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

Committee stage
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.

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.

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?

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.

Maternity Services

Baroness Watkins of Tavistock Excerpts

Thursday 25th January 2024 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw attention to my registered interests in healthcare. I thank the noble Baroness, Lady Taylor, for bringing this important debate to the Chamber. Her speech was an absolutely laser-focused analysis of the current situation and summarised many of the issues that I will return to—without, I hope, too much repetition.

The current state of maternity services in England is of concern to many stakeholders, but this must be put in context. Most expectant mothers and their significant others receive high-quality care during pregnancy and are delivered of healthy babies. However, the latest CQC report rates 10% of maternity services as inadequate and 39% as requiring improvement. This margin of error in such a vital service is really concerning.

Shockingly, safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for safety and 12% rated as inadequate for being well led. I think we can all agree that this is an unacceptable failure of the women, their partners and babies in this country. Of particular note is the fact that poor provision is disproportionately failing many mothers form minority-ethnic groups, as others have outlined, but also white women who suffer economic deprivation.

Many factors contribute to this situation. Part of it might be that there has been less regard for the profession in the last decade than there was. I remember coming to the end of my general nurse training, just 500 yards down the road, and being asked what I was going to do next. I said I wanted to do mental health nursing, and I still remember the sister tutor saying to me, “But you’re bright enough to be a midwife”. We should hold on to that. I am happy to tell you that I got an obstetrics certificate so that I could work abroad and ended up as a mental health sister with a mother and baby unit in that ward—so I actually used it wisely.

Midwives are now men and women, and we do not seem to have recognised that in some of our structures in multidisciplinary teams. With men, we hoped that it would improve the provision of employment for midwives, as well as double the amount of people from whom we could recruit the pool. That does not actually seem to be working as well as we might have hoped.

Quite frankly, most multidisciplinary teams face large, unmanageable caseloads, and have to work with what—in some areas—are unsafe staffing ratios. To my mind, they often do not receive fair compensation for their important work. As commended by the CQC 2023 report, midwives and staff on maternity wards go above and beyond, when possible, to provide the best care.

However, services are being pushed to breaking point. As has already been acknowledged, it is estimated by the Royal College of Midwives that we have 2,500 full-time vacancies. This obviously leads to overload and understaffing in some areas, and the quality of care provided is put under threat. This is recognised in the 2023 NHS England Three Year Delivery Plan for Maternity and Neonatal Services, which highlights that supporting the workforce to develop skills and extra capacity is vital to providing future high-quality care.

I want to put this in context. When I went off to do mental health nursing as a second qualification, I was paid as a staff nurse. Now, it is almost impossible to get a second qualification without going back on a bursary. I will leave that for people to think about. I therefore support the commitments that have been made to ensure that trusts will meet staffing levels and achieve full rates for midwifery by 2027-28. However, it remains very difficult for a registered nurse to do a shortened course to become a midwife. I therefore suggest that women will continue to face what some do now: hurried care with staff having little time to provide truly person-centred support.

Like many other contributors to today’s debate, I have my own children and know that good health during pregnancy and labour and postnatally is vital. So is good healthcare. If you do not start with good health and then have poor healthcare, that is a pretty difficult situation. Staff need time to listen to mothers and fathers and to act when concerns are identified. As I have told this House before, with my first child, I felt ill. My husband came to visit me in the hospital the day she was born. I do not remember this, but apparently I grabbed his hand and said, “You will look after this baby if I die?” Then he realised he should go and talk to somebody, because this was not the way I normally talked about things. I had fantastic, fast intervention and had my baby within half an hour—who I am pleased to tell you is now a taxpayer. That was a good, cost-effective solution, but too often people do not listen to significant others, who sometimes understand very well what mothers are saying. We therefore cannot rest the whole responsibility on the mother in a time of distress.

It is necessary to think seriously about access to interpreters on a 24-hour rota system, so that women who are unable to speak or understand English because it is not their first language can be assisted in communicating with the staff caring for them. We have situations in some areas in which it is impossible to get an interpreter. That makes the situation really difficult, both for the midwives and for the mother. One cannot always rely ad hoc on a relation interpreting what is really going on. Can the Minister comment on how access to interpreters is monitored within the NHS and, if this is not being undertaken, can he ask the Government to make provision to do so? I have been informed that this is particularly important in genetic counselling in families from cultures that are different from those of the midwives involved.

Staff are often unhappy due to pressure at work, in part associated with low levels of staffing. As other noble Lords have said, it is also because senior midwives are retiring or retiring earlier than planned, for a variety of reasons. Many who are leaving are specialist mid-career midwives, whose skill set cannot be easily replaced, particularly in terms of supervising student midwives. I am really proud that the daughter who is the taxpayer is a teacher. However, teachers get rewarded on top of their salaries for supporting student teachers if they are the lead in it. This is an example of something we could learn from.

In part, retention issues reportedly stem from inflexible working practices. Flexible working is difficult to manage in a 24-hour, seven-day service. I know; I have tried it. However, some trusts have much better retention than others. How can best practice be shared and replicated to retain midwives across the NHS services?

The stress of unmanageable expectations at work is creating burnout, as some others have reported, and encouraging some midwives to leave the profession. Perhaps we should think about a structure for sabbaticals for some midwives. Midwifery is, at the best of times, hard physical and emotional labour. We do not always recognise that. When things go well you get the rewards but, as my noble friend Lord Patel has just spoken about, when things go badly it can be devastating.

Capacity is being undermined by a lack of investment in continual staff development. This is highly worrying because, as others have said, we face an increase in complex births, as more women are giving birth over the age of 35—as I did—maternal diabetes has increased, the use of induction and caesarean has increased, and pre-term births are becoming more common. These cases require specialist skills so that mothers and babies are safe. However, a lack of training and development opportunities for midwives, both men and women, can lead to a deficit of skills that are vitally needed for our specialist services to survive in the future. Midwives need to be skilled at recognising complications in pregnancy, ensuring that they pass those to other members of the multidisciplinary team for assessment, so that, wherever possible, early intervention can be undertaken.

The vast majority of our student midwives in England report having to take on additional debt, over and above the loans available to students, to cover their basic costs. This is undoubtedly putting people off coming into midwifery. The National Union of Students reported a worrying drop in applications to university courses, from 13,500 in 2021 to just over 10,000 in 2023. Can the Minister say whether the Government will consider the NHS undertaking loan repayments for university fees after, say, three or five years of NHS service? It would aid the retention of midwives, nurses and indeed junior doctors, as well as other professions allied to medicine.

Our midwives work tirelessly to provide the best care they can, but they are often unable to do so because of the issues highlighted by other noble Lords and in my own contribution. We must ensure that these issues are tackled, so that every woman is provided with truly person-centred, skilled and compassionate care, and that all babies have the best possible start. The Royal College of Nursing has produced nursing workforce standards that could apply to paediatric intensive care units. Similarly, the Royal College of Midwives has provided evidence on the necessary ratios of midwives to expectant mothers at differing stages of pregnancy. Are this Government prepared to consider legislation on workforce standards in the NHS in future?

Adult Social Care: Staffing

Baroness Watkins of Tavistock Excerpts

Tuesday 12th December 2023 Lords Chamber

[Lord Markham (Con)]

It is absolutely understood that, to have a highly motivated workforce, you need to look at everything—pay and conditions, and training and motivation. We see that while, on average, staff turnover is almost 30%—which is way too high—about 20% of care home providers have a turnover of less than 10%. Why is that? It is because they are investing in their staff and they have a training programme. That is why we are trying to do a similar thing. The national care certificate that we are putting in place will take time; for it to be valuable, we will need to put the right things in order, including the digital platform to pay the 17,000 providers. These are all parts of the reform, which will make a difference.

[Baroness Watkins of Tavistock (CB)]

My Lords, does the Minister accept that many delayed transfers of care from hospital are associated with difficulty in getting social care in people’s own homes? In rural areas, we are still not paying for time spent travelling. Surely there is something we could do much more quickly, before the training certificate, to employ local people in a fair way to provide care in people’s homes, particularly in rural areas.

[Lord Markham (Con)]

The noble Baroness is correct about that; it is a key pillar of this reform. This is why we have tried to learn one of the main lessons from last year, by putting the £600 million discharge fund out early, so we can get those sorts of measures in place. That is why we have expanded the virtual care ward network to 10,000 beds, with the idea that people can be cared for in their own home but with support from the staff there. That is absolutely the direction we are moving in.

Learning Disabilities and Autism: Solitary Confinement in Hospital

Baroness Watkins of Tavistock Excerpts

Thursday 23rd November 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a NED at NHS England and as a qualified nurse. I commend my noble friend Lady Hollins on her thorough report on the current use of solitary confinement for autistic people and people with learning disabilities using in-patient hospital services. I remind people that the noble Lord, Lord Crisp, has written a book, Health is Made at Home, which argues that hospital should be for therapeutic intervention for short periods. This report clearly shows that that is not so for this cohort of patients.

The report raises key issues around the use and overuse of solitary confinement methods and outlines important recommendations for the improvement of care. However, rather than making my heart break, this report made me angry in the same way that another report, Sans Everything—that report was about long-term care in mental hospitals—did 50 years ago. We need to turn the anger and broken hearts into positive action.

I wholeheartedly support the concept that there should be no long-term use of solitary confinement for autistic people and people with a learning disability. However, I wish to highlight the need for discussion to consider in more detail other patients’ safety and well-being when people are in relatively confined environments. In addition, nursing staff are sometimes put at risk in understaffed, outdated clinical environments when, due to an acute autistic episode or meltdown, an individual patient resorts to violence that is difficult to cope with, often because of the reasons just given about inappropriate responses. Such circumstances can be distressing for other patients and staff.

Additionally, this debate should acknowledge the challenges that staff face due to high patient-staff ratios, which make truly individualised, person-centred care difficult to deliver in many circumstances. Agency nursing is used because it pays better but such nurses often do not know the individuals well enough to know how best to respond.

I state my full support for recommendation 12 of the report. Funding is needed to deliver person-centred interventions in order to reduce the use of solitary confinement vastly. This needs to be accompanied by funding to support staff’s continued education, training and professional development.

Although I agree that it is necessary to have formal recording and notifying practices in instances where solitary confinement has been used, I question the feasibility and staff resource requirements in the details of recommendation 6, in particular reporting immediately to the CQC. An alternative proposal could be that notifications to ICBs should be made if solitary confinement measures have been used for an individual in two or more instances in a set period, for example for more than 12 hours on two occasions within 10 days. However, reports should also be made to the boards that are responsible for the delivery of care.

Recommendation 7, which recommends that clinical contracts be agreed before admission, may not always be achievable in a situation of acute crisis. Therefore, I suggest that it should be clinical policy that contracts are agreed within five days of admission as a maximum and that pre-admission contracts are always considered best practice.

Finally, with regard to recommendation 8, which aims to secure family visiting rights for autistic people in solitary confinement, we also need to secure the rights for the autistic person to refuse such visits. Family relations can be very complex and, in some situations, abusive; therefore, in extremely rare situations, unwanted visits can lead to increased distress among autistic people and people with a learning disability. However, I must stress that I am a firm advocate of the visiting options in recommendation 8, which would also require people being cared for much closer to home than many are at the moment in order to make regular contact achievable. Too many people are sent too far from home, often to private health facilities, with possibly 10 different contractors for just one or two patients. This makes it difficult to maintain good relationships between providers and purchasers and to oversee the quality of care that is being delivered.

I ask the Minister: do His Majesty’s Government acknowledge that, although some of the recommendations may not be achievable without changes to the Mental Health Act 1983, many of them could be with additional financial investment to pilot programmes based on the suggestions in the report and to provide training for staff in order to ensure that they can safely deal with de-escalating crisis situations to reduce significantly the use of solitary confinement? We owe autistic people and those with learning difficulties more rapid change to the situation so ably outlined in this report. We would not stand for delay in introducing contemporary practice for people suffering from cancer or diabetes.