will provide some explanation for the variance with the Law Commission proposals and the unexpected timing of the Bill, which seems to have taken many by surprise.

A quick glance at the statistics reveals the scale of the problem. Last year, more than 200,000 DoLS applications were made—a number certain to rise. The average time taken to complete the assessments was 120 days, with a backlog of more than 120,000 cases. The Law Commission has estimated that the annual cost of all this might end up being close to £2 billion, so there is clearly a major problem here that needs fixing.

The proposals in the Bill, essentially allowing NHS staff rather than the Court of Protection to oversee when and where to deprive people of their liberty, on the face of it seem to strike a better balance between care planning and the provision of what has too often been a box-ticking procedural safeguards process. The Bill comes at the same time as the recommendations from the Joint Committee on Human Rights only last week that a new legal definition of deprivation of liberty should be debated and defined, which could,

“produce greater clarity and would extend safeguards only to those who truly need them, whilst respecting the right to personal autonomy of those who are clearly content with their situation, even if they are not capable of verbalising such consent”.

All the briefings I have received from those working in the sector make it clear that the lack of such a new legal definition is a serious omission and risks jeopardising this legislation’s chance of successful implementation. That all adds up to my overall feeling about this Bill: that we risk acting with indecent haste before all the relevant pieces of the jigsaw are in place to allow a coherent and joined-up new system to be put in place—and I know that that new system is much needed. I note that Sir Simon Wessely, chair of the Mental Health Act review, said as much in a recent blog, drawing attention to the fact that at the moment some people lacking the capacity to consent to their admission for care and treatment will fall under the Mental Capacity Act and the proposed new liberty protection safeguards, and some will be detained under the Mental Health Act. But—and it is a big but—the boundaries between the two are not clear. My main concern about the Bill is that, in rushing ahead to fix the clear deficiencies of the DoLS procedures, we are creating further complexity in an area already beset with confusion and complexity. My view, like that of some other noble Lords today, is that it would have been far preferable to have a single, fully integrated Act covering both mental illness and mental capacity.

The interaction with the Mental Health Act is at the very least a messy one. There is a real tension between wanting to tackle problems with the current mental capacity law straightaway—I fully understand that—and the need to properly link it with plans to improve the Mental Health Act. I know that the JCHR has called on the Government to move quickly on reforming the Mental Capacity Act, but this should not prevent close consideration of the two pieces of legislation and how they relate to each other. In response to the Law Commission’s proposals, I noted that the Government stated that they would await the Mental Health Act review’s recommendations on interface issues, including how reformed DoLS would interact with the Act. I find that quite a confusing statement. Could the Minister say whether and how the Government plan to fulfil that undertaking?

I am also concerned, as are others, that the focus of the Bill is on deprivation of liberty alone, rather than the wider amendments to the Mental Capacity Act proposed by the Law Commission. In particular, the important recommendation to put particular weight on a patient’s wishes in any Mental Capacity Act best interests decision-making process is absent, as are any additional provisions about advanced consent. As I have said, I really feel—others have said it far more eloquently than me—that this is a missed opportunity to treat vulnerable people with the dignity and respect that they deserve in what we all agree is a very difficult situation.

I turn to the issue of including 16 and 17 year-olds in the Mental Capacity (Amendment) Bill, as originally proposed by the Law Commission. The main reasons for this are twofold. First, using parental responsibility to authorise Article 5 deprivation denies 16 and 17 year-olds the uniform statutory protections available to people aged 18 and older. Secondly, including 16 and 17 year-olds would create greater certainty and standardised practices for this age group than currently exist. It is all a bit technical but, as I understand it, presently Article 5 deprivation can be authorised by four different mechanisms: parental responsibility, a court order, a police protection order under the Children Act, or the Mental Health Act.

Front-line clinicians I have spoken to are often unsure which option to pursue. This can cause delays of a number of weeks while professionals argue with each other about the most appropriate option. In the meantime, the 16 to 17 year-old is in a legal limbo, often stuck in a paediatric ward or A&E while these debates take place. The situation gets even more confusing if two people with parental responsibility disagree or if the local authority shares parental responsibility—for example, for children on a care order. This is an opportunity to make the situation for 16 to 17 year-olds much better, and we should take it.

The Law Commission’s proposals also included the very interesting idea that we follow the lead of many countries and include in the Mental Capacity Act a framework allowing people to make formal support agreements. This would hugely benefit family members of the person under the liberty protection safeguards and value their input to the process. However, the wording in the Bill is unhelpfully convoluted, and will make it more difficult for staff, patients and their families to understand.

As the Bill stands, there is a heavy burden on care home managers to manage the applications. An individual would be reliant on the motivation, knowledge and skill of the care home manager to identify deprivation of liberty and to take appropriate safeguarding steps. Managers’ level of knowledge and experience will inevitably vary enormously, resulting in an individual’s human rights potentially being neglected if a manager simply does not recognise what constitutes a deprivation of liberty and takes appropriate action. As other noble Lords have said, a major training programme would be needed, as well as significant resources for implementation.

My final point relates to the phrase “unsound mind”, which I understand is still used because of the reference to the European Court of Human Rights. This is dated terminology which is offensive and stigmatising and has no clinical value. Imagine if you learned that this was an outcome of an assessment of your parent, partner or sibling. I stress again the importance of keeping the patient at the centre of our legislation, not the conventions or convenience of lawyers. Will the Government commit to removing the reference to “unsound mind” from the Bill?

In conclusion, I return to my concern about timing and the outcome of the review of the Mental Health Act, given that both Acts relate to the non-consensual care and medical treatment of people. The overlap between the two systems is one of the reasons that the current system is so complicated, and changes to address problems under one system will inevitably have unintended knock-on consequences for the other. What is needed is simplification and streamlining, rather than incremental, piecemeal reform. There is much to do to improve the Bill; I hope that the Government will be open minded and in listening mode.

The NHS

Baroness Tyler of Enfield Excerpts

Thursday 5th July 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate the noble Lord, Lord Darzi, on securing this extremely timely debate, and pay tribute to the wonderful work and care of all staff in both the health and social care sectors. I will start with my favourite Bevan quote before someone else gets it in. Back in 1948 he said:

“Illness is neither an indulgence for which people have to pay nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community”.


How do we reinterpret this incredibly important founding sentiment of the NHS in the modern age and over the next 70 years?

Recent polling by the King’s Fund shows that the British people have a great deal and pride in and good will towards the NHS. Despite this, securing proper long-term investment to achieve a fully integrated health and care service has sometimes felt like pulling teeth. Yes, the Prime Minister announced that the NHS would get a 3.4% yearly rise for its birthday and of course that is to be welcomed, but we cannot ignore the fact that the often-cited 4% necessary to even maintain existing standards, let alone improve and transform services, is still some way off. Sadly, as others have said, this new long-term funding settlement has so far ignored social care and public health and there is no clarity on what proportion of this money will go into mental health care—something I hope the Minister will be able to help us with this afternoon.

To meet increasing demand, the NHS will need more than just money: it will need a wholesale shift to promoting health as well as healthcare, to ensuring wellness rather than just treating illness, and to integrating health services so that they can be centred around the individual and the holistic needs of each patient. It came as no surprise to read in the Guardian last week that keeping the same doctor improves a patient’s life expectancy. This is great news so why is it so often not the case?

Turning briefly to social care, as we have just heard, continuous cuts, coupled with chronic long-term underinvestment, have left social care in a dire state. In their recent report, What’s the Problem with Social Care, and Why Do We Need to Do Better?, four leading health and social care bodies reported that to qualify for publicly funded social care, someone now needs to be 12% poorer than eight years ago. Meanwhile, informal carers continue to carry the bulk of the burden. The IPPR estimates that insufficient social care costs the NHS £3 billion a year, and with an ageing population these costs are bound to increase. If we are serious about safeguarding the NHS and its future, social care needs its birthday cake, too, and it needs to be a big one.

Turning to public health, in their recent report, The NHS at 70: Are We Expecting Too Much from the NHS?, those same four health bodies again emphasised that the most important factors in people’s health and life expectancy relate to the economic, physical and social environment in which they live. Therefore, public health must be made a priority if we are to have a healthier population.

Mental health is starting to get the public attention that it deserves. A recent Ipsos MORI poll found that the public rate it as their second-to-top health priority, which is great—but it is critical that those money increases are accompanied by mental health services that are much better integrated with physical health, community care and social care. So when the Minister winds up, perhaps he will tell us whether he feels that it is acceptable that currently only some one in four people with a mental health problem is able to access treatment, and what plans the Government have to increase this—and, specifically, what percentage of the new money announced for the NHS will go to mental health.

I conclude by saying that a good way of addressing all the issues that I and others have raised today will be to reframe the way we talk about the NHS as a national wellness service rather than one that just treats illness. I like to think that Aneurin Bevan and Beveridge would approve of that sentiment.

National Health Service: Mental Health Funding

Baroness Tyler of Enfield Excerpts

Wednesday 20th June 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Baroness makes an excellent point. The emerging science tells us that heading off mental illness in adolescence is critical to ensuring that it does not deepen and become more severe in later life, with great human as well as economic cost. At the moment, the mental health budget for children and young people does not reflect the burden that children and young people have, which is why the Prime Minister announced an extra £1.4 billion for children and young peoples’ services, as well as £300 million on top of that to support the plans set out in the child mental health Green Paper.

[Baroness Tyler of Enfield (LD)]

My Lords, the Minister has already referred to the mental health investment standard, but recent figures issued by the Royal College of Psychiatrists show that 15% of clinical commissioning groups are not following NHS England’s instruction to increase the proportion of their spend on mental health. What practical steps are the Government taking to ensure that all CCGs meet this standard?

[Lord O'Shaughnessy]

The noble Baroness is quite right in her figures: it was 85% compliance in 2017-18—175 of the 207 trusts. It has to be 100%. It will be independently audited and reported against. Indeed, interventions will take place if that does not happen.

Carers: Health and Well-being

Baroness Tyler of Enfield Excerpts

Tuesday 12th June 2018 Lords Chamber

[Lord O’Shaughnessy]

The importance of respite care is agreed by everybody. I point my noble friend to the better care fund, which provides around £130 million a year to support respite care and carers’ breaks, building on the commitment made in the Care Act 2014.

[Baroness Tyler of Enfield (LD)]

My Lords, the action plan contains a number of generalised statements about the need for health and social care professionals to have improved understanding and awareness of the needs of carers. What specific plans do the Government have to ensure that social worker training—both initial training and later professional development—contains practical guidance on how to identify carer fatigue and distress and ensure that carers receive the support to which they are entitled?

[Lord O’Shaughnessy]

The noble Baroness makes a very important point. Indeed, in the carers action plan there is a specific commitment from the department to work with local authorities to improve social work guidance in terms of spotting carers, many of whom are not even aware that they are formally designated as carers, and signposting them to the right support. There will also be an awareness-raising campaign among social workers so that they understand their duties.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Tyler of Enfield Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, in its excellent report, the Select Committee chaired by the noble Lord, Lord Patel, makes it plain that very significant investment in the NHS and social care is needed to ensure its long-term sustainability and avoid further damage both to the quality of and the access to care. Indeed, it is no exaggeration to say that the current system is near breaking point. We cannot carry on patching a gaping wound with a sticking plaster.

The recent Nuffield Trust report said that public satisfaction with the NHS is falling. The main reasons cited included staff shortages, long waiting times, lack of funding and government reforms. Primary care is particularly underfunded and overstretched, placing far more pressures further downstream on hospitals. A recent Daily Mail survey found that one in seven patients had to wait longer than a fortnight for an appointment with their GP. In a report earlier this year, the King’s Fund describes public health as dying from a thousand cuts. All the evidence shows that, to mitigate further costs, we must greatly ramp up our public health efforts to prevent disease. That was well addressed in the Select Committee report—but where is the response?

As the Select Committee report plainly stated, the issue of the workforce,

“represents the biggest internal threat to the sustainability of the NHS”,

and I want to focus most of my remarks there. As we heard in our recent debate in this Chamber on Brexit and the NHS, there are roughly 40,000 vacancies in nursing. Yesterday, the Guardian reported three times more departures from nursing than before Brexit. I was struck by a piece on Monday’s “Today” programme about GPs leaving because of the immense stress and pressure that they were under, which left patients in Plymouth regularly waiting two to three weeks for an appointment and one patient calling 93 times to be connected with her doctor. Britain has fewer GPs per person than other wealthy countries and, like nurses, they are leaving faster than they are coming. Those shortages increase the strains further down the system in the more expensive bits of the health service. A trip to the GP costs less than one-third of a visit to A&E. But nowhere is the situation more acute than in the mental health sector. Psychiatry is experiencing some of the highest vacancy rates—between 15% and 20%, with mental health nursing at 15%. In the current climate, it is salutary to note that some 40% of mental health staff come from overseas.

So what is being done about this? Health Education England’s recent draft workforce strategy provided, frankly, precious few solutions. There is a distinct lack of detail, with no modelling for the future NHS workforce beyond 2020-21. A better plan must surely look beyond the culture of short-termism to staffing solutions that can meet long-term demand, address supply issues, promote innovative and technological change and consider—this is really critical—new roles for health professionals and new ways of working for doctors and nurses. This should include applying best practice from overseas and looking at radical reconfiguration of services.

In addition, we must ensure that the workforce operates within far more efficient systems that allow people to get on with their jobs and to spend the time they need with patients rather than dealing with regulation and bureaucracy. Some of our current systems are very unproductive compared with other countries, which other speakers in this debate have touched on. It is clear that the NHS has yet to get to grips with these critical and worsening workforce issues and the current—opaque, I feel—division of responsibility between NHS England and Health Education England is not helping. Can the Minister, when he concludes, say who is ultimately responsible for the long-term planning on these key issues, such as workforce planning and productivity?

Turning specifically to mental health, what should be read into the fact that the key recommendation relating to mental health regarding parity of esteem was totally ignored in the Government’s response? To say it is not encouraging is something of an understatement. What does it say about the Government’s commitment to integrated care? The mental health investment standard is the statutory requirement to increase mental health investment in line with other services. However, recent data from the Royal College of Psychiatrists shows that more than one in 10 CCGs are failing to meet this standard. Can the Minister also say what action the Government intend to take in this area?

It sometimes feels as if we are engulfed in a veritable blizzard of new initiatives of the alphabet soup variety—we have STPs, ACOs and vanguards; I looked on the NHS website and there are a raft of others. I did not really understand what they even stood for and, frankly, it was impossible to understand how one related to another. We know the sustainability and transformation partnerships were set up to integrate health and social care across wide geographical areas, which is absolutely key to sustainability. But STPs have been told in no uncertain terms that they must prioritise cutting debt over everything else.

Achieving long-term sustainability will also need a far greater emphasis on integrated care. If I had more time—which I do not—I would give an excellent example in my own area, at the Whittington Hospital and the Highgate Hospital, of mental health and physical health having a really excellent physical health liaison service and working well together. From these small seeds longer-term change can grow, but it needs real political will and leadership.

On the big picture for future funding, I have been very interested to hear politicians of all stripes and other expert commentators talking about various ideas, including the Liberal Democrats’ long-term funding solution for the NHS and social care, which is a progressive hypothecated tax. Cross-party consensus is important and I hope that a cross-party commission will be set up. I am very rarely disappointed in the noble Lord, Lord Hunt, but I was disappointed at the beginning of this debate when he said that he did not think that was a good way forward. I think it is. We await further details from the Prime Minister on the long-term funding settlement but, frankly, we cannot wait much longer. Unlike previous cash injections that have gone into the black holes of hospital trust debt, any new funding must go to radical reform and, particularly, more resources for primary, community and mental health care.

To conclude, the time is right for a national conversation on all this; it is long overdue, which is something that I think the noble Lord, Lord Turnberg, said. The time is right for it now. The general public have responded quite positively to ideas such as an earmarked tax, as long as it is tied to deliverable promises of real improvements in the health and social care that they receive and they know what they will be getting for their money. This is where we really need to focus moving forward.

Brexit: Health and Welfare

Baroness Tyler of Enfield Excerpts

Thursday 29th March 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I, too, congratulate my noble friend Lady Brinton on securing this vital debate and introducing it so powerfully. I was also very moved by the compelling personal testimony that we heard from a number of contributors to this debate.

As we have discussed in this Chamber on many occasions, the NHS and social care sector—and we simply must see it as one integrated picture, not two separate sectors—has been struggling to cope under tremendous pressures for too long now. We have already been hearing—and we heard it powerfully in today’s debate—how Brexit and the ongoing negotiations are compounding existing serious problems. At last week’s debate in another place on this very subject, it was frankly alarming to hear details of the flight of EU staff from across the NHS. My right honourable friend Tom Brake explained that this flight was because EU staff had been hit by what he called “a triple whammy”. He explained that not nearly enough had been done since the referendum to make NHS staff feel valued and appreciated in the UK. With the falling pound, their salaries are now worth less back home and, as the UK economy slows behind the G7, they are increasingly likely to miss out on more lucrative jobs there too. These reasons to leave, he said, are sadly also reasons why critical talent with skills that we are crying out for in the UK are now thinking of not coming.

In that same debate, Dr Lisa Cameron MP reported that nearly half of EEA doctors have said,

“that they were considering leaving the UK following the referendum vote”.—[Official Report, Commons, 22/3/18; col. 228WH.]

As a Londoner myself, I was alarmed to read of a recent poll of doctors, in which 86% of London doctors who responded believed that leaving the EU will have a negative impact on recruitment to the NHS in London. These perceptions really matter.

In 2017, for the first time in a decade more nurses left the profession than joined. Indeed, the Commons Health Select Committee reported that the proportion of EU nurses choosing to leave the NHS has risen by a third in just one year. Critically, Nursing and Midwifery Council data shows that in the year following the referendum there was a fall of 89% in new EU registrations. Meanwhile, the social care sector is being drastically hit too, with the Nuffield Trust predicting a possible shortfall of 70,000 carers by 2025. We all know how shortages in social care exacerbate problems in the NHS and vice versa. I am sorry to quote so many statistics, and I know that other noble Lords have quoted many figures too, but it is really important that we understand the big picture. To say that it is not encouraging would frankly be a bit of an understatement.

I am particularly concerned about staffing in mental health services, and that is going to be the main focus of my remarks today. Though the staffing data for NHS mental health services is not as good as it could be, the available information is also not encouraging. According to the King’s Fund, there has already been a 13% reduction in mental health nurses since 2009, with in-patient care nurses being reduced by nearly a quarter. According to the Royal College of Psychiatrists, child and adolescent psychiatrists have fallen by 6.3% since 2013, something that we debated yesterday at Question Time. Currently, almost a 10th of all posts in specialist mental health services in England are vacant, and the mental health network of the NHS Confederation warns that it simply will not be feasible to meet health and social care staffing needs through domestic recruitment, training or non-EEA recruitment.

The conclusion that I draw from this is that psychiatry, as a shortage specialty, is under stress. We are undeniably struggling to fill roles, and we are highly reliant on international trainees, with more than two out of five coming from abroad. That is the highest of any medical specialty. Any exodus of EU-trained psychiatrists would throw an already overstretched system into crisis. The Government’s plans to recruit an additional 570 consultant psychiatrists by 2021 might be welcome, as are their plans to recruit child and adolescent psychiatrists and other mental health staff set out in the recent Green Paper. But as the Royal College of Psychiatrists reminds us, it takes 13 years to become a fully qualified psychiatrist, and the scale and ambition of these plans will work only if medics choose to become psychiatrists.

What is the effect of all this happening? As staff and budgets are strained across the NHS, morale is taking a hit, and consequently, outcomes for patients can suffer too. A recent Guardian survey of NHS staff showed that only 2% of participating staff felt that there were always—it is important to stress that word—enough people to provide safe care. As someone who has had occasion to use the NHS quite a bit recently, I find these figures truly shocking and frightening.

What are the Government doing about these alarming trends? In response to the debate in the other place I already mentioned, the Minister of Health, Stephen Barclay, seemed intent on ignoring the mounting evidence of EU staff’s flight from the UK and instead repeated a single figure that seems to justify the Government’s position, saying repeatedly that 3,200 new EU staff were working for the NHS. However, as the helpful briefing pack for this debate produced by the Library pointed out, this number is almost certainly inaccurate. The increase reflects an improvement in the way we record this information; in the same timeframe, more than 10,000 staff are no longer counted as “unknown nationalities”.

Pay is clearly an important factor in recruiting and retaining staff in the NHS. Although of course I welcomed the news of an end to the NHS pay cap, it seems that a pay rise of 6.5%—which sounds good, and I am sure it is welcome—may not amount to that much in real terms. If the OBR’s inflation forecasts are accurate, a 6.5% pay rise will increase pay by just a third of 1% in three years, still leaving wages significantly below what they were in 2010.

Similarly, the recent announcement to increase the number of midwifery training places offered, while again welcome, may not be enough to make our system sustainable. As with psychiatrists, the increase in these fee-paying places may increase the number of newly trained midwives in the UK from 2022, but there is little guarantee that these extra places will be taken up by students or that those who study will necessarily be employed by the NHS once they graduate. The only way to ensure that we have a real shot at making the UK a safer place to give birth will be through further incentivising training, recruitment and development of midwives at home and abroad, not simply offering more places.

I do not wish to sound simply like a counsel of despair—although there is a lot to be gloomy about—but I will suggest some positive steps that the Government should be taking. As the noble Baroness, Lady McIntosh of Pickering, so forcefully said, we need to see a much greater sense of urgency from the Government. First and foremost, we must move beyond mere lip service and demonstrate how much we value the contribution of our health and social care staff. Parliament has an important role to play here in the way we talk about these issues and in the language we use. There are other concrete steps that we can take to make the UK a more attractive place for people to work.

The UK must continue to welcome new doctors and provide urgent guarantees to those working here as to their rights under future residence. We should also give clarity to those who might come during the 21-month transition period as to their rights. We must better recognise EU and overseas professional qualifications to reassure doctors that their skills are respected, and broaden the national shortage occupation list to include staff with much-needed skills from the EU—a point I made yesterday with regard to psychiatrists. The visa application process for international staff should be simplified, streamlined and improved, and the Medical Training Initiative—a government-approved exchange programme—should be extended and enlarged to send a message to the world that the UK is not closed to foreign doctors. I hope the Minister will respond to those points. I have one specific question for him. Would the Government consider extending the cap on the length of the Medical Training Initiative to give more international psychiatrists and other medical professionals a chance to work for a period in the NHS while alleviating our workforce challenges?

I am pleased that the Prime Minister, albeit very late in the day, has come to recognise that the NHS needs significantly more funding and has started to talk about a long-term funding settlement. This revelation was no doubt helped by the broad coalition of MPs pushing for the adoption of the Liberal Democrats’ proposals to sustainably fund our NHS and social care through an earmarked tax. There is growing public support for such a tax because the public recognise the pressure that the NHS is under and it is so important to them in their lives. I strongly encourage the Government to include the cash-starved social care sector in the funding plan and to implement these proposals soon, in order to signal to the British people and the international community that we are serious about maintaining the best health system in the world.

Children and Young People: Mental Health

Baroness Tyler of Enfield Excerpts

Wednesday 28th March 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, given that the number of child and adolescent psychiatrists has declined by over 6% since 2013, and the number of mental health nurses by more than that, will the Government agree to consider the recommendation from the Royal College of Psychiatrists to add child and adolescent psychiatrists to the national shortage occupation list?

[Lord O'Shaughnessy]

There has undoubtedly been an impact on mental health nursing. In fact, the widest definition of the mental health and learning disability workforce according to the latest workforce stats is up by around 3,000 full-time equivalent posts. But we agree that more needs to be done. That is why there is an ambition to bring in 4,400 more mental health staff to support children and young people over the next few years. It is also reassuring to know that there are 8,000 mental health nurses in training at the moment.

Mental Health: Young People

Baroness Tyler of Enfield Excerpts

Thursday 9th February 2017 Grand Committee

[Baroness Tyler of Enfield (LD)]

My Lords, I congratulate the noble Baroness, Lady Massey, on securing this vital debate. Parental and family relationships have a huge impact on children’s mental health. This debate is all the more timely, taking place during Children’s Mental Health Week. Recent research revealed that up to two-thirds of children aged 10 and 11 worry all the time, with concerns about family and friends topping the list of causes of anxiety. Figures released last week show that more than 50,000 young people turned to ChildLine last year because of a serious mental health problem. In the light of these very worrying figures, it is hard to overstate the importance of the role of parents in supporting children with mental health problems.

In the time available, I can make only two key points. First, parents are a vital support and often a lifeline to children with mental ill-health. Given that parents spend more time with their child than anyone else involved, they have a crucial role in advocating on behalf of and supporting their child through difficult times. However, as the results from the “There for you” survey show, too often parents feel unprepared and ill-equipped to support their child and consequently struggle to play the vital role that they would like to. Indeed, the YoungMinds parents’ helpline found that 41% of parents said that they felt excluded from their child’s treatment, with other parents saying that they felt confused and isolated. We have to acknowledge that for a variety of reasons, some already mentioned, some parents are simply unable to provide the support that their children need. Obviously, there is a particular issue for children in care. Another specific concern that I want to highlight is perinatal mental health. More than one in five mothers develop a mental health illness during pregnancy or in the first year after birth. The knock-on effect of a mother’s perinatal depression on the mental health of her child can be severe.

My second point is that, as the noble Lord, Lord Farmer, reminded us, the quality of parental relationships has a significant impact on children’s well-being. Children growing up with parents who have low parental conflict, whether together or separated, enjoy better physical and mental health, better emotional well-being and higher educational attainment. Conversely, research indicates that parents who engage in frequent, intense and poorly-resolved conflict put their children’s mental health and long-term life chances at risk. In a recent survey of more than 4,000 children, family relationship problems were reported by CAMHS clinicians as being the biggest presenting issue.

We must promote greater involvement of children and parents in children’s treatment and do all that we can to ensure that effective resources are available to parents. I pay tribute to the free confidential parent helpline run by YoungMinds and its Parents Say network, bringing together parents to form a vital support network. Policy solutions and interventions need to take account of the wider family relationship in which children live and are supported. I urge the Government to prioritise support for parental-couple relationships in wider government policy, to reduce one of the often unspoken root causes of children’s mental health problems.

Mental Health: Children’s Services

Baroness Tyler of Enfield Excerpts

Thursday 19th January 2017 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, given the frankly shocking revelation that more than half of clinical commissioning groups are diverting the new money they receive to improve children’s mental health services to other priorities, will the Government commit not to sign off any sustainability and transformation plans that do not contain a clear commitment to spend every penny assigned to mental health for those purposes?

[Lord O’Shaughnessy]

The noble Baroness is a great campaigner on these issues, and I have huge respect for the work that she has done. The sustainability and transformation plans will obviously include these local transformation plans for mental health, and it is up to NHS England to ensure that it delivers on the many commitments we now have. Those commitments include the first ever access and waiting times for mental health, which is both access to talking therapies and access to help after psychotic incidents. We have new targets coming up for children and young people who seek help when eating disorders or other generic mental health problems are identified. There are robust targets and there is now a mental health improvement team in NHS England to make sure that those CCGs deliver what they should.