Mental Health Bill [HL]

Baroness Watkins of Tavistock Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Merron (Lab)]

I thank my noble friend for pointing that out. On the points raised about protections for young carers, the code highlights that children who are caring for parents with severe mental illness are entitled to request a young carer’s needs assessment under the Children Act. It goes on to cover the information that young carers should be offered to help navigate such a challenging time.

Returning to the guidance about which I was speaking, as has been identified, it already outlines the responsibility of multiagency safeguarding partners. Protecting children at risk of abuse and stopping vulnerable children falling through the cracks is very much at the heart of the Children’s Wellbeing and Schools Bill, which was introduced to Parliament last month.

[Baroness Watkins of Tavistock (CB)]

I thank the Minister. I want to raise the issue that so many children and adolescents are placed for care out of their area, which makes the subsequent treatment plan hard to manage. Can the Minister at least look at whether the code of conduct needs strengthening on that issue? For example, it could include a recommendation that a local team visits the person in the hospital before they are discharged. Of course, I would like to see more beds closer to home, but we have to face the reality.

[Baroness Merron (Lab)]

I appreciate that point, and I certainly would be happy to have a look at that.

Mental Health Bill [HL]

Baroness Watkins of Tavistock Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, my amendment is very closely aligned to the amendment just moved by the noble Lord, Lord Kamall, but it is in relation to children. This is an issue that I raised at Second Reading. A number of children and young people are admitted to mental health settings informally on the basis of their own consent or parental consent—notwithstanding what was just said by the noble and learned Baroness, Lady Butler-Sloss.

Research from the Children’s Commissioner for England suggests that around one-third of in-patients aged under 18 are informal. However, NHS Digital does not publish data on the number of young people admitted informally so it is impossible to accurately track the total number of young people in hospital or to identify trends. Concerns have previously been raised, particularly by the Children and Young People’s Mental Health Coalition, that young people who are informal patients are often under exactly the same conditions as those who are detained but without access to the safeguards that children formally detained have. Many children and young people who are informal patients are also often unaware of their rights and, as has already been acknowledged, do not feel that their voices are listened to.

The coalition believes that it is crucial that informal patients aged under 18 have the same safeguards as those detained under the Act. There are two key provisions in the Mental Health Bill that can be strengthened to improve care for children and young people admitted informally. The most important, the coalition argues, is extending care and treatment plans to informal patients aged under 18, which is what my amendment is designed to do.

The reason for that is, if you manage to get somebody who is under 18 to accept informal care, they have no mental health formal record for their future. Most of us who have worked with young people under 18 bust a gut to get them to accept an in-patient admission if it is really necessary—I am talking about families as well as professionals—in order to ensure that they get treatment.

If that treatment is not guaranteed on discharge through a care and treatment plan, in the way that it would be for a detained patient, can your Lordships not see that families would be put in such difficult positions? They would ask, “Would it be better if my child is sectioned and detained in order for them to get long-term care?” This brings me back to my continued, impassioned plea that we need to think about proper standards of elective care for people with mental health problems, most importantly for those under 18.

[Lord Davies of Brixton (Lab)]

My Lords, I remind the Committee of my entry in the register of interests that I am on the advisory board of the Money and Mental Health Policy Institute. I mention this particularly because the three amendments in my name, dealing with the financial implications for people who struggle with their mental health, have been based on the work of the institute.

As I have reminded the House on many occasions, these amendments speak to the undeniable but all too often overlooked fact that our mental health and money are closely linked. When someone is hospitalised for a mental health crisis, bills still need to be paid and debts can mount up, resulting in financial difficulties that greatly damage people’s prospects of recovery.

It is worth focusing on the numbers. In 2022-23, almost 90,000 adults were admitted to hospital for a mental health problem. The Adult Psychiatric Morbidity Survey indicated that around one-quarter of people experiencing a mental health problem are also in problem debt. The rate of problem debt is undoubtedly higher among people experiencing a mental health problem, which leads to hospitalisation. An earlier study from 2008 found that one-third of all people with probable psychosis are in problem debt.

The three amendments dealing with the link between finance and mental health deal with different aspects of the problem, and they are, quite rightly, being considered in turn in relation to the relevant parts of the Bill. Today, we start with my Amendment 59, and I thank the noble Baronesses, Lady Tyler of Enfield and Lady Neuberger, for their support for it. Like the other amendments in this group, it deals with care and treatment plans. Later, we will come to the implications of advance choice documents, which is currently in group nine, and then provision for mental health crisis breathing space, which is currently in group 17.

The Mental Health Bill provides an important opportunity to tackle the vicious cycle of poor mental health often leading to financial problems, and financial problems often leading to poor mental health. We must break that cycle and ensure that people’s financial needs are addressed as part of a supported recovery from a mental health crisis. That focus is missing from the Bill in its current form, and my amendments seek to address that gap.

As I have already indicated, these amendments are informed and supported by the independent charity, the Money and Mental Health Policy Institute, which has done considerable and excellent work in this area. They are small changes designed to improve the Bill and the outcomes for those it aims to help, by ensuring that a person’s financial situation is routinely considered and acted on as part of their treatment and recovery from a mental health crisis. Addressing a person’s finances is one of the many factors that mental health practitioners must consider in their assessment and care planning.

However, services cannot rely on patients to tell them when they are facing financial difficulties. The experience is that people rarely take the initiative to tell mental health professionals about money problems, often because they are too unwell or because the stigma around both mental health and financial problems acts as a barrier to disclosure. Adding an explicit prompt about people’s financial situation in care and treatment plans will ensure that this is routinely and consistently considered by healthcare professionals and will open up more opportunities to safeguard patients from financial harm.

There is a precedent for this. In Wales, “finance and money” is already included as a section in the care and treatment plan template. That does not mean that busy healthcare professionals are required to support people with their money in a way that they are not trained or intended to do. Rather, this is a case of empowering them to identify those in need and refer them to the relevant welfare adviser in their service, so that healthcare professionals can focus on medical care. Ultimately, that could free up time for health professionals, as well as improving outcomes for patients.

I will illustrate the need for this proactive inquiry with testimony from someone with lived experience of money and mental health problems, as they do it so much more powerfully than I can. A participant in Money and Mental Health Policy Institute research shared:

“I didn’t realise how much my mental health affected my finances and vice versa. I lived for years in shame and horrific anxiety about money which caused my mental health to spiral. I thought there was no help out there for me and I didn’t want to be alive, as I couldn’t see a way out of my money troubles”.


Legislating to include a consideration of people’s finances, when they are in a mental health crisis and throughout their recovery, will help prevent further illness, support recovery and reduce waiting lists, and will help people return to daily life, including work, more smoothly.

I can imagine what my noble friend the Minister’s response will be, because she has already written to the institute. She said in her letter: “We intend to set out in secondary legislation the required contents of the statutory CTP. However, we plan to further consult stakeholders to make sure that the CTP covers all the information that is critical to an individual’s recovery and timely and effective discharge from the Act”. I hope that she does not mind me taking the opportunity to stress the importance of this issue. Does she agree with that, including the importance of its place in treatment plans?

Health and Social Care: Winter Update

Baroness Watkins of Tavistock Excerpts

Tuesday 21st January 2025 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as an NHSE board member and a fellow of the Royal College of Nursing. I absolutely acknowledge that the Health Secretary and the team, including the Minister, are trying to resolve many of these problems. However, I echo the comments of the noble Lord, Lord Laming, that we need something much more quickly than the long-term plan. Can serious consideration be given to funding four or six weeks of care as soon as people leave hospital, whether or not there is a legal entitlement to that cost, to get the one in seven people currently lingering in hospital beds out into better facilities so that they can be supported by their families and friends? Also, the criticism of the advertisements for corridor nurses is absolutely incorrect; we need a higher percentage of nurses in A&E and surrounding departments if they have a much higher number of patients than they were originally established for.

[Baroness Merron (Lab)]

I thank the noble Baroness for bringing her comments before the House and for acknowledging our efforts, direction and commitment, because this is not easy and, as she knows, will not happen overnight. However, we need to tackle delayed discharge, following the point made by my noble friend Lady Winterton, through the development of local partnership working between the NHS and social care and making sure that the right support is there to return home—if that is the best place for people—or for an intermediate arrangement. This should not be just an issue of hospital or home; sometimes people need facilities along that trajectory, because they have different needs and their conditions do not stay still. That is why it has to be local partnerships.

Every acute hospital has access to a care transfer hub which brings together professionals from the NHS and social care to manage discharges of people with more complex needs who need extra support. We will shortly publish the better care fund policy framework, which will drive greater impact from over £9 billion of public spending on integrated care. Reducing delayed discharge will be a key part of that. I heard the request from the noble Baroness. She will understand that we have to take account of the financial situation we inherited, but we also need innovation, creativity and practicality to find answers to these very long-standing challenges.

Mental Health Bill [HL]

Baroness Watkins of Tavistock Excerpts

Committee stage
Monday 20th January 2025 Lords Chamber

[Baroness Parminter (LD)]

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

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

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

[Baroness Watkins of Tavistock (CB)]

My Lords, as an ex-community mental health nurse, I wish in particular to support Amendment 139. I am convinced that we need appropriate ratios of such staff to deliver preventive services in the community as well as ongoing support. We need to remember that the NHS rests in the future on preventing rather than treating, and this is an important amendment that acknowledges that.

[Baroness Buscombe (Con)]

My Lords, I want to add to what the noble Baroness just said. Amendment 139 goes to the heart of the Bill in terms of changing the culture and the way that we treat people. The Bill will become a piece of law that is practical only if we can honestly put hand on heart and say that we will substantially increase community-based services. Without that, it will not deliver that which we all believe will be the minimum to improve people’s lives.

--- Later in debate ---

[Baroness Watkins of Tavistock (CB)]

My Lords, I support this group of amendments in principle, but I want to make two points. We talk about powers a great deal, but the therapeutic relationship is not about power; it is about collegiate working with patients and users of the service. I appreciate that there are times when we need to intervene when the patient does not want intervention, but we must be careful about the nomenclature as we redraw elements of the Bill.

In particular, I welcome the phrase that the noble Lord has just used, which is used so frequently in New Zealand and Australia: emergency care orders. We should think carefully about the fact that what we need is emergency assessment and care orders. People who work regularly with patients over a long period are often the best people to recognise a change in a patient’s behaviour earlier.

I fully support the idea that this should be extended beyond police constables, as the noble Baroness, Lady May, outlined, but I also recognise that there will be healthcare professionals, be they psychologists, nurses or social workers, who do not want to take this on. We must make certain that we do not lose some of our valuable team by making it compulsory to take on that extended responsibility.

--- Later in debate ---

[Lord Davies of Brixton (Lab)]

With your Lordships’ permission, I want to respond to what the noble Lord has just said. On the front line in this are the paramedics; they are the ones who will have to deal with this issue, most of the time. They need recognition for the additional work that they are already doing. The noble Baroness referred to the gap—the gap is being filled, but in a very inefficient and unrecognised way. We need to recognise that this is something that needs to be dealt with properly, with the staff involved being given the appropriate powers to deliver.

[Baroness Watkins of Tavistock (CB)]

To add to that, the key thing about paramedics is that they do not have long-term therapeutic relationships with the people we are talking about. Therefore, an intervention is totally appropriate.

[Baroness Butler-Sloss (CB)]

I too want to add, equally with great care, to this very interesting discussion. I am concerned about the police. I have not quite understood from the Minister her thoughts on a point that has been made twice now by the noble Lord, Lord Meston about everybody waiting for the police. Are the Government thinking of making it unnecessary for the police regularly to attend?

Mental Health Bill [HL]

Baroness Watkins of Tavistock Excerpts

Tuesday 14th January 2025 Lords Chamber

Doing this could set a really important precedent. It could be of wider benefit to people who may not be covered by this legislation but who, for example, have had strokes, who struggle to express themselves, who may be in a care home. I have personal experience of this, ensuring that my late mother’s communication needs were properly addressed during care plan review meetings in her care home when she had had a stroke. It was very difficult for her to express her views. I was a central part of that, and it would not have happened without me being there. It should be a guiding principle for all people being looked after in all care settings of whatever nature, but it would be great to get this precedent established in this Bill.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support the amendment in the name of the noble Baroness, Lady Barker, with relation to housing. I do not want to go back 20 years for any reason except to say that, when we were closing the vast majority of mental health in-patient beds, the main aim of many of us doing those change programmes was to ensure that people had somewhere to live when they had been living in hospital for 10, 20 or, in some cases, 30 years, and that the housing had to be appropriate to their level of ability. Spending 30 years in a hospital does not exactly teach you self-reliance. There are some real challenges about that, so housing must be considered in any discharge planning.

On Amendments 19 and 20, the noble Baroness, Lady Hollins, has sent me a copy of her speeches in her absence. Like others, I think that it shows her commitment to this House that at this point in her life she is trying to make sure that her voice is heard. I add my condolences to those of others in the Committee. Her point is that you would not discharge people from acute hospital without some proper care and treatment plan. I want to use my own words rather than hers, but when you say that somebody needs dialysis or that they need regular checking of their heart monitor, we automatically do it. Elective care is still getting a huge amount of focus, but elective care in this country is defined as acute hospital care, not elective care for mental health patients and people with learning disabilities. I want to rest it there, but that is why I support Amendments 19 and 20 so strongly.

[Lord Stevens of Birmingham (CB)]

I too am supportive of the spirit and intention behind Amendments 19 and 20, but I want to raise two textual questions relating to whether they would give effect as was intended.

In respect of Amendment 19, I am not sure that the explanatory statement accurately characterises what the amendment proposes. It says that the amendment ensures that ICBs and local authorities would

“have a duty to carry out”,

whereas at the point at which those words would be inserted it appears that the duty would also then fall to the patient’s responsible clinician. Amendment 19 by itself would essentially see CETRs overriding the judgment of the responsible clinician, which I think is quite a significant step to take.

In any event, I wonder whether Amendment 20 undoes any of the good work that Amendment 19 proposes in the first place. It says that you can ignore the exhortations of Amendment 19 if there is a “compelling reason” to do so. My question to the drafters of Amendment 20 would be: what statutory interpretation should be placed on “compelling reason” and how might the courts be expected to adjudicate in the event of judicial review?

Mental Health Bill [HL]

Baroness Watkins of Tavistock Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the previous three speakers. I declare my interests as a non-executive member of the NHS England board and 45 years as a registered mental health nurse.

I warmly welcome the long-overdue reform of the Mental Health Act and congratulate the new Government on bringing it swiftly in their term. I appreciate the opportunity that the Minister has taken in holding discussions about the Bill prior to Second Reading and offering to consult further about potential amendments to strengthen and clarify particular sections. Modernising the 1983 legislation provides a real opportunity to reduce injustices in implementation and provide equitable support for people suffering from a mental health crisis, giving them more autonomy and choice and including a new right for service users to choose a nominated person to advocate for their interests.

First, I am pleased that the Bill aims to end the unnecessary detention of those with autism or learning disabilities, yet I share the concerns of the Royal College of Psychiatrists and other professional bodies that further clarity is needed around assessment and treatment. For many, the proposed 28-day limit for assessment may not be long enough to reach a comprehensive diagnosis, especially considering that those with autism often present with additional complexities. It may be difficult to admit, assess and support some patients within the time limit outlined in the Bill, risking recurrent use of overstretched A&E or admission and detention under Part III of the 1983 Act should there be safety concerns. The NHS Confederation drew on the example of New Zealand, where similar changes to mental health legislation saw a temporary increase in patients being sent

“to prison, left neglected in the community or admitted to forensic facilities as secure patients”.

Failing to allow for thorough assessment may worsen mental health care provision and further racial inequalities, as currently Part III detentions disproportionally affect black men.

To combat this, an emphasis on continuity of community care would cut the number of people admitted for an assessment, while ensuring that patients remain safe within the community, yet there is a chronic lack of community-based workers, with a third of all nursing vacancies being in mental health services. I therefore ask the Government to provide clarity on how they will ensure that those who, in the past, would have been detained for assessment and treatment will still be able to obtain a full diagnosis and the support that they deserve, preferably without hospital admission. Careful consideration of workforce planning in the community for social work and allied health professions, as well as psychiatrists, general practitioners and nurses, should form a significant part of the preparation for this Bill’s implementation; then patients and cares could more often be appropriately assessed, treated and cared for by both mental and physical health services, in community and primary care settings, thus avoiding admission.

The Bill offers an opportunity to improve support for those under the age of 18 who are admitted formally under the 1983 Act, yet it is estimated that 31% of under-18s are—thank goodness—admitted informally to hospital for assessment and treatment. I fully support the introduction of new statutory care and treatment plans, but I ask the Minister if they could be extended to those admitted informally, if it is a correct solution.

The Government are right to state that these plans will encourage patients to engage with treatment towards their discharge and beyond. Care and treatment early in a person’s life provides better outcomes than later intervention, so extending these plans to the significant number of informal patients aged under 18 could provide a solid foundation for later life. Additionally, ensuring the availability of quality community services would also reduce childhood detention. I therefore ask the Government to confirm their plans to encourage this early intervention via both the community and the care and treatment plans.

The Bill would be strengthened if it were to improve the environment for young patients. I will not repeat what has been so ably explained by the noble Earl, Lord Howe. However, we really ought to move to a statutory requirement that young people are not allowed to be kept in adult wards for treatment in crisis, or treated miles from home.

There must also be an exploration of the place of parental responsibility before the Bill is finalised. The introduction of a “nominated person” as well as “advance choice documents” are commendable steps to improve agency for those detained under the Mental Health Act. Some young people will choose not to include their parents for either of these. I therefore ask whether the Government can provide clarity as to how this will function with expectations of parental responsibility.

Healthcare professional bodies support the principle of ensuring that prisoners with severe mental health conditions are swiftly transferred to hospital, where they can receive proper treatment, but I have questions of practicality for the Government. What is the plan to ensure capacity in the in-patient sector? What happens to those who clearly cannot be properly treated in the in-patient sector, or who are a significant danger to others on the ward? As a former ward sister, I know that this is a real question from people working in those environments at the moment.

Will there be an assessment at the end of a patient’s treatment to determine whether they are recalled to prison or given a community treatment order if it is safe to do so and better for their mental health? I would welcome working with the Government to get clarity on this issue, particularly in relation to a code of practice.

As I have already said, continuity of care in the community will be essential to prevent unnecessary detention and to provide support to patients after detention. I therefore ask the Government to clarify the implementation timetable for the Bill in order to ensure that current staff have time to receive the development needed and that the necessary new staff are recruited.

I ask too whether there should be a research investigation into safe staffing ratios in the community. The Royal College of Nursing is calling for a maximum caseload for mental health community nurses to ensure that community treatment orders are conducted properly and that nurses can assist in preventing crises, but very little research into this ratio issue has been done outside in-patient facilities. It seems right that research and planning be done to ensure that the community can help fulfil the Bill’s admirable aims. A recent paper by King’s College refers to “frugal innovation” in healthcare. Investing properly in community care will reduce the costs overall.

I trust that the potential shortcomings of the Bill as it stands can be amended and/or resolved through the code of conduct to ensure that it is future-proofed and significantly enhances mental health service provision for patients, which is the aim of His Majesty’s Government, the vast majority of Members of this House and healthcare professionals themselves.

Carers and Poverty: Carers UK Report

Baroness Watkins of Tavistock Excerpts

Thursday 21st November 2024 Lords Chamber

[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.

[Baroness Watkins of Tavistock (CB)]

My Lords, has further consideration been given to reducing or having an amnesty on repayments by carers who were overpaid due to the complex algorithm involved in being able to work for a certain amount of money? Having acknowledged that they should be able to earn at least another £2,000 without such a disadvantage, could we not cancel the situation for many, particularly over this winter, before the new carer’s allowance comes in?

NHS: Treatment of Children from Other Countries

Baroness Watkins of Tavistock Excerpts

Thursday 21st November 2024 Lords Chamber

[Baroness Merron (Lab)]

I am very happy to add my congratulations to the hospital, which my noble friend knows very well. There are several approaches that we take on donors. One is the increased use of technology to ensure that organs donated can be used when and where needed. We tend to lose a lot of organs because that is not possible to do, depending on the technology. Another approach is to ensure that organ donation is a route that people are assured they can take, feel confident in, and are willing to participate in, including where somebody has died and we must deal very delicately, of course, with their loved ones.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a member of the board of NHS England. Clearly we need to meet the needs of our own population at the moment but also need to retain staff, and there could be a real opportunity for working with the overseas development aid budget to enable exchange sabbaticals between Commonwealth countries and staff here in relation to these special services, so that children from Commonwealth countries who otherwise would not have access to these rare treatments could do so both here and abroad. Could the Minister talk with the ODA department to see whether such an initiative could be developed?

[Baroness Merron (Lab)]

I will certainly ensure that officials take up the suggestion of the noble Baroness to explore possibilities.

Anaesthesia Associates and Physician Associates Order 2024

Baroness Watkins of Tavistock Excerpts

Monday 26th February 2024 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I was a member of the GMC until the end of January, so at the council meetings I was involved in a number of discussions about the responsibilities of the GMC in the lead-up to this order being laid. Unsurprisingly, I strongly support it.

I listened to the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, and clearly they raised issues that the Minister will need to respond to. However, the combination of statutory regulation by the GMC and a proper governance framework within each employment body seems the most appropriate course for us to take. Therefore, I say to the noble Baroness, Lady Bennett, that passing the order is the best way to secure the safety of patients, which is why I hope the House will give it resounding support tonight.

My second point comes back to the noble Baroness, Lady Bennett, on democratic accountability and legitimacy. The Minister mentioned that a combination of the Health Act 1999 and the Health and Care Act 2022 has brought this order before us. Since I took the 1999 Act through this House, I feel some responsibility to stand up for what it essentially aims to do. The whole problem of regulation of the professions in the health service is that it has never had the priority it deserves from the Government. The Law Commission reported in 2014, and here we are 10 years later, just about getting round to the first tranche of orders that we need to modernise the regulation of our health professions.

If you rely on primary legislation to make this kind of change, nothing will ever change. It is slow enough with secondary legislation, but with primary legislation it becomes almost impossible to get sensible change made. All the regulatory bodies are utterly frustrated that they have very old-fashioned processes and procedures, because they do not have the discretion needed to make changes that would be to both the public’s and the professions’ benefit. Therefore, I am glad we have this order and I hope we can follow it through.

My third point is about the noble Baronesses saying that they do not like the campaign of what is essentially vilification that has been going on over the last few months against the physician and anaesthetist associates. I wish they had paid a little more tribute to the members of those professions and the fantastic work they do. I have met physician and anaesthetist associates, and they are going through a torrid experience. They have been subjected to a nasty campaign and, even in their own employing body, there have been reports of bullying at work and they have been subjected to rude and antagonistic comments from colleagues.

What is the context in which we are to judge this litany of mistakes that they have made? They seem to be isolated examples and, to my knowledge, there is no comparative data on errors by consultants, principal GPs or postgraduate medical trainees. I would not like to see a list of all their mistakes. What would happen if we asked people to report mistakes made by F1 medics each August? The BMA is playing with fire in the campaign it has adopted of putting these poor professionals, who are doing their best, in this frame. I protest about this and the general lack of medical leadership from the profession when it should have been defending the associates. The way it has run away from this issue has been a disgrace. It will find that its lack of leadership and strength will bite it in future. I have not been impressed by the way in which employing authorities have dealt with this either; they have left individual AAs and PAs to withstand the pressure and bullying without the support they need.

The Minister needs to reflect on some of the points raised. First, in addition to declaring his confidence in physician and anaesthesia associates, he needs to set out a long-term plan for their contribution to the NHS, ensuring that the voices of those professions are heard. The Government’s ambitions on the numbers of AAs and PAs seem very modest. Why? Does he think we need to revisit that? Secondly, he needs to make it clear to NHS England and to employing authorities that bullying and intimidation of any healthcare professional in their employment must not be tolerated.

Thirdly, in response to the noble Baronesses, Lady Brinton and Lady Finlay, the Minister needs to ensure that each employing body adopts an appropriate local governance framework to deal with some of the issues that they have legitimately raised. Fourthly, we need research on the clinical outcomes of physician and anaesthesia associates and, frankly, comparative data with other health professionals. That is the only way to deal with the toxicity of these lists of mistakes that have been circulated. Finally—here I agree with the noble Baronesses, Lady Finlay and Lady Brinton—there clearly needs to be a plan of communication to the public to explain the role of the associates and the contribution they can make in future.

The order is important. Some legitimate issues have been raised, but equally we need to defend the associates, uphold the work they do and give them confidence about the future.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a NED of the NHS Executive. I support this order, for many of the reasons that the noble Lord, Lord Hunt, has just explained, but stress that I am extremely unhappy about the division between the reports from various medics and the associates that are planned. One of the big problems is that we do not value junior doctors enough. The phrase we use is inappropriate. I have been married for 43 years to a doctor who has been called a house officer, a senior house officer, a registrar and a senior registrar—those things would now be referred to as a junior doctor. I want to put that on record.

I also support what the two noble Baronesses have said, which is that we need a distinguishing factor for a qualified doctor, be that “MD” or whatever else is selected by the medical profession. I am a nurse, and I am proud of being a nurse. We have nursing associates, but I know that I am a registered nurse and I know that I have a doctorate, but I would never refer to myself as a doctor in the clinical area. These issues are difficult to deal with because we need to value people’s different experience and training.

I was appointed by a previous Secretary of State to chair the grandfathering of the paramedics on to the new register, when it came into being, and look at the success that that has been.

[Lord Winston (Lab)]

My Lords, I regret to say that I totally disagree with my noble friend speaking from the Front Bench, a person for whom I have the greatest respect, both as a colleague and as a previous Minister of Health in an earlier Government. He is not medically qualified; he is not a doctor who has been in practice. I speak simply as a fellow of the Royal College of Surgeons of Edinburgh and—it seems a bit immodest to say this—I was the triennial gold medal holder at the Royal College of Surgeons in London for innovative research. I never know quite how I got that award, but I did, and it hangs in my lavatory—I probably should not say that either.

There is a very serious issue here: anaesthesia. I do not want to frighten anybody, but I am not exaggerating when I say that there is no point at which a doctor has a patient closer to death than when the patient is anaesthetised under a general anaesthetic. It is then that things can happen which are completely unexpected, and there are all sorts of ways that the qualifications of that anaesthetist are incredibly important. Doing anaesthesiology is, most of the time, deadly dull; nothing goes wrong, you sit there quietly while the surgeon carries on acting out his wonderful role leading the operating theatre and controlling everything. The person who is really at risk is the person who is under anaesthesia, and that is something we should never forget; it is really important.

We do not even understand fully how anaesthetics work. It is true to say that even though we use gas and other agents, how they work exactly on the brain is not certain and we are still learning, years after the first anaesthetics in Victorian times. We have to recognise that this is quite a strange area of medicine, and that is why I am making this speech.

I want to tell a story about an anaesthetist friend of mine with whom I worked. Before I was doing regular in vitro fertilisation, I did a huge amount of reproductive surgery—surgery in the pelvis and telescope examinations, including laparoscopy. He and I worked as a team regularly on a very large number of patients, with complete success. On one occasion, I had a young woman, who was only 19, as my patient. She had severe abdominal pain, and I wondered, for somebody that age to have that pain, whether she had some unusual condition, and I thought she should have a laparoscopy.

My anaesthetist, as he always did, went to see the patient before the surgery and examined her to make certain she was well. He took her into the anaesthetic room and started with the anaesthesia, while I was waiting in the operating theatre. Then, quite suddenly, my anaesthetist friend wheeled the patient in on a trolley and said to me, “Robert, I think we have a spot of trouble here”. That was all he said, but there was something in his tone of voice and I thought, “This is really a weird thing for him to say”. The patient was unconscious and not intubated, and she remained unconscious. Her heart went and she had, in effect, died. We got her on to the operating table and I, as the surgeon, had a decision to make: what do I do? Do I, as the person leading the team, interfere, or do I leave it to my anaesthetist, in whom I had complete trust? I asked him whether he thought I needed to do heart massage or various other things. He said, “No, hang on for a bit”.

NHS: Dementia Commission Report

Baroness Watkins of Tavistock Excerpts

Thursday 22nd February 2024 Lords Chamber

[Lord Markham (Con)]

We have set out a dementia good care planning guide to exactly those commissioners because, as ever, we need uniformity in these areas. Part of the strength of ICBs is that they have freedom to deliver local services, but we have to make sure that they are always achieving at least the minimum levels that the noble Lord referred to. That is what the guidelines are about, and we are setting monitoring against that to make sure that they are delivering on it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I have two questions. First, I understand that NICE will review rather than approve the drugs in question. Secondly, it appears that they extend life but that the end of life is still very similar, so what do the Government intend to do to ensure that carers have sufficient respite and that there is a standard ratio of Admiral nurses to support families, certainly for the next decade until science gives us the answer?

[Lord Markham (Con)]

The noble Baroness is correct that the science is unfortunately not there yet. That is why we are investing £160 million a year in research, because more needs to be done. In the meantime, and I suspect for ever, we will need to make sure that support networks are around this space, and the voluntary care sector, for want of a better phrase, is a vital part of that. We are making moves towards it; we are giving respite care and making some payments. I freely admit that there is more we could be doing in this space, but we have done quite a bit as well.